Every finding on record at Shaw Mountain of Cascadia

Based on record review, observation, interview, and facility policy review, the facility failed to adhere to infection control practices and policies during wound care when staff failed to wear a gown for one resident (Resident (R) 36) on Enhanced Barrier Precautions (EBP) and failed to implement EBP for one resident (R92) with open wounds requiring dressing changes of three residents observed for wound care in a total sample of 26 residents. The deficient practice increased the risk for cross contamination and infections. Findings include:1. Review of R36's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R36 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebrovascular disease, neuromuscular dysfunction of bladder, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 03/16/26 revealed R36 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated R36 had moderate cognitive impairment. The assessment documented that R36 had an indwelling urinary catheter. Review of R36's Orders, located under the Orders tab of the EMR, revealed an order for Enhanced barrier precautions for Foley Catheter. Gown and gloves required for high-contact patient care with foley catheter device. Gown and gloves are not required when not performing high-contact care. Resident may leave room which originated on 03/11/24. Review of R36's care plan, located under the Care Plan tab in the EMR, revealed R36 had an indwelling catheter and was on enhanced barrier precautions. During an observation on 05/13/26 at 10:06 AM, Registered Nurse (RN) 1 and Certified Nurse Aide (CNA) 5 entered R36's room to perform urinary catheter care and wound care. Posted on R36's room door was a blue sign that stated: Visitors and personnel – gown and gloves required for high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, toileting or changing briefs, device care or use (central line, catheter, feeding tube, tracheostomy), wound care: any requiring a dressing. Catheter was circled. RN1 and CNA5 performed hand hygiene, donned gown and gloves, and completed catheter care. Once completed with catheter care RN1 told CNA5 We can take our gowns off since EBP is only for the catheter. RN1 and CNA5 removed their gown and gloves, performed hand hygiene and donned clean gloves. CNA5 positioned the resident so RN1 could perform a dressing change to R36's right heel and pinky toe. R36's right heel skin was intact but red and the pinky toe was scabbed. During an observation on 05/13/26 at 10:31 AM, RN1 and Nurse Aide (NA) 2 entered R92's room to perform wound care. R92 did not have an EBP sign or personal protective equipment (PPE) outside the door. RN1 and NA2 performed hand hygiene, donned gloves, and completed wound care. RN1 and NA2 did not wear gowns while performing wound care. R92 had open wounds to her posterior right lower extremity, inner left lower extremity, and outer left lower extremity. Dressing changes included cleansing the wounds, applying collagen with wound gel and alginate dressing, covered with border gauze dressings. During an interview on 05/13/26 at 10:58 AM, RN1 stated, Wounds that would require EBP would include chronic wounds, pressure, venous and arterial wounds . EBP would only be required for the specific situation requiring EBP. [R36] only requires EBP while caring for her catheter. During an interview on 05/13/26 at 11:29 AM, CNA5 stated I look on the sign to find out what we need to gown up for. [R36] is on precautions for her catheter care. I would gown up only if providing catheter care, brief care, or taking her to the bathroom. I would not gown up if transferring her from bed to chair since I'm not having contact with her catheter. During an interview on 05/14/26 at 11:37 AM, the IP stated EBP was for chronic wounds, indwelling devices such as peripherally inserted catheters (PICC) foley catheters, feeding tubes, and nonhealing surgical wounds. Acute wounds would usually be less than 30 days and chronic is longer. If a resident has a foley catheter, then staff would only need to gown up and use gloves. If they are transferring, staff do not need to gown up. Staff would only need to gown up if providing care to the foley catheter. During an interview on 05/14/26 at 1:24 PM, the Director of Nursing (DON) stated, EBP is for residents with devices or dressing changes to prevent MDRO [multidrug resistant organisms]. Even if staff are not providing care specifically for the foley catheter, staff should still be wearing gown and gloves. 2. Review of R92's admission Record, located under the Profile tab of the EMR, revealed R92 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease and immunodeficiency depression. Review of the annual MDS, located under the MDS tab of the EMR, with an ARD of 03/18/26 revealed R92 had a BIMS score of 10 out of 15 which indicated R92 had moderate cognitive impairment. Review of R92's Progress notes, located under the Prog notes tab of the EMR, revealed documentation of the left and right posterior leg wounds had originated as skin tears on 04/04/26 and were slowly healing as of 04/15/26. The lower left lateral leg wound was a skin tear originated on 04/17/26. Review of R92's Orders, located under the Orders tab in the EMR, revealed R92 had wound care orders to right and left posterior legs and left lateral leg that included Gently cleanse with wound cleanser and gauze. Pat dry with clean gauze. Treat periwound [zone of tissue surrounding the wound] with skin prep. Apply collagen mixed with wound gel to wound bed. Follow with alginate. Cover with Border gauze dressing which originated on 05/12/26. There was not order for enhanced barrier precautions. Review of R92's care plan, located under the Care Plan tab in the EMR, revealed R92 had the potential for alteration in skin related to decreased mobility, peripheral vascular disease, and oxygen use. During an observation on 05/13/26 at 10:31 AM, RN1 and Nurse Aide (NA) 2 entered R92's room to perform wound care. R92 did not have an EBP sign or personal protective equipment (PPE) outside the door. RN1 and NA2 performed hand hygiene, donned gloves, and completed wound care. RN1 and NA2 did not wear gowns while performing wound care. R92 had open wounds to her posterior right lower extremity, inner left lower extremity, and outer left lower extremity. Dressing changes included cleansing the wounds, applying collagen with wound gel and alginate dressing, covered with border gauze dressings. During an interview on 05/13/26 at 10:58 AM, RN1 stated, Wounds that would require EBP would include chronic wounds, pressure, venous and arterial wounds. [R92's] are open but acute. They are not chronic. The Infection Preventionist (IP) determines which residents are placed on EBP During an interview on 05/14/26 at 11:37 AM, the IP reviewed wound care orders for R92 and stated [R92] has open wounds and should be on EBP. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 09/20/25, provided by the facility indicated, This facility utilizes Enhanced Barrier Precautions (EBP) as an additional mitigation strategy to reduce transmission of multidrug resistant organisms (MDROs) within the facility. This policy aligns with the Centers for Disease Control and Prevention (CDCs) guidelines. Definitions. Adhesive dressing: Refers to a type of wound dressing that is widely used for minor injuries such as cuts, scrapes, burns, blisters, insect bites and splinters. They are flexible, sterile strips with an adhesive coating made of various materials such as fabric, plastic or latex. High contact care activities: include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, medical device care or use, and wound care. This practice is applied for residents that meet the following criteria; . Chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The intent of EBP with chronic wounds is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. Therefore, chronic wounds include but are not limited to pressure ulcers, diabetic foot ulcers; unhealed surgical wounds, and venous stasis ulcers. Shorter-lasting wounds do not require EBP, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Indwelling medical device examples include but are not limited to . urinary catheters, . PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.

Based on record review, interview, and facility policy review, the facility failed to offer pneumococcal vaccines based on Centers for Disease Control and Prevention (CDC) guidelines for one of five residents (Resident (R) 51) reviewed for immunizations out of a total of 26 sample residents. The deficient practice had the potential to increase the risk for this resident to contract pneumonia. Findings include:Review of R51's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated R51 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic kidney disease, and history of malignant neoplasm of breast. R51 was over [AGE] years of age. Review of R51's Immunizations, located under the Immunizations tab, and Immunization Record, located under the Documents tab, in the EMR revealed R51 had received PPSV23 (pneumococcal polysaccharide vaccine) on 06/07/04 and Prevnar 13 (also known as PCV13, a pneumococcal conjugate vaccine) on 11/04/14. R51 was older than [AGE] years of age when vaccinated. Review of R51's Informed Consent Form for vaccines, located under the Documents tab in the EMR and dated 09/17/25, revealed the Pneumococcal section had not needed written with PPSV23 received on 06/07/04 and Prevnar 13 received on 11/04/14. During an interview on 05/14/26 at 11:31 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) reviewed R51 vaccine records and stated, I keep track of resident vaccine records on a spreadsheet. [R51] had received PCV13 and PPSV23. She is not fully vaccinated according to the CDC. She should have been offered the PCV20. I'm not sure why 'not needed' was written on her consent form. During an interview on 05/14/26 at 1:24 PM, the Director of Nursing (DON) stated, My expectation is that residents' vaccine status is reviewed on admission and tracked when due. I would expect the IP nurse to review pneumonia vaccine status to determine if the resident is fully vaccinated and offer the vaccine if not fully vaccinated. Review of the facility's policy titled, Pneumococcal Vaccination for Residents, revised 09/25/25, indicated, Pneumococcal disease poses significant risks due to its major clinical syndromes-pneumonia, bacteremia, and meningitis-which contribute to serious morbidity and mortality. ln alignment with the recommendations of the Advisory Committee on Immunizations Practices (ACIP) and the Centers for Medicare & Medicaid Services (CMS), the facility is committed to ensuring that all eligible residents are offered pneumococcal vaccination. This proactive approach aims to reduce the risk of pneumococcal-related complications, hospitalizations, and mortality, thereby promoting the health and well-being of ourresident population. If the resident has previously received one or more of the other vaccines the facility should consult with the primary provider to determine what vaccination would be clinically indicated for the resident. The CDC recommendations for Pneumococcal Vaccine schedules can be found here: https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html. Review of CDC Adult Immunization Schedule, dated 07/02/25, located at https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html#note-pneumo, revealed Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision–making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose.

Based on record review, observation, and interview, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one resident of two residents (Resident (R) 67) reviewed for respiratory care out of a total sample of 26. This failure had the potential to expose the resident to infections. Findings include:Review of R67's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and unspecified dementia. Review of R67's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 02/20/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R61 had intact cognition. Review of R67's Care Plan Report, located in the EMR under Care Plans tab, revealed a focus dated 12/27/24 which indicated R67 had terminal prognosis due to COPD. An intervention for staff was to administer medications as ordered by the physician. A care plan revealed a focus, dated 12/27/24 which indicated R67 had shortness of breath (SOB). An intervention instructed staff to administer inhaler as ordered. Review of R67's Physician Orders, located in the EMR under the Orders tab, revealed the following order, dated 01/14/25, ipratropium-albuterol inhalation solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) two times a day related to COPD. During an observation in R67's shared room on 05/11/26 at 3:53 PM, R67's nebulizer mask was lying on top of the machine. During an interview on 05/11/26 at 3:55 PM, Certified Nurse Aide (CNA) 1, confirmed R67's nebulizer mask was lying on top of the machine. During an observation in R67's shared room on 05/13/26 at 8:42 AM, R67's nebulizer mask was lying on top of the machine. During an interview on 05/13/26 at 8:44 AM, Nurse Aide in training (NA1), confirmed R67 nebulizer mask was lying on top of the machine. During an interview on 05/13/26 at 3:33 PM, Licensed Practical Nurse (LPN) 1 stated the masks were cleaned after use, dried and stored on the top of the machine. She confirmed this could be an infection control issue. During a subsequent observation LPN1 confirmed R67's nebulizer mask was on top of the machine. During an interview on 05/14/26 at 11:17 AM, with the Director of Nursing (DON) and the Administrator, the DON stated the mask should be washed, dried and placed on a clean surface. She stated she did not know the policy specified the mask should be stored in a plastic bag when not in use but confirmed it could be an infection control issue. Review of facility policy titled Oxygen Administration, Safety, Storage, & Maintenance, dated 10/10/25, specified The facility will administer, story, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practioner orders. Store oxygen and respiratory supplies in a plastic bag when not in use.

