Every finding on record at Royal Plaza Health and Rehabilitation of Cascadia

Based on observation, review of the FDA Food Code, and staff interview it was determined the facility failed to follow sanitary requirements for food safety, including an appropriate hand washing sink, food sanitation, and appropriate cleaning and storage for resident's freezers. This was true for 76 residents who received food plated and delivered by the facility's meal serving room, and whose personal foods were stored in the residents freezer's. This deficient practice created the potential for harm by placing residents at risk for foodborne illnesses and/or adverse health outcomes. Findings include:1. The FDA Food Code Section 2-301.14 When to Wash documented food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils . (H) before donning gloves to initiate a task that involves working with food.On 6/25/26 at 11:55 AM, the facility's Dietary Manager (DM) brought in the hot food cart and donned gloves without handwashing. He moved the hot food into the steam table and then began to take food temperatures without washing hands between tasks or before donning gloves.On 6/25/26 at 12:00 PM, the Dietitian and DM stated hands should be washed between tasks and prior to donning gloves.2. The FDA Food Code Section 3-303.12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water.a. On 6/22/26 at 1:03 PM, in residents' Freezer #2, physical therapy ice was stored alongside food ice packs. On 6/25/25 at 12:40 PM, the Dietitian stated that physical therapy ice should not be stored with food ice.b. On 6/25/26 at 12:04 PM, it was observed that ice cubes were directly placed on the resident's juice cup lids. Hospitality aides were seen removing the ice from the juice lids before placing them on the resident's meal trays. On 6/25/26 at 12:34 PM, the Dietitian and DM stated ice cubes should not be stored directly on the juice cup lids, and the juice cups should be placed on top of or around the ice instead. 3. The FDA Food Code Sections 5-205.11, 6-301.12, 6-301.14, and 6-301.20 documented a handwashing sink must not be used for any other purpose than handwashing; handwashing sinks must have individual, disposable towels, or a continuous towel system that supplies the use of a clean towel; handwashing signage must be clearly visible and the area must have a waste receptacle. On 6/25/26 at 11:50 AM, the handwashing sink in the facility's meal dispensing area was observed to have dirty dishes in the sink, a reusable cup was stored next to the sink, without disposable towels, a trash can, and lacking employee handwashing signage.On 6/25/26 at 12:05 PM, the Dietitian and DM stated the handwashing sink did not contain disposable towels, a trash can, employee handwashing signage, nor should it contain dirty dishes or be a storage area for personal employee cups.

Based on record review and staff interview, it was determined the facility failed to ensure residents and/or their representatives were provided with complete facility discharge information. This was true for 3 of 6 residents (#4, #5, and #46) whose records were reviewed for hospital discharges. This failure placed the residents at risk for psychosocial harm, advanced directive misunderstandings, and a lack of medical history if the transferring facility did not receive a completed resident discharge record. Findings include:1. Resident #4 was re-admitted [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD-a progressive lung disease that blocks airflow and makes breathing difficult), congestive heart failure (CHF-a chronic condition where the heart's muscle becomes stiff or weak preventing it from pumping blood efficiently), and depression. On 2/10/26 the facility initiated an emergent discharge/transfer to hospital which identified what paperwork was sent to the hospital. Review of the Communication for Emergent Discharge/Transfer to Acute, the following documents were not included in the hospital transfer documents: -Resident Transfer Form -Face Sheet with Diagnosis -Care plan goals -Physician H&P -Advance directives -POST/POLST -Notification of resident family/resident advocate On 6/26/26 at 10:10 AM, the Administer brought in packet of the paperwork sent for Resident #4, and stated, This is everything the facility sent. The facility was unable to provide documentation the items listed above were sent with Resident #4. 2. Resident #5 was readmitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, respiratory failure with hypoxia (a critical condition where lungs cannot transfer enough oxygen to the bloodstream, resulting in dangerously low blood oxygen levels), diabetes, kidney disease, and dementia. On 3/12/26, the facility initiated an emergent discharge/transfer to acute [facility] which identified what paperwork was sent to the receiving location [hospital]. Upon review of the paperwork the following documents were not included in the hospital transfer paperwork: -Resident Transfer form -Treatment Administration Record (TAR) -Care plan goals -Physician H&P -Advanced Directives -Notification of residents' family and/or advocate 3. Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including CHF, hypertension (a condition where the force of blood pushing against artery walls is consistently too high), and vascular disease (any condition affecting the circulatory system). On 6/23/26, the facility initiated an emergent discharge/transfer to acute [facility] which identified what paperwork was sent to the receiving location [hospital]. Upon review of the paperwork the following documents were not included in the hospital transfer paperwork: -Resident Transfer Form -Face sheet with diagnosis -Order summary with report -TAR -Care plan goals -Physician H & P -Advanced Directives -POST -Verbal report with transport staff -Notification of residents' family and/or advocate -Notices signed for transfer and bed hold On 6/23/26, a review of Resident #46's record included a Resident's Notice of Transfer and Bed Hold that were signed, but not checked off on the Communication for Emergent Discharge/Transfer to Acute checklist. On 6/25/26 at 8:36 AM, the CNO stated the checklist form is provided to prove we have sent the information; however, it appears there are documents that were not sent with the patient as it is not checked off on the forms for Resident #5 and Resident #46.

Based on the review of the Facility's Arbitration agreement, CMS SOM Appendix PP, and staff interview, it was determined the facility failed to ensure the facility's arbitration agreement provided the selection of a venue that is convenient to both parties. This was true for all residents who reside in the facility who signed an Arbitration Agreement. This failure created the potential for residents to be inconvenienced or the inability to participate during the arbitration process. Findings include:On 6/24/26 at 4:15 PM, after review of the arbitration agreement and the federal regulation requirement the Administrator stated the arbitration agreement was missing the regulatory requirement of a convenient location of arbitration for both parties.

Based on record review and staff interview, it was determined the facility failed to ensure residents were offered the opportunity to create an advance directive. This was true for 1 of 10 residents (Resident #13) whose advance directive was reviewed. This failure created the potential for Resident #13 to not have their wishes met if they were to require end of life care. Findings include: Resident #13 was re-admitted [DATE], with multiple diagnoses including hypertension, chronic kidney disease (a progressive condition where damaged kidneys lose their ability to filter waste and fluid from the blood), and mild cognitive impairment.On 6/24/26, review of Resident #13's medical record revealed the resident did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated she did not have documentation education was provided to Resident #13, nor were there attempts to obtain an advance directive.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 3 residents (Resident #63) reviewed for abuse. This failure placed Resident #63 at risk for psychosocial harm when a video recording was taken of them during a sensitive moment and the video was shared with people not privileged to Resident #63's protected information. Findings include: Resident #63 was admitted to the facility on [DATE] with multiple diagnoses including dementia with behavioral disturbances, hypertension, and chronic kidney disease. Review of the State Agency Long Term Care Reporting Portal, on 8/12/25 at 9: 50 PM, Resident #63 was video recorded by 1 staff with another staff present. The facility's investigation report documented the description of the video as follows: At approximately 10:00 AM on August 13, 2025, a staff member from the Assisted Living unit at [facility name] presented a video to the Administrator of [Skilled Nursing Facility Name]. The video, approximately seven seconds in length, depicted [Resident #63] standing fully clothed in the shower, holding the shower head and spraying water into the bathroom and adjoining room. Certified Nursing Assistant [CNA #5] was visible in the video, laughing for the last couple seconds of the video.The investigation documented CNA #5 identified CNA #10 as the person who recorded the video. The staff from the Assisted Living facility stated they received the video from CNA #5. Resident #63 was interviewed and was unable to recall the incident. The state agency attempted to contact CNA #5 and CNA #10 during the investigation, and the CNA's did not return the state agency's calls. The facility was unable to provide the name or phone number of the staff who worked for the neighboring Assisted Living facility and showed the Administrator the video, for interview. Following the incident, the facility took the following actions: -Resident #63 was assessed for psychosocial harm by the Medical Director, no psychosocial harm evidence was identified-Both CNA's were suspended pending the investigation-The incident was reported as an allegation of abuse to the State Agency-Staff and residents were interviewed about abuse and HIPAA (Health Information and Accountability Act- laws which keep personal information safe)-The facility's cell phone policy was updated-The facility retrained all staff on HIPAA and abuse On 6/24/26 at 4:04 PM, the Administrator stated, the CNA's should not have video recorded Resident #63 during a sensitive moment and although the video was not recorded with malicious intent, the video should not have been shared with people who were not privileged to know about Resident #63's protected information. There was sufficient evidence the facility corrected the non-compliance as of 8/21/25, as there was no further incidents of staff recording residents after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on observation, CMS SOM Appendix PP, and staff interviews, it was determined the facility failed to create a comprehensive care plan. This was true for 2 of 18 residents (#9 and #19) reviewed for care plan development. This deficient practice had the potential for harm if their care plans were not developed to ensure Resident's and/or their representatives, and facility staff were educated on individual diagnoses, treatment interventions, and treatment outcome goals specific for each resident. Findings include:1. Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including anemia, nutrition deficiency, anorexia, dementia, and depression.A review of Resident #19's care plan dated 1/7/26, included treatment interventions for nutrition decline, but did not include treatment or interventions related to Resident #19's diagnosis of unspecified anemia.On 6/25/26 at 3:01 PM, the CNO stated Resident #19's anemia diagnosis and treatment interventions were not included in his care plan, and it should have been.2. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including PTSD (Post Traumatic Stress Disorder), anxiety, depression, mood disorder, dementia, and Alzheimer's disease.A review of Resident #9's care plan dated 6/6/23, documented Resident #9 had mood problems due to past trauma, depression, and anxiety. PTSD Interventions were included but did not address specific PTSD triggers experienced by Resident #9 and what interventions or redirections were needed by staff to assist Resident #9.On 6/25/26 at 3:09 PM, the CNO stated Resident #9's care plan was not comprehensive and did not include specific PTSD triggers and/or education/redirection for the staff and the resident or the resident's representative.

Based on record review and staff interview, it was determined the facility failed to ensure quality care was provided related to medication administration. This was true for 1 of 7 residents (Resident #35) whose medication regimen records were reviewed. This failure placed Resident #35 at risk for harm if they were to suffer adverse effects from receiving a medication outside the physicians prescribed parameters. Findings include: Resident #35 was admitted to the facility on [DATE] for care following a fall with fracture, with multiple diagnoses including chronic respiratory failure with hypoxia and hypercapnia (high blood carbon dioxide), and hypertension. Resident #35's June 2026 MAR documented the following physicians order, dated 6/12/26:-Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 50 mg by mouth in the morning related to essential (primary) hypertension, HOLD FOR SBP [systolic blood pressure - less than] 100 OR DBP [diastolic blood pressure - less than] 60 (systolic is the top number and diastolic is the bottom number in a blood pressure reading). Resident #35's blood pressure records documented they had a SPB less than 100 or a DPB less than 60 on June 13, 14, 17, 18, 20, 21, 22, 23, 24, and 25. Resident #35's MAR documented the blood pressures were out of parameter, and the Losartan blood pressure medication was administered on June 20, 22, and 23. On 6/25/26 at 5:14 PM, the CNO stated Resident #35's blood pressures were out of parameters according to the physician order and the doses of Losartan on June 20, 22, and 23 should have been held, and they were administered in error.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 1 of 2 residents (Resident #4) whose respiratory device was not stored properly; and 1 of 2 residents (Resident # 56) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen. Findings include: The facility's policy titled, Oxygen Administration, Safety, Storage and Maintenance, revised 10/10/25, stated, The facility will administer, store and maintain oxygen safely in accordance with current standard of practice and licensed practitioner orders. 1. Resident #56 was admitted [DATE] with multiple diagnoses including congestive heart failure, hypertension, and pulmonary hypertension (high blood pressure in the arteries of the lungs).Resident #56's physician's orders included the following:-Oxygen at 2 LPM (liters per minute) per nasal cannula continuously via O2 (oxygen) concentrator, dated 8/28/25.On 6/22/26 at 5:25 PM, Resident #56 was observed with nasal cannula in her nares, oxygen on at 1 liter per minute.On 6/22/26 5:31 PM, RN #2 came into Resident #56's room and verified the oxygen was set at 1 LPM. RN #2 checked order and stated, Resident #52's oxygen should be set at 2 LPM. 2. Resident #4 was re-admitted [DATE], with multiple diagnoses including CHF, COPD, and muscle weakness. Resident #4's physician's orders included the following:-Oxygen at 1-3 LPM intermittently per nasal cannula to maintain oxygen saturations at greater than 88%, via O2 concentrator/or tank with humidification, dated 6/15/26.On 6/23/26 at 2:20 PM, Resident #4 was observed in his bed with nasal cannula directly on his nightstand. RN #4 confirmed the nasal cannula was on the nightstand and should be stored in a bag.

Based on observation, policy review, staff interview and record review, it was determined the facility failed to ensure that expired medication was removed from medication storage area and discarded in accordance with professional standards and facility policy. This was true for 1 of 2 medication carts reviewed for medication storage and cart review. This deficient practice had the potential to affect the strength, quality and purity of the medication. Findings include:The facility's policy titled Medication Storage and Labeling, released [DATE] stated, The facility will ensure that medications are stored and labeled in accordance with CMS regulations, state law and acceptable professional principles to ensure safety, efficacy, and compliance. It further stated, Expired or discontinued medications must be removed promptly and disposed of per facility policy and DEA guidelines to prevent diversion.On [DATE] at 10:04 AM, during medication storage and cart review, the surveyor in the presence of RN #3, found a bottle of liquid lorazepam for Resident #2, dated with an expiration of [DATE].On [DATE] at 10:05 AM, RN #3 acknowledged medication was expired. RN #3 stated, the medication must be removed from the cart and discarded immediately.

Based on record review and staff interview, it was determined the facility failed to ensure resident records were complete and accurate. This was true for 1 of 7 residents (Resident #68) whose medication regimen was reviewed. This failure created the potential for poor continuity of care for Resident #68. Findings include: Resident #68 admitted to the facility on [DATE], with multiple diagnoses including CHF, and bacteremia (the presence of bacteria in the bloodstream). a. Resident #68's June 2026 MAR documented the following physician orders, dated 6/20/26:-Crestor Oral Tablet 10 MG (rosuvastatin calcium) Give 10 mg by mouth at bedtime related to hyperlipidemia-Rosuvastatin Calcium Oral Tablet 10 MG (rosuvastatin calcium) Give 10 mg by mouth at bedtime relatedto hyperlipidemia The order for Crestor was signed as administered on June 20, 21, 22, 23, and 24. The order for rosuvastatin was signed as held due to duplicate therapy on June 20, 21, and 24; on the 22nd and 23rd, the medication was signed as administered. On 6/25/26 at 4:20 PM, the CNO verified the pharmacy had delivered 1 card of rosuvastatin medication for Resident #68 on 6/20/26. The CNO verified the medication card had 5 doses administered, indicating Resident #68 had not received the same medication twice on June 22nd and 23rd. On 6/25/26 at 4:35 PM, the CNO stated, Resident #68 had two of the same medication order, Crestor and rosuvastatin transcribed to their MAR in error, and on June 22nd and 23rd, the MAR documented they received the medication twice in error. b. Resident #68's June 2026 MAR documented the following physician order, dated 6/19/26:-Cefepime HCl Intravenous Solution 2 GM/100ML (Cefepime HCl) Use 2 gram intravenously every 8 hours related to bacteremia for 30 Administrations until finished Resident #68's MAR, on June 21, at 9:00 PM, the IV antibiotic, Cefepime was not signed as administered and there was a blank in the MAR. On 6/25/26 at 5:02 PM, the CNO verified how many doses of Cefepime had been delivered from the pharmacy for Resident #68 and verified the correct number of doses had been administered based on the number of doses remaining. On 6/25/26 at 5:06 PM, the CNO stated, the nurse who administered Resident #68's Cefepime at 9:00 PM on June 21 should have signed for it, and the MAR was left blank in error.

