Every finding on record at River's Edge Rehabilitation & Living Center

Based on observation, the FDA Food Code, the SOM, and staff interview, it was determined the facility failed to ensure ice machines were cleaned. This deficient practice had the potential to affect all facility residents who consumed ice prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned in equipment such as ice bins and enclosed components of equipment such as ice makers, at a frequency specified by the manufacturer, or absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.The SOM Appendix PP revised 7/23/25, documented equipment can become contaminated in various ways including improper sanitation.On 4/12/26 at 2:58 PM, the ice machine was observed to have a black residue along the interior metal plate of the ice machine.On 4/12/26 at 3:05 PM, the Dietary Manager confirmed there was a blackish brown residue along the interior metal plate of the ice machine. When asked how often the ice machine was cleaned, the Dietary Manager stated the ice machine was a rented unit and maintenance was responsible for cleaning the ice machine.On 4/12/26 at 3:50 PM, the Plant Operations Personnel confirmed a black substance in the ice machine and stated the rental company provides quarterly cleaning of the ice machines and monthly maintenance.

Based on observation, resident interviews, and staff interviews, it was determined the facility failed to provide a homelike environment when a resident's closet doors and sink countertop were left unrepaired. This was true for 1 of 16 residents (Resident #9) whose rooms were observed. This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment. Findings include: Resident #9 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with multiple diagnoses including cognitive communication deficit, muscle weakness, and hemiplegia and hemiparesis following a stroke (weakness and paralysis to one side of the body).On 4/13/26 at 2:50 PM, it was observed in Resident #9's room there were large, jagged round and oblong areas on Resident #9's closet doors with chipped, cracked, and missing paint exposing white and brown patches. Several long black scuff marks and scratches were observed along the mid to lower closet doors and to the bottom drawers of the closet. A large oblong and jagged area of the sink countertop was observed to be damaged and missing, exposing brown wood.On 4/13/26 at 2:59 PM, when asked if the room felt homelike, Resident #9 pointed to the closet doors and the sink countertop, huffed, and said, no. Resident #9 stated the room did not feel homelike due to the condition of the closet and the countertop and further stated she would like the closet doors painted and the counter fixed.On 4/16/26 at 1:57 PM, the Maintenance Director accompanied the surveyor to Resident #9's room and confirmed the closet doors, sink counter, and the lower corner wall near the sink needed to be repaired. He further stated the closet had been painted approximately 3 or more months ago. When asked for documentation for the repair, the Maintenance Director stated he did not keep documentation on painting repairs and that he only kept documentation on repairs to outlets, lights, wheelchairs, walkers, etc.

Based on observation, facility policy review, and staff interview, it was determined the facility failed to ensure medications were stored in a safe and secure manner. This failure had the potential to affect all residents in the facility, as unsecured medications could be accessed by individuals for whom they were not prescribed, creating a risk for harm. Findings include:The facility's Medication Storage policy, revised April 2025, documented medications must be stored safely, securely, and properly in accordance with manufacturer or supplier recommendations and applicable federal and state regulations. The policy also stated that the medication supply would be accessible only to authorized personnel.On 4/12/26 at 10:39 AM, a medication cart was observed in the 100-hall. The medication cart was unlocked, and no staff were present in the area.On 4/12/26 at 10:41 AM, LPN #1 confirmed she had left the medication cart unlocked and stated it should have been locked.

Based on record review and staff interview, it was determined the facility failed to ensure a medication was provided with adequate indications for its use. This was true for 1 of 6 residents (Resident #57) whose records were reviewed for unnecessary medications. This failure placed Resident #57 at risk for harm when they were taking a medication which they did not have a clinical diagnosis for. Findings include: The National Library of Medicine web page titled, Tamsulosin (generic for Flomax): Ureteral Stones, accessed 4/23/26, documented dosage and duration of Flomax use for kidney stones, Oral tamsulosin 0.4 mg daily, usually at bedtime, for 7 to 42 days or until expulsion of stones. Resident #57 admitted to the facility on [DATE] with multiple diagnoses including right sided hemiplegia and hemiparesis following a stroke, a seizure disorder, and dementia. Resident #57's record documented the following physicians order, dated 4/26/21:-Flomax 0.4 mg (a medication to relax urinary tract muscles, to make it easier to empty the bladder), give 1 capsule by mouth at bedtime [related to] stent removal and calculus of the kidney (kidney stones). On 4/16/26 at 1:46 PM, the DON stated, Resident #57 had not had treatment for kidney stones or a stent since his admission. She added, his records documented he had a ureteral stent and treatment for kidney stones in 2020, before his admission to this facility. The DON stated Resident #57 did not currently have any urological diagnoses to indicate the use of Flomax.

Based on record review and staff interview, it was determined the facility failed to ensure physician orders for oxygen therapy were followed for 1 of 1 residents (Resident #56) reviewed for oxygen therapy. This failure placed resident #56 at risk for adverse effects, including respiratory infections. Findings include: Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including mild cognitive impairment, chronic obstructive pulmonary disease (COPD), and the need for assistance with personal care.Resident #56's medical record included the following physician orders:-Administer oxygen at 2 liters per minute via nasal cannula continuously, initiated 4/25/25.-Change tubing, clean filter, and change oxygen water every 7 days, initiated 12/1/25.A review of Resident #56's record documented the orders were followed as written.On 4/12/26 at 10:13 AM, Resident #56 was observed resting in bed with her nasal cannula in place connected to an oxygen concentrator. The attached humidifier bottle was dated 4/5/26, and the cannula storage bag was dated 3/29/26.On 4/12/26 at 10:38 AM, CNA #2 stated oxygen tubing is changed every 7 days and confirmed the date written on the bag reflects when the tubing was last replaced. CNA #2 confirmed Resident #56's oxygen tubing had not been changed in 14 days.

Based on observation, record review, review of nationally recognized standard of practice, and staff interviews, it was determined the facility failed to prevent avoidable accidents by not ensuring residents received the level of supervision and assistance required by their care plans. This was true for 2 of 6 residents (#1 and #2) whose records were reviewed for accidents. This failure resulted in falls during care and created the potential for serious injury to all residents requiring assistance with transfers or repositioning. Findings include:The Agency for Healthcare Research and Quality (AHRQ) website, accessed 4/21/26, identifies preventable accidents as those resulting from failures in:- Supervision- Environmental safety- Communication- Adherence to care plans- Use of assistive devices- Staff traininga. Resident #1 was admitted to the facility 9/11/14 with multiple diagnoses including quadriplegia, anxiety disorder, and the need for assistance with personal care.An Annual MDS assessment dated [DATE], documented Resident #1 was cognitively intact and dependent on staff for rolling left and right in bed.Resident #1's care plan, revised 2/13/20, documented she was totally dependent and required assistance from two staff members for repositioning and turning in bed.The facility's I & A report dated 4/1/26, documented Resident #1 was being changed in bed by a CNA when she rolled off the bed. Resident #1 was observed yelling out in pain. When the nurse entered the room, she found Resident #1 lying on the floor slightly on her right side. The report documented that Resident #1 was transported by emergency medical services for further evaluation.An Interdisciplinary Team progress note dated 4/4/26 documented Resident #1 would be evaluated by therapy and occupational therapy to review environmental modifications, including assessing for appropriate bed size. The note also documented that Resident #1's activities of daily living needs would be evaluated for appropriate support staff.On 4/16/26 at 11:42 AM, the DON confirmed that two CNAs should have been in the room to assist with turning Resident #1 at the time of the fall on 4/1/26.b. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including difficulty in walking, muscle weakness, and the need for assistance with personal care.A Quarterly MDS assessment dated [DATE], documented Resident #2 required substantial/maximal assistance for chair, bed, and toilet transfers.Resident #2's care plan, revised 1/13/26, directed staff to use two staff members for stand and pivot transfers, both to and from her wheelchair.The facility's I & A report dated 4/8/26, documented a CNA was assisting Resident #2 with a stand-and-pivot transfer when the resident's legs buckled and she was assisted to the floor. The report documented Resident #2 was not wearing appropriate footwear for the transfer. When the nurse entered the room, she placed appropriate footwear on the resident and used two staff members to assist with transferring Resident #2 to her wheelchair after assessing her for injuries. The report documented that staff training was provided regarding safe transfers and proper footwear.A review of the facility's staff training dated 4/8/26, documented education was provided on safe transfers as well as reviewing and following the Kardex (a quick reference for the level of care to be provided by CNAs).On 4/16/26 at 9:26 AM, the DON confirmed Resident #2's fall could have been prevented if the care plan had been followed, as Resident #2 required the assistance of two staff members for transfers.

Based on observation, review of professional standards of practice, and staff interviews, it was determined the facility failed to ensure medications were prepared and administered safely and in accordance with nationally recognized standards. This failure was observed when licensed nurses pre-poured medications and left pre-poured medication cups including narcotics unsecured in medication carts. This deficient practice had the potential to affect all residents in the facility by increasing the risk of medication errors, contamination, diversion, and administration of medications to the wrong residents. Findings include:The Institute for Safe Medication Practices (ISMP) website, accessed 4/20/26, in the article titled, ISMP Guidelines for Safe Medication Practices in Long Term Care, documented medications should be prepared and administered immediately and should not be pre-poured for later administration. The ISMP further documented the following risks associated with pre-pouring medications:- Wrong resident errors- Wrong dose errors- Contamination- Loss of medication integrity- Inability to verify the five rights at the time of administrationa. On 4/12/26 at 9:50 AM, LPN #2 was observed in the 200 hall placing pre-poured medication cups into the top drawer of her medication cart.On 4/12/26 at 9:57 AM, LPN #2 stated a CNA had called out sick and LPN #2 had been assisting residents to get up all morning. She stated she was behind and pre-poured medications to pass them out faster. LPN #2 confirmed she should not pre-pour medications.b. On 4/12/26 at 10:39 AM, a medication cart was observed in the 100 hall. The cart was unlocked, and no staff were present in the area. Upon opening the top drawer of the cart, three medication cups were observed. Two cups were stacked together and labeled with one resident's name, and a third cup was labeled for a different resident's name.On 4/12/26 at 10:40 AM, LPN #1 stated the top stacked cup contained morphine and confirmed the narcotic had been signed out on the controlled substance log at 10:09 AM. She confirmed she should not pre-pour medications and disposed of the medications located in her top drawer.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's comprehensive assessment was accurate. This was true for 1 of 2 residents (Resident #21) whose resident assessments were investigated for potential errors. This failure placed Resident #21 at risk for their needs to go unmet due to the inaccuracy. Findings include: Resident #21 was admitted to the facility on [DATE] for end of life care related to heart failure and chronic kidney disease. Resident #21's record documented a certification of terminal illness signed by a hospice physician on 2/2/26, prior to Resident #21's admission to the facility. Resident #21's Admissions MDS Assessment (Minimum Data Set- a standardized assessment tool that measures health status in nursing home residents) was completed 3/5/26. In the assessment, under section O, for special treatments, procedures, and programs, at item K1 for hospice services, K1 was marked no, indicating they were not receiving hospice services. On 4/15/26 at 4:27 PM, the Administrator stated Resident #21 admitted to the facility with hospice services and their admissions MDS assessment was not accurate.