Based on interview, record review, and review of the facility policy, the facility failed to ensure two abuse allegations were reported within two hours to the State Agency for two of three residents (Resident (R) 70 and R110) reviewed for abuse out of a total sample of 26 residents. This failure had the potential to negatively affect the facility by not making the State Agency aware of the situation timely.Findings include: 1. Review of R70's admission Record, located in the Profile tab of the electronic medical record (EMR), indicated that resident (R) 70 was re-admitted to the facility on [DATE] with diagnoses including severe dementia and schizophrenia. Review of R70's admission Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 03/09/26, revealed R70 had a Brief Interview for Mental Status (BIMS) of two out of 15, indicating severe cognitive impairment. Attempted to interview R70 on 05/10/26 at 11:50 AM; however, R70 was alert yet confused, mumbling as she colored and unintentionally ambulated with her wheelchair around the assisted dining room. Review of the Facility Reported Incident (FRI) summary (5-day) revealed that on 07/15/26, staff witnessed R10 grabbing R70's breast from behind, while resident R70 was coloring. R70 was witnessed trying to remove R10's hands and verbally communicating to stop, however R10 proceeded until the therapists wheeled the wheelchair of R10 from the dining room. The allegation was verified by evidence collected during the investigation. Review of the Resident to Resident Event Assessment, dated 07/15/25, revealed the event occurred at 07/15/25 at 3:30 PM. The State Agency was notified of the incident on 07/16/25 at 8:00 AM, sixteen and a half hours after the event occurred. 2. Review of R110's admission Record, located in the Profile tab of the EMR, indicated that R110 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease and chronic respiratory failure. R110 was not in the facility during the survey. Review of R110's admission MDS with an ARD 09/30/25, located in the Profile tab of the EMR, revealed that R110 had a BIMS of nine out of 15, indicating she was moderately cognitively impaired. Review of the Facility Reported Incident (FRI) summary (5-day) revealed that on 09/14/25 at 3:30 PM, the Housekeeper (HSK) reported an incident between R10 and R110. R110 reported that R10 had reached towards her breast. R110 slapped R10's hands and expressed he was not allowed to do that. R10 retaliated by slapping the hand of R110. The allegation was verified by evidence collected during the investigation. R10 was witnessed to have reached for R110's breast. Review of the Resident to Resident Event Assessment, dated 09/14/25, revealed the FRI occurred on 09/14/25 at 3:30 PM. The State Agency was notified on 09/15/26 at 2:00 PM, twenty-two hours after the incident occurred. During an interview on 05/14/26 at 11:25 AM, the Administrator stated FRIs should be reported timely and agreed the incident that occurred on 07/15/25 and 09/14/25 were not reported timely and should have been. Review of a policy document provided by the facility titled Abuse Investigation, revised 09/04/25 indicated The facility will promptly and thoroughly investigate allegations of abuse.and reported as required by state law.

Based on interview, record review, and review of the facility policy, the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident (R) 70) and R110) of three residents reviewed for abuse out of a total sample of 26. R10 touched R70's breast and R10 touched R110's breast. This failure had the potential to negatively affect R70 and R110's overall physical and mental health. Findings include: 1. Review of R70's admission Record, located in the Profile tab of the electronic medical record (EMR) indicated that resident (R) 70 was re-admitted to the facility on [DATE] with severe dementia and schizophrenia. Review of R70's admission Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 03/09/26, revealed R70 has a Brief Interview for Mental Status (BIMS) of two out of 15, indicating severe cognitive impairment. During an attempted interview 05/10/26 at 11:50 AM, R70 was alert yet confused, mumbling as she colored and unintentionally ambulating with her wheelchair around the dining room. Review of the Facility Reported Incident (FRI) summary (5-day) revealed that on 07/15/26, Staff witnessed in the dining room, resident [R10], grabbing another residents breast from behind, while resident [R70] was coloring. [R70] was witnessed trying to remove [R10's] hands and verbally communicating to stop, however [R10] proceeded until the therapists wheeled the wheelchair of [R10] from the dining room. The allegation was verified by evidence collected during the investigation. Plan of action to have a staff member in common areas when residents are present and closely monitor [R10] when in presence of female residents. Review of the Interview Record, dated 07/15/25 revealed, an interview was conducted from the Occupational Therapist (OT). The Interview Record, revealed Re: inappropriate groping . massage therapist reported to [OT] that a patient was in the dining room grabbing a patient's breasts without consent. I went into dining room and [R10] was seated at the edge of his wheelchair behind and on the left of [R70] who was seated in wheelchair coloring at table. No staff was in the room. [R10] was reaching around [R70] and grabbing her breasts. [R70] was trying to remove [R10's] hands but he would not let go. I told [R10] to stop and he continued until I moved his chair. I took [R10] to his hall and reported the incident to nursing and social services. Review of the Resident to Resident Event Assessment, dated 07/19/25, revealed [R10] did not receive mental health services due to cognitive decline . [R10] has been placed with care staff after each visit with family to remove him from unsupervised visits with other residents. [R10's] family has been educated on this and has been agreeable . care plan reviewed and updated . Resident has a history of reaching out to others . Review of R10's admission Record, located in the Profile tab of the EMR, indicated that R10 was re-admitted to the facility on [DATE] and was in the hospital during the survey. R10 had diagnoses that included dementia. Review of R10's Five Day MDS, found under the MDS tab, with an ARD of 09/30/25, revealed R10 has a BIMS of one out of 15, indicating severe cognitive impairment. During an interview on 05/14/26 at 12:05 PM, the OT stated she was notified by the massage therapist that R10 had his hand on R70's breast. The OT stated she went into the dining room and told R10 to stop and he did. The OT stated she then removed R10 from the dining room. 2. Review of R110's admission Record, located in the Profile tab of the EMR, indicated that R110 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. R110 was not in the facility during the survey. Review of R110's admission MDS with an ARD 09/30/25, located in the Profile tab of the EMR, revealed that R110 had a BIMS of nine out of 15, indicating she was moderately cognitively impaired. Review of the Facility Reported Incident (FRI) summary (5-day) revealed that on 09/14/25, Housekeeper [HSK] reported the incident on 09/14/25 at 3:30 PM . The incident between residents [R10] and [R110] was witnessed in the 300-hallway next to the mechanical room. Skin evaluation, res[ident] to res[ident] and psych evaluations performed . [R10] had reached towards [R110's] breast. [R110] slapped [R10's] hands and expressed he was not allowed to do that. [R10] retaliated by slapping the hand of [R110] . The allegation was verified by evidence collected during the investigation. [R10] was witnessed to have reached for [R110's] breast . Action taken as a result of the investigation: [R10] was immediately removed from the incident to another area at the charting station of 400 hall an area of decreased traffic. Continues on 30 minute checks for increased supervision. Will have supervision while in dining room and activities, first assisted out and last assisted in . [R10] has a pattern of reaching out with hands towards others. Assessments and care plans completed. Resident to be further than arms length around others. Review of the Interview Record, dated 09/14/25, an interview with HSK documented, [R10] and [R110] were next to each other talking when [R10] reached for [R110's] breasts, she then slapped [R110] hand and got upset and let him know not to do that, [R10] then slapped [R110's] hand after she slapped him. Additionally, on the Interview Record was R110's statement, which documented, [R10] did not hurt [R110], [R10] grabbed hard enough to irritate me. Review of the Resident to Resident Event Assessment, dated 09/14/25, revealed [R10] was moved to another area/near dining room/400 hall charting area. 15 minute checks on resident initiated (on q [every] 30-minute checks previously) . [R10] is mostly nonverbal and does not report feeling unsafe. Family reports that she feels safe and does not have any concerns. [R110] is well-groomed and cared for . [R10] has pattern of reaching out toward other . Resident continues to be on 30-minute checks for increased supervision. Care plan updated: Assist with keeping resident from being parked in high trafficked areas when up out of his room . [R10] should be kept further then [sic] arm's length around others and supervision provided at all times in activity room and in the dining rooms . [R10' was reviewed by Physician Assistant, [R10] receiving new orders for Paxil [anti-depressant] . During an interview on 05/13/26 at 1:30 PM, HSK stated R10 and R110 were talking and being friendly with each other until R10 grabbed R110's left breast. HSK stated R110 stated hey you and R10 yelled back. HSK stated she moved R110'w wheelchair back. During an interview on 05/14/26 at 11:25 AM, the Director of Nursing (DON) stated she and the Administrator substantiated both incidents and during both investigations R10 was started on 15-minute and 30-minute checks. The facility conduct multiple skin checks on each R10, R70, and R110. The nurse practitioner was notified after the first event and the physician's assistant was notified after the second incident and a medication review was conducted for R10, and an anti-depressant was added. Review of a policy document provided by the facility titled Identification Abuse, revised 09/04/25 indicated The facility is committed to upholding each resident's right to live free from abuse . Sexual abuse is defined as non-consensual sexual contact of any type with a resident . Examples of sexual abuse include unwanted touching . touching the breasts