Based on observation, policy review, and staff interview, the facility failed to ensure the facility staff followed proper infection control practices and glove change protocols. This was true for 1 of 18 residents (Resident #6) when staff failed to perform hand hygiene when going from a dirty environment to a clean environment. This deficient practice placed residents at risk for cross-contamination, and the spread of healthcare associated infections. Findings include: The facility's policy titled Hand Hygiene, revision date 9/15/25, stated, Hand hygiene is recognized as a cornerstone of effective infection control and is essential in preventing the transmission of healthcare-associated infections (HAIs). All healthcare workers should perform hand hygiene at critical moments during resident care, according to CDC guidelines:-Immediately before and after touching a resident.-Before moving from work on a soiled body site to a clean body site on the same resident.-After contact with objects and surfaces in the resident's environment.-After contact with blood, body fluids, or visibly contaminated surfaces.Resident #6 was re-admitted [DATE], with multiple diagnoses including type 2 diabetes, hypertension and chronic pain syndrome.On 6/24/26 at 12:17 PM, RN #3 was observed doing a glucose finger stick on Resident #6 with clean gloves on, then removed the dirty gloves and put on clean gloves without performing hand hygiene.On 6/26/26 at 10:02 AM, the IP stated hand hygiene should be performed when changing gloves and when going from a dirty environment to a clean environment.

Based on policy review, CDC guidelines, record review, and staff interview, it was determined the facility failed to ensure immunizations were offered and/or provided as indicated. This was true for 2 of 5 residents (#2 and #13) reviewed for pneumococcal immunization. This deficient practice placed residents at risk of developing pneumococcal pneumonia and developing serious, potentially life-threatening complications. Findings include:The CDC webpage titled, Pneumococcal Vaccination accessed on 6/25/26, documented there are two types of pneumococcal vaccines. They are Pneumococcal conjugated vaccines (PCV) and Pneumococcal polysaccharide vaccine. The CDC recommended pneumococcal vaccination for:-All adults 50 years or older.-Adults 10 through [AGE] years old with certain risk conditions. 1. Resident #2 was re-admitted [DATE] with multiple diagnoses including, peripheral vascular disease (a progressive circulation disorder characterized by narrowing, blockage or spasms in blood vessels outside the heart), diabetes type 2, and vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain).Resident #2's Immunization Information, documented she refused to receive the pneumococcal vaccine, no dates listed.There was no documentation in Resident #2's record she and/or her representatives was offered and educated regarding the risk and benefits of having pneumococcal vaccines.2. Resident #13 was admitted [DATE], with multiple diagnoses including HTN, glaucoma (an eye disease that damaged the optic nerve due to abnormally high ocular pressure), and chronic kidney disease (damaged kidneys that cannot filter blood as they should).Resident #13's Immunization Information, documented she refused to receive the pneumococcal vaccine no dates listed.There was no documentation in Resident #13's record he and/or his representatives was offered and educated regarding the risk and benefits of having pneumococcal vaccines.On 6/26/26 at 10:01 AM, the IP stated she was unable to find documentation Resident #2 and Resident #13 were offered or educated of the risks and benefits of the pneumococcal vaccination.

Based on observation, Food Drug Administration (FDA) Food Code, record review, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained, cleaned, and sanitized, and food was within the correct temperature at service. These deficiencies had the potential to affect the 57 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include: 1. 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. Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. The FDA Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 4/16/25 at 1:35 PM, the following was observed: -The floor in the walk-in freezer had not been swept as there was an accumulation of onion peelings and other food debris on the floor leading from the freezer to the walk-in refrigerator. -The convection oven doors and the interior back area had a thick layer of dark encrusted residue. -Two ovens had a layer of black encrusted residue on the bottom area of each oven. -The flat top grill had a layer of black encrusted residue on the back left and front areas of the grill. -Cooking skillets had a black layer of encrusted residue. On 4/16/25 at 1:55 PM, a thick accumulation of dust and food particles was observed on top of the dish washing machine. On the interior of the dish washing machine, a thick layer of white particles was observed (an accumulation of lime/hard water deposits). On 4/16/25 at 2:00 PM, [NAME] #1 stated the dish washing machine and other areas of the kitchen are supposed to be cleaned daily, but it had not been done due to short staffing. The RDN confirmed kitchen cleaning and sanitation should be done at least weekly, if not daily. 2. FDA Food Code 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding documented except during preparation, cooking, or cooling, the time/temperature control for food safety should be maintained at 135 F or above, or 41 F or less. On 4/16/25 at 12:05 PM, a facility test tray was plated and delivered to surveyors by 12:10 PM. Temperatures of the food were noted to be: 43 degrees F: Milk 120 degrees F: Chicken Cordon Blue Bites 145 degrees F: Mashed potatoes/gravy 114 degrees F: [NAME] Beans A review of the dining room steam table Temperature Log for Lunch, dated 4/16/25 documented the following: 170 degrees F: Chicken Cordon Blue Bites 200 degrees F: Mashed potatoes & gravy 180 degrees F: [NAME] beans On 4/16/25 at 12:15 PM, the RDN confirmed the food temperature for the milk, chicken cordon blue bites, and green beans were not within the food safety standard for service.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 15 residents (Resident #40) reviewed for bowel and bladder care. This failed practice created the potential for Resident #40 to experience discomfort when his medications were not administered according to the physician's order. Findings include: Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, diabetes, and constipation. A quarterly MDS assessment dated [DATE], documented Resident #40 his decision making was poor and he needed cues and/or supervision. A physician's order, documented Resident #40 was to receive the following medications: -Milk of Magnesia (MOM, laxative) suspension 1200 mg/15 ml, give 30 ml by mouth as needed for bowel care if no bowel movement for 2 days. If no results within 24 hours, see Dulcolax Suppository ordered, 9/12/24. - Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel care if no results from MOM, if no results in 24 hours, see Fleets Enema order, ordered 9/12/24. -Fleets enema 7-19 gm/118 ml, insert 1 rectally as needed for bowel care if no result from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify physician if no results, ordered 9/12/24. Resident #40's Bowel Movement Records, dated 3/16/25 through 4/16/25, documented he did not have a bowel movement from: 4/7/25 through 4/16/25 (9 days). Resident #40's MAR, dated 3/16/25 through 4/16/25, documented he did not receive any bowel care medications when he did not have a bowel movement for 9 days. On 4/16/25 at 4:05 PM the DON reviewed Resident #40's record and stated Resident #40 should have been given MOM suspension when he did not have a bowel movement for 2 days and the physician should have been notified prior to the visit on 4/15/25.

Based on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 1 of 3 residents (Resident #10) reviewed for insulin administration. This failure created the potential for Resident #10 to experience hypoglycemia when she was administered insulin which was not according to her physician's order. Findings include: The WebMD website, accessed on 4/21/25 at www.webmd.com/drug-medication stated the following seven rights of medication administration: right individual, right medication, right dose, right time, right route, right documentation and right response. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and hypertension. The March and April 2025 MAR, documented Resident #10 was to receive seven units of insulin Aspart subcutaneously before meals, hold if her blood sugar is less than 140 mg/dl. The March and April 2025 MAR, documented Resident #10 was administered seven units of insulin Aspart when her blood sugar was less than 140 mg/dl on the following dates: - 3/31/25 at 7:30 AM, BG was 124 mg/dl - 3/31/25 at 11:30 AM, BG was 98 mg/dl - 3/31/25 at 5:00 PM, BG was 124 mg/dl - 4/3/25 at 11:30 AM, BG was 137 mg/dl - 4/13/25 at 11:30 AM, BG was 123 mg/dl On 4/16/25 at 10:27 AM, the DON reviewed Resident #10's record. The DON stated according to the documentation Resident #10 received insulin Aspart when her blood sugar was less than 140 mg/dl and it should have been held.

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: A Resident Group interview was attended by 8 residents on 11/6/24 at 10:00 AM. All the residents voiced concerns related to staffing and long call light response times. The residents stated these issues were an ongoing problem in the facility. The Resident Council minutes from May 2024 through October 2024 documented residents' concerns. Examples include: a. Resident Council Minutes, dated 5/2/24, documented residents voiced issues related to staffing continuity and the scheduling of nursing aides. b. Resident Council Minutes, dated 6/18/24, documented, evening [staff] needs more training. The Minutes did not document what actions were taken to address and resolve the concern voiced during the 5/2/24 meeting. c. Resident Council Minutes, dated 8/9/24, documented, A nurse tried to have a resident clean the toilet. Going through resident's things. Aides having bad attitudes. Empty trash cans in rooms. Call lights need answered. The Minutes did not document what actions were taken to address and resolve the concerns voiced during the 6/18/24 meeting. d. Resident Council Minutes, dated 9/10/24, documented, The staff needs to communicate more. Beds need made. Not taking dirty laundry. Not answering call lights. The Minutes did not documented what actions were taken to address and resolve the concerns voiced during the 8/9/24 meeting. e. Resident Council Minutes, dated 10/11/24, documented, some aides aren't taking laundry. Not going around with snack cart. The Minutes did not documented what actions were taken to address and resolve the concerns voiced during the 9/10/24 meeting. On 11/07/24 at 05:44 PM, the Administrator and the Activities Director were interviewed together, and the Resident Council Minutes were reviewed in their presence. The Activities Director stated she had been employed in her role since August 2024. She stated the residents' concerns were discussed during staff stand-up meetings, and she would inform each department head of the residents' concerns. The Activities Director stated she did not document the resolutions to the residents' concerns and was unaware that she was required to. When asked for documentation of call light audits for May through October 2024, the Administrator stated there were none.

Based on policy review, review of grievances, and staff interview, it was determined the facility failed to ensure resident grievances were investigated and resolutions were documented. This deficient practice placed all residents at risk of having unmet needs and poor quality of life when their concerns were not properly addressed. Findings include: A review of the facility's grievances from May 2024 to October 2024 revealed the following grievance continued and unresolved: Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including sepsis, urinary tract infection, and quadriplegia (complete or severe loss of motor function in all four limbs). A facility grievance report, dated 7/10/24, documented Resident #14 activated his call light, then a staff member came into his room, turned off his call light, and left his room without assisting him. The report did not document the investigation or actions taken by the facility to address Resident #14's concerns related to the call light. On 11/08/24 at 09:43 AM, the Administrator confirmed the facility did not address Resident #14's grievance related to issues with call light response.

Based on review of records and staff interview, it was determined the facility failed to ensure glucometers were calibrated to maintain accuracy of results for 3 of 3 halls (Oak Hall, Maple Hall, and Transitional Care Unit - TCU) whose glucometers were reviewed. This deficient practice had the potential for a higher risk for inaccurate blood glucose readings of residents who required blood glucose monitoring. Findings include: The EvenCare Blood Glucose Monitoring System under the section Control Solution Testing documented a control solution should be performed when: - Using the meter for the first time. - Using a new package of EvenCare G3 Blood test strips. - At least once per week to verify that the meter and test strips are working properly together. The facility's glucometer calibration logbooks were reviewed and revealed the following: - Oak Hall glucometer calibration was not consistently done for the month of October to November 7, 2024 - Maple Hall glucometer calibration was not done for the month of October to November 7, 2024. On 11/7/24 at 4:08 PM, RN #1 stated the glucometer was being calibrated by the night shift nurse. On 11/7/24 at 5:33 PM, the CNO stated the facility did not have a policy for calibrating the glucometer. The CNO reviewed the log book for Oak and Maple Hall, and stated the calibration were not consistently done. When asked about the TCU logbook, the CNO stated she was unable to find the logbook for the TCU glucometer calibration.

Based on record review, and staff interview, it was determined the facility failed to ensure information was provided to the receiving hospital for 3 of 5 residents (#3, #45 and #51) reviewed for transfers. This deficient practice had the potential to cause harm if residents were not treated in a timely manner due to lack of information. Findings include: The State Operations Manual, Appendix PP, revised 02/03/23, documented when the facility transfers or discharges a resident under any of the circumstances, the facility must ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Documentation in the resident's medical record must include: - The basis for the transfer or discharge. - Contact information of the practitioner(s) responsible for the care of the resident, - Resident representative information and contact information. - Advance Directive information, - All special instructions/precautions for ongoing care, and as appropriate treatments - Comprehensive care plans and goals and - All other necessary information including a copy of the resident's discharge summary and any other documentation to ensure a safe and effective transition of care. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, and dementia. A review of records documented Resident #3 was transferred to the hospital on 5/8/24, and 7/24/24. Resident #3's record did not include documentation of medical information was provided to the hospital when she was sent to the hospital on 5/8/24 and 7/24/24, to ensure a safe and effective transition of care. 2. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure with hypoxia (low levels of oxygen in your body tissues), chronic obstructive pulmonary disease, and stroke. A review of records documented Resident #45 was transferred to the hospital on 7/18/24, and 7/23/24. Resident #45's record did not include documentation of medical information was provided to the hospital when she was sent to the hospital on 7/18/24 and 7/23/24, to ensure a safe and effective transition of care. On 11/08/24 at 9:33 AM, the CNO confirmed the facility has not been providing hospital paperwork when a resident is transferred to the hospital. She stated the facility does not have a hospital transfer policy. The CNO confirmed Resident #3 and Resident #45 did not have any documentation of hospital transfer paperwork. 36193 3. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including right hemiplegia and hemiparesis (paralysis and weakness) following stroke. A nursing progress notes, dated 6/1/24 at 3:39 PM documented Resident #51 was clammy, afebrile, and wiggled in bed and was not alert as her usual. The progress notes documented her blood sugar was elevated and her blood pressure was low. An order was received to do a stat (immediately) CBC (complete blood count) and CMP (complete metabolic panel). A nursing progress notes, dated 6/1/24 at 4:32 PM documented an order was received to send Resident #51 to the emergency room due to critically BUN (blood urea nitrogen - kidney function test) and high sodium level. Resident #51's record did not include documentation information was provided to the hospital to ensure safe and effective transition of care. On 11/7/24 at 12:49 PM, the CNO when a resident transferred to the hospital, face sheet, MAR, and POST were sent with them. The CNO stated she was unable to find documentation the necessary documents were sent with Resident #51 when she went to the hospital on 6/1/24.

Based on record review and staff interview, it was determined the facility failed to ensure transfer notices were provided to the ombudsman. This was true for 3 of 5 residents (#3, #45, and #51) reviewed for transfers to the hospital. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights related to transfers. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, and dementia. A review of records documented Resident #3 was transferred to the hospital on 5/8/24, and 7/24/24. Resident #3's record did not include transfer notices to the ombudsman regarding the patient hospital transfers on 5/8/24 and 7/24/24 to ensure a safe and effective transition of care. 2. Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure with hypoxia (low levels of oxygen in your body tissues), chronic obstructive pulmonary disease, and stroke. A review of records documented Resident #45 was transferred to the hospital on 7/18/24, and 7/23/24. Resident #45's record did not include transfer notices to the ombudsman regarding the patient hospital transfers on 7/18/24 and 7/23/24 to ensure a safe and effective transition of care. On 11/08/24 at 9:33 AM, the CNO confirmed the facility this has not been providing ombudsman hospital notifications when a resident is transferred to the hospital. The CNO confirmed the ombudsman's was not notified Resident #3 and Resident #45 were transferred to the hospital. 36193 3. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including right hemiplegia and hemiparesis (paralysis and weakness) following stroke. A nursing progress notes, dated 6/1/24 at 3:39 PM documented Resident #51 was clammy, afebrile, and wiggled in bed and was not alert as her usual. The progress notes documented her blood sugar was elevated and her blood pressure was low. An order was received to do a stat (immediately) CBC (complete blood count) and CMP (complete metabolic panel). A nursing progress notes, dated 6/1/24 at 4:32 PM documented an order was received to send Resident #51 to the emergency room due to critically BUN (blood urea nitrogen - kidney function test) and high sodium level. On 11/7/24 at 12:49 PM, the CEO stated the facility did not inform the Ombudsman of Resident #51's discharge to the hospital.