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 when staff did not perform hand hygiene or use Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) during cares. This was true for 1 of 1 residents (Resident #1) observed for infection control during cares. This failed practice created the potential for adverse outcomes including infection due to cross contamination. Findings include: The facility's Hand Hygiene policy revised 12/2023 instructed staff to use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:-Before and after coming on duty;-Before and after direct contact with residents;-Before preparing or handling medications;-Before performing any non-surgical invasive procedures;-Before and after handling an invasive device (e.g., urinary catheters, IV access sites);-Before donning sterile gloves;-Before handling clean or soiled dressings, gauze pads, etc.;-Before moving from a contaminated body site to a clean body site during resident care;-After contact with a resident's intact skin;-After contact with blood or bodily fluids;-After handling used dressings, contaminated equipment, etc.;-After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;-After removing gloves;-Before and after entering isolation precaution settings;-Before and after eating or handling food;-Before and after assisting a resident with meals; and-After personal use of the toilet or conducting your personal hygiene.-After removing and disposing of personal protective equipment.a. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including quadriplegia, Friedreich's ataxia (a disorder that affects some of the body's nerves and the heart), and neuromuscular dysfunction of the bladder (electrical signals are interrupted between your nervous system and bladder function). A review of Resident #1's physician orders dated 3/3/25 directed staff to maintain Enhanced Barrier Precautions: PPE required for high resident contact care activities for indwelling urinary catheter and percutaneous endoscopic gastrostomy tube (a PEG-tube is a feeding tube surgically placed directly into the stomach through the abdominal wall). An EBP sign was posted outside Resident #1's room directed all individuals to sanitize hands before entering and after leaving the room, and directed health care providers to wear gloves and gowns when performing high contact resident care activities, including: -Dressing/bathing -Transferring -Changing linens -Providing hygiene assistance -Changing briefs or assisting with toileting -Device care or use (central line, urinary catheter, feeding tube, tracheostomy) -Wound-care (any skin opening requiring a dressing) On 4/14/26 at 10:17 AM, CNA #1 was observed providing incontinence care and changing Resident #1's brief. CNA #1 removed PPE and exited Resident #1's room to obtain more supplies to provide care. No hand hygiene was performed after removing PPE or exiting Resident #1's room. On 4/14/26 at 10:21 AM, CNA #1 returned to Resident #1's room with supplies, performed hand hygiene, applied PPE, and resumed incontinence care for Resident #1. Upon completion of the task, CNA #1 disposed of PPE, gathered the trash, and performed hand hygiene at the sink. On 4/14/26 at 10:33 AM, CNA #1 obtained socks and clothing from Resident #1's closet. CNA #1 applied Resident #1's socks and then applied gloves to handle Resident #1's catheter for dressing tasks. CNA #1 was not observed to use hand hygiene before putting on gloves or donning a gown before handling Resident #1's catheter and dressing her. CNA #1 completed the dressing task, performed hand hygiene, and removed trash from Resident #1's room. On 4/14/26 at 10:48 AM, CNA #1 returned to Resident #1's room with CNA #3 and a hoyer lift. Neither CNA #1 nor CNA #3 were observed performing hand hygiene upon entering Resident #1's room. CNA #1 then donned a gown and CNA #3 donned a gown and gloves to transfer Resident #1 from her bed to her wheelchair. On 4/14/26 at 11:20 AM, when asked when hand hygiene is performed, CNA #1 confirmed hand hygiene is performed before and after cares, and upon entering and exiting resident's rooms. When asked when PPE is worn, CNA #1 stated it was their understanding PPE only needed to be worn when providing cares. When asked if PPE is needed when performing dressing tasks, CNA #1 stated they didn't think so. When asked to verify tasks on the EBP sign that require PPE, CNA #1 verified dressing as a task requiring PPE and stated they should have worn PPE to dress Resident #1. b. On 4/16/26 at 11:16 AM, LPN #3 was observed administering medications and nutrition to Resident #1 through her PEG-tube. LPN #3 was observed entering the residents room, introducing herself and explaining what she was going to do, and setting down the medications on Resident #1's over bed table. LPN #3 completed hand hygiene with ABHR, then donned PPE. LPN #3 picked up a graduated cylinder and a luer-lok piston syringe from beside Resident #1's sink, she turned on the water, and filled the graduated cylinder. LPN #3 then mixed water with the crushed medications appropriately and drew up the first medication in the piston syringe. LPN #3 accessed Resident #1's PEG-tube and administered the medications and nutrition as ordered. LPN #3 was not observed to change her gloves or perform hand hygiene between touching the sink and accessing Resident #1's PEG-tube. On 4/16/26 at 1:56 PM, the DON stated, LPN #3 should have changed gloves and completed hand hygiene after touching the sink and before accessing Resident #1's PEG-tube.

Based on record review, facility policy review, and staff interviews, it was determined the facility failed to ensure residents' identifiable information was secured. This failure had the potential to affect all residents in the facility, as unsecured electronic records could allow unauthorized access to protected health information. It was also determined the facility failed to ensure resident records were accurately documented for 1 of 16 residents (Resident #8) reviewed for record accuracy. These failures created the potential for breaches of confidentiality and inaccurate medical documentation. Findings include:The facility's Resident/Patient Confidentiality policy, undated, documented that the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule establishes national standards to protect individuals' medical records and other personal health information. The policy further documented that appropriate safeguards must be in place to protect the privacy of personal health information and that limits and conditions apply to the use and disclosure of such information without patient authorization.a. On 4/12/26 at 10:40 AM, a medication cart was observed in the 100-hall with a laptop attached. The laptop screen was on and displayed the facility's electronic medical record system with resident information visible. No staff were present at the cart.On 4/12/26 at 10:42 AM, LPN #1 stated she forgot to lock the screen and acknowledged she should have done so.b. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder.Resident #8's care plan, revised 5/1/24, directed staff to monitor the resident every shift and notify the physician if the resident verbalized suicidal thoughts.A review of Resident #8's behavior monitoring records dated 1/1/26 through 4/15/26 documented that the resident had expressed suicidal thoughts on the following dates:- 3/6/26- 3/12/26- 3/19/26- 4/1/26- 4/2/26- 4/3/26- 4/10/26On 4/15/26 at 10:12 AM, a request was made for documentation of physician notification for Resident #8's reported suicidal statements.On 4/15/26 at 11:05 AM, the DON stated Resident #8 had not verbalized suicidal thoughts and reported the behavior monitoring records were inaccurately documented by the same nurse on each date.

Based on review of the State Operations Manual, Appendix PP, Nurse Aides (NA) job description, staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a NA were either in a State approved training and competency evaluation program or had recently and successfully completed such a program. This was true for 4 of 11 NAs (NA #1, #2, #3, and #4) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for the 54 residents living in the facility. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented, A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless- (i) That individual is competent to provide nursing and nursing related services; and (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State. The facility's Nursing Assistant job description, dated 12/17/21, documented under section Qualifications: Education and/or Experience: - High School Diploma or equivalent - Graduate or student of an accredited CNA program The following employees had worked full-time as an NA beyond 4 months without obtaining their nurse aide certification: - NA #1 was hired 11/21/23. - NA #2 was hired 4/11/24 (completed the class but has not tested ). - NA #3 was hired 6/5/24. - NA #4 was hired 6/13/24. On 12/6/24 at 11:45 AM, the HR Manager stated the facility was out of compliance with the NAs not being certified within 4 months of their hire date.

Based on Resident Group interview, Resident Council Meeting minutes review, and staff interview, it was determined the facility failed to ensure resident concerns were addressed. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Findings include: The Resident Council minutes from June 2024 through November 2024 documented residents' concerns. Examples include: a. Resident Council Minutes, dated 6/26/24, documented residents voiced issues related to dietary, housekeeping, and offsite activities. b. Resident Council Minutes, dated 7/25/24, documented residents' concerns including running out of milk, bread, and staples, not having fresh fruit, or menus being posted. Residents requested more outings to the movies and Baby Farms, concerns with Hand Hygiene in the kitchen, call light response time, staff behavior and responses to the residents. The Minutes did not document what actions were taken to address and resolve the concerns voiced during the 6/26/24 meeting. c. Resident Council Minutes, dated 8/29/24, documented residents' concerns with meals not matching personal preferences, wanting more outings, and staffing concerns related to too much staff in the morning and not enough in the evening, with limited help in the afternoon from 2:00 PM - 3:00 PM. They voiced concerns with missing laundry. The Minutes did not document what actions were taken to address and resolve the concerns voiced during the 7/25/24 meeting relating to outings, call light response time, staff behavior, and hand hygiene in the kitchen. d. Resident Council Minutes, dated 9/26/24, documented residents' request for more bingo and outings, housekeeping, and laundry concerns with stained clothes being returned to residents, meal temperatures, and call light response time. The Minutes did not document what actions were taken to address and resolve the concerns voiced during the 8/29/24 meeting relating to missing laundry, and staffing concerns. e. Resident Council Minutes, dated 10/24/24, documented residents' concerns with meal temperatures, requesting more bingo and outings, call light response time, delay in picking up meal trays, and housekeeping not cleaning or mopping their rooms well. The minutes did not document what actions were taken to address and resolve the concerns voiced during the 9/10/24 meeting outside of laundry concerns which had improved between 9/26/24 and 10/24/24. f. Resident Council Minutes, dated 11/21/24, documented residents' concerns with cold coffee being served, wanting more Bingo and outings, call light response time, meal trays not being picked up timely, missing laundry, dirty rooms, and stained clothes being returned. A Resident Group interview was attended by Resident #4, #12, #17, #18, #21, #47, and #49 on 12/3/24 at 3:00 PM. All the residents voiced concerns related to housekeeping, staffing, heating, and long call light response times. The residents stated these issues were an ongoing problem in the facility. On 12/4/24, a call light audit report was provided to surveyors, documented a completed call light audit from 10/28/24, which identified there was room for call light response time improvement. However, no additional follow-up was provided or documented the resident's had been informed of the call light audit results. The facility did not provide information regarding how the identified need for call light improvement would be addressed. On 12/4/24 at 4:52 PM, the Social Services Designee (SSD) stated concerns from Resident Council are taken to the staff stand up meetings and addressed there. The Administrator or DON will take the concerns and complete whatever follow-ups are needed. The residents' concerns about call lights, staff, and laundry have not been responded to on a separate form/report. These concerns continue to be brought up in the meetings. The SSD was not aware of any follow-up regarding the concerns. On 12/4/24 at 4:54 PM, a joint interview with the Administrator and Activities Director (AD), confirmed the AD was new to her position, and she ran the meetings with the SSD covering for her when she is not available. The AD and/or SSD take the resident's concerns to the Administrator, who will then do trainings with the staff or a complete a report to ensure the residents are being taken care of. The Admin and AD were unable to provide written responses provided to the Resident Council Meeting addressing their concerns. On 12/6/24 at 8:49 AM, during a follow-up interview with the Administrator, clarified concerns voiced at the Residents Council meeting are brought to the attention of staff during the following mornings IDT stand up meeting. The Administrator stated, he was not sure if the audit was taken back to the resident's, however, the residents are informed verbally of what is happening. We have not been writing everything down as it is discussed in the team meetings or when we inform the residents. He further stated the AD and SSD will keep the concerns on the resident council notes until the area of concern is fully resolved.

Based on review of the State Operations Manual, Apprendix PP, record review, and staff interview, it was determined the facility failed to ensure a notice of transfer was provided to the State Long Term Care Ombudsman when residents where transferred to the hospital. This was true for 4 of 5 residents (Resident #19, #30, #32, and #33) whose records were reviewed for hospital transfers. This deficient practice had the potential for harm if residents were discharged inappropriately without access to the Ombudsman who could inform them of their rights. Findings include: The State Operations Manual, Appendix PP, revised on 8/8/24 documented, Before transfers or discharges of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 1. Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including spastic quadriplegic (paralysis of all four limbs) cerebral palsy and aphasia (a communication disorder that it makes it hard to use words). A Nursing Notes, dated 10/25/24 at 12:27 PM, documented Resident #19 vomited dark brown and black small to moderate amounts, and was transported to the emergency department for possible gastrointestinal bleeding. Resident #19's record did not include documentation the State Ombudsman was notified of his transfer to the hospital. On 12/5/24 at 11:22 AM, the Administrator stated he was not aware the State Ombudsman needed to be notified of facility-initiated discharges or hospital transfers. 2. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including TBI (Traumatic Brain Injury), anxiety, and diabetes. Resident #30's medical record documented he was transferred to the hospital on 11/7/24, and returned to the facility on [DATE]. Resident #30's medical record did not document the State Ombudsman was notified of the hospital transfer. 3. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including cancer, anemia, and heart failure. Resident #32's medical record documented he was transferred to the hospital on 12/18/23, and returned to the facility on [DATE]. Resident #32's medical record documented he was transferred to the hospital on 11/19/24, and returned to the facility on [DATE]. Resident #32's medical record did not document the State Ombudsman was notified of the hospital transfers on 12/18/23 or on 11/19/24. On 12/5/24 at 11:22 AM, The Administrator stated he was not aware the State Ombudsman needed to be notified of facility-initiated discharges or hospital transfers. 4. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including a fracture of the right leg, anemia, and congestive heart failure. A facility-initiated hospital stay from 11/21/24 through 11/26/24, did not include documentation the Ombudsman was notified of the hospital transfer. On 12/5/24 at 11:22 AM, the Administrator verified the Ombudsman is not being notified of resident's who are discharged from the facility or for hospitalization transfers. 36193 50603

Based on observation 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 when gown was not donned during sorting of dirty laundry. These failures had the potential for negative outcomes by exposing resident to the risk of infection and cross-contamination. Findings include: 1. The State Operation Manual Appendix PP, revised 8/8/24, documented, The facility staff should handle all used laundry as potentially contaminated and use standard precautions (gloves, gowns when sorting and rinsing). On 12/6/24 at 9:26 AM, the Laundry Personnel #1 was observed folding the clean laundry in the Laundry Room. When asked where the soiled linen was being sorted, the Laundry Personnel #1 stated it was being sorted in the Soiled Room, which was outside of the Laundry Room. The surveyor then asked the Laundry Personnel #1 to show the surveyor the Soiled Room. In the Soiled Room, the surveyor asked the Laundry Personnel #1 her process of sorting the dirty laundry. The Laundry Personnel #1 stated she would don gloves, open the plastic bags containing the dirty laundry, and place them inside the bin. When asked if she sorted the dirty laundry this morning prior to folding the clean laundry in the Laundry room, the Laundry Personnel #1 stated, Yes. When asked if she did wear a gown prior to sorting the dirty linen, the Laundry Personnel stated she did not wear a gown when she sorted the dirty laundry. On 12/6/24 at 9:41 AM, the DON stated gowns and gloves should be worn when sorting the dirty laundry.