Based on record review, interview, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) level one screen was updated with a new major mental illness diagnosis for one of two residents (Resident (R) 19) reviewed for PASARR out of a total of 26 sample residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate. Findings include: Review of R19's admission Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 03/30/26, revealed R19 was admitted to the facility on [DATE]. R19 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R19 had sever cognitive deficits. Per the MDS, R19 had a diagnosis of Post Traumatic Stress Disorder (PTSD). Review of R19's Idaho Preadmission Screening and Review (PASRR) Level 1 HW00087, dated 03/19/26 and located in the EMR under the Documents tab, revealed in Section 1 under Does the individual have an of the following Major Mental Illnesses (MMI)? No was checked. PTSD was included on the form as a major mental illness, however the form did not indicate this as a diagnosis for R19. Review of R19's Interim History and Physical, dated 03/25/26 and located in the EMR under the Documents tab, revealed R19 had a diagnosis of PTSD. During an interview on 05/13/26 at 4:26 PM, the Social Services Director (SSD) stated he reviewed the resident hospital records and chart to ensure the diagnosis listed on the admitting PASARR matched with the resident has. The SSD confirmed R19 admitted with the diagnosis of PTSD. The SSD stated he missed the PTSD diagnosis and it should have been marked on the PASARR. During an interview on 05/14/26 at 11:17 AM with the Director of Nursing (DON) and the Administrator, the DON stated her expectation was to have all the PASSARs correct and if they were not correct at admission a new one should have been submitted. Review of facility policy titled Pre-admission Screening & Resident Review (PASRR) Process, dated 08/19/25, specified The facility will ensure that potential admission are screened for possible serious mental disorders or intellectual disabilities and related conditions.this is completed prior to admission.A positive level I PASARR screen necessitates an in-depth evaluation of the individual by the state-designated authority, knowns as a PASSAR level two II, which is to be conducted prior to admission unless otherwise authorized by such agency.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents' choices. This was true for 3 of 8 residents (Resident #1, #2, and #4,) whose records were reviewed for quality of care. This failure created the potential for harm when residents were not reassessed to ensure the plan of care was effective, when physician orders were conflicting, and physician orders were not implemented or followed when ordered. Findings include:1.The American Heart Association website accessed 12/30/25, documented the following blood pressure categories: Normal: less than 120/ less than 80 Elevated: 120-129/ less than 80 Stage 1 hypertension: 130-139/ 80-89 Stage 2 hypertension: 140 or higher / 90 or higher Severe hypertension: Higher than 180 / higher than 120 Hypertensive emergency Higher than 180/ higher than 120 a) Resident #1 was admitted on [DATE] with multiple diagnoses including congestive heart failure and hypertension. Review of Resident #1's care plan, revised 11/26/25, directed staff to monitor and report to the physician any adverse changes in cardiac status, including: Chest pain or pressure Heartburn Nausea or vomiting Shortness of breath Excessive sweating Dependent edema Lung congestion Changes in capillary refill Abnormal vital signs Review of Resident #1's record documented the following blood pressure readings: 12/1/25: 187/75 12/2/25: 179/60 12/5/25: 148/74 12/13/25: 143/83 12/14/25: 194/89 b) Med-Health.net accessed 12/31/25 documented the following edema levels: 1+ 2mm or less: slight pitting, no visible distortion, disappears rapidly. 2+ 2-4mm indent: somewhat deeper pit, no readably detectable distortion, disappears in 10-25 seconds. 3+ 4-6mm: pit is noticeably deep. May last more than a minute. Dependent extremity looks swollen and fuller. 4+ 6-8mm: pit is very deep. Lasts for 2-5 minutes. Dependent extremity is grossly distorted. Review of Resident #1's MAR dated 12/1/25–12/22/25 documented 3+ edema on the following dates: 12/8/25 12/9/25 12/15/25 12/21/25 On 12/29/25 at 4:28 PM, a request for edema notification to provider was made and not provided. On 12/30/25 at 4:38 PM, the Director of Nursing (DON) confirmed that blood pressures above 180 are considered severely elevated. After reviewing Resident #1's record, the DON stated she was unable to locate documentation of reassessment related to the elevated blood pressures. She also confirmed the record did not include documentation of provider notification regarding the increased edema. The DON stated staff provided verbal notifications to the provider; however, this was not documented in the medical record. 2.The National Library of Medicine, accessed 12/31/25, documented that absent bowel sounds may be associated with serious complications including bowel obstruction, intestinal ischemia, paralytic ileus, or peritonitis, all of which require further clinical intervention. Resident #2 was admitted on [DATE] with multiple diagnoses including muscle weakness, retention of urine, and cognitive communication deficit. A nursing progress note dated 11/8/25 documented Resident #2 had a distended abdomen with absent bowel sounds and was administered Milk of Magnesia. On 12/29/25 at 5:09 PM, the survey team requested documentation of physician notification regarding Resident #2's condition. On 12/29/25 at 6:33 PM, the DON provided a nursing progress note dated 11/9/25, documenting Resident #2 had not had a bowel movement in over 72 hours and continued to have abdominal distention. The note documented the physician was notified, with no new orders received. On 12/30/25 at 4:50 PM, the DON stated that absent bowel sounds are considered an emergency. She confirmed the provider was not notified of the absent bowel sounds assessed on 11/8/25 until 11/9/25. 3. Resident #4 was admitted to the facility on [DATE] for care following sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's own organs and tissues) and multiple abscesses (pus-filled infected pockets of fluid) of of his liver. Upon his admission, Resident #4 had 3 drain tubes surgically placed in his abdomen to drain waste from the liver abscesses into collection bags outside his body. On 3/14/25, a drain check note from Interventional Radiology documented: Drain #1 was removed, drain #2 and #3 remain in place, re-check tubes in 7 to 10 days Empty drain bags daily and record output on each drain On 3/21/25, a drain check note from Interventional Radiology documented: Drain #2 removed, drain #3 remains, re-check tubes in 2 weeks If output is less than 10 ml for two consecutive days call interventional radiology to schedule a sooner check Flush with 5 ml sterile saline once daily Resident #4's treatment administration record documented the following physician orders: Flush each drain daily with 10 ml of sterile saline up into the drain, release and let flow back out at bedtime, start date 3/13/25, discontinue date 3/24/25. Drain #2 and #3 remain in place. Empty drain bags daily and record output every day during day shift, start date 3/15/25, discontinue date 3/24/25. Drain tube check in 2 weeks, if output is less than 10 ml for two consecutive days call IR to schedule check sooner. Flush with 5 ml once daily, start date 3/22/25, discontinue date 3/24/25. a. On 1/30/25 at 5:03 PM, the DON stated, Resident #4's TAR had two conflicting orders, one to flush the drains with 10 ml of sterile saline, and one to flush the drains with 5 ml of sterile saline. She stated, the order to flush with 10 ml should have been discontinued on 3/21/25 when new orders were received. b. On 1/30/25 at 5:04 PM, the DON stated Resident #4 received new orders for his drain tubes on 3/14/25 and 3/21/25, and those orders were not implemented on the TAR until 3/15/25 and 3/22/25 respectively. She stated, the new orders should have been implemented the same day they were received, not the following day. c. On 1/30/25 at 5:06 PM, the DON stated Resident #4's record did not document the amount of fluid drained from his collection bags on 3/14/25, 3/16/25, and 3/17/25, and the nurses did not follow the physician order to record output.

Based on record review and staff interview, it was determined the facility failed to ensure sufficient staff were on-site to provide nursing services. This failure had the potential to affect all residents living in the facility and placed them at risk for harm if their call lights were not able to be answered in a timely manner or care was not provided due to not having adequate numbers of staff. Findings include:The facility Grievance Log was reviewed for July-December 2025, and documented the following:On 8/8/25, a resident reported long call light wait times. The facility completed call light audits and staff were provided education to answer call lights in a timely manner. On 8/15/25, a resident reported they were left soiled for 2 hours while their call light was on, once staff responded they seemed hurried. The facility provided one to one training to the CNA for answering call lights.On 8/22/25, a resident reported they used their call light for incontinence care, a CNA responded and turned off the call light, then said they would come help them with a shower, then did not return for 1 hour 15 minutes. The facility provided one to one education for the CNA and the CNA would not be assigned to work with that resident in the future. On 9/19/25, a resident representative reported their loved one had been wearing the same clothes all weekend. The facility provided education to staff for providing care and activities of daily living. On 11/3/25, a resident representative reported their loved one was observed to be in their recliner in their bedroom soiled with urine and stool. The facility provided education to staff to provide incontinence care every two hours. On 11/14/25, a resident representative reported their loved ones call lights were not being responded to. The facility provided education to all staff about answering call lights. On 12/10/25, a resident reported they waited 2 hours and 30 minutes to use the restroom because no staff were available to answer their call light. The facility did not address this concern. On 1/30/25 at 5:25 PM, the DON stated, call lights are a constant problem. She stated they do call light audits and education with the staff when concerns were brought to their attention. The DON stated the administrative staff were encouraged to answer call lights when they notice them. She added, the administration was struggling to find a solution to long call light wait times.

Based on record review and staff interview, the facility failed to ensure resident records were accurately documented in accordance with professional standards of practice. This was true for 1 of 8 residents (Resident #4) whose records were reviewed for accuracy of resident records. This failure resulted in inaccurate clinical documentation. Findings include:Resident #4 was admitted to the facility on [DATE], for care following sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's own organs and tissues) and multiple abscesses (pus-filled infected pockets of fluid) of his liver. Upon his admission, Resident #4 had 3 drain tubes surgically placed in his abdomen to drain waste from the liver abscesses into collection bags outside his body. On 3/14/25, a drain check note from Interventional Radiology documented: Drain #1 was removed, drain #2 and #3 remain in place, re-check tubes in 7 to 10 days On 3/21/25, a drain check note from Interventional Radiology documented: Drain #2 removed, drain #3 remains, re-check tubes in 2 weeks Resident #4's progress notes from 3/11/25 through 3/24/25, documented the following: On 3/11/25 at 1:58 PM, in a Clinical Evaluation Summary note, Resident #4 had 3 drains to his liver. On 3/11/25 at 1:59 PM, in a Skin Inspection Note, Resident #4 had 3 drains to his liver in his left upper abdomen, On 3/13/25 at 1:01 AM, in a Health Status Note, Resident #4 had 3 drains to his liver. On 3/13/25 at 11:21 PM, in a Health Status Note, Resident #4 had 3 drains to his liver. On 3/14/25 at 10:07 AM, in a Health Status Note, Resident #4 had 3 drains to his liver and went to an appointment that day to check his drains. On 3/15/25 at 12:31 AM, in a Health Status Note, Resident #4 had 3 drains to his liver. On 3/17/25 at 4:49 AM, in a Health Status Note, Resident #4 had 3 drains to his liver. On 3/17/25 at 11:54 PM, in a Health Status Note, Resident #4 had 3 drains to his liver, both drains were flushed during the night shift. On 3/18/25 at 11:00 PM, in a Skilled Charting Note, Resident #4 had 3 drains to his liver that were drained in the evening On 3/19/25 at 11:34 PM, in a Health Status Note, Resident #4 had 3 drains to his liver that are drained and flushed every evening, draining serous-bloody drainage, 25 ml from one drain, and 15 ml from the other. On 3/20/25 at 11:00 PM, in a Health Status Note, Resident #4 had 2 drains to his liver that were drained in the evening On 3/21/25 at 7:07 PM, in a Health Status Note, Resident #4 had an appointment that day for a drain check, drain #2 was removed and drain #3 remained. On 3/21/25 at 11:00 PM, in a Skilled Charting Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded. On 3/22/25 at 8:49 PM, in a Health Status Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded. On 3/23/25 at 5:09 AM, in a Health Status Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded. On 3/24/25 at 11:26 AM, in a Health Status Note, Resident #4 had 1 drain to his liver and was preparing to discharge home. On 1/30/25 at 5:12 PM, the DON stated multiple progress notes documented the wrong number of drains and Resident #4's medical record documents were not accurate. She added, the nurses may have been copying and pasting their progress notes.