Based on record review, Incident and Accident (I&A) report review, resident, family, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to prevent residents with diminished cognitive ability from elopement from the facility and to prevent falls. This was true for 2 of 6 residents (#6 and #12) reviewed for supervision and accidents. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #12 in immediate jeopardy of serious harm, impairment, or death. The facility's failure to ensure Resident #6 received the level of supervision necessary to prevent falls placed him at risk of bone fractures and/or other serious injuries when he sustained repeated falls over a 3 month period. Findings include: 1. Resident #12 was admitted to the facility 11/12/20, with multiple diagnoses including dementia and depression. Idaho Preadmission screening and resident review (PASARR), dated 11/12/20, documented Resident #12 had a history of a suicide attempt and suicidal talk and ideas. It stated she received mental health services on 12/9/19, and had a suicide attempt or gesture on 3/16/20. Resident #12's quarterly MDS assessment, dated 5/3/21, documented she was severely cognitively impaired and walked with a walker. A nursing progress note, dated 12/21/20 at 5:42 PM, documented Resident #12 had exited the building at 5:00 PM and walked over to the assisted living building, located on the same property. The note documented Resident #12 did not have injuries. The note documented Resident #12's family member and the physician were notified, and an order was received to place a wander guard bracelet on Resident #12's wrist. The wander guard was placed on Resident #12 and her TAR documented staff were to check the site (wrist) and function of her wander guard every shift, beginning on 12/21/20. Resident #12's care plan for elopement risk documented the following interventions: * Distract Resident #12 from wandering, initiated on 12/22/20. * Identify the pattern of Resident #12's wandering, initiated on 12/22/20. * Provide structured activities, initiated on 12/22/20. * Apply wander guard to wrist and check every shift and as needed to ensure it was in place and monitor for proper functioning, initiated on 12/23/20. * Offer to walk with Resident #12 when she becomes restless, initiated on 12/23/20. A social services progress note, dated 12/24/20 at 10:43 AM, documented a care conference was held with Resident #12's family to discuss her wandering. The note documented if Resident #12 continued to wander they may need to look for a dementia unit for her. The note documented her family agreed. A nursing note, dated 3/24/21 at 3:20 PM, documented Resident #12 attempted to exit from the front door and her wander guard alarm sounded. The note documented Resident #12 was confused and was able to be redirected. A nursing progress note, dated 4/7/21 at 3:38 PM, documented Resident #12 had left the facility with family for an outing and her wander guard did not alarm. The note documented the wander guard was going to be assessed upon Resident #12's return. A nursing progress note, dated 4/8/21 at 1:21 PM, documented Resident #12 was .wandering around more today . and her wander guard was not working. The note documented management was aware Resident #12's wander guard was not working and were attempting to locate .a new band for her new wander guard. Progress notes documented Resident #12 was not wearing her wander guard bracelet on 4/9/21 at 10:17 AM and 4/11/21 at 2:38 PM, 2:39 PM, and 2:56 PM. Resident #12's wander guard was not functioning and/or worn for 4 days. A nursing progress note, dated 4/11/21 at 6:21 PM, documented Resident #12 was up and roaming around facility more than before. The note documented Resident #12 did not have her wander guard on and the oncoming nurse was notified. Progress notes documented Resident #12 was not wearing her wander guard bracelet on 4/12/21 at 2:10 AM and 12:54 PM. A social services progress note, dated 4/20/21 at 5:58 PM, documented staff reported to the Social Services Director Resident #12 was displaying increased behavior of eloping/wandering and increased signs and symptoms of depression. The note documented behavior monitoring was in place and the Social Service Director was going to speak with Resident #12 the following day. The next note by the Social Services Director was on 4/30/21, 10 days later, which documented she had left a message with Resident #12's family member to set up a care conference. A nursing progress note, dated 4/25/21 at 6:02 PM, documented Resident #12 made several attempts to leave the building, stating she needed to go home. The note documented she was redirected by staff. A nursing progress note, dated 4/27/21 at 7:41 PM, documented Resident #12 made several attempts to leave the building, stating she needed to go home. The note documented she was redirected by staff. A nursing progress note, dated 4/29/21 at 11:25 AM, documented Resident #12 had gathered some personal belongings and was attempting to leave the building. The note documented she was redirected by staff. A nursing progress note, dated 4/29/21 at 2:17 PM, documented a call was received from Resident #12's husband and he stated Resident #12 was at their house. The note documented her husband stated Resident #12 was wearing the wander guard. The note documented staff had reported Resident #12 was attempting to exit the facility at approximately 10:30 AM and she was with a staff one-on-one until .she calmed down. The note documented Resident #12 was last seen by a nurse at approximately 11:30 AM. The note also documented Resident #12's husband stated he planned to bring her back to the facility after he visited with her. An I&A report, dated 5/4/21, documented Resident #12 left the faciity on [DATE] without staff knowledge. The I&A report documented the facility became aware Resident #12 had left when her husband called the facility at 2:17 PM. Resident #12's husband reported she was at his home and her wander guard was in place on her wrist. The report documented the root cause of the elopement was due to Resident #12's poor safety awareness, confusion, and that she missed her family. The report documented the plan was to replace her wander guard bracelet and they ordered a transmitter to check the function of the wander guard device. The report also documented staff were to .complete routine visual checks on residents. Staff education provided. It was unclear in the documentation from the facility the amount of time Resident #12 was away from the facility and without supervision. On 7/23/21 at 11:45 AM, Resident #12's family member stated when Resident #12 left the facility her alarm was not working. She stated Resident #12 walked to a business complex near 21st Street and stated it was at least 1 to 2 miles from the facility. Resident #12's family member stated a couple picked her up in that area and dropped her off at her husband's house. The family member stated Resident #12's husband called the facility and notified them she was gone. The TAR for May 2021 documented Resident #12 was to be observed hourly and to document in a progress note what she was doing, any behaviors, and any interventions, beginning on 4/29/21 at 5:00 PM. Nursing progress notes from 4/29/21 at 6:21 PM to 4/30/21 at 6:03 AM, included hourly documentation of Resident #12. There was no hourly documentation in the progress notes from 6:03 AM to 7:03 PM on 4/30/21 (13 hours). Hourly documentation in the progress notes resumed on 4/30/21 at 7:03 PM and continued through 5/4/21 at 6:18 PM. After that time, the documentation was not every hour on a consistent basis. A nursing progress note, dated 5/7/21 at 1:28 PM, documented Resident #12 attempted to exit the facility but was redirected. A nursing progress note, dated 5/18/21 at 6:56 PM, documented Resident #12 attempted to exit the facility to go home at dinner but was redirected. The TAR for June 2021 documented Resident #12 was to be observed hourly and to document in a progress note what she was doing, any behaviors, and any interventions. The TAR also directed staff to check on Resident #12 once a shift. A nursing progress note, dated 6/30/21 at 5:44 PM, documented Resident #12 had increased exit seeking behavior and she was convinced she needed to go home. The note documented Resident #12 became agitated with staff .redirecting her to alternative options like her mail and going to her room. A nursing progress note, dated 7/1/21 at 9:02 PM, documented Resident #12 exited the facility after dinner and was redirected by staff back into the facility. A nursing progress note, dated 7/16/21 at 1:10 PM, documented Resident #12 was walking down the hallway toward the exit door. Resident #12 did not respond when the nurse called her name, and she exited the building. The MDS nurse followed Resident#12 and asked her what she was doing. Resident #12 stated she was going .to jump of [sic] the cliff. The facility was situated on a hill with an approximate 50-foot drop 10 yards from the hallway exit door Resident #12 opened to leave the facility. There was no fencing around the drop, and the hillside had medium sized rocks along the exposed side. The clinical alerts listing report, documented on 7/16/21 at 3:07 PM, stated Resident #12 was put on alert charting and documented staff were to monitor Resident #12 for wandering and encouraged line-of-sight monitoring by staff when she was not with her family or sleeping. There was no documentation that line-of-sight observation was implemented or occurred. On 7/23/21 at 9:50 AM, Resident #12 stated she felt sad every day, throughout the day, for several months. When asked if anyone had asked her how she was feeling or if she was feeling sad, she stated only her husband had asked. On 7/23/21 at 3:14 PM, CNA #1 was interviewed regarding line-of-sight monitoring. CNA #1 stated the staff must always have an eye on the resident, and they must always be within staff's visual field. CNA #1 stated you cannot do line-of-sight observations while walking up and down the hallway and periodically looking into the room at the resident. When asked if any residents were on line-of-sight monitoring in the facility, CNA #1 stated no. On 7/23/21 at 3:20 PM, CNA #2 was interviewed regarding line-of-sight monitoring. CNA #2 stated that line-of-sight monitoring was like one-on-one monitoring. When asked if walking in the hallway and looking into a room to check a resident would be line-of-sight monitoring CNA #2 stated no. When asked if any residents in the facility were on line-of-sight monitoring, CNA #2 stated she did not know. On 7/22/21 at 5:38 PM, DDCO documented on the surveyor document request form the facility's change of condition policy was standard of practice and the facility did not have a line-of-sight procedure or policy. On 7/23/21 at 10:00 AM, LPN #1 was asked to describe what was being monitored on Resident #12's alert charting. LPN #1 stated she was new, and she did not know. On 7/23/21 at 10:15 AM, RN #1 stated the facility has five exits and the wander guard only alarmed on the hallway the resident exits out of. She stated staff on the other halls would not hear the wander guard alarm alert. On 7/23/21 at 2:43 PM, the physician stated during a phone call he was not notified of Resident #12's elopement on 7/16/21. On 7/23/21 at 5:42 PM, the DON stated line-of-sight supervision was when staff encouraged residents to stay within a specific area, so the nurse can always see them. On 7/23/21 at 6:05 PM, the DON, with the RCN present, was asked about Resident #12's risk for elopement. The RCN interrupted the DON's answer and stated, She has an alarm, and staff were alerted, that is my answer. This failed practice placed Resident #12 at risk for serious harm, impairment, or death. On 7/23/21 at 7:58 PM, the Administrator, DON, and RCN were verbally informed and provided written notification of the Immediate Jeopardy determination at F689. The Immediate Jeopardy was not removed prior to the survey exit on 7/24/21. 2. The facility's policy for Fall Evaluation (Morse Scale) and Management, updated March 2018, documented the following: * A licensed nurse was to complete the Morse Scale fall evaluation on admission. If the total Morse scale score was greater than 45, the resident was considered as having a high potential for falls. * A licensed nurse completed re-evaluations with each fall and significant change in condition. * After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse (LN) would evaluate the resident's neurological status and monitor the resident for seventy-two hours after unwitnessed fall or falls that involved the resident's head striking a surface. The LN would update the Morse Scale, complete orthostatic vital signs, a progress note, a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. The LN would review and update the care plan with newly identified interventions as needed. This policy was not followed. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses, including monoplegia (paralysis that impacts one limb) of the left leg, dementia, and anxiety disorder. The admission Morse Fall scale assessment dated [DATE], documented Resident #6 was at high risk for falls. Resident #6's care plan for fall risk, initiated on 4/15/21, documented staff were to anticipate and meet his needs, ensure his call light was within reach and encourage him to use it, ensure he was wearing appropriate footwear when ambulating, keep him in line-of-sight with frequent checks, and anticipate his toileting needs. The care plan did not specify what was meant by line-of-sight and frequent checks. An admission MDS assessment. dated 4/21/21, documented Resident #6 was cognitively intact and required extensive assistance of one to two staff members for all daily care. He used a wheelchair for locomotion and had a history of falls prior to admission and in the facility. A quarterly MDS assessment, dated 7/9/21, documented Resident #6's mental status had declined from cognitively intact to severely cognitive impaired. A progress note, dated 4/13/21 at 1:42 PM, documented Resident #6, At this time resident has nearly fallen six times if not more. Therapy has been assisting as much as they can in monitoring him as he is requiring constant supervision and reminding for his safety. Resident #6 had eleven falls in three months from 4/17/21 to 7/17/21, 9 unwitnessed falls and 2 witnessed falls. Resident #6 sustained injuries from 3 of the falls, 6/20/21, 7/3/21, and 7/17/21. Examples include: a. An I&A report, dated 4/17/21 at 10:30 AM, and a nurse progress note dated 4/17/21 at 1:12 PM, documented Resident #6 had an unwitnessed fall. He was found seated between his wheelchair and bed. Resident #6 was confused, oriented to self only. He had a 4 cm by 2 cm skin tear on the back of his right arm. Resident #6 was not able to give a description of what happened. Resident #6's care plan for fall risk was revised on 4/19/21, and the following interventions were added: * Vital signs per center policy. Take blood pressure lying /sitting/ standing one time in the first 24 hours. Initiated on 4/19/21. * Provide activities that promote exercise and strength building when possible. Provide one on one activity if bed bound. Initiated on 4/19/21. * Offer to lay down or rest in recliner between meals. Initiated on 4/19/21. The I&A report included an IDT review note, dated 4/22/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior as he appeared to have fallen trying to transfer to bed. The IDT note documented the intervention developed to decrease his risk of falls was to offer assistance to bed or a recliner between meals. b. An I&A report, dated 4/20/21 at 10:39 AM, and a nurse progress note dated 4/20/21 at 10:49 AM, documented Resident #6 had an unwitnessed fall. He was found on the floor beside his bed. His wheelchair was next to the head of the bed and the brakes were not locked on his wheelchair. The I&A report included an IDT review note, dated 4/23/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior. New interventions were to apply an anti-roll back device to his wheelchair and continue with the previous interventions for his fall risk care plan. Resident #6's fall risk care plan was revised to include a new intervention for Antirollback [sic] to be added to W/C [wheelchair] when available, initiated on 4/26/21. c. An I&A report, dated 5/3/21 at 2:15 PM, and a nurse progress note dated 5/2/21 at 2:02 PM, documented Resident #6 had an unwitnessed fall. He was found on the floor with his buttocks facing the wheelchair and his bed. His wheelchair brakes were locked. Resident #6 said, I think I bumped the side of my head. The I&A report included an IDT fall review note, dated 5/8/21, which documented the root cause of the fall was Resident #6's poor safety awareness, overestimating his own abilities, and weakness. The intervention to decrease Resident #6's falls was to check orthostatic blood pressure (a condition in which your blood quickly drops when you stand up from a sitting or lying position which may cause dizziness and fainting) for 3 days and to check his blood pressure and heart rate 4 times a day for 3 days to monitor for trends. Resident #6's fall risk care plan was revised, on 5/3/21, to include the following new interventions: * When the resident gets restless, offer food and fluids. Offer bathroom. Check to see if resident has any pain. Offer diversional activities. * Follows the 4 R's: - Relieve-ask about pain during the visit. Is anything needed to relieve pain? - Reposition. - Restroom, assist the resident to the restroom if needed. - Reach, verify resident's items are within reach. Resident #6's care plan was also revised to include a new intervention for drug regimen review related to the fall on 5/2/21, initiated on 5/7/21. d. An I&A report, dated 5/15/21 at 3:00 PM, and a nurse progress note dated 5/15/21 at 4:39 PM, documented Resident #6 had an unwitnessed fall. He was found on the floor next to his bed with his back against the side of the bed, next to his wheelchair. Resident #6 was unable to describe what happened and was confused. Resident #6 had socks on with no shoes. The I&A report included an IDT fall review note, dated 5/19/21, which documented the cause of the fall was related to Resident #6 removing his shoes and having poor safety awareness. The intervention to decrease Resident #6's fall risk was for non-skid socks to be worn while out of bed. Resident #6's fall risk care plan was revised to include the new intervention for non-skid socks to be worn with his shoes when he was out of bed, initiated on 5/19/21. e. An I&A report, dated 5/24/21 at 10:51 PM, and a nurse progress note dated 5/24/21 at 11:24 PM, documented Resident #6 had a witnessed fall of sliding off the bed. The I&A report included an IDT fall review note, dated 5/25/21, which documented the fall occurred related to Resident #6's impulsive behavior and lack of safety awareness. A diagnosis of overreactive bladder was added as a contributing factor. Resident #6's fall risk care plan was revised to include the new intervention for a 72-hour one-on-one (1:1) time study, initiated on 5/25/21. The care plan did not specify what was meant by a 1:1 time study. f. An I&A report, dated 5/30/21 at 1:13 PM, and a nurse progress note dated 5/30/21 at 1:21 PM, documented Resident #6 had an unwitnessed fall. He was sitting on the floor by the end of his bed, approximately two feet in front of his wheelchair. He said, I was going to take that plate and this cup out of my room. The I&A report included an IDT fall review note, dated 6/3/21, which documented the fall occurred related to Resident #6's attempt to self-transfer and his poor safety awareness. The new intervention was for 1:1 staffing to further track his behaviors and try to identify patterns or fall triggers. Resident #6's fall risk care plan was revised to include the new intervention of pick up dishes after resident finishes meals and pick up clutter, initiated on 6/3/21. g. An I&A report, dated 6/7/21 at 12:20 PM, and a nurse progress note dated 6/7/21 at 12:29 PM, documented Resident #6 had an unwitnessed fall. He was lying on the floor by the staff bathroom without his wheelchair. The I&A report included an IDT fall review note, dated 6/10/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior. The intervention to decrease Resident #6's falls was to conduct an incontinence evaluation to assess if toileting would benefit him and decrease his impulsive behavior. Resident #6's fall risk care plan did not include new interventions. h. An I&A report, dated 6/18/21, and a nurse progress note dated 6/17/21 at 2:42 AM, documented Resident #6 had an unwitnessed fall. He was found sitting on the floor in his bathroom and he was confused. The I&A report included an IDT fall review note, dated 6/18/21, which documented the root cause of Resident #6's fall was lack of awareness regarding safety limitations. The plan to decrease Resident #6's risk for falling was ongoing education, frequent checks, and staff would keep him in eyesight at all times. Resident #6's fall risk care plan was revised to include new interventions, as follows: * Do not leave the resident alone in the bathroom, initiated on 6/17/21. * For no apparent acute injury, determine and address causative factors of the fall, initiated on 6/18/21. i. An I&A report, dated 6/20/21 at 5:58 PM, and a nurse progress note dated 6/20/21 at 6:36 PM, documented Resident #6 had an unwitnessed fall. He was found lying next to his shoes on the floor in his bathroom with a 4 cm cut to the side of his head. Resident #6 continued to attempt self-transfers several times before being redirected to his evening meal. The family requested the resident be sent to the emergency room (ER) for evaluation. A progress note, dated 6/20/21 at 6:59 PM, documented Resident #6's family declined to send him to the ER after talking with paramedics who stated the ER would not do anything for Resident #6. The note documented the wound on Resident #6's head was a cut that was no longer bleeding. The I&A report included an IDT fall review note, dated 6/22/21, which documented the root cause of the fall was Resident #6 was unaware of safety limitations. The intervention to prevent Resident #6's falling was to request a care conference related to the need for placement in a private facility with less stimulation, continue 1:1 resident in staff eyesight until accommodations are met related to safety. The review note also documented ongoing education was to continue with Resident #6 related to weakness and the need for one person to assist him with all transfers. Resident #6's fall risk care plan had a revised intervention to keep him in-line of sight as able, continue frequent checks, and anticipate toileting needs, initiated on 4/15/21 and revised on 6/22/21. j. An I&A report, dated 7/4/21 at 10:45 AM, and a nurse progress note dated 7/3/21 at 10:46 AM, documented Resident #6 had a witnessed fall. He had attempted to reach the newspaper on the nursing station counter and lost his balance. He was noted to have two cuts, one on his right temple area and the other on his right cheek, a small skin tear to his right wrist, and some bruising to both of his arms. A progress note, dated 7/3/21 at 11:10 AM, documented Resident #6 was sent to the hospital for an evaluation. The I&A report included an IDT fall review note, dated 7/4/21, which documented the facility would continue to monitor Resident #6, keeping him within vision of staff and continue with discharge planning. Resident #6's care plan did not include new interventions. Resident # 6's record included an In-service Education Summary, dated 7/3/21, which documented the topic and content was Resident #6 was to be in line-of-sight at all times. A nurse or CNA needed to be with him at all times for his safety. Staff were to encourage Resident #6 to relax and rest in a recliner in the day room, so he remained in line-of-sight of staff at all times. k. An I&A report, dated 7/18/21 at 12:49 AM, and a nurse progress note dated 7/17/21 at 13:28 AM, documented Resident #6 had a witnessed fall. It documented Resident #6 was sitting in his wheelchair by the nurse's station, attempted to pick up a bag of crackers off the floor, and fell out of his wheelchair. He landed on the floor and hit his right temple, shoulder, and hip. His laceration on his right temple from the prior fall incident on 7/3/21 reopened and grew to 4 cm by 0.2 cm. The I&A report included an IDT fall review note, dated 7/19/21, which documented the root cause of the fall was Resident #6 was unaware of safety limitations, was confused, and education was not effective because of his memory and confusion. The plan to prevent Resident #6's falls was to continue to ask family for assistance throughout the day and encourage resident to participate in daily activities. Resident #6's care plan for fall risk was revised on 7/19/21. There were no new interventions documented on his care plan but two interventions, initiated on 5/25/21 and 6/3/21, were revised. The two interventions were a 72 hour 1:1 time study and to keep him in line-of-sight, continue frequent checks, and anticipate his toileting needs. The care plan did not specify what was meant by line-of-sight, frequent checks, and what the time study involved. On 7/23/21 at 5:35 PM, the DON stated Resident #6 had multiple falls because he had no safety awareness. The intervention was keep him in line-of-sight at all times and Staff to encourage him to participate in activities. When asked how staff knew who was responsible for keeping Resident #6 in line-of-sight at all times, the DON said they had a staff in-service and alert charting to remind everyone. The facility did not provide the staff supervision necessary to protect Resident #6 from repeated falls. Based on observation, record review, family interview, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to meet resident needs to prevent elopement and falls. This was true for 2 of 6 residents (#6 and #12) reviewed for supervision and accidents. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #12, and other residents who were at risk for elopement, in immediate jeopardy of serious harm, impairment, or death. Findings include: 1. Resident #12 was admitted to the facility 11/12/20, with multiple diagnoses including dementia and depression. Resident #12's quarterly MDS assessment, dated 5/3/21, documented she was severely cognitively impaired and walked with a walker. A nursing progress note, dated 12/21/20 at 5:42 PM, documented Resident #12 had exited the building at 5:00 PM and walked over to the assisted living building, on the same property. The note documented Resident #12 did not have injuries. The note documented Resident #12's family member and the physician were notified, and an order was received to place a wander guard bracelet on Resident #12's wrist, which it was. The TAR for Resident #12 documented to check the site and the function of her wander guard every shift, beginning on 12/21/20. Resident #12's care plan for elopement risk documented the following interventions: *Distract Resident from wandering, initiated on 12/22/20. *Identify the pattern of Resident #12's wandering, initiated on 12/22/20. *Provide structured activities, initiated on 12/22/20. *Apply wander guard to wrist and check every shirt and as needed to ensure it was in place and monitor for proper functioning, initiated on 12/23/20. *Offer to walk with resident when she becomes restless, initiated on 12/23/20. A social services progress note, dated 12/24/20 at 10:43 AM, documented a care conference was held with Resident #12's family to discuss her wandering. The note documented if Resident #12 continued to wander they may need to look for a dementia unit for her. The note documented her family agreed. A nursing note, dated 3/24/21 at 3:20 PM, documented Resident #12 attempted to exit from the front door and her wander guard alarm sounded. The note documented Resident #12 was confused and was able to be redirected. A nursing progress note, dated 4/7/21 at 3:38 PM, documented Resident #12 had left the facility with family for an outing and her wander guard did not alarm. The note documented the wander guard was going to be assessed upon Resident #12's return. A nursing progress note, dated 4/8/21 at 1:21 PM, documented Resident #12 was .wandering around more today . and her wander guard was not working. The note documented management was aware Resident #12's wander guard was not working and were attempting to locate .a new band for her new wander guard. Progress notes documented Resident #12 was not wearing her wander guard bracelet on 4/9/21 at 10:17 AM and 4/11/21 at 2:38 PM, 2:39 PM, and 2:56 PM. Resident #12's wander guard was not functioning and/or worn for 4 days. A nursing progress note, dated 4/11/21 at 6:21 PM, documented Resident #12 was up and roaming around facility more than before. The note documented Resident #12 did not have her wander guard on and the oncoming nurse was notified. Progress notes documented Resident #12 was not wearing her wander guard bracelet on 4/12/21 at 2:10 AM and 12:54 PM. A social services progress note, dated 4/20/21 at 5:58 PM, documented staff reported to the Social Services Director Resident #12 was displaying increased behavior of eloping/wandering and increased signs and symptoms of depression. The note documented behavior monitoring was in place and the Social Service Director was going to speak with Resident #12 the following day. The next note by the Social Services Director was on 4/30/21, 10 days later, which documented she had left a message with Resident #12's family member to set up a care conference. A nursing progress note, dated 4/25/21 at 6:02 PM, documented Resident #12 made several attempts to leave the building stating she needed to go home. The note documented she was redirected by staff. A nursing progress note, dated 4/27/21 at 7:41 PM, documented Resident #12 made several attempts to leave the building stating she needed to go home. The note documented she was redirected by staff. A nursing progress note, dated 4/29/21 at 11:25 AM, documented Resident #12 had gathered some personal belongings and was attempting to leave the building. The note documented she was redirected by staff. A nursing progress note, dated 4/29/21 at 2:17 PM, documented a call was received from Resident #12's husband and he stated she was at their house. The note documented her husband stated Resident #12 was wearing the wander guard. The note documented staff had reported Resident #12 was attempting to exit the facility at approximately 10:30 AM and she was with a staff one-on-one until .she calmed down. The note documented Resident #12 was last seen by a nurse at approximately 11:30 AM. The note also documented Resident #12's husband stated he planned to bring her back to the facility after he visited with her. An I&A report, dated and signed on [TRUNCATED]