Based on observation and staff interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 1 of 8 residents (Resident #44) whose room was observed for cleanliness, safety, and homelike environment. This deficient practice created the potential for diminished quality of life and safety risk. Findings include: Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including dementia, malnutrition, and hypertension. On 12/2/24 at 10:30 AM, observed Resident #44's room, to have: - A six inch section of baseboard near the bathroom not attached to the wall and a corner of the baseboard broken off. - A roll of toilet paper was hanging on the grab bar in Resident #44's bathroom and not on the toilet paper roll holder. - The grab bar in the bathroom, which had been painted, had large sections of chipped and peeling paint. - The hand washing sink was corroded with rust and chipped around the drain. On 12/4/24 at 10:21 AM, the Maintenance Director stated he was not notified there was a problem with the toilet paper roll or the sink and the Housekeeping Supervisor is usually responsible for putting in a work order. On 12/6/24 at 12:30 PM, the Housekeeping Supervisor, with the Administrator present, was shown photos of the baseboard, sink, and bathroom. The Housekeeping Supervisor stated the toilet paper should be attached to the toilet paper holder. The Housekeeping Supervisor and the Administrator stated there was no way to clean the sink and it would need replaced.

Based on State Operation Manual Appendix PP, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 3 residents (Resident #45) reviewed for Pre-Admission Screening and Resident Review (PASARR) level II evaluations. This deficient practice had the potential to cause harm if the residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority to provide coordinated care. Findings include: The State Operation Manual Appendix PP revised on 8/8/24, documented if a PASARR level I identified a major mental illness, an in-depth evaluation, known as a PASARR level II evaluation is completed by the state-designated authority, which must be completed prior to admission to a nursing facility. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder (MDD), and dementia. Resident #45's care plan, created on 4/3/24, documented Resident #45 was prescribed antidepressant medication related to depression, and directed staff to monitor signs and symptoms of depression. On 6/5/24, the care plan was updated to include additional staff direction identifying Resident #45 as taking psychotropic medication related to MDD, dementia with behavioral disturbance, and Insomnia behavior management. Resident #45's pre-admission PASARR level I screening, dated 4/1/24, identified Resident #45's had MDD and she was taking paroxetine (antidepressant) 20 mg daily related to MDD. The preadmission PASARR level I was not forwarded to the appropriate state-designated authority. Resident #45's admission MDS, dated on 4/12/24, documented a PASARR level II was not completed. On 12/5/24 at 5:11 PM, the DON stated she was unaware the PASARR level I form was filled out incorrectly and a PASARR level II should have been completed.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 3 of 3 residents (#32, #48, and #52) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including cancer, anemia, and heart failure. Resident #32's quarterly MDS assessment, dated 9/23/24, documented he had an active diagnosis of pneumonia. Resident #32's significant change MDS assessment, dated 11/25/24, documented he had an active diagnosis of pneumonia. On 12/05/24 at 3:57 PM, the DON stated Resident #32 had pneumonia on 6/27/24, which resolved. The DON confirmed the quarterly MDS assessment on 9/23/24 and the significant change MDS assessment, dated 11/25/24, was incorrect. 2. Resident #48 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower extremities), diabetes, and viral hepatitis. Resident #48's admission MDS assessment, dated 10/10/24, documented he was taking an anticoagulant (a medication that decreases blood clotting). Resident #48's physician orders did not document the use of an anticoagulant. On 12/5/24 at 4:03 PM, the DON stated she did not think Resident #48 was taking an anticoagulant, but she would verify with the MDS Coordinator. On 12/5/25 at 4:44 PM, the DON confirmed Resident #48 was not taking an anticoagulant and the MDS was coded incorrectly. 3. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (Post Traumatic Stress Disorder), and anemia. Resident #52's medical record documented a PASARR level II (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has a mental diagnosis, intellectual disability, or related condition, and recommends what, if any, specialized services and/or rehabilitative services the individual needs) was completed on 10/18/24. Resident #52's admission MDS assessment dated [DATE], documented Resident #52 did not have a PASARR level II evaluation. 12/5/24 at 4:20PM, the DON stated resident #52's MDS should have documented a PASARR level II evaluation was completed.

Based on observation, record review and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 29 medications (6.9%) which affected 1 of 9 residents (Resident #41) whose medication administration was observed. This failure created the potential for Resident #41 to experience low or high blood sugars when she received an incorrect amount of insulin. Findings include: The insulin lispro website, accessed on 12/10/24, stated, Priming insulin pens is recommended to remove air from the needle to ensure full dose administration. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. A physician's order, dated 11/21/24, documented Resident #41 was to receive the following medications: 1. Insulin Glargine 100 unit/ml, 15 units subcutaneously in the morning. 2. Insulin Lispro 100 unit/ml, inject per sliding scale before meals as follows when the blood glucose: - 0 - 100 = 0 unit - 101 mg/dl - 150 mg/dl = 5 units - 151 mg/dl - 200 mg/dl = 10 units - 201 mg/dl - 250 mg/dl = 12 units - 251 mg/dl - 350 mg/dl = 15 units - 351 mg/dl - 500 mg/dl = 18 units Notify provider if over 500 On 12/4/24 at 7:45 AM, RN #1 stated Resident #41 blood glucose was 256 ml/dl. RN #1 took the insulin lispro pen replaced the needle with a new one and dialed the pen to 15 units. RN #1 also took the insulin Glargine pen, replaced the needle with a new one and dialed the pen to 15 units. RN #1 then went to Resident #41's room and injected the insulin to Resident #41's lower abdomen. RN #1 was not observed to prime the insulin pens before dialing the prescribed dose of insulin for Resident #14. On 12/4/24 at 12:32 PM, when asked about the preparation of insulin pen injections, RN #1 stated she did not prime Resident #41's insulin pens. On 12/4/24 at 12:34 PM, the Unit Manager #1 stated insulin pens should be primed prior to administration to ensure resident receive the prescribed dose of insulin.

Based on observation, record review, policy review and staff interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 2 of 2 residents (#18 and #25) whose records were reviewed and 1 of 6 residents (Resident #27) observed during medication administration. These failed practices created the potential for residents to experienced adverse effects when their medications were not administered according to the physician's order. Findings include: The facility's Care and Treatment policy and procedure, revised May 2020, documented in order to ensure the safety and accuracy of medication administration the following are the six rights of medication administration: 1. Right Resident - Resident is identified prior to medication administration. 2. Right Time - Medications are administered within the prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed 5. Right Route - Medications are administered according to the route prescribed. 6. Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns. 1. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower body), diabetes, and chronic pain. A physician's order, dated 8/7/23, documented Resident #18 was to receive Tramadol (opioid pain medication) 50 mg (milligrams) by mouth two times a day. A Medication Error Report, dated 10/9/24, documented Resident #18 was administered Norco (opioid pain medication) 5 mg instead of the scheduled Tramadol 50 mg. The report documented, This card was directly behind Tramadol card for different patient. On 12/4/24 at 4:02 PM, the DON stated Resident #18 was monitored and did not have adverse reactions after she received the wrong medication. The DON stated education was provided to the nurse who administered the wrong medication to Resident #18 regarding the six rights of medication administration. The DON also stated she did biweekly check-ins with the nurse and spoke to her regarding her time management. 2. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including esophagitis (inflammation of the esophagus) with unspecified bleeding. A Medication Error report, dated 10/30/24, documented Resident #25 was administered rivaroxaban (anticoagulant) 20 mg which was intended for another resident. On 12/4/24 at 4:02 PM, the DON stated LPN #1 was training RN #1 when the medication error occurred. LPN #1 handed Resident #36's rivaroxaban to RN #1 to administer it to the resident, but RN #1 administered the medication to Resident #25. The DON stated LPN #1 and RN #1 were educated regarding the six rights of medication administration. 3. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). A physician' order, dated 4/18/24, documented Resident #27 was to receive ipratropium-Albuterol (a bronchodilator that relax the airway muscles) 0.5 - 2.5 mg/ml (milliliter) orally three times a day for shortness of breath. On 12/3/24 at 12:29 PM, the Medication Technician #1 administered Anoro Ellipta (a bronchodilator that relax airway muscles) to Resident #27. On 12/3/24 at 12:39, the Medication Technician #1, together with LPN #2, was asked what the physician's order for Resident #27 was. LPN #2, stated Resident #27, preferred to receive the Anoro Ellipta over ipratropium-Albuterol and they have an order to give Anoro Ellipta if Resident #27 refused the ipratropium-Albuterol. LPN #2, then reviewed the physician's order and stated she did not find the order for Anoro Ellipta. LPN #2, stated it was discontinued on 4/17/24. LPN #2, stated I don't know what happened. On 12/3/24 at 2:32 PM, the DON stated, Resident #27's Anoro Ellipta was discontinued on 4/17/24, and should not have received the medication.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident-centered care was provided in accordance with professional standards of nursing practice and residents' comprehensive care plans. This was true for 2 of 17 residents (Resident #6, and Resident #19) reviewed for quality of care. This deficient practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practice. Findings include: 1. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses, including metabolic encephalopathy (a brain dysfunction which impairs cerebral metabolism), diabetes, and hypoglycemia (low blood sugar). A physician's order, dated 9/12/24, directed staff to follow the Hypoglycemia protocol and to notify provider if blood glucose (BG) is less than 70 mg/dl, or if the levels were greater than 400 mg/dl. A review of Resident #6's medical record showed BG was over 400 mg/dl on the following days and times: - On 11/7/24 at 7:23 PM and 8:19 PM, the BG was 481 mg/dl. - On 11/8/24, the BG was 407 mg/dl. Resident #6's record did not include documentation the physician was notified when her blood glucose was greater than 400 mg/dl. On 12/5/24 at 4:41 PM, the DON stated the attending nurse notified the nurse practitioner of the high BG on both days, but she did not document the notification in Resident #6's chart. 36193 Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including spastic quadriplegic (paralysis of all four limbs), cerebral palsy, and aphasia (a communication disorder that it makes it hard to use words). Resident #19's care plan, revised 8/20/19, documented he required two-person total assist to reposition and turn him in bed. On 12/4/24 at 11:26 AM, CNA #1 entered Resident #19's room and stated she would change his bed sheet. CNA #2 followed CNA #1 and told her she would help CNA #1 after answering the call light of another resident. CNA #1 was observed to reposition and turn Resident #19 to his left side, and then to his right side as she removed, and applied a new bed sheet. On 12/4/24 at 11:39 AM, when asked why she did not wait for CNA #2 before changing Resident #19's bed sheet, CNA #1 stated, I always do it by myself. Most of the time I can change him by myself. On 12/4/24 at 11:49 AM, the Unit Manager #1 reviewed Resident #19's care plan and stated Resident #19 should be assisted by two staff for bed mobility. CNA #1 should have waited for CNA #2 before changing his bed sheet.