Based on observation, review of the State Operations Manual, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when 1) staff was assisting residents with meals and 2) medication administration, and 3) unsanitary conditions in the laundry room. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The State Operations Manual, Appendix PP, updated 8/8/24, documented failure to change gloves and wash hands between tasks, such as medical treatments or contact with residents .can contribute to cross-contamination. The facility policy, Dining Standards, updated 9/10/20, documented staff was to complete hand hygiene using soap and water at the beginning of meal service and are to sanitize hands when changing tasks or assisting different residents. The following issue were observed in the dining room; On 3/3/25 at 8:37 AM, CNA #5 was observed alternating between 2 of 5 residents sitting at the same table, offering spoon feeding assistance using the same gloved hand. CNA #5 did not change gloves, wash hands, or hand sanitize in between feeding each resident. On 3/3/25 at 8:45 AM, CNA #5 grabbed a folding chair located behind her to sit in. CNA #5 did not change her gloves, wash hands, or hand sanitize before continuing to feed the 2 residents. On 3/6/25 at 10:00 AM, the DON stated when staff is feeding more than one resident, they should have a designated hand for each resident or hand sanitize in between each resident assist. The following was observed for medication administration; Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and anxiety. Resident #3's physician order dated 1/17/24, documented Buprenorphine HCl Sublingual Tablet Sublingual 2 MG (Buprenorphine HCl). Give 1 tablet sublingually one time a day for pain. On 3/5/25 at 7:50 AM, observed RN #1 place a Buprenorphine HCl tablet in her bare hand then place it in Resident #3's medication cup. RN #1 then administered the pill to Resident #3. On 3/5/25 at 7:54 AM, RN #1 stated she should not have touched Resident #3's pill with her bare hand. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Spastic Diplegic Cerebral Palsy (a neurological disorder that affects movement and causes overly toned muscles) and anxiety. Resident #21's Physicians order dated 11/15/24, documented enteral feed every shift. For enteral nutrition precautions check feeding tube placement by observing change in the external length 4cm's marked at entry point before administering formula, medication administration, or flushing of tube. On 3/5/25 at 7:08 AM, observed in Resident #21's room a feeding pole and pump with a dried light brown substance on the pump and on the base of the pole. On 3/5/25 at 7:08 AM, the following was observed when LPN #1 was flushing Resident #21's feeding tube; - LPN #1 placed the 60cc syringe on Resident #21's bed while she put her stethoscope on. - LPN #1 connected the 60cc syringe to the feeding tube. - LPN #1 removed the plunger from the 60cc syringe and placed it on Resident #21's bed. - LPN #1 poured the crushed medication with liquid into the 60cc syringe barrel. - LPN #1 picked the syringe plunger up off the bed and inserted it back into the 60cc syringe which was still connected to Resident #21's feeding tube. On 3/5/25 at 7:27 AM, LPN #1 stated Resident #21's feeding pole and pump should have been cleaned daily or when there was a spill. On 3/5/25 at 11:07 AM, the DON stated LPN #1 should have placed her tube feeding supplies on a protective cover on top of Resident #21's bedside table, not on her bed. On 3/5/25 at 7:35 AM, observed Hall 300 medication cart with RN #1's personal drink on top of the cart. On 3/5/25 at 7:41 AM, RN #1 stated she should not have had her personal food or drinks on the medication cart. The following was observed in the laundry room; On 3/6/25 at 3:41 PM, observed the following in the laundry room: - a large amount of water, with a dark green substance on it, in front of the washing machine. - a thick layer of fuzzy gray substance under hand washing sink. - no goggles available in laundry room, in case of splashing. - the pipes between washers observed with a thick layer of gray, fuzzy substance. - the pipes behind dryer observed with thick layer of gray, fuzzy substance. - the ceiling piping cover above the clean linen folding table was observed with a thick layer of fuzzy gray substance. - two outside wall vents were observed with a thick fuzzy substance. On 3/6/25 at 3:47 PM, the Laundry Manager stated the laundry room is cleaned daily but there was no check off sheet to direct the staff on what needed to be cleaned. On 3/7/25 at 9:38 AM, the Administrator stated the laundry room should have been kept clean. 49552

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: The facility's Controlled Substance Administration & Accountability policy dated 12/16/24, documented it is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. On 3/5/25 at 12:41 PM, during hall 300's medication cart audit, observed the narcotic accountability record, dated 11/22/24 to 12/3/24, with 16 licensed nurse signatures for each shift not documented. Review of the narcotic accountability record, dated 2/9/25 to 3/5/25, with 2 licensed nurse signatures for each shift not documented. On 3/5/25 at 12:33 PM, RN #1 stated the nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart.

Based on observation, review of the State Operations Manual, policy review, and staff interviews, the facility failed to treat residents with respect and dignity during dining operations. This failed practice had the potential to negatively affect resident's self-esteem, decreased enjoyment of meals and mealtime, and may negatively impact resident's food and fluid intake. Findings include: State Operations Manual, Appendix PP, updated 8/8/24, documented to promote independence and dignity while dining, avoid standing over residents while assisting them to eat. The facility policy, Dining Standards, updated 9/10/20, documented staff are to sit down next to the resident while feeding and/or assisting with feeding. On 3/3/25 at 8:37 AM, CNA #5 was observed standing next to the dining room table, spoon feeding 2 of 5 residents seated at the table eating their breakfast. On 3/3/25 at 8:45 AM, LPN #2 stated staff should not be standing over the residents when assisting with feeding. 03/06/25 at 10:00 AM, the DON stated staff should not be standing while feeding residents.

Based on record review and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This was true for 2 of 24 Residents (#18 and #30) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include: 1) Resident #18 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease with dyskinesia (a condition where someone with Parkinson's disease experiences involuntary, uncontrolled movements) and dementia. Resident #18's medical record had not contained a copy of his Advance Directives. Resident #18's admission agreement document which contains the following wording By signing below, I acknowledge that I am legally bound by this Agreement and I indicate that I have: been offered information regarding Advance Directives was not signed by the resident or resident representatives. Resident #18's Social Services Progress note dated 2/19/25, documented social services will request DPOA, Power of Attorney, and Living Will from the family. Resident #18's Multidisciplinary Care Conference dated 2/20/25, documented under Key Reviews 4b. Does the resident have an advance directive: YES, 4c. Does the facility have a copy of the resident's advanced directives on file? YES. On 3/7/25 at 9:45 AM, the Administrator stated the Social Services Director incorrectly checked the YES 4b. box and facility had not obtained a copy of the Resident #18's Advance Directives. 2) Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including pulmonary embolism (a condition where a blood clot (embolus) travels from another part of the body, usually the legs (deep vein thrombosis), and blocks an artery in the lungs) and acute respiratory failure with hypoxia (occurs when the lungs are unable to exchange oxygen and carbon dioxide properly, resulting in low oxygen levels in the blood). Resident #30's medical record had not contained a copy of his Advance Directives. Resident #30's admission agreement document which contains the following wording By signing below, I acknowledge that I am legally bound by this Agreement and I indicate that I have: been offered information regarding Advance Directives was not signed by resident or resident representatives. Resident #30's Multidisciplinary Care Conference dated 1/6/25, documented under Key Reviews 4b. Does the resident have an advance directive: YES, 4c. Does the facility have a copy of the resident's advanced directives on file? YES. Resident #30's Social Services Progress note dated 2/18/25, documented Social Services Director will request DPOA, Power of Attorney, and Living Will from the family. On 3/7/25 at 9:45 AM, the Administrator stated the Social Services Director incorrectly checked the YES 4b. box and facility had not obtained a copy of the Resident #30's Advance Directives.

Based on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 at least 2 days prior to discharge for 1 of 3 residents (Resident #302) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include: Resident #302 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event) and cirrhosis (a condition in which your liver is scarred and permanently damaged). Resident #302 was discharged from Medicare Part A 12/16/24, and the NOMNC was signed on 12/16/24. On 3/7/25 at 9:45 AM, the Administrator stated Resident #302's NOMNC had not been completed at least 2 days prior to Medicare Part A ending as required.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 24 residents (Resident #52) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include: The facility's Comprehensive Care Plans policy, revision date 10/15/22, documented the team of qualified persons monitors the resident's condition and effectiveness of the care plan interventions and revises the care plan annually, with a significant change assessment, or more frequently as needed. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses which include dementia and weakness. Resident #52's medical recorded documented that she fell out of bed on 12/7/24. Resident 52's care plan was not updated with new fall interventions. On 3/5/25 at 3:45 PM, the DON stated the Fall Investigation report documented the new fall intervention was for Resident #52's bed to be in the lowest position. The DON stated her care plan was not updated with this new fall prevention intervention, and it should have been.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #21) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice. Finding include: The facility's Enteral Nutrition policy, revised 10/30/18, directed staff to verify tube placement by gently tugging on the tube and taking note of the marking on the tube. The policy also directed staff to properly label and date the enteral formula bottle. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Spastic Diplegic Cerebral Palsy (a neurological disorder that affects movement and causes overly toned muscles) and anxiety. Resident #21's Physician's order dated 11/15/24, documented enteral feed every shift. For enteral nutrition precautions check feeding tube placement by observing change in the external length 4cm's marked at entry point before administering formula, medication administration, or flushing of tube. On 3/5/25 at 7:08 AM, observed LPN #1 check Resident #21's feeding tube placement by using a 60cc syringe, a stethoscope, and pushing 10cc of air into Resident #21's feeding tube while auscultating her abdomen. Resident #21's Physician's order dated 1/1/25, documented she was to receive Jevity 1.2 at 85 ML/HOUR for 12 hours. On 3/5/25 at 7:08 AM, observed in Resident #21's room a bottle of Jevity 1.2 (a type of feeding formula that provides complete, balanced nutrition). The bottle of Jevity 1.2 was not labeled with resident's name, start date, time, and rate of feeding to be delivered per hour. On 3/5/25 at 7:27 AM, LPN #1 stated Resident #21 received the feeding on the night shift, the bottle of Jevity 1.2 should have been labeled and the feeding pole should have been cleaned daily or when there was a spill. On 3/5/25 at 2:04 PM, the DON stated Resident #21's Jevity 1.2 bottle should have been labeled when it was started and the feeding pole should have been cleaned.