Based on policy review, record review, staff interview, and resident interview, it was determined the facility failed to ensure a resident was provided with behavioral health care services to maintain her highest practicable physical, mental, and psychosocial well-being consistent with her needs. This was true for 1 of 4 residents (Resident #12) reviewed for behavioral health. The health and safety of all residents residing in the facility were placed in immediate jeopardy when a) Resident #12 was at risk of suicide and ongoing elopement due to inadequate behavioral health services and b) the other 43 residents residing in the facility were at risk of experiencing isolation and compromised physical and psychosocial well-being related to a lack of preventing, relieving, and/or accommodating a resident's psychological distress. Findings include: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and depression. The facility's policy for behavior management, updated 1/19, documented new or increased behaviors were communicated to the IDT team. It documented the IDT team reviewed the resident's record, behavior monitoring flow sheet, and evaluated the effectiveness of the current plan. The IDT team would note the effectiveness of interventions in the medical record and if further evaluation was needed, new interventions would be implemented. This policy was not followed. On 5/3/21, Resident #12's quarterly Minimum Data Set (MDS) assessment documented Resident #12 was severely cognitively impaired and walked with a walker. The Idaho Preadmission screening and resident review (PASARR), dated 11/12/20, documented Resident #12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It stated she received mental health services on 12/9/19 and had a suicide attempt or gesture on 3/16/20. On 7/15/20, a neuropsychological evaluation documented Resident #12 was hospitalized in a psychiatric facility in January 2000 due to increased depression, anxiety and suicidal ideation. The discharge recommendation from her psychologist regarding treatment and follow-up care documented Resident #12 should have regular supervision throughout the day and should not be left alone for extended periods of time. It documented Resident #12 should be seen for a psychiatric follow-up evaluation to monitor further cognitive decline and update treatment/supervision recommendations as needed. Resident #12's care plan initiated on 12/22/20 documented no interventions for suicidal risk monitoring, elopement, or behavioral health services. On 6/29/21 at 12:21 PM, a progress note documented an appointment request was filled out for Resident #12 to see a mental health provider. There was no documentation in Resident #12 record that she was seen by a mental health provider after the appointment request was filled out. On 7/16/21 at 1:10 PM, a progress note documented Resident #12 was walking down the oak hallway toward the oak hallway exit door. She did not respond when the nurse called her name, and she exited the building. The MDS nurse followed the resident and asked her what she was doing. Resident #12 stated she was going to jump off the cliff. The facility was situated on a hill with an approximate 50-foot drop 10 yards from the oak hallway exit door. There is no fencing around the drop, and the hillside has medium sized rocks along the exposed side. On 7/16/21 at 3:09 PM, Resident #12 was put on alert charting which documented staff were to monitor Resident #12 for wandering and encourage line-of-sight monitoring by staff when she was not with her family or sleeping. Resident#12's alert charting also directed staff to monitor her for depression and self-harm acts. There was no documentation in Resident #12's record the physician was notified related to her statement she was going to jump off the cliff. Resident #12's record did not include behavioral monitor flowsheets for suicidal behaviors, triggers, interventions, or outcome. Resident #12's depression behavioral monitor flowsheets documented no for any depressive symptoms for May-July 2021. On 7/23/21 at 3:14 PM, CNA #1 was interviewed regarding what line-of-sight care. He/she stated that you must always have an eye on the patient, and they must always be within your visual field. He/she stated you cannot do line-of-sight observations while walking up and down the hallway and periodically looking into the room at the resident. When asked if any residents were on line-of-sight care in the facility, he/she stated no. On 7/23/21 at 3:20 PM, CNA #2 was interviewed regarding line-of-sight care. He/she stated that line of sight care was like 1-on-1 services. When asked if walking in the hallway and looking into a room to check a resident would be line-of-sight care he/she stated no. When asked if any residents in the facility were on line-of-sight care he/she stated he/she didn't know. On 7/22/21 at 5:38 PM, the lead Divisional Director of Clinical Operations (DDCO) was asked for the suicide precaution policy. On the surveyor document request form, she documented the facility did not have one and wrote call 911 beside the request. She documented the facility change of condition policy was standard of practice and the facility had no line -of -sight procedure or policy. On 7/23/21 at 9:50 AM, Resident #12 stated she felt sad every day, throughout the day, for several months. When asked if she had been offered psychiatric services she stated No, but I hope they will because it would help. When asked if anyone had asked her how she was feeling or if she was feeling sad, she stated only her husband had asked. On 7/23/21 at 10:00 AM, LPN #1 was asked to describe what was being monitored on Resident #12's alert charting. LPN #1 stated she was new, and she did not know but she would print it and find out. On 7/23/21 at 2:43 PM, the physician stated in a phone call with a surveyor he was not notified of Resident #12's suicidal elopement or her statement of her intent to jump off the cliff on 7/16/21. On 7/23/21 at 5:50 PM, the Regional Clinical Nurse (RCN) was asked if she was aware Resident #12 recently had suicidal thoughts, she stated what is documented in the chart is she wanted to jump off a cliff. When asked if she was aware Resident #12 had a suicide attempt and it was documented on the PASRR I, she stated she could not find it. When a copy of the PASSAR I was given to her with the highlighted information regarding Resident #12's suicidal history, she stated So, I'm looking and I'm not seeing it. I can't find the form you have. On 7/23/21 at 6:05 PM, the DON stated when residents have suicidal thoughts, staff would monitor that resident, or they would send them to the emergency department. She stated she based suicidal evaluation and interventions on risk, and she would assess a resident's risk related to elopement and suicide or send the resident to the ER for evaluation. When asked what Resident #12's risk was for suicidality and elopement, the RCN interrupted the DON's answer and stated, She has an alarm, and staff were alerted, that is my answer. The facility did not provide Resident #12 necessary behavioral health care and services and placed Resident #12 at risk for serious harm, impairment, or death. On 7/23/21 at 7:58 PM, the Administrator, DON, and RCN were notified verbally and in writing of the Immediate Jeopardy to residents' health and safety. The IJ was unable to be removed by the survey team prior to the end of survey on 7/24/21.