Based on staff interview, record review, and review of facility incident reports, it was determined the facility failed to ensure a seatbelt and wheelchair anchor straps were properly secured for a resident during transport in the facility's van. The facility also failed to ensure the facility's transport staff were properly trained to transport and secure the residents in the facility's van. This was true for 1 of 3 residents (Resident #1) reviewed for falls and accidents. Resident #1 was harmed when he sustained a skin tear and abrasion to his scalp and a C2 (second cervical vertebra) fracture related to a fall during transport in the facility's van. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including C7 (seventh cervical vertebrae) fracture, diabetes mellitus and pneumonia. An Admission Minimum Data Set assessment, dated 10/31/20, documented Resident #1 was cognitively intact and he required extensive assistance of one staff member with activities of daily living except for eating and drinking. A Fall Scene Investigation Report, dated 11/10/20, documented Resident #1 was being transported in the facility's van to his medical appointment. During the ride and following completion of a full stop in response to a STOP sign, Resident #1's wheelchair tipped backward when the van driver made a turn at the corner. The van driver pulled over to the curb and assisted Resident #1 to stand up and got him back to his wheelchair. The report documented Resident #1's elbow was bleeding and he had a spot on his head that looked like it might have an abrasion. The van driver then covered Resident #1's elbow with a clean facemask, hooked up his wheelchair, and drove him to his appointment. When Resident #1 arrived in the clinic and found out what happened, an ambulance was called, and he was sent to the hospital. An emergency room report, dated 11/10/20 at 2:56 PM, documented Resident #1 had a skin tear and abrasions to his scalp. A Computerized Tomography (CT) scan documented Resident #1 had a nondisplaced fracture of his C2 and a healing fracture of his C7 vertebrae. On 12/17/20 at 1:05 PM, Van Driver #1 said she drove the residents to their appointments when the main facility's van driver was not available. Van Driver #1 said on 11/10/20 she drove Resident #1 to his medical appointment. Van Driver #1 said she secured Resident #1's wheelchair in the van and drove to the clinic. When she made a turn at a corner Resident #1's wheelchair tipped backward. Van Driver #1 said it happened so fast and Resident #1 kept asking her to get him up. Van Driver #1 said she found the strap on the back of the right wheel of Resident #1's wheelchair was undone. Van Driver #1 said she then assisted Resident #1 to get up, covered his right elbow which was bleeding with a clean facemask and drove him to his medical appointment. Van Driver #1 was then asked if she could show the surveyors the facility van. The inside of the facility's van was observed. The van had four straps, 2 near the front of the van and the other 2 located near the back of the van. The straps were attached to the floor and at the end of each strap was a J shaped hook. Van Driver #1 said she put Resident #1's wheelchair brake on and then attached the J shaped hook on the front and on the back of both wheels of Resident #1's wheelchair and then placed the lap belt. Van Driver #1 said she did not remember placing the shoulder strap on Resident #1. On 12/17/20 at 1:30 PM, Van Driver #2, who was the facility's main driver to transport residents to their appointments, demonstrated how to secure a resident's wheelchair in the van. Van Driver #2 said the J shaped hooks should be attached on the wheelchair's front and rear main frame and not on the wheels of the wheelchair. Van Driver #2 said even if only one hook was attached on the front of the wheelchair's main frame, the wheelchair would not tip backward. Van Driver #2 said the only way the wheelchair would tip backward is when the front hooks were not attached properly to the wheelchair's main frame. On 12/17/20 at 3:50 PM, the Activity Director (AD) said she did not receive training from the facility to drive the facility's van when she was hired since she had experience as a van driver for 6 years with 2 previous nursing homes. The AD said Van Driver #1 had ridden along with her during van transport about 3 - 4 times and she showed her how to load and properly secure the resident's wheelchair in the van. The AD said Van Driver #1 then demonstrated to her how to load and secure the resident's wheelchair in the facility's van. The AD said Van Driver #1 did it well and she had no concern. On 12/17/20 at 2:15 PM, the Director of Nursing (DON) with the Administrator present, said Van Driver #1 was the facility's back-up driver and had driven residents to their medical appointments several times in the past. When asked how often Van Driver #1 drove residents to their appointments, the DON said Van Driver #1 had driven residents to their appointment at least once a month. The DON said he did not ask Van Driver #1 to demonstrate to him how she secured Resident #1's wheelchair in the van. The DON also stated he and Van Driver #2 inspected the straps in the van and found all 4 straps were working properly. The Administrator said the facility did not have a formal training for their van drivers. The Administrator said it was all verbal. The DON said Van Driver #1 should not have moved Resident #1 after the wheelchair had tipped backward. The DON said she should have called 911 and then call the facility. Resident #1 was harmed when he sustained skin tears and abrasions to his scalp and a C2 fracture. The facility failed to ensure van drivers were properly trained in loading and securing a wheelchairs in the facility's van.

Based on observation, staff interview, resident interview, and review of facility policies, resident records, and Incident and Accident (I&A) Reports, it was determined the facility failed to prevent the development and worsening of a pressure ulcer. This was true for 1 of 3 sample residents (#32) reviewed for pressure ulcers. This deficient practice caused harm to Resident #32 when she developed a bruise on her left calf which deteriorated, became infected, and required surgical debridement. Findings include: Resident #32 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] (disabling disease of the brain and spinal cord) and generalized muscle weakness. Resident #32's quarterly MDS assessment, dated 9/11/17, documented she was cognitively intact, required extensive assist of two staff for bed mobility, transfers, dressing and bathing, had impairments on both upper and lower extremities, used a wheelchair for locomotion, and was at risk for pressure ulcers. Resident #32's care plan, documented she had actual impairment to skin integrity related to [MEDICAL CONDITION] and fragile skin with an abrasion. Interventions included Prevalon boots at all times to both lower extremities and staff were directed to keep the skin clean and dry, use lotion on dry skin, monitor/document location, size and treatment of [REDACTED]. Resident #32's (MONTH) (YEAR) to (MONTH) (YEAR) Treatment Administration Records (TAR) documented, Monitor bilateral [MEDICAL CONDITION] to lower extremities, Keep feet elevated as patient will allow. Offer to lay down in bed for offloading of legs/feet twice daily during daytime. Prevalon boots at all times. The TARs did not include monitoring of Resident #32's feet for skin breakdown at bedtime. Resident #32's TAR dated (MONTH) (YEAR) documented, Resident #32's feet and lower legs were checked for skin integrity for seven days related to new orthotic shoes. The TAR did not include monitoring of Resident #32's feet at bedtime. A Non Pressure Ulcer Skin Assessment, dated 10/30/17, documented Resident #32 pointed out a quarter sized bruise on her left calf and said it was present for about two weeks. The Skin Assessment did not document the actual measurement of Resident #32's bruise. The facility's (MONTH) (YEAR) I&A Reports did not include report related to Resident #32's bruise when it was first discovered. There was no investigation documented regarding the origin of Resident #32's bruise. The facility's 5/2007 policy for Incident Accident Reporting documented a report will be completed for any incidents and accidents resulting in an injury or potential for injury involving residents, staff, or visitors. The charge nurse on the shift when the incident/accident was discovered is required to complete the report before the end of the shift, and the resident's physician and representative should be notified. Resident #32's Skin/Wound Progress Notes (SW), Interdisciplinary Team Progress Notes (IDT), Skin Assessments (SA), Nursing Notes (NN), Wound Clinic Notes (WCN), Geriatric Notes, Orthotic Clinic Note, and physician progress notes [REDACTED]. *11/9/17 IDT - scabbed bruise being monitored for healing and was improving *11/13/17 SA - treated with ice therapy, [MEDICAL CONDITION] noted to the BLE (bilateral lower extremities), elevation encouraged as tolerated *11/17/17 SW - decreased firmness to area and dry with scab in the middle, area remains open to air, ice treatment was discontinued, use skin prep to area until resolved *11/20/17 SA - small scabbed, no signs and symptoms of infection on the area noted *12/1/17 IDT - improving, Prevalon boot protects the area from contacting the wheelchair's leg rest *12/4/17 NN - left calf monitored by nursing, area is clean, dry and intact, 1+ to 3+ [MEDICAL CONDITION], tubi grips applied *12/8/17 NN - area improving with current therapy, Prevalon boots in placed for protection *12/11/17 SA - scab to the left calf being monitored by nursing, skin clean, dry and intact *12/11/17 IDT - skin was currently closed and scabbed, Prevalon boots in place at all times, off-loading continued as resident would allowed. Resident #32 wished to be up in power chair for most of the day. *12/15/17 IDT - 1.2 cm x 0.6 cm, improving with current treatment, Resident #32 was sometimes reluctant to get into bed and off-load feet from her power chair *12/18/17 SA - scab to the left calf was being monitored by nursing, skin was clean, dry and intact *12/22/17 SW - area of concern at left posterior calf, wound clinic classified the area as an ulceration. Treatment provided at time per wound clinic orders. Prevalon boots or orthotic in place at all times. Area is not receiving pressure from power chair or bed *12/25/17 SA - scab being monitored by nursing staff, dressing was clean, dry and intact. Skin was warm, dry and intact *1/5/18 at 11:54 AM IDT - additional intervention to include investigation of Resident #32 use of her power chair in her room. Prevalon boots to be worn immediately after showers prior to being transferred to bed for dressing *1/5/18 at 2:58 PM IDT - RN Resource investigated Resident #32's use of her power chair and determined her left calf potentially came into contact with the metal portion of her power chair when her foot comes off the foot plate. A new strap was fabricated to keep Resident #32's feet on the foot plate. Prevalon boots were worn when up in power chair. *1/8/18 Orthotic Clinic Note - documented Wound on L (left) posterior tibial shank/calf is concerning please have evaluated by wound care prior to resuming AFO (ankle foot orthosis) use on L side. Recommend stretching ankle/foot prior to donning AFOs in AM: abduct forefoot while dorsiflexing ankle (2-5 minutes) on ea(ch) side . *1/8/18 Geriatric Note - documented L calf wound, DTI (deep tissue injury) now surfaced w/ (with) ulceration w/ large eschar (dead tissue), pt (patient) to f/u (follow-up) w/ wound care next week, dressing applied. *1/10/18 Physician's PN - documented .The patient has a new ulcer and it is in her right (left) posterior calf. It started as a deep bruise and then eventually erupted itself. This was treated with some offloading and she has been going to the wound clinic .The left sore seems to be a deeper pressure sore that is now sloughing off. She has a wound care appointment in two days . *1/10/18 NN - assessed by the physician, continue current treatment, referred to wound clinic for possible debridement *1/12/18 SW - 2.0 cm x 1.6 cm with no depth, pressure relieving measures in place *1/12/18 WCN - eschar 2.8 cm x 1.9 cm x 0.1 cm post debridement measurement, Interventions included a [MEDICATION NAME] and directed staff to change dressings 2-3 times per week *1/26/18 WCN - left posterior calf biopsied, continue with [MEDICATION NAME] *1/26/18 IDT - wound continues to be painful and not improving *1/31/18 SW - 4.2 cm x 2.5 cm x 0.8 cm after recent debridement *2/2/18 Biopsy result - Fragments of fibroconnective tissue with ulceration, granulation tissue, mixed inflammation and fat necrosis, no fungal organism seen on stain, negative for malignancy *2/2/18 Wound Culture result - multiple organisms found with predominance of Proteus mirabilis (type of infection) *2/9/18 IDT - ulceration at the posterior calf slow to heal and infected, treated with antibiotics *2/12/18 WCN - [MEDICATION NAME] had been used for quite some time now and the ulceration continues to deepen, deep enough for a snap VAC(uum). Ideally, we would use a snap VAC but given that she is in a facility, the wound VAC would be more appropriate. New order obtained to change dressings with wet to dry micro-cleanse and staff were directed to apply a [DEVICE] *2/16/18 SW - 4.0 cm x 2.5 cm by 0.8 cm after recent debridement. Wound clinic had recommended wound VAC (vacuum) therapy which was scheduled to arrive 2/19/18 *2/23/18 IDT - [DEVICE] in place, wound clinic involved with care *2/24/18 NN - [DEVICE] in place, patent with no foul odor *2/26/18 WCN - 4.8 cm x 2 cm x 0.6 cm with a tendon exposure, antibiotic completed, and with [DEVICE] on her left posterior calf. Interventions were to hold the [DEVICE] therapy and staff were directed to keep the ulcer dry with all personal cares, change dressing and apply [MEDICATION NAME] 3 times per week *3/7/18 Physician's PN - documented .She had developed some sores on her legs. They are working on them. They did appear to be infected. She has been treated with antibiotics and that has improved. Their healing has somewhat stagnated secondary to her vasculature (vein structure) as well as comorbid states (multiple diagnoses) . *3/9/18 IDT - wound is stagnant in healing with recent debridement *3/15/18 WCN - documented .Multiple different wound care modalities have been used on the left proximal lower leg ulcer without much success. These include [MEDICATION NAME] as well as [MEDICATION NAME] wet-to-dry's, VAC therapy and most recently Iodosorb .I do feel she has persistent rubbing from the left leg wheelchair support directly causing trauma to the calf. This ongoing trauma has resulted in progressive deterioration now down to necrotic muscle and tendon. She is in a Prevalon boots at all times as well but the wound is at the superior edge of the Prevalon boot which may be causing further trauma. *3/20/18 SW - 5.5 cm x 2.6 cm x 0.7 cm, followed by wound clinic *3/28/18 SW - 5.0 cm x 2.25 cm x 1.0 cm, treatment with [MEDICATION NAME] and ABD (Absorbent Dressing) pad changed daily *3/29/18 WCN - ulceration had significant odor and necrosis of subcutaneous, muscle and tendon, debridement done *3/31/18 NN - wound bed is beefy red, free of odor and dark areas after recent debridement done at the wound clinic *4/4/18 Physician's PN - documented .She is seeing a chronic wound doctor. Her wound is slowly healing and she currently has a wound VAC . *4/9/18 SW - continue with NPWT (negative pressure wound treatment) at 125 mm/hg (millimeter mercury) being change 2 times weekly. Ulcer is 40% filled this week with healthy beefy granulation tissue, tendon is covered with healthy granulation tissue, no odor noted, skin is pink, and blanchable *4/11/18 WCN - left posterior calf ulceration is a healthy granulating muscle level. There is some scattered areas of [MEDICATION NAME] and necrosis both superiorly and inferiorly that debrides to a healthy muscle base. Continue with VAC therapy *4/24/18 SW - continue with NPWT at 125 mg hg, ulcer is 50% filled in this week with healthy beefy granulation, with little pain with dressing, no odor noted, peri(pheral)skin is pink and blanchable, no redness or bogginess noted *4/3018 SW - ulcer is 80% filled this week with healthy beefy granulation tissue noted, Resident #32 with little to no pain with dressing changes, no redness or bogginess noted *5/3/18 WCN - 4.1 cm x 2.1 cm x 0.3 cm. Left posterior calf ulceration into muscle and tendon improved On 5/1/18 at 9:21 AM, Resident #32 was in her power wheelchair inside her room. She had a [DEVICE] on her left leg under her pants. Resident #32 said she had a wound on her left leg which was probably due to her left leg rubbing on the leg support of her power wheel chair. Resident #32 said I have MS ([MEDICAL CONDITION]) and I can't move my legs. Resident #32 said her wound vac had been changed a day before by the wound nurse, and she was very happy with the progress of her wound healing. On 5/2/18 at 10:50 AM, LN #5 said Resident #32 had a non-pressure wound on her left calf which started as an abrasion which could be due to the resident's leg resting on the leg support of her wheelchair or secondary to the orthotic shoes she was wearing. LN #5 said Resident #32 had MS, was unable to move her legs, and needed a belt to keep her legs together whenever she was using her power wheelchair. On 5/4/18 at 1:07 PM, RN #1 said Resident #32 wore different types of orthotic shoes, and they had found a discolored area on her left calf, that was possibly due to trauma. RN #1 described the area as a bruise, and said it was closed. RN #1 said they were unable to determine the source of the bruise. On 5/4/18 at 10:25 AM, the DON said the facility's process for skin checks is that CNAs complete a skin sheet form if they find something on the resident and report it to the nurse. The nurse on duty then informs the physician, wound nurse and the resident's family. The DON said she could not locate the I&A Report for Resident #32's bruise on her left calf after it was discovered, and one should have been completed. The DON said Resident #32 wore orthotic shoes, and the best practice was for the staff to check the resident's skin whenever the orthotic shoes or Prevalon boots were removed. The DON said she did not find the documentation that Resident #32's skin was being checked for new skin breakdown in the Resident #32's September, (MONTH) and (MONTH) (YEAR) TARs. Resident #32 was harmed when the bruise on her left posterior calf deteriorated, became infected, required surgical debridement, and placement of a [DEVICE]. There was no documented investigation regarding the origin of Resident #32's bruise, at the time she reported it on 10/30/17. The wound clinic classified the area as an ulceration according to Resident #32's 12/22/17 Skin/Wound Progress Notes. The IDT initiated an investigation on 1/5/18 regarding Resident #32's bruise.