Based on personnel record review, resident record review, and staff interview it was determined the facility failed to ensure employees had completed the required annual trainings and competencies necessary to care for resident's needs. This was true for 1 of 5 employees whose training information was reviewed and 1 of 1 resident (Resident #32) medical records reviewed. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents if staff were not trained on how to provide care and services to residents. Findings include: 1) RN #2's hire date was 5/29/21. Review of his personnel file did not document he had completed his dementia and communication training. RN #2's personnel file documented a Statement of Discussion dated 1/2/25, regarding the need to complete assigned training. On 3/7/25 at 10:00 AM, the DON stated RN #2 had not completed his training. 2) Resident #32 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties) and depression. On 3/4/25 at 8:22 AM, Resident #32 was not wearing her oxygen cannula during this visit and stated she wears the oxygen when she needs it. Resident #32's physician oxygen order dated 10/1/24, documented oxygen at 2 to 3 liters per minute to keep oxygen saturations (SpO2) greater than 90% continuously via nasal cannula with humidification. Check Q4 hours. Resident #32's oxygen SpO2 was checked on the following dates and times; - 10/6/24 20:20 SpO2 86% room air (R/A) by CNA #1 - 11/10/24 10:16 SpO2 90% R/A by CNA #3 - 11/18/24 03:22 SpO2 82% R/A by LPN #4 - 11/25/24 09:06 SpO2 87% with oxygen by LPN #5 - 12/3/24 05:35 SpO2 87% with oxygen by CNA #4 - 1/24/25 08:05 SpO2 3% with oxygen by LPN #6 - 2/26/25 05:00 SpO2 85% R/A by LPN #7 - 2/27/25 01:42 SpO2 88% R/A by LPN #4 - 2/27/25 05:29 SpO2 291% with oxygen by LPN #4 - 3/4/25 19:32 SpO2 89% R/A by RN #3 Resident #32 medical record had not contained nursing progress notes documenting nursing staff addressed the low O2 levels or that Resident #32 was not on her oxygen per physician's orders. On 3/7/25 at 8:47 AM, the DON stated the oxygen SpO2 desaturations should have been addressed by nursing staff and was not. 51121

Based on observation, CDC guidelines review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication storage rooms inspected and 3 of 5 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication and to receive expired medications with decreased efficacy. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. On 3/5/25 at 10:45 AM, the Hall 100 medication cart was audited with RN #4 present. In the top drawer of the medication cart a dairy digestive tablet was observed with an expiration date of July 2024. On 3/5/25 at 10:47 AM, RN #4 stated the dairy digestive tablet should not have been in the medication cart. On 3/5/25 at 12:33 PM, the medication storage room audit was done with LPN #8 present. Observed in the medication storage room a bottle with 12 Calcium tablets with an expiration date of October 2023. On 3/5/25 at 12:36 PM, LPN #8 stated the expired medication should have been in the medication destruction tote. On 3/5/25 at 12:41 PM, the Hall 300 medication cart was audited with RN #1 present. Observed in the second drawer, under blister packs, one loose Losartan tablet. On 3/5/25 at 12:45 PM, RN #1 stated that the loose pills should have been placed in the drug buster (drug disposal system). On 3/5/25 at 12:48 PM, the Friendship house medication cart was audited with LPN #3 present. The following was observed: - In the bottom of the second drawer on the left, one Remeron (antidepressant) tablet. - In the bottom of the third drawer, three yellow pills and three white pills. - Also in the third drawer one multi-dose vial of Lidocaine with no open date. On 3/5/25 at 12:54 PM, LPN #3 stated the loose pills should have been destroyed and the bottle of Lidocaine should have been dated when it was opened.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 3 medications (8.82%) which affected 1 of 6 residents (Resident #58) whose medication administration were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication. Findings include: The facility's Oral Medication Administration policy dated 1/1/18, documented oral medications are to be administered per physician orders. The facility's Eye Drop Administration policy dated 2/28/18, documented wait a sufficient contact time of approximately 3-5 minutes before applying additional medication to the eye. The facility's Insulin Pen Use policy undated, documented before administering insulin, a 2-unit air shot must be performed to remove air bubbles and ensure accurate dosing. The following was observed during the medication pass: 1. Resident #58 was admitted [DATE], with multiple diagnoses including kidney disease and right leg, below the knee, amputation. Resident #58's physician order documented Glargine insulin, administer 10 Units subcutaneously. On 3/5/25 at 7:35 AM, observed RN #1 remove Glargine insulin pen from the medication cart and dial the insulin pen to 10 Units. RN #1 did not prime the insulin pen before dialing the ordered dose. RN #1 then administered the Glargine insulin to Resident #58. On 3/5/25 at 7:39 AM, RN #1 stated she did not realize she needed to prime the insulin pen before dialing the insulin pen to the ordered dose. Resident #58's physician order documented Dorzolamide (eye drops used to treat increased pressure in the eye) 22.3-6.8mg/ml 1 drop to her left eye and Rednisol acetate (steroidal eye drop used to treat redness and swelling) 1 %, give 1 drop left eye. On 3/5/25 at 7:40 AM, observed RN #1 administer both of Resident 58's ordered eye drops. RN #1 did not wait the required 3-5 minutes in between eye drop administration. On 3/5/25 at 7:46 AM, RN #1 stated she should have waited 3-5 minutes before she gave the second ordered eye drops.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a lap tray was used to treat a medical symptom and not used as a physical restraint for 1 of 1 resident (Resident #78) who was observed for use of restraints. This resulted in harm to Resident #78 was left in a wheelchair with a lap tray for long periods which resulted in skin impairment and psychosocial distress. Findings include: Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), anxiety disorder, and malnutrition. Resident #78's admission MDS assessment, dated 12/9/23, documented she was severely cognitively impaired with unclear speech and rarely/never understood others. The assessment documented Resident #78 was dependent on eating and personal hygiene assistance and required maximal assistance for upper body dressing, sitting to standing, and transfer. The assessment further documented Resident #78 did not use a restraint device, including a chair to prevent rising. A progress note, dated 12/11/23 at 2:26 PM, documented Resident #78 was very anxious during the shift and continuously attempted to get out of her chair and was trying to push tables. The note documented Resident #78 was not able to be redirected. A progress note, dated 12/12/23 at 6:16 PM, documented Resident #78 was extremely anxious when she woke up in the afternoon after a nap. She continued to wander in her wheelchair and was agitating other residents. The note documented Resident #78 would constantly try to get out of her wheelchair and could not be redirected. A progress note, dated 12/12/23 at 9:03 PM, documented Resident #78 was found on the floor at the foot of the bed at 3:35 PM. The note documented Resident #78 was very anxious and could not appropriately answer questions. A progress note, dated 12/15/23 at 7:20 PM, documented Resident #78 continued to be anxious and was exhibiting repeated motions. Resident #78 was impulsive and not able to be redirected. The note documented staff attempted to sit with Resident #78 for one-on-one attention, but it was not effective. A progress note, dated 12/15/23 at 9:09 PM, documented a CNA wheeled Resident #78 down the hallway, and she leaned forward to grab a dresser. Resident #78 hit the right side of her head while wearing a soft protective helmet and sustained a skin tear to her right hand. Resident #78 was placed in the area visible to the nurse for the rest of the shift, with occasional one-on-one supervision to prevent additional falls. A progress note, dated 12/16/23 at 7:46 PM, documented Resident #78 was very anxious during the shift. The note documented she slept until 2:00 PM, and her morning medication was missed. Resident #78 was receiving scheduled Ativan (antianxiety medication) and Seroquel (antipsychotic medication) with little effect. The note further documented a staff member had to sit with her while she was awake because Resident #78 constantly attempted to stand up, walk, and push tables. A progress note, dated 12/17/23 at 3:38 PM, documented OT evaluated Resident #78 for use of a lap tray during mealtime. Resident #78's daughter was informed and agreed with the recommendation. A Mobility Positioning Device Evaluation, dated 12/17/23 at 1:07 PM, documented, Lap tray table utilized during meals and activities to assist with keeping food and items from falling on the floor. The evaluation further documented the lap tray restricted access to Resident #78's body and was considered a physical restraint. The potential risk or concern identified was Lap tray recommended per therapy. The resident is not able to release the lap tray, to be used only during meals and activities for a duration of no more than 2 hrs. Staff to assist and release lap tray. A physician's order, dated 12/17/23, documented to use a lap tray during mealtime three times a day with a start date of 12/17/23. Resident #78's MAR for December 2023, documented use of the lap tray was signed by the charge nurse three times a day. There was no documentation of when and how long Resident #78 used the lap tray each day and if she was released before the 2-hour limitation window, as the Mobility Positioning Device Evaluation stated. An Assistive/Enabling Device consent, with verbal consent by Resident #78's daughter on 12/17/23, documented the potential risks of the physical restraint as follows: - Accidental injury-related potential entrapment. - Incidence of incontinence. - Functional decline, change in muscle condition. - Incidence of pressure sores and related infections. - Incidence of agitation or delirium. - Symptoms of depression, withdrawal, reduced social contact - Reduced independence., loss of dignity. Resident #78's record did not include interventions related to the care, monitoring, and prevention of the physical risks and psychosocial impacts related to the use of the lap tray as a restraint from 12/17/23. A progress note, dated 12/23/23 at 8:12 PM, documented Resident #78 slept until 4:00 PM and refused to allow staff to get her up. Once she was up, she was very anxious and wandered around the dining room, agitating other residents. A physician's order, dated 1/5/24, documented a lap tray to be used for Resident #78 during mealtimes and activities only. The order directed staff to assist Resident #78 with releasing and removing the lap tray every two hours for toileting and repositioning out of the wheelchair when in use, every shift. Resident #78's MAR for January and February 2024, documented the charge nurse signed her lap tray use once per shift, twice a day. Resident #78's care plan for malnutrition was revised on 1/5/24 with the new intervention of lap tray during mealtimes and activities only. The care plan documented to assist with releasing and removing the lap tray every two hours with toileting and repositioning out of the wheelchair when in use. Resident #78's record did not include documentation of when the lap tray was used and whether it was released every two hours when in use. A progress note, dated 2/3/24 at 7:50 PM, documented Resident #78 was sent to the hospital for evaluation due to a change in her status. A progress note, dated 2/4/24 at 12:07 AM, documented Resident #78 returned to the facility from the hospital with a urinary tract infection diagnosis, and she was receiving antibiotic medication. Resident #78's daughter noted Resident #78 had an area of redness of 1 cm on her elbow and a 7 cm by 3.5 cm red area at the edge of her ribcage; it was marked and noted. The nurse on the prior shift expressed concerns that Resident #78 was leaning forward on her tray for a significant amount of time, and the nurse was unable to reposition her. A progress note, dated 2/5/24 at 6:46 AM, documented Resident #78 was observed by a CNA at bedtime to have new redness and discoloration to the left side of her ribs. The note documented Resident #78 was leaning on the lap tray in her wheelchair. A progress note, dated 2/5/24 at 2:14 PM, documented Resident #78 had discoloration to the left side of her ribs. The note documented it was likely from the tray on her chair she had been leaning forward over, which caused the discoloration. The note documented foam noodles (cylindrical piece of flexible, buoyant polyethylene foam) be placed along the inside of the tray to protect Resident #78's abdomen. A Skin Inspection note, dated 2/5/24 at 4:47 AM, documented Resident #78's left lower arm had multiple red and purple discoloration areas on the underside. There was a large red scratch on the upper side of the lower right arm. The left side of the lower rib cage was red with some peeling. The skin inspection note did not include measurements of the areas identified. On 2/6/24 from 10:50 AM to 12:00 PM, Resident #78 was observed in a wheelchair with a black lap tray placed in front of her attached on both sides of the wheelchair with handles in front of her around her waistline; there was a black strap that tightened the table fastened behind her wheelchair. The table blocked her ability to stand up. Resident #78 was observed frequently attempting to stand up and could not do so. On 2/7/24 from 11:00 AM to 11:21 AM, Resident #78 was observed wearing a helmet in a Broda chair (positioning wheelchair helps prevent falls and provides personalized upper lateral support for positioning). On 2/7/24 at 11:23 AM, Resident #78 tried to stand up from her Broda chair two to three times in the group room. LPN #1 and CNA #4 were observed placing Resident #78's lap tray on her wheelchair and secured it with a black strap behind her wheelchair. On 2/7/24 at 11:30 AM, LPN #1 said she had to put the lap tray on Resident #78 because the tray was to prevent residents from falling. The LPN said last week Resident #78 had redness on her left lower rib to the abdominal area because she was leaning toward the lap tray and had a bruise on her left elbow. LPN #1 said Resident #78 was now using the Broda chair. On 2/7/24 at 4:15 PM, Resident #78 was sitting in the same Broda chair with a lap tray. Resident #78's feet were hanging down without touching the floor and there was no support. Resident #78 continually tried to get up but was stopped by the lap tray on her chair. She appeared sad with a red face and dropping her eyes with wrinkles between her eyes on her forehead; her jaws and lips appeared tense. During an interview while observing Resident #78, LPN #1 said Resident #78 went out for an appointment around 12:00 PM and was back around 1:45 PM, and she had been in the Broda chair since then. LPN #1 said without the Broda chair, Resident #78 would need one-on-one care to prevent her from falling. A progress note, dated 2/7/24 at 7:01 PM, documented the nurse was to monitor Resident #78's posture while in a standard wheelchair. The note documented Resident #78 could use a Broda chair per OT only if Resident #78 was leaning in a way that made her uncomfortable. The note further documented if a Broda chair was necessary, to make a note. On 2/8/24 at 8:25 AM, the DON said Resident #78's lap tray was a restraint because Resident #78 could not remove it. She said use of the lap tray was documented under the nutrition care plan. The DON said there was an order for using the lap tray and to release the tray every 2 hours, but there was no documentation when it was used or released every 2 hours when in use. On 2/9/24 at 8:32 AM, the DON said Resident #78 started to use a lap tray on 12/17/23 for help with self-feeding. She stated later it was added for Resident #78's leaning forward during activity and trying to pick up objects on the floor which led to falls. On 2/9/24 at 10:20 AM, the DON said there were only two interventions for the restraint; one was to release it every two hours, and the other was for OT evaluation and treatment. The DON said there was no documentation staff were monitoring potential physical or psychosocial risks and adverse outcomes of a physical restraint.