Based on observation, record review, Facility Assessment review, policy review, review of the Facility Assessment, review of I&A Reports, review of staffing schedules, and interviews with residents, family, and staff, it was determined the facility failed to ensure there were sufficient numbers of competent staff to meet supervision, ADL needs, medication administration, and answer call lights in a timely manner for residents. This was true for 16 of 22 residents (#2, #3, #6, #12, #20, #21, #25, #27, #29, #32, #35, #37, #38, #39, #141, and #630) reviewed for staffing concerns. This deficient practice caused residents physical harm from lack of sufficient staff when Resident #37 and Resident #630 developed pressure ulcers, Resident #6 had falls with injury, and Resident #39 had psychosocial harm due to embarrassment from lack of personal hygiene. This deficient practice also had the potential to effect the other 25 residents residing in the facility. Findings include: The facility's Facility Assessment, 2021 stated, the facility provides services to residents who are one-person, two-person, and total assist. The assessment stated the Center has hired licensed staff and non-licensed staff to provide all the required services to the residents. The assessment also documented competencies for staff during the past year included but were not limited to: * Person Centered Care * Care of persons with Alzheimer's and Dementia * Care of persons with mental/psychological disorders * Skin Care * Fall prevention * Elopement * Privacy and Dignity * Bathing The Facility Assessment was not followed. 1. Resident #12 was admitted to the facility 11/12/20 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #12's quarterly MDS assessment, dated 5/3/21, documented she was severely cognitively impaired and walked with a walker. a. A nursing progress note, dated 12/21/20 at 5:42 PM, documented Resident #12 had exited the building at 5:00 PM and walked over to the assisted living building, on the same property. The note documented Resident #12 did not have injuries. The note documented Resident #12's family member and the physician were notified, and an order was received to place a wander guard bracelet on Resident #12's wrist. A nursing progress note, dated 4/29/21 at 2:17 PM, documented a call was received from Resident #12's husband and he stated she was at their house. The note documented her husband stated Resident #12 was wearing the wander guard. The note documented staff had reported Resident #12 was attempting to exit the facility at approximately 10:30 AM and she was with a staff one-on-one until .she calmed down. The note documented Resident #12 was last seen by a nurse at approximately 11:30 AM. The note also documented Resident #12's husband stated he planned to bring her back to the facility after he visited with her. An I&A report, dated and signed on 5/4/21, documented Resident #12 left the faciity on [DATE] without staff knowledge. The I&A report documented the facility became aware Resident #12 had left when her husband called the facility at 2:17 PM. Resident #12's husband reported she was at his home and her wander guard was in place on her wrist. The report documented the root cause of the elopement was due to Resident #12's poor safety awareness, confusion, and her missing family. The report documented the plan was to replace her wander guard bracelet and they ordered a transmitter to check the function of the wander guard device. The report also documented staff were to .complete routine visual checks on residents. Staff education provided. It was unclear in the documentation from the facility the amount of time Resident #12 was away from the facility and without supervision. On 7/23/21 at 11:45 AM, Resident #12's family member stated when she left the faciity on [DATE] her alarm was not working. She stated Resident #12 walked to a business complex near 21st Street and stated it was at least 1 to 2 miles . from the facility. Resident #12's family stated a couple picked her up in this area and dropped her off at her husband's house. The family member stated Resident #12's husband called the facility and notified them she was gone. On 7/23/21 at 2:43 PM, the physician stated during a phone call he was not notified of Resident #12's elopement on 7/16/21. On 7/23/21 at 6:05 PM, the DON, with the RCN present, was asked regarding Resident #12's risk for elopement, the RCN interrupted the DON's answer and stated, She has an alarm, and staff were alerted. This failed practice placed Resident #12 at risk for serious harm, impairment, or death. b. The Idaho Preadmission screening and resident review (PASARR), dated 11/12/20, documented Resident #12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It stated she received mental health services on 12/9/19 and had a suicide attempt and/or gesture on 3/16/20. On 7/15/20, a neuropsychological evaluation documented Resident #12 was hospitalized in a psychiatric facility in January 2020 due to increased depression, anxiety and suicidal ideation. The discharge recommendation from her psychologist regarding treatment and follow-up care documented Resident #12 should have regular supervision throughout the day and should not be left alone for extended periods of time. It documented Resident #12 should be seen for a psychiatric follow-up evaluation to monitor further cognitive decline and update treatment/supervision recommendations as needed. Resident #12's care plan initiated on 12/22/20 documented no interventions for suicidal risk monitoring or behavioral health services. On 6/29/21 at 12:21 PM, a progress note documented an appointment request was filled out for Resident #12 to see a mental health provider. There was no documentation in Resident #12's record that she was seen by a mental health provider after the appointment request was filled out. On 7/16/21 at 1:10 PM, a progress note documented Resident #12 was walking down the oak hallway toward the exit. She did not respond when the nurse called her name, and she exited the building. The MDS nurse followed Resident #12 and asked her what she was doing, Resident #12 stated she was going to jump of [sic] the cliff. The facility was situated on a hill with an approximate 50-foot drop 10 yards from the exit door. There was no fencing around the drop, and the hillside had medium sized rocks along the exposed side. On 7/16/21 at 3:09 PM, Resident #12 was put on alert charting which documented staff were to monitor Resident #12 for wandering and encourage line-of-sight monitoring by staff when she was not with her family or sleeping. Resident#12's alert charting also directed staff to monitor her for depression and self-harm. There was no documentation in Resident #12's record the physician was notified related to her statement she was going to jump off the cliff. Resident #12's record did not include behavioral monitoring for suicidal behaviors, triggers, interventions, or outcome. Resident #12's depression behavioral monitoring documented no for any depressive symptoms for May 2021 to July 2021. On 7/23/21 at 3:14 PM, CNA #1 was interviewed regarding what line-of-sight care meant. CNA #1 stated that you must always have an eye on the patient, and they must always be within your visual field. CNA #1 stated you cannot do line-of-sight observations while walking up and down the hallway and periodically looking into the room at the resident. When asked if any residents were on line-of-sight care in the facility, CNA #1 stated no. On 7/23/21 at 3:20 PM, CNA#2 was interviewed regarding line-of-sight care. CNA #2 stated that line-of-sight care was like 1-on-1 services. When asked if walking in the hallway and looking into a room to check a resident would be line-of-sight care CNA #2 stated no. When asked if any residents in the facility were on line-of-sight care CNA #2 stated she did not know. On 7/22/21 at 5:38 PM, the lead DDCO was asked for the suicide precaution policy. On the document request form from the survey team, she documented the facility did not have one and wrote call 911 beside the request. She documented on the same form the facility had no line-of-sight procedure or policy. On 7/23/21 at 9:50 AM, Resident #12 stated she felt sad every day, throughout the day, for several months. When asked if she had been offered psychiatric services she stated No, but I hope they will because it would help. When asked if anyone had asked her how she was feeling or if she was feeling sad, she stated only her husband had asked. On 7/23/21 at 10:00 AM, LPN #1 was asked to describe what was being monitored on Resident #12's alert charting. LPN #1 stated she was new, and she did not know. On 7/23/21 at 2:43 PM, the physician stated in a phone call he was not notified of Resident #12's suicidal elopement or her statement of her intent to jump off the cliff on 7/16/21. On 7/23/21 at 5:50 PM, the RCN was asked if she was aware Resident #12 had a suicide attempt and it was documented on the PASRR I, she stated she could not find it. When a copy of the PASSAR I was given to her with the highlighted information regarding Resident #12's suicidal history, she stated So, I'm looking and I'm not seeing it. I can't find the form you have. On 7/23/21 at 6:05 PM, the DON stated when residents have suicidal thoughts, staff would monitor that resident, or they would send them to the emergency department. She stated she based suicidal evaluation and interventions on risk, and she would assess a resident's risk related to elopement and suicide or send the resident to the ER for evaluation. When asked what Resident #12's risk was for suicidality and elopement, the RCN interrupted the DON's answer and stated, She has an alarm, and staff were alerted. The facility did not provide Resident #12 necessary behavioral health care and services which placed Resident #12 at risk for serious harm, impairment, or death. 2. Residents were not turned and repositioned and subequently developed pressure ulcers. The National Pressure Injury Advisory Panel website, accessed on 7/28/21, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable [CONDITION(S)] (red discoloration of skin as a result of injury) which may appear differently in darkly pigmented skin. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The Lippincott Manual of Nursing Practice, 10th edition, pages 183-184, directed nurses to reposition residents every 2 hours to relieve pressure. The manual also listed risk factors for pressure ulcers, including malnourishment, [CONDITION(S)] (swelling caused by excess fluid trapped in the body's tissues), and immobility. This guidance was not followed. a. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37's admission MDS assessment, dated 12/22/20, documented the following: * He had no pressure ulcers on admission. * He was at risk of developing pressure ulcers. * He required extensive assistance with activities of daily living and required two plus staff assistance for bed mobility and transfers. * He did not transition (move himself to change positions) or walk. * He had impairment in his upper and lower extremities on both sides. Resident #37's care plan, dated 12/14/20 and revised 4/6/21, documented he had the potential for pressure ulcer development related to decreased mobility, incontinence of bowel, skin frequently moist due to perspiration, and history of chronic non-healing pressure injuries. The care plan listed the goal was for Resident #37 to have intact skin, free of redness, blisters or discoloration, dated 12/15/20 and revised on 6/28/21. One of the interventions listed was Resident #37 was dependent on assistance for turning and repositioning and was to be turned/repositioned at least every 2 hours, and more often as needed or requested, initiated 12/15/20. A hospital virtual visit (a face-to-face meeting with a health care professional using video technology without leaving the facility) report, dated 2/22/21, documented Resident #37 had a new Stage 3 pressure ulcer on each hip. Resident #37's care conference report, dated 3/24/21, documented he was to be turned every 2 hours from side to side. The report stated staff were to document Resident #37's cares and turn schedule, and to notify the family if Resident #37 refused cares. On 6/18/21, a care conference note documented Resident #37 was no longer able to be up in his chair in order to help heal his buttocks [pressure ulcer]. A virtual hospital report, dated 6/21/21, documented Resident #37 was having sacral (a triangular area in the lower back situated between the hipbones) decubitus (pressure) ulcer breakdown again. Resident #37's record did not include documentation as when the pressure ulcer originally developed after Resident #37 was admitted . Resident #37's bed repositioning records from 6/24/21 through 7/14/21, documented he was not turned or repositioned every 2 hours or a total of 12 times during a 24-hour period as follows: * Resident #37 was turned/repositioned 2 times on 7/4/21 and 7/13/21 * Resident #37 was turned/repositioned 3 times on 6/27/21, 6/28/21, 6/29/21, 7/1/21, 7/3/21, 7/6/21, 7/8/21, 7/11/21, and 7/14/21. * Resident #37 was turned/repositioned 4 times on 7/5/21, 7/9/10, 7/10/21, and 7/12/21. * Resident #37 was turned/repositioned 5 times on 6/24/21, 6/30/21, and 7/2/21. * Resident #37 was turned/repositioned 6 times on 6/25/21, 6/26/21, and 7/7/21. The length of time recorded between turing/repositioning of Resident #37 ranged from 2.5 hours (occurring twice) to 9 hours or more (17 times), and 18 hours (1 time). On 7/20/21 at 11:35 AM, Resident #37 stated he was to be repositioned every hour, but it was not happening. On 7/23/21 at 10:21 AM, the DON stated staff kept track of Resident #37's repositioning and refusals on the form hanging on the his door. The DON stated Resident #37's refusals and many of the dates were not documented on the form. The DON stated repositioning and refusals were not documented in the electronic record. On 7/23/21 at 7:11 PM, when asked to review the repositioning documentation, the RCN stated there were lapses in Resident #37's repositioning. The RCN stated it was not documented Resident #37 was repositioned every 2 hours, or he refused repositioning. b. Resident #630 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #630's admission nursing evaluation, undated, documented Resident #630 had no pressure ulcers. The evaluation documented Resident #630 was an older adult and had [CONDITION(S)] in both lower extremities, which were both risk factors for pressure ulcers. Resident #630's physician orders, dated 5/14/20, documented a weekly skin assessment was to be completed every Wednesday. Resident #630's care plan, dated 5/15/20, documented Resident #630 was at high risk for skin impairment, and directed staff to turn Resident #630 every 2-3 hours. Resident #630's skin integrity evaluation, dated 5/14/20, documented Resident #630 was at moderate risk for pressure ulcers, with the following risk factors: * Her ability to walk was severely limited or nonexistent and she could not bear her own weight. * She had a potential problem with skin friction or shear against sheets, chair, or other devices, and occasionally she slid down in her chair or bed. Resident #630's pain evaluation, dated 5/27/20, documented she had pain at her tailbone when sitting and when laying, but she did not shift position in bed because her feet were elevated to decrease [CONDITION(S)]. A weekly skin evaluation, completed on 5/27/20 (13 days after admission), documented Resident #630 had a 2 cm x 1.5 cm Stage 2 pressure ulcer on her sacrum. Resident #630's ADL flowsheet from 5/14/20 through 6/6/20, documented she was not turned or repositioned every 2 to 3 hours as her care plan directed as follows: * Resident #630 was turned/respositioned 1 time on 6/2/20 and 6/3/20. * Resident #630 was turned/repositioned 2 times on 6/6/20. * Resident #630 was turned/repositioned 3 times on 5/14/20, 5/15/20, 5/16/20, 5/17/20, and 5/31/20, * Resident #630 was turned/repositioned 4 times on 5/26/20 and 6/1/20. * Resident #630 was turned/repositioned 5 times on 5/19/20, 5/24/20, 5/27/20, 5/28/20, 5/29/20, 5/30/20, 6/4/20, and 6/5/20. * Resident #630 was turned/repositioned 6 times on 5/25/20 * Resident #630 was turned/repositioned 7 times on 5/18/20, 5/20/20, 5/21/20, and 5/22/20 On 7/23/21 at 7:15 PM, the RCN said the facility's policy was to measure pressure wounds and start treatment upon discovery of the wound. When shown the ADL flowsheets, the RCN said Resident #630 was not repositioned every 2 hours, and she stated there was no documentation. 3. Residents did not receive adequate staff supervision which resulted in falls. The facility's policy for Fall Evaluation (Morse Scale) and Management, updated March 2018, documented the following: * A licensed nurse was to complete the Morse Scale fall evaluation on admission. If the total Morse scale score was greater than 45, the resident was considered as having a high potential for falls. * A licensed nurse completed re-evaluations with each fall and significant change in condition. * After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse (LN) would evaluate their neurological assessment and monitor the resident for seventy-two hours for unwitnessed fall or falls that involve the resident's head striking a surface. The LN would update the Morse Scale, complete orthostatic vital signs, a progress note, a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. The LN would review and update the care plan with newly identified interventions as needed. This policy was not followed. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses, including monoplegia (paralysis that impacts one limb) of the left leg, dementia, and anxiety disorder. The facility's Neurological Evaluation policy, dated 9/14, documented residents' neurological status should be assessed following an unwitnessed fall or accident with injury to the head. The policy documented neurological assessments were to be completed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 1 hour for 4 hours, then every 8 hours for the remaining 64 hours after the fall. This policy was not followed. The admission Morse Fall scale assessment dated [DATE], documented Resident #6 was at high risk for falls. Resident #6's care plan for fall risk, initiated on 4/15/21, documented staff were to anticipate and meet his needs, ensure his call light was within reach and encourage him to use it, ensure he was wearing appropriate footwear when ambulating, keep him in line-of-sight with frequent checks, and anticipate his toileting needs. The care plan did not specify what was meant by line-of-sight and frequent checks. An admission MDS assessment. dated 4/21/21, documented Resident #6 was cognitively intact and required extensive assistance of one to two staff members for all daily care. He used a wheelchair for locomotion and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 7/9/21, documented Resident #6's mental status had declined from cognitively intact to severely cognitive impaired. A progress note, dated 4/13/21 at 1:42 PM, documented Resident #6, At this time resident has nearly fallen six times if not more. Therapy has been assisting as much as they can in monitoring him as he is requiring constant supervision and reminding for his safety. Resident #6 had eleven falls in three months from 4/17/21 to 7/17/21, 9 unwitnessed falls and 2 witnessed falls. Resident #6 sustained injuries from 3 of the falls, 6/20/21, 7/3/21, and 7/17/21. Examples include: a. An I&A report, dated 4/17/21 at 10:30 AM, and a nurse progress note dated 4/17/21 at 1:12 PM, documented Resident #6 had an unwitnessed fall. He was found seated between his wheelchair and bed. Resident #6 was confused, oriented to self only. He had a 4 cm by 2 cm skin tear on the back of his right arm. Resident #6 was not able to give a description of what happened. Resident #6's care plan for fall risk was revised on 4/19/21, and the following interventions were added: * Vital sign per center policy. Take blood pressure lying /sitting/ standing one time in the first 24 hours. Initiated on 4/19/21. * Provide activities that promote excise and strength building when possible. Provide one on one activity if bed bound. Initiated on 4/19/21. * Offer to lay down or rest in recliner between meals. Initiated on 4/19/21. The I&A included an IDT review note, dated 4/22/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior as he appeared to have fallen trying to transfer to bed. The IDT note documented the intervention developed to decrease his risk of falls was to offer assistance to bed or a recliner between meals. b. An I&A report, dated 4/20/21 at 10:39 AM, and a nurse progress note dated 4/20/21 at 10:49 AM, documented Resident #6 had an unwitnessed fall. He was found on the floor beside his bed. His wheelchair was next to the head of the bed and the brakes were not locked on his wheelchair. The I&A included an IDT review note, dated 4/23/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior. New interventions were to apply an anti-roll back device to his wheelchair and continue with the previous interventions for his fall risk care plan. Resident #6's fall risk care plan was revised to include a new intervention for Antirollback [sic] to be added to W/C [wheelchair] when available, initiated on 4/26/21. c. An I&A report, dated 5/3/21 at 2:15 PM, and a nurse progress note dated 5/2/21 at 2:02 PM, documented Resident #6 had an unwitnessed fall. He was found on the floor with his buttocks facing the wheelchair and his bed. His wheelchair brakes were locked. Resident #6 said, I think I bumped the side of my head. The I&A report included an IDT fall review note, dated 5/8/21, which documented the root cause of the fall was Resident #6's poor safety awareness, overestimating his own abilities, and weakness. The intervention to decrease Resident #6's falls was to check orthostatic blood pressure (a condition in which your blood quickly drops when you stand up from a sitting or lying position which may cause dizziness and fainting) for 3 days and to check his blood pressure and heart rate 4 times a day for 3 days to monitor for trends. Resident #6's fall risk care plan was revised, on 5/3/21, to include the following new interventions: * When the resident gets restless, offer food and fluids. Offer bathroom. Check to see if resident has any pain. Offer diversional activities. * Follows the 4 R's: - Relieve-ask about pain during the visit. Is anything needed to relieve pain? - Reposition. - Restroom, assist the resident to the restroom if needed. - Reach, verify resident's items are within reach. Resident #6's care plan was also revised to include a new intervention for drug regimen review related to the fall on 5/2/21, initiated on 5/7/21. d. An I&A report, dated 5/15/21 at 3:00 PM, and a nurse progress note dated 5/15/21 at 4:39 PM, documented Resident #6 had an unwitnessed fall. He was found on the floor next to his bed with his back against the side of the bed, next to his wheelchair. Resident #6 was unable to describe what happened and was confused. Resident #6 had socks on with no shoes. The I&A report included an IDT fall review note, dated 5/19/21, which documented the cause of the fall was related to Resident #6 removing his shoes and having poor safety awareness. The intervention to decrease Resident #6's fall risk was for non-skid socks to be worn while out of bed. Resident #6's fall risk care plan was revised to include the new intervention for non-skid socks to be worn with his shoes when he was out of bed, initiated on 5/19/21. e. An I&A report, dated 5/24/21 at 10:51 PM, and a nurse progress note dated 5/24/21 at 11:24 PM, documented Resident #6 had a witnessed fall of sliding off the bed. The I&A report included an IDT fall review note, dated 5/25/21, which documented the fall occurred related to Resident #6's impulsive behavior and lack of safety awareness. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's fall risk care plan was revised to include the new intervention for a 72 hour 1:1 time study, initiated on 5/25/21. The care plan did not specify what was meant by a 1:1 time study. f. An I&A report, dated 5/30/21 at 1:13 PM, and a nurse progress note dated 5/30/21 at 1:21 PM, documented Resident #6 had an unwitnessed fall. He was sitting on the floor by the end of his bed, approximately two feet in front of his wheelchair. He said, I was going to take that plate and this cup out of my room. The I&A report included an IDT fall review note, dated 6/3/21, which documented the fall occurred related to Resident #6's attempt to self-transfer and his poor safety awareness. The new intervention was for 1:1 staffing to further track his behaviors and try to identify patterns or fall triggers. Resident #6's fall risk care plan was revised to include the new intervention of pick up dishes after resident finishes meals and pick up clutter, initiated on 6/3/21. g. An I&A report, dated 6/7/21 at 12:20 PM, and a nurse progress note dated 6/7/21 at 12:29 PM, documented Resident #6 had an unwitnessed fall. He was lying on the floor by the staff bathroom without his wheelchair. The I&A report included an IDT fall review note, dated 6/10/21, which documented the root cause of the fall was Resident #6's poor safety awareness and impulsive behavior. The intervention to decrease Resident #6's falls was to conduct an incontinence evaluation to assess if toileting would benefit him and decrease his impulsive behavior. Resident #6's fall risk care plan did not include new interventions. h. An I&A report, dated 6/18/21, and a nurse progress note dated 6/17/21 at 2:42 AM, documented Resident #6 had an unwitnessed fall. He was found sitting on the floor in his bathroom and he was confused. The I&A report included an IDT fall review note, dated 6/18/21, which documented the root cause of Resident #6's fall was lack of awareness regarding safety limitations. The plan to decrease Resident #6's risk for falling was ongoing education, frequent checks, and staff would keep him in eyesight at all times. Resident #6's fall risk care plan was revised to include new interventions, as follows: * Do not leave the resident alone in the bathroom, initiated on 6/17/21. * For no apparent acute injury, determine and address causative factors of the fall, initiated on 6/18/21. i. An I&A report, dated 6/20/21 at 5:58 PM, and a nurse progress note dated 6/20/21 at 6:36 PM, documented Resident #6 had an unwitnessed fall. He was found lying next to his shoes on the floor in his bathroom with a 4 cm cut to the side of his head. Resident #6 continued to attempt self-transfers several times before being redirected to his evening meal. The family requested the resident to be sent to the emergency room (ER) for evaluation. A progress note, dated 6/20/21 at 6:59 PM, documented Resident #6's family declined to send him to the ER after talking with paramedics who stated the ER would not do anything for Resident #6. The note documented the wound on Resident #6's head was a cut that was no longer bleeding. The I&A report included an IDT fall review note, dated 6/22/21, which documented the root cause of the fall was Resident #6 was unaware of safety limitations. The intervention to prevent Resident #6's falling was to request a care conference related to the need for placement in a private facility with less stimulation, continue 1:1 resident in staff eyesight until accommodations are met related to safety. The review note also documented ongoing education was to continue with Resident #6 related to weakness and the need for one person to assist him with all transfers. Resident #6's fall risk care plan had a revised intervention to keep him in-line of sight as able, continue frequent checks, and anticipate toileting needs, initiated on 4/15/21 and revised on 6/22/21. j. An I&A report, dated 7/4/21 at 10:45 AM, and a nurse progress note dated 7/3/21 at 10:46 AM, documented Resident #6 had a witnessed fall. He had attempted to reach the newspaper on the nursing station counter and lost his balance. He was noted to have two cuts, one on his right temple area and the other on his right cheek, a small skin tear to his right wrist, and some bruising to both of his arms. A progress note, dated 7/3/21 at 11:10 AM, documented Resident #6 was sent to the hospital for an evaluation. The I&A report included an IDT fall review note, dated 7/4/21, which documented the facility would continue to monitor Resident #6, keeping him within vision of staff and continue with discharge planning. Resident #6's care plan did not include new interventions. Resident # 6's record included an In-service Education Summary, dated 7/3/21, which documented the topic and content was Resident #6 was to be in line-of-sight at all times. A nurse or CNA needed to be with him at all times for his safety. Staff were to encourage Resident #6 to relax and rest in a recliner in the day room, so he remained in line-of-sight