Based on observation, resident family and staff interviews, and review of facility policies, resident records, and Fall Scene Investigation Reports, the facility failed to ensure sufficient supervision of residents to prevent falls. This was true for 1 of 5 sampled residents (#34) reviewed for falls. Resident #34 was harmed when she fell in her room multiple times and sustained vertebral fractures (fractures in the spine), increased pain, decreased appetite, and a hematoma (a collection of blood under the skin) to her forehead. Findings include: The facility's Fall Prevention policy, dated 5/2007, documented the facility would investigate circumstances around resident falls, implement action to decrease additional falls, and minimize the potential for injuries. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and age-related [MEDICAL CONDITION]. Resident #34's admission MDS assessment, dated 9/18/14, documented the following: * Severe cognitive impairment. * Required extensive assistance of two persons with bed mobility, transfers, and toileting. * Required limited assistance of one person with ambulation. * Required use of a wheelchair and walker. * No restraints or alarms were in place. * The resident experienced falls prior to admission. Resident #34's Fall Risk Evaluation, dated 3/2/18, documented she was at high risk for falls. Resident #34's significant change MDS assessment, dated 3/24/18, documented the following: * Severe cognitive impairment. * The resident exhibited inattention, disorganized thinking, and altered level of consciousness. * Required extensive assistance from two people for bed mobility, transfers, and toileting. * Two falls since admission, including one with major injury. * A bed alarm was in place. Resident #34's care plan documented the following interventions related to falls: * Interventions initiated on 9/11/14 included ensuring the resident wore appropriate footwear, keeping needed items within reach, and maintaining a clear pathway. * A bed pressure alarm was initiated on 3/7/18. * A lipped mattress was initiated on 3/19/18. * Interventions initiated on 3/29/18 included a physical therapy evaluation, placing the bed in the lowest position, and moving her to a room closer to the nurse's station. A Fall Scene Investigation Report, dated 3/6/18 at 12:00 AM, documented the following: * Resident #34 was confused at times. * Resident #34 was found on the floor in her room. * Resident #34 was coming back from the bathroom, she was unassisted, and she fell . * The root cause of the fall was the resident lost her balance when she was walking back to her bed from the bathroom. * The follow-up investigation recommended a pressure alarm, try to move closer to the nurse's station, and check with the physician regarding a back brace. Resident #34's Fall Prevention Devices flowsheet documented the following: * Checks were made for non-skid slippers and a visual check of the resident at 12:16 AM on 3/6/18. * A check was made for the bed in low position at 1:59 PM on 3/6/18. * A visual check of the resident was made at 3:21 PM on 3/6/18. A Progress Note, dated 3/6/18 at 12:10 AM, documented the nurse was called into the resident's room by a CNA, and the resident was lying on the floor on her right side. Resident #34 said she was going back to bed after using the bathroom, she lost her balance and fell . No injuries were noted by the nurse, and the resident was assisted back to bed by two staff members. A physician's orders [REDACTED]. A report from a CT scan (a radiology imaging study) of the lumbar spine (low back), dated 3/6/18 at 9:01 AM, documented the following: * A fracture at L1 (the first lumbar vertebra), similar to a previous study from 9/5/14. * A fracture at L3 (the third lumbar vertebra) which could have been acute (of recent onset). A report from a CT scan of the abdomen and pelvis, dated 3/6/18 at 9:06 AM, documented the following: * Severe compression fracture of T8 (the eighth [MEDICATION NAME] vertebra, near the mid-back), age undetermined but it was new since a previous study in 2014. * Stable severe compression fracture of T12 (the twelfth [MEDICATION NAME] vertebra, near the upper portion of the low back). A Progress Note, dated 3/7/18 at 9:39 AM, documented Resident #34 fell and sustained a fracture that occurred on 3/6/18. She was evaluated in the emergency room related to back pain, and X-rays showed fractures of lumbar and [MEDICATION NAME] vertebrae. A physician's note, dated 3/7/18, documented Resident #34 fell and was transported to the hospital for a CT scan. The CT scan showed a stable fracture of T12 and a probable new fracture in the lumbar spine. Resident #34 complained of pain, and the [MEDICATION NAME] (narcotic pain medication) was not effective in controlling her pain. The [MEDICATION NAME] (narcotic pain medication) dosage was increased from 37 to 50 micrograms, anti-[MEDICAL CONDITION] medication was added, the dosing of narcotic medication was increased to every four hours as needed, and Tylenol was added four times a day for two weeks. A physician's orders [REDACTED]. A Progress Note, dated 3/10/18, documented Resident #34 complained of pain in her back continuously. She received a [MEDICATION NAME], [MEDICATION NAME], and Tylenol, and she whimpered when she was up in the chair for a meal. A Fall Scene Investigation Report, dated 3/17/18 at 12:00 PM, documented the following: * Resident #34 was found on the floor in her room. * She attempted to self-transfer and fell . * The bed alarm was not turned on. * The root cause of the fall was the resident being hungry and an unsafe self-transfer. * The follow-up investigation recommendations included staff education on alarms and using a lipped mattress (a mattress with raised edges that help define the perimeter of the mattress). Resident #34's Fall Prevention Devices flowsheet documented the following: * The mobility monitor (alarm) was checked at 9:19 AM, 3:23 PM, and 11:57 PM on 3/17/18. * Non-skid slippers were checked at 9:19 AM on 3/17/18. * Visual checks were made of the resident at 9:19 AM, 3:23 PM, and 11:58 PM on 3/17/18. A Progress Note, dated 3/17/18 at 10:37 PM, documented Resident #34 was found sitting on the floor and she was crying, whimpering, and complaining of pain. There were no visible injuries. She was assisted back to bed and medicated with [MEDICATION NAME] for pain. A Progress Note, dated 3/18/18 at 2:57 PM, documented Resident #34 was whimpering and complaining of pain when assisted getting up into a chair. She received [MEDICATION NAME] every 4 hours and she would say please don't make me move. A Progress Note, dated 3/19/18 at 9:57 AM, documented that at the time of the 3/17/18 fall Resident #34 was found lying on the floor after a self-transfer. The note stated Resident #34 was alone in her room and was wearing one sock. It further documented Resident #34 complained of increased pain since the fall, pain medication was given, and a lipped mattress was going to be placed on her bed. A Progress Note, dated 3/21/18 at 3:40 PM documented the LCSW and the MDS nurse spoke to Resident #34's family member about the recent falls and possibly moving her to a room closer to the nurse's station. The resident's family member did not want to move the resident to a different room due to the resident's familiarity with her room. A Fall Scene Investigation Report, dated 3/28/18 at 3:25 PM, documented the following: * Resident #34 was found on the floor in her room. * The bed alarm did not sound to alert staff the resident got up from bed * Prior to the fall, Resident #34 was confused and picking at things that aren't there. * Resident #34 got out of bed and walked across the room. She removed pieces of the cotton-like material from her incontinence brief, which was clean and dry. * She fell and hit her head, and the result was a large lump above her right eye. * The root cause of the fall was increased confusion and an alarm that was not functioning properly. * The follow-up investigation recommendations included moving to a room closer to the nurse's station, physical therapy evaluation, and changing out the alarm. Resident #34's Fall Prevention Devices flowsheet documented the following: * A check was made for the bed in low position at 11:06 AM and 9:32 PM on 3/28/18. * The mobility monitor was checked at 11:06 AM and 9:31 PM on 3/28/18. * The mobility monitor for the chair was checked at 9:31 PM on 3/28/18. * A visual check of the resident was made at 9:32 PM on 3/28/18. A Progress Note, dated 3/28/18 at 4:33 PM, documented Resident #34 was not aware of her safety needs and frequently attempted to self-transfer. A Progress Note, dated 3/28/18 at 7:06 PM, documented the fall earlier in the day where Resident #34 was found on the floor in her room and she was calling for help. The bed alarm was not sounding when the resident was found on the floor. Resident #34 had a large lump on her forehead above her right eye. Resident #34 was moved to a room closer to the nurse's station, her family member was notified and agreed to the room change. A physician's orders [REDACTED].#34. A physician's note, dated 4/4/18, documented Resident #34 had a vertebral compression fracture, had recently fallen again and had a contusion (bruise) to her head. Resident #34 had occasional hallucinations and was writhing in pain at times. The physician's note documented While it is possible that she has another compression fracture causing the pain since she is complaining about pain all over and palpating her back does not elicit any discomfort, we will just go with the generalized [MEDICAL CONDITION] causing the pain. A Progress Note, dated 4/5/18 at 1:44 PM, documented Resident #34 had a new order to increased the dosage of her [MEDICATION NAME] to 50 micrograms per hour. A Progress Note, dated 4/5/18 at 7:23 PM, documented Resident #34 had a change of condition related to falls and fractures in her back, increased pain medication, and decrease in appetite. A Progress Note, dated 4/19/18 at 12:51 PM, documented Resident #34's weight had decreased by 8.6 pounds since 2/19/18. She had 3 recent falls, her oral intake decreased after the falls but was improving. Resident #34 was in bed with a bed alarm in place on 4/30/18 at 11:57 AM, 4/30/18 at 12:40 PM, and 5/2/18 at 10:00 AM. On 5/1/18 at 2:09 PM, Resident #34's family member said she was aware of 3 or 4 falls in the past month, and there were previous falls at home and in the previous assisted living facility. Resident #34's family member said the resident would have periods where she didn't sleep and would get wound up, possibly looking for her husband, and she would get weaker the longer she was up. Resident #34's family member said the resident did not remember to ask for help to get up and had turned her bed alarm off at times. On 5/2/18 at 10:21 AM, LPN #1 said Resident #34 would try to get up by herself, would not use the call light and was at high risk for falls. LPN #1 said Resident #34 had a couple of falls in the past one to three months, and she used to have an alarm prior to her fall but it was discontinued for a time due to the new state regulations and the facility was trying to slowly decrease the use of alarms. The alarm was re-instated after the resident fell . LPN #1 said she routinely made sure the alarm was on when she administered medications and when the resident was in her chair, and the CNAs could refer to the care plan Kardex for guidance regarding monitoring Resident #34's alarm and the level of assistance she required. On 5/2/18 at 11:10 AM, the MDS nurse said Resident #34 had an alarm before the first fall, but it was discontinued because she didn't have any falls and was getting herself up to the bathroom without calling for assistance. The MDS nurse said the alarm was re-instated after the first fall, a lipped mattress was put in place after the second fall, and physical therapy was implemented after the third fall. On 5/2/18 at 2:07 PM, CNA #1 said she would ask Resident #34 what level of assistance she needed. CNA #1 said Resident #34 fell a couple of months ago and sustained a bruise to her head. CNA #1 said she should ensure the bed alarm is on when Resident #34 lays down, and there were times she found the alarm not working or not turned on and she fixed it. On 5/2/18 at 2:13 PM, CNA #2 said the CNAs should read the care plan Kardex every day for instructions on assisting and monitoring residents. CNA #2 said she was involved in Resident #34's care the day she fell and hit her head. CNA #2 said Resident #34 had been up late and was tired, so she took her to the restroom and then assisted her to lie down. The alarm was on and they were supposed to check her often. CNA #2 said she went on a break after Resident #34 was assisted to lie down, and found out she had fallen during the time she was on break. CNA #2 said the alarm would act weird if the battery was low, but it was working when she last checked the resident. CNA #2 said Resident #34 was not getting up on her own very much after she hurt her back, and sometimes she would use the call light but needed frequent reminding. After Resident #34 fell , CNA #2 said they were to watch her closer by looking in the room when passing by to make sure she was safe, but they did not document it. On 5/2/18 at 2:44 PM, the LCSW said the facility was reducing the use of alarms prior to Resident #34's first fall and had just removed her alarm prior to the fall. The LCSW said after the third fall Resident #34's family member agreed to moving her to a different room. The LCSW said Resident #34 was walking pretty well when she was first admitted to the facility, and she was previously a lot more social and interactive and used to go out for dinner with her family before her falls. On 5/2/18 at 3:06 PM, the DON said if a resident was admitted to the facility with a history of falls, she would want an alarm placed and it was not appropriate for Resident #34's alarm to be removed. The DON said she expected staff to make sure the alarm was turned on and was functioning, and she did not know how often staff checked the alarm.