Based on record review, policy review, Reportable Incident review, staff time card review, and staff interview, it was determined the facility failed to ensure residents were free from verbal and mental abuse. This was true for 1 of 1 resident (Resident #3) reviewed for abuse. This failure resulted in Resident #3 being abused by a staff and the staff continuing to care for Resident #3, placing Resident #3 at risk if continued abuse and the other residents in the facility at risk of abuse. Findings include: The facility's policy for Preventing Abuse, released on 10/1/17 and revised on 7/13/18, documented the following: * The facility had processes in place to assist with preventing abuse. * Residents, visitors, and staff were observed to identify inappropriate behaviors. * Staff received information on how and to whom they could report concerns. * Residents were identified who were most at risk of neglect and abuse, including those who had dementia, psychosocial, interactive, and/or behavior dysfunction. * Concerns/problems were identified, and corrective action was taken to assist with preventing re-occurrences. The facility's policy for Abuse, released on 11/28/17 and revised on 7/23/19, documented the following: * Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, exploitation, deprivation of goods and services by staff, and misappropriation of resident property are strictly prohibited. * The facility implemented seven key components, including: screening, training, prevention, identification, investigation, protection, and reporting/responding to allegations of abuse. * Allegations of abuse were reported to the Administrator immediately, and to the state agency within two hours if there was alleged abuse. These policies were not followed. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan documented he had multiple focus areas for problematic behavior, which was characterized by ineffective coping, physical aggression/abuse, verbal aggression/abuse, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior note, dated 2/25/21 at 5:18 AM, documented Resident #3 was combative and aggressive with staff during morning cares. An IDT note, dated 3/1/21 at 3:00 PM, documented Resident #3 was reviewed at the weekly Behavioral meeting due to being combative and aggressive with cares, and an investigation showed inappropriate staff approaches. Staff was to be re-educated and monitored. A Reportable Event notification from the facility to the State Survey Agency, dated 3/8/21, documented an incident of abuse involving Resident #3 occurred on 2/25/21. A CNA reported another caregiver became upset when Resident #3 was noncompliant during an attempt to assist him with putting on a shirt. Resident #3 grabbed the shirt from the staff member, who yelled and threw the shirt back at him. On 3/3/21, the DON notified the Administrator that an incident of potential abuse to Resident #3 was reported to her from a staff member. A statement was obtained from the staff who reported the incident. When the involved staff came in for his shift, he was interviewed about the incident and a statement was collected. The involved staff was placed on Administrative leave until the investigation was completed. An Interview Record, dated 3/3/21 at 6:00 PM, documented a written statement from NA #1, completed as part of the facility's investigation. NA #1 documented he was assisting a CNA with cares for Resident #3 when he became resistive to cares, and Resident #3 attempted to punch him. NA #1 stated he attempted to put a shirt on Resident #3, and Resident #3 grabbed the shift and threw it at him. NA #1 threw the shirt back at Resident #3, and it struck him in the face. NA #1 stated he reported the incident to the nurse on duty, and he discussed it with the CNA. NA #1 stated he used a different approach with Resident #3 later that week, and received a much more positive result. An undated Interview Record documented a written statement from CNA #1. CNA #1 stated on 2/25/21 at approximately 5:00 AM, NA #1 asked her to help get Resident #3 up into his wheelchair. Resident #3 appeared to be agitated with NA #1, and in a raised voice he told NA #1 to get out and leave him alone. NA #1 attempted to help Resident #3 put on a shirt, and Resident #3 grabbed the shirt and threw it at NA #1. NA #1 then aggressively took the shirt from [Resident #3] and threw it fairly hard at [Resident #3's] face. Resident #3 again told NA #1 to leave him alone. Review of NA #1's time cards documented he worked the following days: * He clocked in on 2/24/21 at 6:02 PM and clocked out on 2/25/21 at 6:15 AM, which was shortly after the incident involving Resident #3. * He clocked in on 2/26/21 at 6:04 PM and clocked out on 2/27/21 at 6:17 AM. * He clocked in on 2/27/21 at 5:57 PM and clocked out on 2/28/21 at 6:17 AM. NA #1 worked two 12 hour shifts after the abusive incident involving Resident #3. On 3/11/21 at 10:00 AM, the SSD said if a staff member abused a resident, there was a full investigation and the involved staff's employment was terminated. The SSD said the incident was reported to the state agency, and the Administrator entered the information regarding the incident, but he relied on others to help gather the information. The SSD said there was a recent investigation regarding abuse of Resident #3 when a staff member attempted to provide cares to him. Resident #3 became combative and threw something at a staff member, and the staff member threw it back at him. The SSD said Resident #3's care plan documented staff were to back off if Resident #3 became combative, and the involved staff did not back off. The SSD said the involved staff was sent home the night of the incident, and there was a delay in it being reported to her and to the Administrator. On 3/11/21 at 11:40 AM, RCM #1 said if there was an incident of abuse, it should be reported to the Administrator, and the involved staff should be sent home. RCM #1 said there was a recent incident of abuse when an employee tried to get Resident #3 up and he became upset and threw something. The staff member then threw a shirt back at Resident #3, and the staff member was put on leave and then was let go. RCM #1 said she did not know if the involved staff member worked in the facility after the incident, but he should not have worked after that. On 3/11/21 at 11:53 AM, the Administrator said there was an incident where a staff member lost his cool when Resident #3 threw a shirt at him, and the staff member threw the shirt back at Resident #3. The Administrator said he and the DON interviewed the staff member and put him on administrative leave, and then they decided to end his employment in the facility. The Administrator said the incident happened on 2/25/21, and he was notified on 3/3/21. The Administrator said the nurse on shift at the time of the incident was from an agency, and the facility was not able to reach her despite attempts to reach her through the agency. The Administrator said it was his understanding that the incident was reported to the nurse on shift at that time, but she did not report it to them. When asked how the facility ensured all staff, including agency staff, were trained regarding abuse and the facility's policies/expectations regarding abuse, the Administrator said the facility provided a binder to the agency which contained information the facility wanted them to know. When asked if the facility verified with the agency staff that they reviewed and understood the information provided by the facility, the Administrator said, That's up to HR (Human Resources) and they deal with those things. The DON, also present during the interview, said the incident happened at the end of shift, and the involved NA went home after that. The DON said she believed the involved NA worked one shift in the facility after the incident because she was not aware of incident yet. The DON said the involved NA should not have worked after the incident occurred. The DON and Administrator said they became aware of the incident on 3/3/21 when another staff member informed the DON. The facility failed to ensure Resident #3 was free from verbal and mental abuse when a staff member raised his voice and threw a shirt, which struck him in the face.