Based on record review, resident representative interview, and resident and staff interview, it was determined the facility failed to ensure residents were provided with bathing and oral care consistent with their needs. This was true for 6 of 12 residents (#3, #12, #20, #32, #37, and #39) reviewed for ADLs. This failure caused psychosocial harm to Resident #39 when she experienced embarrassment her showers were not given and created the potential for other residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: 1. Residents did not receive showers and/or baths following their care plan. Examples include: a. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] urinary tract infection and the need for assistance with personal care. The admission MDS assessment, dated 6/28/21, documented Resident #39 was cognitively intact and she required extensive assistance of one staff member for bathing. The facility's shower schedule documented Resident #39's shower day was each Monday and Thursday. Resident #39's Bathing/Bed Bath documentation report for June 2021 and July 2021, documented the following: * Resident #39 received a shower on 7/1/21, 6 days after her admission on 6/25/21. * Resident #39 received a shower on 7/8/21, 7 days after her last shower. * Resident #39 received a shower on 7/15/21, 7 days after her last shower. Resident #39's record documented 3 showers from the time of her admission on 6/25/21 to her discharge on 7/20/21, a total of 25 days. On 7/19/21 at 4:36 PM, Resident #39 said she had been at the facility 3 weeks and was discharging tomorrow. Resident #39 stated I have been here 3 weeks and received 2 showers, 1 shower was offered by the staff and the other was requested by her. Resident #39 said I felt embarrassed because I was not smelling good. I told the staff 'Lord, I really need a shower!' Resident #39 said she told staff about 2 to 3 times a week she needed a shower and staff pretended not to hear her. Resident #39 stated the lack of showers affected her life and It made me feel bad. Resident #39's showers were not provided per her preference. b. Resident #37 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 12/22/20, documented Resident #37 required the assistance of 2 or more staff for bathing and was totally dependent on staff for all ADLs. Resident #37's care plan, dated 12/15/20, documented he would be bathed 3 times a week on night shift on Monday, Wednesday, and Friday. The care plan also documented Resident #37 preferred bathing in the morning but was willing to be bathed at night, and currently was to have only bed baths, revised 5/3/21. Resident #37's Bathing/Bed bath documentation reports for June 2021 and July 2021 documented the following: * Resident #37 received a bed bath on 6/2/21 his next documented bed bath was on 6/22/21, 20 days later. Resident #37 received 2 bed baths from 6/1/21 to 6/30/21, 30 days. * Resident #37 received a bed bath on 7/8/21, 12 days after his last bed bath on 6/30/21. * Resident #37 received a bed bath on 7/15/21, 7 days after his previous bath on 7/8/21. On 7/23/21 at 6:13 PM, the RCN reviewed Resident #37's record and said she saw that Resident #37 did not get bed baths as care planned. The RCN stated if a resident refused, the shower aides should offer a shower again at a more convenient time. Resident #37's bed baths were not provided per his care plan. c. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly MDS assessment, dated 5/3/21, documented Resident #12 was severely cognitively impaired, used a walker, and she required supervision and limited assistance of one staff member for all daily care. Resident #12's care plan, initiated on 11/12/20, documented she would be bathed 2 to 3 times a week. The care plan documented Resident #12 was to be provided showers per the shower schedule. The facility's shower schedule documented Resident #12's shower days were on Wednesday and Saturday. Resident #12's Bathing/Bed Bath documentation reports for May 2021, June 2021, and July 2021, documented the following: * Resident #12 did not have a shower from 5/1/21 to 5/10/21, 9 days. * Resident #12 received a shower on 5/13/21 and her next shower was on 5/18/21, 5 days later. There was no documentation she refused showers during the 5 days. * Resident #12 received a shower on 5/26/21, 8 days after her last shower. The report documented Resident #12 refused showers on 5/21/21 and 5/25/21. There was no documentation she was re-approached and offered a shower after her refusals. * Resident #12 received a shower on 6/8/21, 7 days after her last shower. * Resident #12 received a shower on 6/22/21, 14 days after her last shower. The report documented she refused a shower on 6/18/21, 10 days after her last shower. There was no documentation she was re-approached and offered a shower after her refusals. * Resident #12 received a shower on 7/20/21, 27 days after her last shower. The report documented she refused a shower on 6/29/21, 7 days after her last shower. There was no documentation she was re-approached and offered a shower after her refusal and over the next 20 days. Resident #12's showers were not provided per her care plan. d. Resident #3 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan documented she required extensive assistance of 1 staff with showering. Resident #3's Bathing/Bed Bath documentation reports for May 2021, June 2021, and July 2021, documented the following: * Resident #3 received a shower on 5/14/21, 10 days after her last shower. * Resident #3 received a shower on 5/25/21, 11 days after her last shower on 5/14/21. * Resident #3 received a shower on 6/11/21, 10 days after her last shower on 6/1/21. * Resident #3 received a shower on 6/22/21, 6 days after her last shower on 6/16/21. * Resident #3 received a shower 7/13/21, 6 days after her last shower on 7/7/21. * Resident #3 received a shower on 7/20/21, 6 days after her last shower on 7/13/21. Resident #3's Bathing/Bed Bath reports for May 2021, June 2021, and July 2021 documented she refused a shower once on 6/25/21. There was no further documentation of refusals and/or that she was re-approached for showers. e. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20's care plan, dated 9/4/20, documented he required extensive assistance of 1 staff with showering, and showers were to be completed per the facility's showering schedule and as needed. Resident #20's Bathing/Bed Bath reports for May 2021, June 2021, and July 2021, documented the following: * Resident #20 received a shower on 5/11/21 for May 2021. The report documented he refused a shower on 5/12/21, 5/18/21, and 5/27/21. No additional showers were documented as offered or completed from 5/12/21 to 5/31/21, 20 days. * Resident #20 did not receive a shower in June 2021. The report documented he refused a shower on 6/2/21, 6/9/21, 6/11/21, 6/15/21, 6/16/21, 6/22/21, and 6/24/21. There was no additional documentation Resident #20 was re-approached and/or offered a shower between the dates of his refusals. On 7/22/21 at 11:26 AM, CNA #3 was asked about personal cares for Resident #20. She stated the facility did not have enough staff for the morning cares of residents. She stated due to not enough staff, CNA's were prioritizing assisting residents with toileting. On 7/23/21 at 5:42 PM, the DON, with the RCN present, was asked about Resident #20's missed showers. The RCN stated it was a documentation issue. Resident #20 did not receive showers per his care plan. On 7/23/21 at 6:13 PM, the RCN stated shower aides were scheduled to work from 6:00 AM to 2:00 PM and from 2:00 PM to 8:00 PM. She stated shower aides were pulled off shower duty to work as CNAs on the floor. The RCN stated the charge nurse on the floor was responsible for coordinating showers among CNAs and the licensed nurses. 2. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32's quarterly MDS assessment, dated 6/21/21, documented Resident #32 was severely cognitively impaired and required extensive assistance with personal hygiene (which included shaving, applying makeup, combing hair, etc.). Resident #32's care plan documented she required extensive assistance by 1 staff for personal hygiene. On 7/21/21 at 4:45 PM, Resident #32, a female, was observed in the common area with curling facial hair on her chin. Resident #32 stated she could not pluck her facial hair herself because she would pinch herself, but it was alright for the staff to pluck them. The DON observed the discussion and stated Resident #32 had facial hair. She asked a CNA to pluck Resident #32's facial hair. The facility did not provide personal grooming for Resident #32 as needed.

Based on record review and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent and treat pressure ulcers. This was true for 2 of 4 residents (#37 and #630) reviewed for wounds. This deficient practice resulted in harm to Resident #37 and Resident #630 when they developed avoidable pressure ulcers in the facility. Findings include: The National Pressure Injury Advisory Panel website, accessed on 7/28/21, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable [CONDITION(S)] (red discoloration of skin as a result of injury) which may appear differently in darkly pigmented skin. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The Lippincott Manual of Nursing Practice, 10th edition, pages 183-184, directed nurses to reposition residents every 2 hours to relieve pressure. The manual also listed risk factors for pressure ulcers, including malnourishment, [CONDITION(S)] (swelling caused by excess fluid trapped in the body's tissues), and immobility. This guidance was not followed. a. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37's admission MDS assessment, dated 12/22/20, documented the following: * He had no pressure ulcers on admission. * He was at risk of developing pressure ulcers. * He required extensive assistance with activities of daily living and required two plus staff assistance for bed mobility and transfers. * He did not transition (move himself to change positions) or walk. * He had impairment in his upper and lower extremities on both sides. Resident #37's care plan, dated 12/14/20 and revised 4/6/21, documented he had the potential for pressure ulcer development related to decreased mobility, incontinence of bowel, skin frequently moist due to perspiration, and history of chronic non-healing pressure injuries. The care plan listed the goal was for Resident #37 to have intact skin, free of redness, blisters or discoloration, dated 12/15/20 and revised on 6/28/21. One of the interventions listed was Resident #37 was dependent on assistance for turning and repositioning and was to be turned/repositioned at least every 2 hours, and more often as needed or requested, initiated 12/15/20. A hospital virtual visit (a face-to-face meeting with a health care professional using video technology without leaving the facility) report, dated 2/22/21, documented Resident #37 had a new Stage 3 pressure ulcer on each hip. Resident #37's care conference report, dated 3/24/21, documented he was to be turned every 2 hours from side to side. The report stated staff were to document Resident #37's cares and turn schedule, and to notify the family if Resident #37 refused cares. On 6/18/21, a care conference note documented Resident #37 was no longer able to be up in his chair in order to help heal his buttocks [pressure ulcer]. A virtual hospital report, dated 6/21/21, documented Resident #37 was having sacral (a triangular area in the lower back situated between the hipbones) decubitus (pressure) ulcer breakdown again. Resident #37's record did not include documentation as when the pressure ulcer originally developed after Resident #37 was admitted . Resident #37's bed repositioning records from 6/24/21 through 7/14/21, documented he was not turned or repositioned every 2 hours or a total of 12 times during a 24-hour period as follows: * Resident #37 was turned/repositioned 2 times on 7/4/21 and 7/13/21 * Resident #37 was turned/repositioned 3 times on 6/27/21, 6/28/21, 6/29/21, 7/1/21, 7/3/21, 7/6/21, 7/8/21, 7/11/21, and 7/14/21. * Resident #37 was turned/repositioned 4 times on 7/5/21, 7/9/10, 7/10/21, and 7/12/21. * Resident #37 was turned/repositioned 5 times on 6/24/21, 6/30/21, and 7/2/21. * Resident #37 was turned/repositioned 6 times on 6/25/21, 6/26/21, and 7/7/21. The length of time recorded between turing/repositioning of Resident #37 ranged from 2.5 hours (occurring twice) to 9 hours or more (17 times), and 18 hours (1 time). On 7/20/21 at 11:35 AM, Resident #37 stated he was to be repositioned every hour, but it was not happening. On 7/23/21 at 10:21 AM, the DON stated staff kept track of Resident #37's repositioning and refusals on the form hanging on the his door. The DON stated Resident #37's refusals and many of the dates were not documented on the form. The DON stated repositioning and refusals were not documented in the electronic record. On 7/23/21 at 7:11 PM, when asked to review the repositioning documentation, the RCN stated there were lapses in Resident #37's repositioning. The RCN stated it was not documented Resident #37 was repositioned every 2 hours, or he refused repositioning. b. Resident #630 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #630's admission nursing evaluation, undated, documented Resident #630 had no pressure ulcers. The evaluation documented Resident #630 was an older adult and had [CONDITION(S)] in both lower extremities, which were both risk factors for pressure ulcers. Resident #630's physician orders, dated 5/14/20, documented a weekly skin assessment was to be completed every Wednesday. Resident #630's care plan, dated 5/15/20, documented Resident #630 was at high risk for skin impairment, and directed staff to turn Resident #630 every 2-3 hours. Resident #630's skin integrity evaluation, dated 5/14/20, documented Resident #630 was at moderate risk for pressure ulcers, with the following risk factors: * Her ability to walk was severely limited or nonexistent and she could not bear her own weight. * She had a potential problem with skin friction or shear against sheets, chair, or other devices, and occasionally she slid down in her chair or bed. Resident #630's pain evaluation, dated 5/27/20, documented she had pain at her tailbone when sitting and when laying, but she did not shift position in bed because her feet were elevated to decrease [CONDITION(S)]. A weekly skin evaluation, completed on 5/27/20 (13 days after admission), documented Resident #630 had a 2 cm x 1.5 cm Stage 2 pressure ulcer on her sacrum. Resident #630's ADL flowsheet from 5/14/20 through 6/6/20, documented she was not turned or repositioned every 2 to 3 hours as her care plan directed as follows: * Resident #630 was turned/respositioned 1 time on 6/2/20 and 6/3/20. * Resident #630 was turned/repositioned 2 times on 6/6/20. * Resident #630 was turned/repositioned 3 times on 5/14/20, 5/15/20, 5/16/20, 5/17/20, and 5/31/20, * Resident #630 was turned/repositioned 4 times on 5/26/20 and 6/1/20. * Resident #630 was turned/repositioned 5 times on 5/19/20, 5/24/20, 5/27/20, 5/28/20, 5/29/20, 5/30/20, 6/4/20, and 6/5/20. * Resident #630 was turned/repositioned 6 times on 5/25/20 * Resident #630 was turned/repositioned 7 times on 5/18/20, 5/20/20, 5/21/20, and 5/22/20 On 7/23/21 at 7:15 PM, the RCN said the facility's policy was to measure pressure wounds and start treatment upon discovery of the wound. When shown the ADL flowsheets, the RCN said Resident #630 was not repositioned every 2 hours, and she stated there was no documentation.