Based on observation, record review, resident and staff interviews, review of Fall Scene Investigation Reports, and policy/procedure review, the facility failed to ensure: - a seatbelt was secured during resident transport in the facility's minivan; - alarms were turned on and properly placed; - a care plan to not leave a resident alone while on a toilet was followed; and, - mechanical lift slings were properly placed. This was true for 4 of 4 residents (#s 1, 2, 6, and 8) reviewed for falls. Resident #2 was harmed when she sustained a fractured tibia and experienced pain, decreased mobility, and emotional distress related to a fall during transportation in the facility's van and was not assessed by a medical professional before the transport resumed. Resident #6, who was admitted with a history of falls experienced minor injuries related to 17 falls over 6 months when a bed and/or chair alarm was not turned on or was not properly placed. Resident #8 sustained lacerations to his head and nose from a fall when he was left unattended on a toilet. Resident #1 received abrasions and multiple bruises to her upper extemities related to the use of a mechanical lift sling. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 11/22/13, coded, in part: * Able to make self understood and able to understand others; * Mild cognitive impairment, with a BIMS score of 12; * Extensive 1 person assistance for bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing; * Extensive 2 person assistance for transfers; * Impairment in both upper extremities; * Resident and direct care staff believe resident capable of increased independence in at least some ADLs; * Scheduled pain medication regimen and non-medication intervention for pain; * Occasional pain, rated at 5 on a numeric scale from 1-10; * No falls in the 6 months prior to admission; * No falls since admission; * Received 1 day of occupational therapy (OT); and, * Received 2 days of physical therapy (PT). The resident's CAA Worksheets, all dated 11/27/13, included the following: * Cognitive Loss/Dementia - "Reports pain but has routine pain management and has not requested PRN (as needed) pain medications... Client requires limited to extensive assist with ADL's but anticipate improvement with working with therapy..." * ADL Functional/Rehabilitation Potential - "Self care deficit secondary to limited to extensive assist with ADL's...uses a W/C (wheelchair) for mobility but is able to ambulate a few feet..." * Falls - "Sitting balance good but standing and transfer balance fair..." The resident's Pain Assessment Form, dated 11/17/13, documented no persistent or frequent pain during the past 2 weeks, no medication or treatment for [REDACTED]. The resident's Fall Scene Investigation Reports (FSIR) documented, in part: * Witnessed "slide out/fall from wheelchair" while off premises "in van" on 12/19/13 at 1:15 p.m., resident was alert and oriented and in her usual mental and psychological state, and a seat belt was in use at time of fall; * "At doctors (sic) office since 9 am when done loaded resident in van making sure locks and brakes on seat belt in place and secured. Started to drive home. While on (name of road) coming up to stop light...putting on brakes car cut in front. Resident slid out of w/c on to foot pedals with feet pushed up against wall behind drivers and passengar (sic) seat legs bent. After pulling over I asked resident if she was ok and was she hurting anywhere. She stated No. With her assistance helped back in chair. Asked again if hurting she said No again. Secured her in w/c and proceeded back to facility. Had nurse check resident immediately upon arrival at facility." * "Root Cause of This Fall: Assistive/protective device"; * "What appears to be the root cause of the fall? Seat belt (van) transport"; * "Describe initial interventions to prevent future falls: educate van driver (and) inspection by maintenance of seat belt in van"; * "Care Plan updated (and) Nurse Aide Assignment updated; * "Conclusion: Fracture to (R) (right) tibia Brace to RLE (right lower extremity)." The following documents were attached to the 12/19/13 FSIR: * IDT PN, 12/20/13, "...Upon interview of resident and staff it appears while enroute back to facility from appointment the van driver slowed the vehicle...applied the brake the resident slid from w/c... The van driver immediately inspected the seatbelt for defects...right knee cap fracture..." * Nursing Progress Note, dated 12/23/13, "Upon further information...patella (knee cap) is non-injury. There is a fracture to...right tibia." * A handwritten statement, resident's last name and 12/19/13 at top of the page documented, "I thought the seat belt broke when the car cut us off (and) the driver slowed I slid from my chair. I didn't hurt until later." It was signed by the DNS, not the resident. * A handwritten statement, CNA #4's name and 12/19/13 at top of the page documented, "...coming to Hwy (highway)...putting on brake to slow down car then went to cut me off (resident's name) hollered, I looked in rearview mirror and she was sliding from the wheelchair. When the light turned green I pulled over to side of road. Her feet were against the wall (and) she was sitting on her foot rest. The seatbelt was around her but disconnected for (sic) the wall. I looked at the connection and it did not appear broke or anything. I checked the seatbelt for proper fit (and) to ensure secure prior to leaving doctors office. She denied pain (at) time of event." The statement was signed by the DNS, not the CNA. * "Follow Up Investigation" IDT Recommendations included: physician notified, x-ray completed, follow up with orthopedist, Forteo (antiosteoporotic) initiated, physician assessed, and van driver re-education. Signed by the DNS 12/23/13; however, the Administrator did not sign it until 1/10/14, 23 days after the incident. Right Tibia-Fibula Radiographs, dated 12/19/13, documented, in part, "Conclusion:...No evidence of fracture although an acute nondisplaced fracture can be occult in the setting of severe diffuse osteopenia." CT (computed tomography) scan, dated 12/20/13, documented, in part, "Conclusion: ...Essentially nondisplaced acute fracture in the proximal right tibial metaphysis..." On 12/19/13, after the incident in the facility van, the physician ordered Norco (pain medication) 10/325 1 tablet by mouth 4 times/day prn. (Note: The resident was admitted with orders for gabapentin for diabetic neuropathic pain and Mobic, a nonsteroidal anti-inflammatory, for pain related to arthritis. And, on 11/18/13 a nurse documented, "...c/o HA (complains of headache)...No prn pain meds are ordered for res(ident). Res states that Tylenol is what she has used at home..." The physician ordered Tylenol 500 milligrams (mg) 2 tablets 4 times/day PRN. A 12/26/13, Nurses Note/Reason for Office Visit, documented, in part, "Res having (increased) confusion and (decreased) ability to participate in ADLs since Norco was added for pain..." The physician discontinued Norco, ordered Tylenol #3 1 by mouth 4 times/day prn for) leg fracture. During an interview on 1/12/14 at 2:45 p.m., the resident stated, "I used the bathroom at first, now they use this (pointed to a mechanical lift) to get me up and I have to use that chair (pointed to a bedside commode by the bed) now since my legs won't support me now. I could walk before but now I can't. I just hate it! I just hate it (pointed to the bedside commode again)!" During the interview, the resident had 3 episodes of what she called "cramps" in both legs. She stated, "Oh yes, I have pain since the accident! And, I get these spasms a lot. It's both legs sometimes. And they have to do more for me now. I don't like it! I really don't like it, but I'm not a complainer honey." The resident then pressed the call light to summon staff. On 1/12/14 at 3:00 p.m., the MDS nurse responded to the call light. The resident told the MDS nurse she was having leg pain and spasms. Moments later, LN #5 arrived and asked the resident if she was in pain. The resident said yes. The LN asked the resident to rate the pain on a scale between 0-10. The resident stated, "8." A few minutes later, the LN administered a "pain pill" to the resident. On 1/13/14 at 4:45 p.m., CNA #1 and LN # were observed as they used a Hoyer type mechanical lift to transfer the resident from her bed to her w/c. Alternate Flow Sheet Records (AFSR) for November and December 2013 and January 2014 included, "Assess Resident Q (every) shift for pain." The resident's pain was documented every shift ("nite" "day" and "pm") as follows: * November - 0 (no pain) all shifts 11/15 - 11/30; * December - 0 all shifts 12/1 - 12/19, except 12/4 days = 4; then on 12/19 pm (after the incident in the minivan) it was 8. After that, the resident's pain was documented as 5 once, 6 - 10 times, 8 - 3 times, and 10 once; * January - 1/1 day - "+ (plus sign)," then the pain was documented as 5 - 3 times, 6 - 7 times, and 8 once. There was no documentation on 1/12 nite or 1/13 nite and day. The resident had virtually no pain before the incident on 12/19/13. After the incident, however, the resident's pain level increased to severe or moderately severe nearly every day. In addition, as noted in the interview on 1/12/14 at 3:00 p.m., the resident rated her pain at an 8; however, pain was documented as 0 on the day shift that day on the AFSR. The MARs for November and December 2013 and January 2014 documented prn pain medication were administered as follows: * November - none; * December - Tylenol: 12/4 once, 12/19 twice, 12/20 once, and 12/30 once; Norco: 12/20 once, 12/21 twice, three times on 12/22 and 12/23, and 12/24 once; Tylenol #3: 12/27 twice, and once each day 12/28, 12/30, and 12/31; * January - Tylenol: once on 1/1 and 1/2, 1/8 three times, and 1/11 once; Tylenol #3: 1/1 twice, 1/3 once, 1/5 twice, once on 1/8 and 1/9, twice on 1/11 and 1/12. The resident received stronger pain medication and more often after the 12/19/13 incident in the facility van. The resident's Physical Therapy (PT) records documented, in part: * Evaluation, with 11/20/13 start of care date - "Patient demonstrates good rehab potential as evidenced by recent onset, motivation to return to PLOF (previous level of function), active participation...and motivated to participate... Functional Assessment...Transfers = Mod(erate) (A) (assist) Gait Level Surfaces = Min(imal) (A); Distance Level Surfaces = 50 feet; Assistive Device = Front wheeled walker..." * 12/17/13 Therapy Daily Treatment Note (TDTN) - "...Patient is making steady improvement with ambulation quality and quantity..." * 12/23/13 TDTN - "...has a fractured tibia and is in a knee immobilizer with NWB R LE (non weight bearing right lower extremity)." * 12/26/13 TDTN - "...Patient is reporting significant R knee pain...a bit confused today..." * 12/27/13 TDTN - "Patient is cooperative with treatment focused on transfers...fairly confused and complains of significant knee pain with activity." * 12/31/12 TDTN - "...significant pain in R LE..." * 1/3/14 TDTN - "...confusion...diminising (sic)...pain medication change... Cont(inue) focus on transfer...NWB status..." * 1/7/14 TDTN - "...required frequent cueing secondary to increased confusion about various subjects..." * 1/9/14 TDTN - "...staff training with transfer...pre visit to hospital for MRI post MRI patient returned...vomiting no further treatment given..." * 1/10/14 TDTN - "...patient required multiple sessions today due to pain and nausea..." * 1/13/14 TDTN - "...general discomfort and malaise...states she still cant (sic) hold down food. 3 short sessions today due to poor there(apeutic) ex(ercise) tolerance tremors/shaking t/o (through out) each session..." * Recertification & Updated Plan of Treatment Certification Period 12/20/13 - 1/18/14: LTG (long term goal) and STG (short term goal) regarding gait: baseline (11/20/13) 50 feet, previous (12/12/13) 75 feet, current (12/20/13) 75 feet. "Gait on hold secondary to patient fracturing R tibia and is currently NWB." LTG and STG regarding transfers: baseline (11/20/13) moderate assist, previous (12/12/13) minimal assist, current (12/20/13) minimal assist. "Currently Mod/Max(imum) A secondary to NWB and R LE in a knee immobilizer." Assessment Summary Since Eval, "...Patient was making good progress with functional abilities, but had a major set back with R tibial fracture..." On 1/15/14 at 1:45 p.m., CNA #4 was interviewed. The CNA said she was the minivan (van) driver on 12/19/13 and that she fastened the seatbelt around the resident's w/c and checked to be sure it was secured before she started the drive back to the facility. She stated that within moments after the resident slid out of the w/c, she pulled the van over. The CNA stated the resident denied pain several times when asked and the resident said to just help her up. When asked if the resident was assessed by a medical professional before she was moved back into the w/c, the CNA shook her head no. When asked who would assess a resident after a fall, she stated, "Nurses do an assessment before we move a resident in the facility. But she kept denying everything until about 15 minutes later." When asked if a nurse was in the van at the time of the incident, the CNA stated, "No nurse, just me. I'm a CNA. Hindsight, I wish I would have called 911. I called the facility when I got closer (she indicated the parking area in front of the facility)." When asked about the seatbelt, the CNA stated, "It came loose." On 1/15/14 at about 2:00 p.m., the Administrator and CNA #4 accompanied the surveyor to the facility van. The CNA demonstrated how the seatbelt was attached around the resident's w/c and to a receiver on the right side of the floor. The CNA stated that a second seatbelt was on the floor next to seatbelt receiver on the right. The CNA stated that when she hit the brakes the metal end on the second seatbelt may have caused the spring loaded latching mechanism to come undone and caused the resident's seatbelt come loose. The CNA said the resident denied pain repeatedly and kept saying to get her up. The CNA stated, "And I did (get the resident up)." The CNA said she then removed the second seatbelt and attached the resident's seatbelt to the receiver on the floor. She added that about 15 minutes after she resumed the trip, the resident c/o pain. The CNA stated, "We were already on the way by then so I just continued to the facility. I called the facility after that." The Administrator indicated it was a freak accident and said van drivers were inserviced after the incident. When asked about the inservice, the Administrator referred the surveyor to the Maintenance Supervisor (MS). On 1/15/14 at about 2:30 p.m., the MS was asked about the aforementioned inservice. On 1/15/14 at 2:45 p.m., the MS provided an undated Transportation Services P&P with an "All drivers read and sign" sheet, dated 12/13, attached. Five staff names/signatures were on the read/sign sheet. The MS stated he in-serviced staff after the 12/19/13 event and went over the highlighted areas (#s 1, 6, 7, and 12), which included, "Procedure: 1. In the event of a medical emergency, dial 911 for ambulance services. Do not use facility transport vehicles... 6. ...We do not transport emergent patients/residents in facility vehicles. There is no medical and/or nursing attention that can be provided while a patient/resident is being transported. 