Based on staff interview, review of facility policies, record review, and review of Incident & Accident (I&A) reports, the facility failed to ensure sufficient supervision of residents to prevent falls. This was true for 1 of 4 residents (Resident #9) reviewed for falls. This resulted in harm to Resident #9 when he had multiple falls and bruised and fractured his little finger. Findings include: The facility's Fall Prevention Program policy, revised 11/28/20, directed staff to identify residents who were at risk for falls and develop individual and practical care strategies based on assessed needs, implement the falls management program, provide ongoing assessment, monitoring, and evaluation of the effectiveness of fall management and to complete a root cause analysis to determine the underlying cause of the fall. The policy also documented the Interdisciplinary Team (IDT) would review the root cause analysis to identify potential solutions, review/revise the fall management care plan, recommend medical consultations, and potentially recommend increased supervision for the residents. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including [CONDITION(S)] (a progressive disease of the nervous system that affects movement), repeated falls, and [CONDITION(S)] (a sudden drop in blood pressure when a person stands from a seated or prone [lying] position). A Fall Risk Evaluation, dated 3/2/20, documented Resident #9 was at risk for falls. Resident #9's care plan for Impaired Mobility documented he was at risk for falls related to his [CONDITION(S)], episodes of [CONDITION(S)] ([CONDITION(S)]) and unsteady and shuffling gait and balance, and dementia. The following interventions were documented in his care plan: *Staff were directed to provide him with one-to-one (1:1) supervision, an anti-tip wheelchair with bucketed seat and to evaluate his wheelchair to determine if the auto lock and anti-tilts were potentially restrictive, to follow toileting regimen every morning, before and after meals and at bedtime and ask him if he needs to go, non-skid foot wear at all times, place his personal items and assistive devices within his reach, reinforce safety awareness such as to use call light, lock his wheelchair brakes before transferring, and sit him on the side of bed for a few minutes before transferring. These interventions were initiated on 3/2/20. *Staff were directed to put a pressure sensitive call light to his bed to assist him with communication, initiated on 3/3/20. *Staff were directed to put his bed in lower position, initiated on 3/4/20. *Staff were directed to do frequent checks on him when he was in his room, initiated on 3/18/20. Resident #9 had 13 unwitnessed falls and three witnessed falls from 10/7/20 through 12/18/20. Examples include: An I&A report, dated 10/7/20 at 11:00 AM, documented Resident #9 had an unwitnessed fall. He was wearing shoes when he was found on the floor in his room and blood was on the carpet floor. Resident #9 sustained a 3.5 cm x 1.5 cm x 0.01 cm abrasion to his left cheek and minor abrasions to the left side of his nose and to his lower lip. The report documented the physician and Resident #9's Power of Attorney (POA) were notified the same day at 11:15 AM. Neurological assessments were started on 10/7/20 at 11:00 AM and completed on 10/8/20 at 11:00 AM. There was no documentation of abnormal vital signs or neurological findings. Resident #9's care plan for impaired mobility was revised on 10/7/20 and directed staff to provide supervision and one-person assistance as needed with transfers and to remind him to move slowly when changing his position. An IDT progress note, dated 10/9/20 at 10:10 AM, documented Resident #9 had an unwitnessed fall in his room. The progress note stated Resident #9 was found by the nurse lying in his bed with abrasions to his face. Resident #9 reported to the nurse he had fallen. The progress note documented Resident #9 had a shuffling gait and may have tripped over his own feet or lost his balance and Physical Therapy was working on strengthening with him and he was to be evaluated by the physician or Nurse Practitioner (NP) that week. A physician progress note, dated 10/9/20 at 10:37 AM, stated Resident #9 was seen following a fall. The note documented Resident #9 had increased weakness and confusion. The note included documentation of orders for an evaluation by Physical Therapy and for blood work to be completed. A nursing progress note, dated 10/10/20 at 6:02 PM, documented Resident #9 was sent to a local hospital at 3:00 PM for [CONDITION(S)] and low blood pressure per his physician's request. The progress note documented Resident #9 was confused, lethargic, and having delusions that morning into the afternoon. The progress note documented Resident #9 was given his medication [MEDICATION(S)] (used to treat low blood pressure) twice with ineffective results. The nursing progress note documented Resident #9 fainted after trying to stand up to move to the recliner in his room. Resident #9's POA was notified he was sent to the hospital. The nursing progress note stated the hospital called and Resident #9 was returning to the facility with a stable blood pressure. An I&A report, dated 10/11/20 at 8:00 AM, documented Resident #9 had an unwitnessed fall. The report documented he was barefoot when he was found on the floor in the doorway of his bathroom and the bathroom floor was wet with what appeared to be urine. The report stated Resident #9 was last seen 30 minutes prior and he was sleeping soundly. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. An incident note attached to the I&A report, dated 10/11/20, stated Resident #9's blood pressure was low at the time of the fall. The incident note stated Resident #9 had breakfast, took his medications and his blood pressure was improving. The note also documented the physician and Resident #9's POA were notified. Neurological assessments were started on 10/11/20 at 8:30 AM and completed on 10/12/20 at 12:30 PM. Resident #9's blood pressure was documented as 68/46 at 8:30 AM, 88/58 at 8:45 AM, and 80/54 at 9:00 AM. According to the Mayo Clinic website, accessed on 2/10/21, A blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic) is generally considered low blood pressure. The website documented low blood pressure can cause [CONDITION(S)], dizziness, fatigue, and lack of concentration. The website also stated extreme [CONDITION(S)] can result in shock, which is a life-threatening condition. Signs and symptoms of this include: confusion, especially in older people; cold, clammy, pale skin; rapid, shallow breathing; and a weak and rapid pulse. An IDT progress note, dated 10/12/20 at 10:00 AM, documented the IDT reviewed Resident #9's fall on 10/11/20. There was no documentation of physician orders or changes to his plan of care related to his fall on 10/11/20. An I&A report, dated 10/13/20 at 1:00 AM, documented Resident #9 had an unwitnessed fall. He was found by staff naked from his waist down and barefoot on the floor in is room. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. Neurological assessments were started on 10/13/20 at 1:00 AM and completed on 10/14/20 at 8:45 AM. Resident #9's blood pressure was documented as 79/51 at 1:00 AM and 98/64 at 1:15 AM. Resident #9's care plan for impaired mobility was revised on 10/13/20 and directed staff to place [MEDICATION(S)] stockings (a multi-purpose tubular compression bandage) to his bilateral lower extremities in the morning and to remove them at bedtime to aid with his [CONDITION(S)]. An IDT progress note, dated 10/16/20 at 10:29 AM, documented Resident #9's fall on 10/13/20 was reviewed. The note stated Resident #9 had a new medication, [MEDICATION(S)] [MEDICATION(S)] 5 mg (an antipsychotic medication) and his Fludrocortisone (a steroid to decrease inflammation) was increased. The IDT progress note stated Resident #9's blood pressure measurements were variable and Tubigrips were added to help increase his blood flow. The progress note stated to continue with his current fall interventions and continue to monitor. An I&A report, dated 10/16/20 at 3:00 PM, documented Resident #9 had an unwitnessed fall. He was found by staff on his bathroom floor and was barefoot. The report stated the call light was not on. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. Neurological assessments were started on 10/16/20 at 3:00 PM and completed on 10/17/20 at 3:00 PM. There was no documentation of abnormal vital signs or neurological findings. An I&A report, dated 10/18/20 at 6:20 AM, documented Resident #9 was found by staff in the hallway on the floor. He was barefoot when he was found on his knees and hands on the hallway. The report documented non-skid socks were placed on Resident #9's feet after the fall. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. Resident #9's care plan for impaired mobility was revised on 10/18/20 and directed staff to keep his bed in a position safe for transfers and to lock his bed brakes. It did not specify what was a safe position for transfers. An IDT progress note, dated 10/19/20 at 6:09 PM, documented a message was left for Resident #9's neurologist. The neurologist was updated about Resident #9's increased behaviors and falls, and the neurologist was asked to evaluate Resident #9's [CONDITION(S)] medication. An I&A report, dated 10/19/20 at 6:36 PM, documented Resident #9 had a fall at 5:00 PM in a common area while walking. The report documented he was assisted back up to a standing position and 1:1 assistance was provided when he walked. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. A Physician Assistant visit note, dated 10/19/20, documented Resident #9 had a great increase in behaviors and labile BP blood pressure with some low values. The Physician Assistant documented he spoke to Resident #9's daughter and she agreed to a trial of [MEDICATION(S)] (a sedative and antidepressant) to help Resident #9 with sleep and reduce distress. Resident #9's daughter also agreed with [MEDICATION(S)] but stated she wanted it at the lowest dose possible and for as short a time as possible. The Physician Assistant documented his increased behaviors were making him at higher risk of falls due to not sleeping and combativeness. A nursing progress note, dated 10/21/20 at 4:03 PM, documented Resident #9 was at high risk for falls and was to be within line of sight when he was out of bed. An IDT progress note, dated 10/22/20 at 9:17 AM, documented the team reviewed Resident #9's falls on 10/16/20, 10/17/20, /10/18/20, and 10/19/20. There was no further documentation. A Physician's Assistant progress note, dated 10/26/20, documented Resident #9 was not acting out aggressively and usage of his as needed medications was decreasing. Resident #9's order for [MEDICATION(S)] was not renewed and he was started on [MEDICATION(S)]-[MEDICATION(S)] (helps control body movement) ER (extended release). A nursing progress note, dated 10/27/20 at 10:04 PM, documented staff heard a loud bang and Resident #9 was found on the floor in his room. The progress note stated Resident #9 was assessed and there were no injuries and he denied pain. The note documented the physician and Resident #9's POA were notified. Resident #9's care plan was updated on 10/27/20 to include his risk for falls. The interventions included direction for staff to provide him with slipper socks and to check him frequently to meet his needs. Also, to place two soft touch call lights so they would activate when he attempted to get out of his bed. The care plan identified his need for non-skid footwear to be worn at all times and to check on him frequently while he was in his room under the concern for impaired mobility, initiated on 3/2/20 and 3/18/20 respectively. An IDT progress note, dated 10/30/20 at 10:46 AM, documented Resident #9's fall on 10/27/20 was reviewed. The note stated Resident #9's Mobility Plan of Care was updated with an increase in assistance by staff for his needs to include one-person assistance, contact guard assistance, and use of a walker. Resident #9's care plan related to his impaired mobility did not include documentation of revisions, however the care plan was updated to include a new section for risk for falls. The interventions in this area repeated the need for staff to ensure he wore non-skid socks and his bed was kept in the low position and added a new intervention for staff to place two soft touch call lights on his bed so they would activate when Resident #9 got out of bed. The IDT progress note also stated he was a RED leaf FALL RISK, but did not include documentation what this meant. An I&A report, dated 11/4/20 at 2:30 AM, documented Resident #9 had an unwitnessed fall. He was found on the floor in his room. The I&A report documented Resident #9 was non-compliant, attempting to walk repeatedly. The report documented staff assisted him with all his needs, checked on him frequently, and he settled down about 2:00 AM. Resident #9 was last seen in his bed at 2:25 AM. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. Neurological assessments were started on 11/4/20 at 2:30 AM and completed on 11/4/20 at 6:15 PM. Resident #9's blood pressures were documented as 80/52 at 2:30 AM, 80/50 at 2:45 AM, 80/52 at 3:00 AM, and 80/52 at 3:15 AM. A nursing progress note, dated 11/4/20 at 3:31 AM, documented Resident non compliant [sic] with any assist with cares, has been unsteady with weight bearing, staff attempting to assist, resident not following cues, continuing to ambulate regardless, has fallen x 1 this shift, assessed for injuries none noted thus far will place on alert charting and continue to monitor. An I&A report, dated 11/5/20 at 4:15 AM, documented Resident #9 was seen by a CNA hurrying to the bathroom. The CNA took his wheelchair and when the CNA got to him, he had urinated some on the floor and went down in front of the toilet on his knees. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. Resident #9's care plan was updated on 11/5/20, under the risk for falls section, and directed staff to check and see if he needed to go to the bathroom every 2-3 hours and use a gait belt when ambulating him as he will go down quickly. A Significant Change MDS assessment, dated 11/6/20, documented the following about Resident #9: *Severe cognitive impairment. *Required extensive assistance of two persons with mobility, transfers, dressing, and toileting. *No restraints or alarms were in place. *Not steady with moving from seated to standing position and transfer between bed and chair or wheelchair, only able to stabilize with human assistance. *Had two or more falls since admission. A Nurse Practitioner progress note, dated 11/6/20, documented Resident #9 had two more falls without injury since he was last evaluated by a physician on 11/3/20. The Nurse Practitioner documented the plan for Resident #9's recurrent falls was to continue stringent fall precautions and encourage dietary intake. An IDT progress note, dated 11/6/20 at 10:46 AM, documented Resident #9 was reviewed for multiple falls. The note documented interventions for Resident #9 were to continue to keep him in areas of high visibility when awake, encourage use of wheelchair for mobility, and to have constant supervision and assistance with toileting. Resident #9's care plan was updated to include constant supervision and assistance with toileting under the impaired mobility section. An I&A report, dated 11/9/20 at 11:45 PM, documented Resident #9 had an unwitnessed fall. He was found sitting on the floor in his room. The report documented he was last seen by staff at 11:35 PM and he appeared to be sleeping. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. A Physician Assistant progress note, dated 11/9/20, documented Resident #9 had repeated falls believed to be related to [CONDITION(S)] and hallucinations. The Physician Assistant decreased Resident #9's [MEDICATION(S)]-[MEDICATION(S)] from five times a day to three times a day related to his increase in hallucinations and low blood pressure. A Physician progress note, dated 11/10/20, documented Resident #9 had multiple falls with no injuries despite having a 1:1 sitter. The physician ordered the following changes to his medications. [MEDICATION(S)] was increased to 100 mg at bedtime, [MEDICATION(S)]-[MEDICATION(S)] ER was decreased to one tablet three times a day and [MEDICATION(S)] (medication used to treat [CONDITION(S)]) 10 mg three times a day. There was no documentation in Resident #9's record he had 1:1 supervision as documented in the note. A nursing progress note, dated 11/10/20 at 5:35 AM, documented Resident #9 fell backwards while an LPN was in the room and she was unable to stop the fall. The note documented he hit the side of his head at his right ear on the footboard of the bed. The progress note documented there was no abrasion or cut to the skin. The nursing progress note documented Resident #9 was walking later pushing his wheelchair when He stood up to look at something in the room and went down again I caught him and he slid down my legs. The note documented a CNA was with him at the time of the entry of the progress note. There was no documentation in the progress note if his physician and POA were notified. A nursing progress note, dated 11/10/20 at 10:39 AM, documented Resident #9 required 1:1 supervision or he would get up and fall. There was no further documentation in Resident #9's record of when 1:1 supervision began and/or ended. An IDT progress note, dated 11/11/20 at 11:12 AM, documented Resident #9 had multiple falls. The note documented at times of severe agitation resident has received 1:1 supervision. Resident #9's care plan was updated and directed staff to provide constant supervision and assistance to him during toileting and do not leave him un-assisted. These interventions were unchanged from the interventions documented at the previous IDT meeting on 11/6/20. An I&A report, dated 11/14/20 at 1:45 AM, documented Resident #9 had an unwitnessed fall. A nurse was walking past his room and found him seated on the floor of his room. The report included documentation Resident #9 was assessed with no injuries identified and he denied having pain. The report documented the physician and Resident #9's POA were notified. A nursing progress note, dated 11/14/20 at 6:47 PM, documented Resident was uncontrollable today and had to have one on one care for the day to ensure he wouldn't fall. There was no further documentation when the one on one care began or if it had continued for Resident #9. A nursing progress note, dated 11/14/20 at 10:08 PM, documented Resident #9 was attempting to stand and leave the common area and he was provided with a sitter. There was no further documentation how long the sitter would remain with Resident #9. A nursing progress note, dated 11/19/20 at 8:18 PM, documented [Resident #9] has just become more and more agitated with combative behaviors towards staff attempting to keep him safe and from falling. He was taken to his room but he would not stay in bed. He was up and amb. [ambulating][sic] in the hallway. He would not allow staff to accompany him. If he falls will do the paper work it was not worth him getting even more upset with the staff. A nursing progress note, dated 11/27/20 at 5:20 PM, documented Resident #9 was found on the floor of his room at 12:30 PM. The note documented his pressure light was going off and a CNA went in to assist him and found him crawling on the floor. The nursing progress note documented he had an abrasion to his left knee and he denied having pain. The note documented his physician and POA were notified. An I&A report, dated 12/2/20 at 5:15 PM, documented Resident #9 had an unwitnessed fall. He was found by a CNA on the floor of his room. Resident #9 reported to staff he had to go to use the bathroom before going to Chipotle. Resident #9 was noted to have a red mark on his forehead as well as on his left arm, no open wounds were observed. Resident #9 was assessed and had no injuries and his range of motion was within normal limits. The report documented Resident #9's physician and POA were notified. A nursing progress note, dated 12/3/20 at 2:42 PM, documented the nurse was notified of a bruise on Resident #9's right fifth finger. Resident #9 was assessed, and he was found to have a bruise and limited range of motion of his right fifth finger. The physician was notified, and an X-ray was ordered. An X-ray result, dated 12/3/20, documented Resident #9 had an acute fracture of his fifth proximal phalanx (lower bone of the little finger) and dislocation of his fifth middle phalanx (knuckle area near the middle of the finger). A nursing progress note, dated 12/4/20 at 1:35 PM, documented the Nurse Practitioner reviewed Resident #9's X-ray result and documented orders for a Physical Therapist to apply a splint on Resident #9's little finger, [MEDICATION(S)] 400 mgs every 6 hours as needed, apply ice three times a day, and repeat x-ray and if still dislocated send Resident #9 to the emergency room . A nursing progress note, dated 12/4/20 at 4:54 PM, documented Resident #9 had a repeat X-ray of his right little finger. The note documented X-ray results stated Bony remodeling at the 5th PIP (proximal interphalangeal joint-part of the finger) suggests that the dislocation may be old. Unchanged 5th proximal phalanx fracture [the finger had a fracture which did not change]. The note documented Resident #9's daughter was aware of the X-ray results. An I&A report, dated 12/8/20 at 2:00 PM, documented Resident #9 had an unwitnessed fall. He was found kneeling on the floor next to his bed. There were no injuries noted. He was then assisted into the common area for increased supervision. The report documented Resident #9's physician and POA were notified. An I&A report, dated 12/14/20 at 1:51 AM, documented Resident #9 had an unwitnessed fall. He was found on his knees next to his bed. Resident #9 sustained a 6.5 cm x 2.5 cm abrasion on his upper left forehead. The report documented Resident #9's physician and POA were notified. An IDT progress note, dated 12/14/20 at 11:27 AM, documented the plan was to move Resident #9 to another room for increased visibility by staff due to his recurrent falls. A subsequent IDT progress note, dated 12/16/20 at 11:06 AM, documented Resident #9's falls were reviewed as he had multiple falls in December. The note documented the plan was to move Resident #9 to another room for increased visibility after he was off isolation precautions. The IDT progress note documented the plan was to continue to follow and review interventions in the routine Fall Meeting by staff. An I&A report, dated 12/18/20 at 10:00 PM, documented Resident #9 had an unwitnessed fall. He was found on the floor of his room. The report documented Resident #9 was assessed and had no injuries and was not having pain. The report documented his physician and POA were notified. On 1/28/20 at 8:55 AM, the Physical Therapy Director said Resident #9 was referred to the PT department due to his frequent falls. The Physical Therapy Director said Resident #9 had PT three times a week and it depended on his tolerance. The Physical Therapy Director said Resident #9 did not do well with his therapy and he needed a lot of cueing. The Physical Therapy director said Resident #9 was discharged from Physical Therapy on 12/2/20 due to his lack of progress and inability to participate with therapy. The Physical Therapy Director said staff had been educated on how to safely assist Resident #9 as needed. On 1/28/20 at 9:17 AM, the DON said they did not place a fall mat on Resident #9's bedside because he tended to stand on his own and it would only cause more accidents for him. The DON said they would only put a fall mat at the bedside when a resident tends to roll out of bed. When asked how they knew the resident did not roll out of bed when he was found on the floor in his room, the DON did not provide an answer. The DON said Resident #9 was provided with 1:1 supervision only when he was agitated and restless. The DON said staff were directed to provide constant supervision to Resident #9 and assist him while he was toileting. The DON said Resident #9 was transferred to the facility's dementia unit for increased supervision. The DON said staff were aware of Resident #9 being a high risk for falls and he was checked every two hours. The DON said they did not have documentation of Resident #9 being checked every 2 hours. Resident #9 experienced multiple falls and had abrasions, bruises, and sustained an acute fracture of his right fifth finger as a result of the falls. The facility failed to ensure adequate supervision for Resident #9.