Based on resident and staff interview, policy review, and record review, it was determined the facility failed to provide the services needed to prevent harm and injury of a resident. This was true for 1 of 1 resident (#36) reviewed for accidents. Resident #36 sustained an injury when a staff member failed to follow the care plan when attempting to transfer her during toileting. This failure created harm when the resident suffered a broken femur. Findings include: Resident #36 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #36's record included a care plan with identified deficits related to urinary incontinence and ADLs. The care plan stated Resident #36 required extensive assistance when transferring. The interventions in her care plan included having 2 staff members to assist with transfers and using a gait belt. Resident #36's Care Directive Form, dated 5/11/17, documented she required extensive assistance with 2 staff members for toileting. A facility policy Gait Belt, updated (MONTH) 2008, stated gait belts were to be used when transferring resident from a chair to a commode or toilet. The policy also stated the use of a gait belt was mandatory for transfers. An Occurrence Report, dated 4/22/18, documented Resident #36 fell in her bathroom during a transfer. The report stated after toileting, Resident #36 was attempting to transfer from the toilet to her wheelchair and she was unable to support her weight. In the report Resident #36 stated her knees were feeling weak and she could not hold on anymore. CNA #2 stated in the report Resident #36 was standing after toileting and was holding onto the grab bar and she was standing behind Resident #36 attempting to pull up her adult incontinence brief. CNA #2 stated she observed Resident #36's right leg turning inward and she began to lower. CNA #2 stated she then attempted to help Resident #36 into her wheelchair, by placing her arms underneath Resident #36's arms and slowly lower her into the wheelchair. She stated Resident #36 was partially seated her in wheelchair and screaming her leg hurt. CNA #2 stated she then .kicked her chair out of the way to lay her down. A Nursing Home to Hospital Transfer form, dated 4/22/18, documented Resident #36 was transferred to an acute care hospital with pain to her right lower extremity after a fall. An Emergency Department Note, dated 4/22/18, documented Resident #36 presented for evaluation of her right clavicle, right hip, and right knee due to pain after a fall. The note stated Resident #36 was being transferred from the toilet to her wheelchair when she fell and she landed on her right side. The note documented Resident #36 had swelling to the center or her right clavicle, mild pain in the right hip, and severe pain to her right knee. The note stated x-rays of Resident #36's right knee showed a [MEDICAL CONDITION] distal femur (thigh bone). On 6/26/18 at 11:21 AM, Resident #36 stated she broke her leg during a transfer in the restroom. She stated she twisted her knee and fell . She stated its almost healed. She stated she was not wearing the brace any longer. She denied pain. On 6/26/18 at 4:59 PM, the DON stated CNA #2 transferred the resident without a second staff member and she did not use a gait belt. She stated CNA #2 received additional training and education following the incident.