7. The transport driver will carry the facility cellular phone to communicate with the facility and for use in the event of an emergency. In the event of an emergency, dial 911...12. In the event of a resident fall during transportation van driver are instructed to call DON or Administrator immediately." On 1/15/14 at 4:30 p.m., the MDS nurse was asked about the resident's status. The MDS nurse stated a significant change MDS assessment was in progress, "Because she's had a decline." Resident #2 was harmed when she experienced a fracture with significant pain which necessitated the frequent use of strong pain medication, was NWB on the R LE because of a fracture to the R tibia, required mechanical lift transfers with a major set back in her ability to ambulate and transfer, and suffered emotional distress from having to use a bedside commode instead of a regular toilet, related to the fall in the facility van on 12/19/13. On 1/16/14 at 12:30 p.m., the Administrator, DNS, Quality Improvement Resource person and MDS nurse were informed of harm related to fracture, pain, ADL decline, and emotional distress caused by the resident's fall in the van on 12/19/13. No other information was received from the facility which resolved the issue. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], coded, in part: * Able to make self understood; * Usually able to understand others; * Severe cognitive impairment, with a BIMS score of 7; * No sign/symptoms of delirium and no behavior issues; * Extensive 2 plus person assistance for bed mobility, transfers, dressing, and toileting; * Extensive 1 person assistance for ambulation on and off the unit; * Wheelchair (w/c) use; * Frequent urinary incontinence with decreased wetness after a trial of a toileting program (TP); * Current TP or trial; * Had falls in the last month and 2-6 months before admission; and, * Falls since admission, without injury. The resident's most recent quarterly MDS, dated [DATE], differed from the 3/20/13 MDS above, in part, as follows: * Usually able to make self understood - difficulty communicating some words/finishing thoughts but able if prompted or given time; * Severe cognitive impairment, with a BIMS score of 5; * Signs/symptoms of delirium with fluctuating inattention, fluctuating disorganized thinking, and continual psychomotor retardation; * Wandering occurred 1 - 3 days in the look back period; * Occasional urinary incontinence with a current TP or trail; * Two falls, no injury; and, * Two falls, with injury (not major injury). Review FSIRs revealed the resident had 19 falls between 3/14 - 12/23/13. The FSIRs included the following: * 3/14 at 12:10 a.m. - Found on knees and laying across bed, bed pressure alarm added; * Around 4/1, specific date and time not documented - Found on floor in room with pants and shirt off, tag alarm on w/c which was in restroom; The status of the bed pressure alarm, whether it was on or not, sounded or not) was not documented. * 4/17 at 2:10 p.m. - Intercepted fall as resident attempted self transfer bed to w/c, alarm sounded, assisted to floor, auto lock brake added to w/c; *6/11 at 12:10 a.m. - Found on floor in front of recliner in room, toileting during night and increased observation during night shift implemented; *6/27 at 9:50 p.m. - Found on floor in front of toilet in his restroom, tag alarm not turned on, LN on duty educated staff involved regarding proper use of alarms and to toilet/offer to toilet resident more often, redness to both knees noted; *7/4 at 5:25 a.m. - Found on floor in front of toilet in his restroom "trying to go to the bathroom," last toileted at 4:15 a.m. IDT recommendations on 7/5/13 included, "B/B (bowel and bladder) pattern (times) 7 days." *7/7 at 6 p.m. - Found on floor next to recliner, toileted 5-10 minutes earlier, resident said he, "Was trying to go to the bathroom" and that he hit his head, neuro checks initiated, complained of left hip pain with range of motion, physician/family notified. IDT review on 7/15/13 included, "...has been toileted frequently. Staff initiated post void residuals...less than 100 cc (cubic centimeters) post void...Resident prefers to rest in his recliner, however recliner has been located in his room and alarm in use. Staff have been placing his recliner in DR (dining room)/activity room with increase line of vision and larger screen television. When the recliner is in the DR resident rests quietly vs (versus) when in his room. Will continue to place resident in recliner in DR/activity room and monitor..." *7/19 at 9:30 p.m. - Found on floor in front of w/c in dining room, tag alarm in place but not sounding, LN on duty and IDT review on 7/22 did not address the alarm issue; *9/29 at 1:00 a.m. - Found on floor with back against bed, "yelling out for his wife," tag alarm was still attached to resident and did not sound. IDT review on 10/2 noted resident "may respond better to male caregivers during HS...provide male caregiver at HS as much as possible." *10/17 at 2:30 a.m. - Found on floor by bed, alarm in use but came off bed with resident and did not sound, staff educated on toileting resident through night and alarm placement; *10/18 at 2:30 a.m. - found on floor in prayer position between bed and wall, "said he needed to use the bathroom," dry when last toileted between 10 and 10:30 p.m. (4 - 41/2 hours), skin impairment with abrasion to left knee 2 by 1.8 centimeters (cm) noted, denied pain. IDT review on 10/22/13 included: "Pressure alarm to be initiated to bed and referral to...urology consult. Resident to be toileted between 1:30 a.m. and 2:00 a.m. every noc shift." (Note: A bed pressure alarm was documented as added on 3/14/13.) *11/8 at 1:10 a.m. - Found on floor by bed, "Going pee," dry when last toileted at 10:20 p.m. (2 1/2 hours earlier). *11/8 at 3:20 a.m. - Found on floor by bed, stated he was "sleeping on the floor," dry when last toileted at 1:15 a.m. IDT review on 11/14 noted, "Event is outside his toileting pattern." *11/10 at 3:15 a.m. - Found on floor with back against bed, checked on 15 minutes earlier and dry when last toileted at 1:45 a.m. IDT review on 11/14 included, "POC (plan of care) updated for toileting at (10 p.m., midnight, 2 a.m., and 4 a.m.)" *11/17 at 5:15 a.m. - Found on floor by bed, said "Go to bathroom," dry when last toileted at 3:00 a.m. IDT review on 11/18/13 included, "...to be toileted every 2 hours during HS and monitored through fall committee. Resident has refused referral to urologist, however recently has agreed and appointment...made..." *12/12 at 7:45 p.m. - Found on floor next to w/c in his room, said, "I was trying to go down the hall," last toileted (voided) at 7:30 p.m., LN noted "voiding urgency" and encouraged resident to use call light; *12/20 at 8:15 p.m. - Found sitting on floor between wall and toilet, resident stated, "Get on the toilet," the resident's mental status prior to the fall was, "Grouchy, bad tempered, argumentative, uncooperative," dry when last toileted at 8:05 p.m., CNA #1 documented, "...toileted 4 times between (6:30 - 8:00 p.m.). Was yelling at staff and other residents after dinner at 5:30 p.m." IDT review on 1/2/12 included, "cont(inue) scheduled toileting, F/U (follow up) (with) cardiologist/urologist." *12/23 at 9:30 p.m. - Found on floor next to bed, resident stated he was "trying to get up to use the toilet," last toileted "around 8." IDT review on 1/4/14 included, "Surgery scheduled for 12/27/13 for foreskin r/t (related to) voiding issues." During the survey, the resident was observed as follows: * 1/12/14 at 2:48 p.m. - Asleep in a low bed that was against the wall; * 1/13/14 at 8:42 a.m. - CNA #3 talked to resident through the door while the resident was in the restroom; * 1/13/14 at 9:10 a.m. - Awake, lying on bed; * 1/13/14 at 10:45 a.m. - In Cherry Blossom DR in his w/c with tag alarm in place; * 1/13/14 at 12:15 - 12:45 p.m. - In or near Cherry Blossom DR in his w/c, tag alarm in place; * 1/13/14 at 1:45 p.m. - Self propelling in w/c along handrail in hallway between Side 1 and Side 2; * 1/13/14 at 3:45 p.m. - In Cherry Blossom DR in w/c with tag alarm in place; * 1/13/14 at 4:25 p.m. - In w/c by Side 2 Nurses' Station; * 1/13/14 at 5:20 p.m. - At table in Cherry Blossom DR; and, * 1/15/14 at 10:30 a.m. - Lying in low bed against wall. On 1/15/14 at about 2:15 p.m., the DNS and Performance Improvement (PI) Consultant were asked about the resident's falls. The DNS and MDS nurse from another facility were also present. The DNS and PI Consultant acknowledged there had been problems with the resident's alarms and that voiding pattern monitors were not completed. When asked if increased supervision, such as every 15 minute checks or 1:1 supervision were considered, the DNS stated, "We didn't do 1:1 because it was all based around toileting." The other DNS said that on 10/20/13 every 15 minute checks were done. The documentation was requested. It was not provided. On 1/16/13 at about 10:00 a.m., the Medical Records Supervisor (MRS) was asked to provide all fall assessments for the resident. At 12:25 p.m., the MRS provided 2 Fall Risk Evaluations, dated 3/14/13 and 12/23/13, and stated, "I looked though the paper files too and I couldn't find anymore." The 3/14/13 Fall Risk Evaluation documented, in part: Mental status - disoriented times 2, 1-2 falls in past 3 months, regularly incontinent, balance problem while standing/walking, decreased muscular coordination, requires use of assistive devices, takes 1-2 of the following types of medications: anesthetics, antihistamines, antihypertensive, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemic, narcotic, psychoactive, sedative/hypnotic, and has a predisposing condition. The 12/23/13 Fall Risk Evaluation differed from the earlier one as follows: 3 or more falls in past 3 months and a drop of less than 20 points between lying and standing blood pressure readings. On 1/16/13 at 12:30 p.m., the Administrator was also informed of the issue regarding falls. However, no other information or documentation was received from the facility which resolved the issue. 3. Resident #8 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's FSIRs were reviewed on 1/15/14 and revealed the resident had 5 falls during the past 6 months. The FSIRs included: * 8/28/13 at 4:35 p.m. - Found on the floor in his restroom, "reaching for the pull cord." The initial intervention was, "...to remain (with) patient during toileting." An IDT review on 9/9/13 included, "...Continue POC (plan of care). Resident not to be left alone while toileting now." * 9/13/13 at 4:45 p.m. - Found on the floor in his room. "Factors observed at time of fall:...commode arm came undone when shook (and) What type of assistance was resident receiving at time of fall? Alone and unattended." A re-creation of the last 3 hours before the fall documented, "Res(ident) alert and oriented prior to toileting. Res toileted (at 4:00 p.m.). Placed on commode and left unattended at (4:45 p.m.). Called into room by CNA. Laying on (L) (left) side. Commode arm off (let down). No alarm on." "What was different this time? Res left unattended on commode. No alarm. CNA was sent home..." IDT review on 9/16/13 included, "Interview with resident he stated he had attempted to self position on commode and his hand hit the release mechanism of the commode handle and lost balance and fell forward onto floor. Staff educated and commode removed from building. Resident sent to ER (emergency room ) at (name of local hospital) for evaluation. No sutures needed for lacerations to head and nose. Negative heat CT (computed tomography scan). C (cervical)-collar for comfort..." On 1/15/14 at 5:00 p.m., the DNS and Performance Improvement (PI) Consultant were interviewed about the resident's falls. They acknowledged the care was not followed on 9/13/14 when the resident was left alone on the commode. The facility failed to follow care planned interventions not to leave the resident alone while toileting. No other information or documentation was received from the facility which resolved the issue. 4. Resident #1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's Quarterly MDS, dated [DATE], coded: *Unable to complete the BIMS. *Severely impaired decision making skills, per staff assessment. *Extensive assistance of 2 persons for transfers and dressing. *Extensive assistance of one person for eating. *Did not ambulate. *Range of motion deficits for both lower extremities. Resident #1's care plan for ADL's, with a focus date initiation of 7/11/13, documented an approach of, "...dependent assistance with total mechanical lift for transfers and 2 staff..." NOTE: There was no implementation date documented for the approach. Facility "Skin Event Investigation" forms for Resident #1 documented: *7/8/13 at 5:30 PM, "2 cm (centimeter) diameter abrasion on below (sic) (right) gluteal fold." The "Immediate Action Taken" area of the form documented, "...Educated staff on placement of the Hoyer sling and to remove sling from between legs when in (wheelchair). (There was excessive amount of anti-fungal cream in place over open area.)" The back of the form documented, "Noticed yellow cream covering open area, notified nurse to ensure skin area wasn't accounted for prior to me finding it." The statement was signed by a CNA #1, dated 7/8/13 at 9:35 PM. The "IDT Recommendations" area of the form documented, "MD notified," "Monitor until resolved," "staff education," and "update POC." A facility PN, dated 7/15/13 at 5:36 PM (7 days after the event) documented, "IDT review...After interview of staff it appears resident was found sitting up in her (wheelchair) with straps to mechanical lift sling still located between resident upper legs. It appears the straps of the sling may have contributed to the abrasion...staff education provided." *8/3/13 at 11:40 AM, open area in the right gluteal fold over an irregular size mass. The back of the form had several spaces for "Investigation Interviews". One space documented, "Assisted (LN name) with skin check with (Resident #1) bottom with measuring," and was signed by a CNA. The rest of the spaces were blank. A 8/5/13 PN attached to the form documented, "IDT review...Upon investigation and assessment of area resident is noted to have approximately a 3 cm X 2 cm mass located just above the abrased area. The skin above and around the mass is red and blanchable with a slightly protruding core. It appears the mass is pulling on the skin which could be causing friction from the sling strap during transfers..." There was no documentation as to whether the sling strap placement was investigated, in terms of the education done following the 7/8/13 incident. There were no further updates to Resident #1's care plan regarding mechanical lift sling placement or transfer technique. NOTE: Please see F 280 as it pertains to care plan revisions. * 8/24/13 at 2:45 PM bruising to the right upper thigh, and 8/27/13 at 9:50 AM multiple bruises to bilateral upper extremities (arms and wrists). The facility Skin Event Investigations provided had these incidents stapled together. Only one IDT review was attached, addressing the bruises to her arms. The number, size, and appearance of the bruising was not described on either form. The areas of the 8/24/13 form for "Investigation Interview" contained statements from 2 facility RNs noting the presence of bruising to the upper right thigh, as well as a statement from a corporate resource person. The statements from both RNs identified the bruising consistent with the placement of the resident's adult briefs. The statement from the resource person documented, "Observed transfer resident (with) mechanical lift. Sling rubs against res(ident), res(ident) resistant (due to) dementia. Recommend new sling." None of the statements were dated or signed. Th

Based on staff interview and record review, it was determined the facility had failed to ensure that a resident that did not have a pressure sore did not acquire one while at the facility. Resident #1 was harmed when the facility failed to: * prevent a pressure sore from reoccurring at the same spot as a previous sore; * define and implement interventions for pressure ulcer prevention in accordance with resident needs, goals and recognized standards of practice; * monitor and evaluate the resident's response to preventive efforts; * document response to treatment. This would affect 2 of 10 (#s 1 and 6) sampled residents. Findings include: Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * was cognitively intact, * Required extensive assistance of one staff for bed mobility, transfers, toilet use, personal hygiene and bathing. * was frequently incontinent of urine and occasionally incontinent of bowel. * did not have a pressure sore. A quarterly MDS had an assessment reference date, A 2300, of 4/20/12. The MDS failed to identify the resident had a pressure sore. (See F 278) The resident had a pressure sore documented on the 10/28/10 Interdisciplinary Team Skin Review form. The location is not specified. The Pressure Wound Report, dated 8/16/11, documented a stage II pressure sore on the right buttock that measured 3 cm X 0.2 cm. The preventative measures in place were: elevated heels in bed; pressure reducing mattress; foot cradle; pressure relieving wheelchair (w/c) cushion and repositioning every 2 hours. The documentation indicated the sore resolved on 10/28/11. The Pressure Wound Report, dated 4/20/12, documented a stage II pressure sore on the right buttock that measured 3 cm x 5 cm. The appearance of the wound was an "open area, no drainage, no odor." The preventative measures that were in place prior to development of the pressure area were: pressure relieving w/c cushion and air mattress. The form documented an admission risk assessment of 15 which relates to a mild risk level. (Additional information provided by the facility on 11/30/12 documented a Braden was done on 1/26/12 and the resident scored a 15 also. The Braden was not provided.) The resident's care plan that was in place at the time the sore appeared identified a problem of : "At risk for skin integrity impairment related to history (hx) open area to the coccyx (present on admission), hx of yeasty rash under breast and abdominal folds, hx actinic keratoses, hx bladder incontinence, hx of refusing to be positioned off coccyx, hx of shingles with sores. Hx left and right medial buttock pressure ulcer 9/13/11, and hx periferal (sic) [MEDICAL CONDITION] to lower extremity bilaterally." The approaches were: "* Turn/position every 1 1/2 - 2 hours when up in w/c by shifting weight, toileting or laying down. Position from side to side when in bed using pillows for support. * Provide pericare every shift and after each incontinent episode. Apply moisture barrier cream after each incontinence." * Weekly LN skin checks. * Daily CNA monitoring of skin while providing cares, Notify LN of any skin issues. * Apply lotion to extremities twice a day. * Air Mattress overlay to bed. * Air cushion to wheelchair. * Float heels over a pillow when in bed as a preventative measure. * Treatments per physician's orders [REDACTED]. * Staff to educate prior to providing cares and completing tasks. * Geri-gloves to bilateral extremities... (7/30/10) * Foot cradle to bed as a preventative measure. (8/14/10) * Knee high TED hose twice a day." The Interdisciplinary Progress Notes (IPN) were reviewed. The Nursing documentation related to the sore was not clear as to when it was identified or what occurred. Examples were: On 4/20/12 at 1:00 p.m. the RN documented: "Resident alert and oriented - Bilateral upper extremity skin improved. Wears geri gloves when up. Feeds self after set up. Protective Barrier ointment to buttocks after toileting due to open shearing skin." On 4/25/12 at 8:20 a.m. the IPN documented,"Interdisciplinary Team Review of open area to right buttocks. Resident has hx hypertension, [MEDICAL CONDITIONS] joint disease, [MEDICAL CONDITION] arthritis with pressure ulcer. Right and Left buttock with scar tissue. Area of scar tissue to right buttocks with 3 cm x 5 cm open area. Resident currently has air mattress in bed, air cushion to w/c and encouraged to lie down in afternoon, however resident prefers not to lie down. Recent episodes of loose stools with cultures and lab pending. The open areas appear related to the loose stool irritation to skin and increased wiping for cleansing. Area was cleansed, antibiotic ointment and [MEDICATION NAME] applied...." On 5/4/12 the Interdisciplinary Team Skin Review documented, "Buttocks improving...Continue Plan of Care." On 5/11/12 the Interdisciplinary Team Skin Review documented, "Continue to improving." There was no further documentation about the pressure sore in the record. On 11/27/12 at 3:45 p.m. the Administrator, DON and consultant were interviewed about the pressure sore. The resident had a history of [REDACTED]. When the sore occurred the resident was having multiple co-morbidities. The resident was diagnosed with [REDACTED]. The resident was continent but because of all the wiping her skin broke down. This information was not care planned. On 11/30/12 the medical director submitted information to the agency that documented the multiple medical risks the resident had in February prior to the sore appearing. These included newly diagnosed diabetes type II, decreased hemoglobin, hematocrit, ferritin, protein, [MEDICATION NAME] and an increase in bun/creatinin. The medical director further documented "Her plan of treatment was changed with medication and orders." Review of the resident's care plan it is unclear where the information was incorporated into the nursing care plan. The resident was harmed when the facility: * failed to recognize and assess factors placing the resident at risk for developing a pressure ulcer, including specific conditions, causes and/or problems, needs and behaviors; * failed to define and implement interventions for pressure ulcer prevention in accordance with resident needs, goals and recognized standards of practice; * failed to monitor and evaluate the resident's response to preventive efforts; * failed to revise the approaches as appropriate; * failed to prevent a stage II pressure sore from occurring in the same place as a previous stage II pressure sore; and * failed to document response to treatment of [REDACTED]. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent admission MDS assessment, dated 10/29/12, documented the resident: * was cognitively intact, * required extensive assistance of one to two staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. * was frequently incontinent of urine. * did not have a pressure sore. The resident's initial care plan, dated 10/22/12, documented under section 5. Skin Integrity to "monitor incision site." Nothing else was checked or documented. A Comprehensive Resident Admission Assessment was completed on 10/22/12 and documented the resident's surgical incision, two bruises and a blister on the left hip. No other skin issues were documented. A Braden Scale was completed with the assessment and scored an 18, which relates to the resident being a mild risk for pressure sores. On 10/30/12 at 10:51 a.m. the LN documented the presence of a blister on her left heel. The note further documented the resident's son "states that blister had been there prior to surgery." The Hospital records were obtained and reviewed. There was no documentation that the resident had a blister while a patient in the hospital. The documents had daily documentation of assessing the resident for skin issues. The resident was in Bucks traction part of her stay in the hospital and only the surgical incision was noted. The skin review form dated 10/30/12 documented a blister on the left heel that measured 2 cm by 1.2 cm. The additional documentation was, "Blister intact, no redness surrounding blister, no drainage noted." The resident's care plan, dated 10/30/12, documented, "Altered skin integrity r/t blister on: Left heel." The interventions were: (Note: interventions were not dated so it is unknown when they were developed.) * Observe/report signs and symptoms if infection such as local fever, drainage, pus, pain, tenderness, foul smell, swelling. * Assess progress of blister weekly. * Use preventative equipment: heel lift boots on while in bed. There was no care plan developed addressing the resident at risk for skin breakdown and preventative measures to assure she did not breakdown. On 11/4/12 at 4:21 p.m. the skin review documented, "Blister on left heel that today measures 2 cm L(ong) x 2 cm W(ide) over the mound of fluid inside the blister. Skin is intact." On 11/11/12 at 8:47 p.m. the skin review documented, "Left Heel...Blister is gone." The Administrator, DON and consultant were interviewed on 11/27/12 at 3:30 p.m. They maintained that the blister had to have been on the heel prior to admission to the facility. Information was shared and there was no documentation to indicate that the blister was on the heel prior to 10/30/12 when it was identified by staff. No investigation was provided to find an alternate cause for the sore so preventative measures could be instituted. No further information was provided.