Based on observation, record review and staff interview, it was determined the facility failed to ensure that 4 of 14 residents sampled for pressure sores (#s 13, 20, 32, and 38) received treatment and services to prevent and treat pressure sores. Residents #13, 32, and 38 were harmed by the facility's failed practice. Resident #13 had a history of [REDACTED]. Resident #38 had a Stage III pressure sore with a Methycillin Resistant Stapholococcus aureus (MRSA)infection on the left heel, which resolved in June 2010; the wound recurred as a Stage II pressure sore (blister) on 10/1/10; the resident required narcotic medication to relieve pain where the pressure sore was located. Resident #32 had 2 Stage II ulcers on the right buttock, which resolved and recurred during July, August, and September 2010; the resident also developed a Stage II ulcer on the left buttock in October 2010, which was present during the survey. Resident #20 had "several open areas" on the buttocks in November 2009, which resolved by February 2010 but were not adequately assessed or documented. The facility failed to implement acceptable prevention strategies and treatments, and failed to document wound or dressing assessments at least weekly for residents with pressure sores. Findings include: The facility's 10/3/07 Nutrition at Risk Committee Policy and Procedure documented, "The wound (treatment) nurse is responsible for ensuring anyone with skin integrity issues is reviewed by the NAR committee...." On 11/3/10 at approximately 4:50 PM, LN #6 (the RCM) was interviewed about the facility's wound care processes, and who was in charge of wound care documentation. She stated, "The wound care nurse does that." The surveyor then approached one of the nurses providing resident care, and asked to speak to the wound care nurse. The surveyor was told that LN #6 was the wound care nurse. The surveyor returned to LN #6 and requested clarification, and LN #6 stated, "I follow residents with wounds through the Nutrition At Risk Committee, and the nurses do the treatments and document the wounds." NOTE: Facility staff did not appear to have a clearly defined system, with which all nurses were familiar, regarding which staff were responsible for assessment and treatment of [REDACTED]. 1. Resident #38 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 10/15/10 annual MDS 3.0 assessment coded: * Cognitively intact * Extensive assistance required for bed mobility and transfers * Occasional pain, 5/10 on a 0-10 scale, over the prior 5 days * Mechanically altered therapeutic diet * Risk for developing pressure sores * Stage II pressure ulcer which started 9/30/10 * Pressure relieving device for chair and bed * Ulcer care Care Area Assessments for the resident's MDS 3.0 assessment, dated 10/28/10 documented: * "Diabetes controlled at this time." * "Risk for pressure ulcers (related to) urine incontinence." * "Does have (left) leg (and) foot, ankle pain - usually controlled (with) PRN [MEDICATION NAME]." * "At risk to... develope (sic) pressure ulcers (currently blister to (left) heel).... Could be impacted due to decreased mobility." * "Has a blister to (left) heel, no drainage, order (sic), surrounding skin pink - area is almost healed, no (signs or symptoms) of infection (with) granulation of tissue." * "(Resident) is 1-2 assist for position changes, has a pressure reducing matress (sic) to bed (and) cushion to (wheelchair). Is nonambulatory." * "Is (wheelchair) bound (and) is incontinent but has some continent voids (and) BM's (sic). Puts skin at risk." * "Has factors that put skin at risk, diabetes (and) peripheral neropathy (sic) (with decreased) sensation to (lower extremities). Also [MEDICAL CONDITION](history with) decreased mobility which puts skin at risk." * Has functional (range of motion) limitations due to [MEDICAL CONDITION]." NOTE: The resident's 4/14/10 and 7/15/10 quarterly MDS assessments coded no pain or pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk documented a score of 14 (12 or less represents high risk) on 1/20/10, 4/16/10, 7/16/10, and 10/19/10. The resident's 11/3/10 Care Plan documented the following interventions with an origin date of 6/16/09: * "Pressure reducing matress (sic) to bed and cushion to chair" * "Skin check weekly by LN" * "Pressure relieving boot to (left) foot when in bed and up in (wheelchair), OK to remove for transfers." NOTE: Multiple nurses' notes in the resident's medical record indicated that the boot style and use fluctuated throughout the year, based on resident compliance, family request, nursing assessment, and physician orders. However, the care plan was not updated to reflect these changes. * "Turn and reposition q 2 (hours): 1-2 assist" Nutrition At Risk follow up forms documented a left heel Stage II pressure sore [MEDICAL CONDITION] infection from 12/10/09-6/8/10. The pressure sore was documented as "resolved" on 6/16/10, and on 7/13/10 the resident was discharged from the Nutrition At Risk follow up program due to, "No further breakdown." Wound Assessment Progress Reports documented that the resident's left heel had a Stage III pressure sore from 12/7/09-2/20/10, and a Stage I pressure sore from 3/5/10-5/20/10. It was documented as "resolved" on 5/27/10. NOTE: Nutrition At Risk follow up forms and Wound Assessment Progress Reports contained inconsistent and conflicting documentation regarding Resident #38's left heel pressure sore. According to the documentation, however, the left heel pressure sore was "healed" or "resolved" by 5/27/10 or 6/16/10, and remained so until 9/30/10 or 10/1/10, when a blister was documented on the resident's left heel. Weekly Skin Check Sheets for January - May 2010 documented a left heel pressure sore as either an X drawn over the left heel on a drawing of the human body, or noted as a dressing present over the pressure sore. The resident's left heel was documented as "intact" from 6/11/10-8/27/10. On 10/1/10, a "(Left) heel blister" was documented, and entries on 10/8, 10/16, 10/22, and 10/29 documented only that a dressing was in place. The surveyor did not see any Weekly Skin Check Sheets in the resident's medical record for the period between 8/28/10 and 9/30/10. NOTES: Investigative Guidelines state that when a pressure ulcer is present, daily monitoring should include an evaluation of the ulcer and dressing; the status of the area surrounding the ulcer; the presence of possible complications; and whether pain is being adquately controlled. With each dressing change or at least weekly, an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed, location and staging, size, depth, and the presence, location and extent of any undermining or tunneling/sinus tract; exudate amount, color, and approximate amount; pain nature and frequency; and a description of the wound bed, edges, and surrounding tissue. Physician order [REDACTED]. The left heel wound was documented as "resolved" on 10/30/10. The resident's September and October 2010 PRN Medication Documentation Sheet documented that the resident complained of left heel pain, for which she was medicated with [MEDICATION NAME] on 9/30, 10/5, 10/6, 10/7, 10/8, 10/10, 10/11, 10/13, 10/15, 10/20, and 10/21. The resident's Pain Evaluations dated 4/16/10, 7/16/10, and 10/19/10 documented, "Past (history) of pain (with left) heel ulcer." IPN for 12/2/09-11/1/10 were reviewed, and documented: * 6/4/10 - "Family concerned about foam boot to (left) heel, note left for RCM for possible reorder." NOTE: IPN did not contain documentation of follow up or resolution to this concern. * 10/3/10 - (Dressing left) heel clean (and) dry. (Resident complains of) site is painful. Has been observed frequently to kick off protective boot and rub heel back (and) forth on bed. Suspect decreased sensation will cause her to rub heel til there is tissue damage." NOTE: The resident's medical record did not contain evidence that this possible source of damage to the heel was addressed. Condition Change Forms documented: * 9/14/10 - "(Resident's left) heel has healed. Achilles pad does keep area moist and there is concern that wound may reopen (secondary) to this. Can Achilles pad be (discontinued) but continue to use air boot when (resident) in bed - this elevates foot but has open heel area." * 9/30/10 - "Resident has a blister approx(imately) 3 cm x 2 cm, appears to have fluid in, area around is red.... Resident has [MEDICATION NAME] ordered and is requesting it for foot pain." * 10/30/10 - "(Dressing changed) to (left) heel - (no) redness, drainage, or open areas noted - skin is intact. Will notify MD and (discontinue) treatment." Quarterly Assessment Updates, completed by the RN Assessment Coordinator, documented: * 1/20/10 - "Stage 3 to (left) heel (treated by physician)...." * 4/16/10 - "Skin pink (warm, dry, and) intact. Protective care to (left) heel (and) ankle post (decubitus ulcer) healing (and) surgical closer (sic) on 3/22/10." * 7/18/10 - "Currently skin intact. Pink (warm and dry). Had a follow up (with physician related to left) heel/ankle (decubitus ulcer). Had reopeneded (sic), healed as of 6/16/10 - protective/preventative plan in place." physician progress notes [REDACTED]. * 3/30/10 - "Wound is well approximated. No new changes. No drainage. Closed. No (signs of infection). (Left) heel wound with steri strips applied after removal of sutures." NOTE: The only evidence in the resident's medical record, which indicated where the sutures came from, was a Quarterly Assessment Update done on 4/16/10, which documented, "Protective care to (left) heel and ankle post decub(itus) healing, (plus) surgical closure on 3/22/10." * 4/13/10 - "The (right) heel has a hyperkeratotic rim with no evidence of infection. No [DIAGNOSES REDACTED], [MEDICAL CONDITION] or drainage. No other open wounds or [MEDICAL CONDITION]. (Patient) to continue wearing heel protectors." * 4/22/10 - "Ulceration on posterior heel, 0.2 x 0.3 cm, deep. Other information: The wound is stable with no [DIAGNOSES REDACTED]. No [MEDICAL CONDITION]." * 5/19/10 - "Posterior (left) heel wound well granulated and [MEDICATION NAME]." NOTE: physician progress notes [REDACTED]. A 10/12/10 Physician Telephone Order documented, "May use [MEDICATION NAME] (with) dressing (change) to (left) heal (sic). Wash (with) wound wash, cover...." On 11/4/10, LN #6 (the RCM) stated that Resident #38's pressure sore was, "resolved; the area comes open here and there. Her protein is normal, her heel has resolved. The skin is dry and flaky on a pressure area." On 11/5/10, the facility provided surveyors with a summary of Resident #38's left heel pressure sore and interventions. It included: "9/30/10 wound was noted to left heal (sic) and doctor was notified.... Treatment was initiated on 10/1/10.... Wound is currently resolved and preventative measures are in place." The DON and Administrator were advised of the findings on 11/4/10 at 5:50 PM. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 5/26/10 quarterly MDS assessment coded: * No problems with short- or long-term memory, and independent cognitive skills for daily living * Extensive assistance by 1 person required for bed mobility, and extensive assistance by 2 or more persons for transfers, with no functional limitations to range of motion * Incontinent of bladder, no pain, and no therapeutic diets, or dietary supplements between meals * No current pressure or stasis ulcers, and a history of ulcer resolved in prior 90 days * Pressure relieving devices for chair and bed, and a turning/repositioning program * Application of ointments/medications and other treatments, other than to feet The resident's 8/31/10 annual MDS assessment coded the above items, with the following changes or additions: * Incontinent of bladder, with pads or brief used * [MEDICAL CONDITION] * Mild pain less than daily in the soft tissues * Leaves 25 percent or more of food uneaten at most meals The resident's 9/1/10 RAP modules documented: * ADL functional/rehabilitation potential: "Wheelchair bound. Needs exstensive (sic) assist (with) care, except eating - a factor - has (history) of past [MEDICAL CONDITION]." * Urinary incontinence: "Estensive (sic) assist (with) toileting, wears Attends - could be a factor." * Nutritional status: "PO (oral) intake 51 (percent) overall meeting 77 (percent) of estimated needs.... Stage II to buttocks resolved 8/31/10.... Leaves 25 (percent plus) food uneaten." * Pressure ulcer: "(History of) healed ulcers to coccyx.... (Wheelchair) bound, inc(ontinent) of urine (plus) needs help (with) position changes - a factor. Potential (for) impaired skin." The resident's 10/7/10 Care Plan documented the following interventions, with an origin date of 8/13/03: * Turn and repostion (sic) q (every) 2 hours - 1 assist * Assess skin tugor (sic) weekly - see (treatment) book * Report any s/s (signs or symptoms) of redness to nurse * Monitor for s/s of impaired circulation PRN * Keep skin clean and dry q shift * Handle skin with extreme caution, very fragile.... * Pressure reducing mattress to bed and cushion to (wheelchair) * Float heels on pillow while in bed.... The resident's October 2010 Physician order [REDACTED]. * Check skin turgor q week by tenting, started 6/20/07 * Follow nutrition-at-risk/dietary recommendations PRN, started 10/1/07 * Skin assessment q week, started 6/20/07 The resident's POFS for December 2009 through October 2010 documented redness and dressings on the resident's coccyx from December through March, which resolved on 3/3/10 and did not recur until July 2010, when it was documented as Stage II. * 7/26/10: "Coccyx 2 x 1 open area" * 7/29/10: "Stage 2 to coccyx" * 9/13/10: "Open area (left) buttock keep clean (and) dry. Protect from pressure," and "Red area buttock keep clean (and) dry" The resident's Nutrition Risk Review Progress Notes documented: * 8/10/10 - "Stage II to buttocks" * "Resolved" on 8/31/10 and 9/28/10 Weekly Skin Check Sheets documented: * 7/15/10 and 7/22/10 - an X over the coccyx area. * 7/26/10 - "Stage II ulcers coccyx 2.25 (left) buttock and 0.5 (right) - very superficial." * 7/29/10 - "Open areas coccyx/buttocks." * 8/5/10 - 10/28/10 - various descriptions of the buttocks and coccyx as "pink", "red", dressings present, a circle drawn over the area without description, or no problems noted. * 11/3/10 - "Buttocks (the word healing had a line drawn through it) nearly healed." NOTE: The facility did not assess Resident #13's pressure sores on a daily basis, and weekly skin check documentation lacked assessment requirements as described in the Investigative Guidelines. Condition Change Forms documented: * 7/26/10 - "2 x 1 cm (centimeter) open area found on coccyx." Interdisciplinary Progress Notes (IPN) documented: * 7/26/10 - "(Resident) has 2 open areas in crease of buttocks, just below coccyx. (Left) side 2.25 cm red and rough looking. (Right) side 0.5 cm very superficial. Site covered (with) protective (dressing) to keep skin surfaces from rubbing together." * 7/30/10 - "(Resident complains of) pain in legs, hips, buttocks, coccyx tonight. (Medicated) late on PM shift - (continues) to (complain of) pain (after) med. Repositioned x 2 within 1 (hour). (Dressings) intact...." An 8/3/10 Wound and/or Weight Loss Assessment for (Nutrition at Risk) form documented, "Stage II to buttock" and "Wound to buttock improving." An 8/10/10 Follow-Up for Residents with Nutrition or Skin Risk form documented, "Wound to buttocks improving with... treatment," and "Wound to sacral resolved. Does have denuded areas." An 8/31/10 annual Nutritional Assessment documented, "Stage II to buttocks resolved 8/31/10," and "Previous pressure sore." On 11/4/10 at 12:00 PM, LN #6 (the RCM) was interviewed about Resident #13's recurrent pressure sores. She stated, "I haven't looked. She has a history of a small opening, and had some redness." Resident #13 had a history of [REDACTED]. She complained of pain at her coccyx, and was medicated with narcotics, in July 2010. Daily pressure sore monitoring was not documented. The resident was asked to allow surveyors to visualize the area multiple times throughout the survey, and refused each time. The DON and Administrator were advised of the findings on 11/4/10 at 5:50 PM. 3. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current quarterly MDS, dated [DATE], documented the following: *Cognitive level as moderately impaired *The resident needed limited assistance for bed mobility, transfers, dressing, toileting, personal hygiene *No current pressure or stasis ulcers *No history of ulcer resolved in prior 90 days *Pressure relieving devices for chair and bed *Other preventative/protective skin care (other than to feet) The resident's 12/24/08 Care Plan documented: *Skin will be clean and dry every shift *No skin breakdown *Pressure reducing mattress to bed *Skin check weekly by LN - see (treatment) book *See under ADL's for turning mobility (NOTE: The ADL care plan documented, "Turn and reposition q 2 hours, 1 assist.") *Barrier cream to coccyx after toileting for prevention *Lotion skin every a.m. and p.m., including face *Occupational therapy to evaluate for wheelchair positioning related to pressure and comfort (added 10/21/10) *Alteration in Nutrition Care Plan documented an open area to buttocks on 7/13/10, and resolved 9/10/10 *Roho cushion to wheelchair at all times for pressure relief (added 7/13/10, discontinued on 10/6/10) * "Care Plan Update 10/12/10 Open area L buttock...Roho cushion to w/c at all times, reposition side to side Q 2 (hours)" NOTE: There was nothing in the resident's medical record to indicate why the Roho cushion was discontinued for 6 days. The resident had recurrent pressure sores on the buttocks, over several months, and the facility failed to attempt more frequent repositioning. The resident's October 2010 Physician order [REDACTED]. *Check skin turgor q week by tenting, started 12/24/08 *Follow nutrition-at-risk/dietary recommendations PRN, started 12/24/08 *Skin assessment q week, started 12/24/08. Resident #32's Braden Scale for Predicting Pressure Sore Risk stated a score of 12 or less represents high risk for pressure sores. Resident #32's risk level score indicated an increased risk. Her total score had decreased from 19 (on 1/4/10 and 4/1/10) to 17 (on 7/1/10 and 9/30/10) . The resident's POFS (treatment administration documentation) for July 2009 through September 2010 documented open area/areas to the right buttocks. The October 2010 POFS documented an open area to the left buttocks. The following is a list of treatments / orders included in the POFS: *7/8/10 - "open area x 2 R (right) buttock exuderm to area change (bandage) q 3-5 d (days)...PRN until resolved" *7/8/10 - "Wound assess. (assessment) tool q wk (week)" *7/20/10 - "Resolved" written on form *8/6/10 - "Open area R (right) buttocks apply Calazyme paste q shift" "Resolved" hand written and dated 8/19/10 *8/6/10 - "Wound assess. (assessment) tool q wk (week)", "Resolved" hand written and dated 8/19/10 *8/27/10 - "Calazyme to open area x 3 R (right) buttock every shift until resolved" * 8/27/10 - "Wound asess. tool q wk." *9/1/10 - "Calazyme to open areas, Rt. buttock Q shift and PRN until resolved. *9/10/10 - Hand written statement, "resolved" *10/12/10 - "Open area L (left) buttocks Apply Calazyme Q shift/ PRN until resolved" *10/12/10 - "Wound tool assess (assessment) q week" NOTE: Wound tool assessments were not provided for the weeks of 8/6/10, 8/13/10, 9/3/10, and 10/12/10. Weekly Skin Check Sheets documented: *7/7/10 - There was no documentation of open areas on the right buttocks. *7/14/10 - The diagram had 2 x's on the right buttocks. NOTE: There was no written description of the wounds. The POFS documented 2 open areas on 7/8/10. *7/21/10 and 7/28/10 - There was no documentation of open areas to the right buttock *8/4/10 and 8/11/10 - There was no documentation of open areas to the right buttock, however on 8/11/10 "buttock pink" (area not identified) had been written. NOTE: The POFS documented an open area on the right buttocks on 8/6/10. *8/18/10 - "Drsg (dressing) over open area R buttock." *8/25/10 - There was no documentation of open areas to the right buttock. NOTE: The POFS documented 3 open areas on 8/27/10. *9/1/10 and 9/8/10 - There was no documentation of open areas to the right buttock. NOTE: The POFS documented medication to an open area on 9/1/10, which resolved on 9/10/10. * 9/23/10 - "Buttocks pink blanchable" * 10/6/10, 10/13/10 and 10/20/10 - There was no documentation of an open area to the left buttock. NOTE: The weekly skin sheets did not document an open area 10/6/10 through 10/20/10; however, POFS documented treatment to an open area on the left buttock starting on 10/12/10 through 10/31/10. * 10/28/10 - "Open area L buttock 0.6 x 0.4 cm x 0.1 cm pink in color with well defined margins." The weekly skin sheets did not correspond to the pressure ulcers as identified in the POFS. Further, documentation of the number of ulcers and the description of progress (size, depth, drainage or odors) was not consistently documented. Wound Assessment Progress Reports documented wounds, which were staged, on the following dates: 7/8/10 (2 sites), 7/13/10 (2 sites), 8/27/10 (3 sites). NOTE: There were no Wound Assessment Progress Notes for the weeks of 7/19/10, 7/26/10, 8/2/10, 8/9/10, 8/16/10, and the months of September 2010/October 2010. Condition Change Forms documented: * 7/8/10 - "(Resident) has 2 open areas R buttocks measuring 0.5 x 1.2 at 0.2 x 0.2 area covered = exuderm (bandage)" * 7/13/10 - "Wound x 2 to (R) buttock....Rsdt is incont (incontinent) @ times will add Roho cushion to w/c (wheelchair). Add 13/10 - protein powder 1 scoop to cereal..." * 8/6/10 - "Open area R buttock measuring .5 cm x .5 cm x < 0.1 cm (depth) - 0 drainage or discomfort" * 10/12/10 - "Open area L buttock" * 10/20/10 - "Has open wound (almost resolved) to buttock will req. (require) OT (Occupational Therapy)." Interdisciplinary Progress Notes (IPN) documented: * 7/8/10 - 9:00 p.m. - "Area to buttocks with inflammation (sic) present. Barrier cream applied and positioned on to side to relieve pressure." * 7/9/10 - 3:15 a.m. - Repositioned side to side q 2 hours. * 7/9/10 - 1:30 p.m. - "Exuderm (dressing) intact to R buttocks." * 7/10/10 - 3:10 p.m. - "Drsg (dressing) intact to R buttocks. Reposition every 2 hours..." * 7/10/10 - 2:30 p.m. - "Tx (treatment) nurse observed drg on resident." * 7/11/10 - 2:00 a.m. - "Turned side to side every 2 hours. Dressing intact to right buttock." * 8/6/10 - 10:00 p.m. - No signs or symptoms of infection to buttocks * 8/7/10 - 2:00 a.m. -"No change to buttocks" * 8/7/10 - 9:00 p.m. - "Buttocks rec. (receive) Calazyme prn." * 8/8/10 - 2:05 a.m. - "Buttocks remains red cream applied" * 8/8/10 thru 8/9/10 - No increased redness or signs of infection to the R buttock. * 8/27/10 - 1:00 p.m.. - "Open area to coccyx x 3 measures 0.4 cm. x .05 cm x < 0.1 cm #2, 0.6 cm x 0.4 cm x, 0.1 cm #3, 1.4 cm x 0.6 cm x 0.1 cm all to R buttock" * 8/27/10 thru 8/30/10 - Calazyme was applied to the open area on buttocks * 10/14/10 thru 10/16/10 document Calazyme was applied to the buttocks On 11/3/10 at 3:44 PM - Resident #32's pressure ulcer was viewed by a Surveyor and was observed to be a shallow, pink crater on the resident's left buttock. LN #6 (the RCM) stated it was, "Almost resolved." The resident's right buttock appeared to be intact. On 11/4/10 at 10:55 DON #3 was asked if there was any further documentation in nurses notes, wound assessments or skin assessments regarding Resident #32's pressure ulcers. No further information was provided. 4. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current quarterly MDS, dated [DATE], documented the following: * Independent skills for daily decision making * Extensive assistance for bed mobility, dressing, toileting and personal hygiene. * Total dependence for transfers * No current pressure or stasis ulcers * No history of ulcer resolved in prior 90 days * Pressure relieving devices for bed * Turning/repositioning program * Other preventative/protective skin care (other than to feet) The resident's 7/14/10 Care Plan documented: * Skin will be clean and dry every shift * Skin check weekly by LN - See treatment book * No skin breakdown * Pressure reducing mattress to bed * Nutrashield to buttock QS (every shift) and PRN * Barrier cream to coccyx after toileting for prevention The resident's October 2010 Physician order [REDACTED]. * Check skin turgor q week by tenting, started 9/18/09 * Skin Assessment q week Resident #20's Braden Scale for Predicting Pressure Sore Risk stated a score of 12 or less represents high risk for pressure sores. The 9/2/10 assessment documented a score of 16. The resident's POFS for December 2009 through July 2010 documented the following: * 12/2/09 through 3/1/10: Duroderm border 4 x 5 to be changed every 5 days "until healed to coccyx." * 5/1/10- Zinc oxide to coccyx bid (twice a day) for prevention * 6/1/10- Zinc oxide to coccyx bid for prevention, hand written with a date that was not legible was "And PRN till healed." * 7/1/10 through 10/1/10: Zinc Oxide to coccyx bid for prevention. NOTE: The July POFS did not document the Zinc Oxide had been applied on the day shift on 7/4/10 and 7/30/10. The evening shift did not document the Zinc Oxide was applied on 7/3-7/4/10, 7/9/10, 7/17 - 7/18/10, and 7/24- 7/25/10. Weekly Skin Check Sheets documented: * 12/6/09 - a dressing change to the coccyx * 12/13/09 - An x was marked in the coccyx area of the buttocks of the diagram, written by it was, "buttocks red" 12/20/09 and 12/27/09 - An x was marked in the coccyx area of the buttocks of the diagram. There was no description of the area marked with an x on the diagram. * 1/3/10- There was an x marked on the buttocks. The form documented Coccyx shows healing with mild "excoriation and blanchable." * 1/10/10, 1/17/10, 1/24/10 and 1/31/10 - documented a dressing to the coccyx. * 2/14/10, 2/21/10, and 2/28/10- There was no documentation of open/red area to the buttock Note: Weekly Skin Check not documented the week of 2/7/10. The weekly skin sheets did not the document the number of ulcers or include a description of the ulcer (size, depth, drainage or odors). The facility did not provide Wound Assessment Progress Reports. Interdisciplinary Progress Notes (IPN) for 11/09 through 10/10 documented: * 11/29/09 - 4:00 p.m. - "Rsdt (resident) has developed several open areas of various sizes mostly along crease of buttocks. Med (medicine) used for Psorisis do not seem to help much at site..." * 11/30/09 - 2:45 p.m. - "No significant change in appearance of buttocks." * 12/1/09 - 2:00 a.m. - "Staff attempts to position resident on side. Often refuses to lie on side far enough to get off coccyx." * 12/1/09 - No time - "Changed dressing to coccyx area. Shows 0 drainage blanchable pink tissue." * 12/2/09 - No time - Dressing changed to coccyx, area blanchable and no signs or symptoms of infection or drainage. * 12/7/09-No time- Dressing to coccyx area changed, zinc oxide applied for skin breakdown "Shows improvement with dryness slight pink, 0 inflammation noted." * 12/17/09- No time - "Coccyx intact with mild skin shear. Covered with Silversorb sheet..." * 1/5/10- 5:30 p.m. -"Drsg changed to coccyx. Shows 0 drainage. Red and with slight irritation in spots around coccyx. Areas are blanchable" * 1/18/10 - 4:00 p.m. - Dressing changed to coccyx * 1/23/10 - 2:00 p.m. - "Coccyx looks healed." * 1/28/10 - No time - "Changed dressing to coccyx area 0 breakdown noted skin blanchable." * 2/2/10 - 1:45 p.m. - "Changed dressing to coccyx area. Skin shows clean, dry and intact 0 breakdown noted to skin....inner brusing to skin around coccyx r/t (related to) prior breakdown." IPNs documented "several open areas" to the buttocks on 11/29/10. The IPNs did not document the number of open areas or the size, shape, depth or drainage of the open areas. When asked about Resident #20's pressure ulcers,on 11/4/10 at 12:00 p.m., LN #6 (RCM) stated the Resident had not had any open ulcers for quite sometime. When asked to clarify "quite sometime", LN#6 stated 3 or 4 months.