Based on interview and record review, it was determined the facility failed to permit a resident to remain in the facility after family discovered multiple large bruises, asked to have the nature of the bruises evaluated by a physician, and summoned emergency services when the facility did not respond to this request. The resident was subsequently evaluated at the emergency department (ED) and found to be medically stable to return to the facility. This was true for 1 of 1 Residents (#20) sampled for involuntary discharge. Resident #20 was harmed when the facility refused to allow the resident to return after evaluation in the ED, causing the resident to be discharged to a private home without adequately trained or otherwise prepared caregivers, medications, medical equipment, or follow-up care. Findings include: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20 had two daughters involved with her care. Resident #20's annual MDS assessment, dated 5/31/17, documented she had severely impaired cognition, delusions, wandered, and was at risk of elopement from the facility. The MDS documented Resident #20 required assistance for bed mobility, transfers, dressing, toilet use, and hygiene; and supervision with ambulation. The MDS documented Resident #20 had no physical or verbal aggression towards others. Resident #20's care plan, Nurse's Notes, and Social Services progress notes for (MONTH) through (MONTH) of (YEAR), did not include documentation regarding family interference with Resident #20's care. Resident #20's Nurse's Notes documented a Monthly head to toe assessment on 5/25/17 at 12:16 am. No bruising or other skin abnormalities were documented. The next entry in the Nurse's Notes was dated 6/8/17 at 1:50 pm and documented, Shower not given as there were time constraints. A Skin Event form in Resident #20's record documented bruises were discovered on her right wrist (5.3 x 4 cm), right upper arm (6.5 x 17 cm), left upper arm (5.4 x 3.3 cm), right hip (5.2 x 10.8 cm); and a scab (0.6 x .05 cm) was discovered on her left elbow, all on 6/9/17 at 9:20 pm. The form was signed and dated on 6/14/17. On 6/9/17, Resident #20's Nurse's Notes documented: * 9:39 pm: Received call from resident's daughter, (Name of Daughter #1), who was concerned about new bruises found on resident's right upper arm, left upper arm, and right hip area. Resident's daughter wanted to know the cause of the bruises - resident has had no recent falls . * 9:44 PM: Noted bruise on right wrist. Upon further assessment other bruises were noted on both right and left underarms. Noted bruising on her right hip . No further entries were documented in Resident #20's record until the following morning. On 6/10/17, Resident #20's Nurse's Notes documented: * 10:55 am (Late entry): Staff alerted that (police department) was in the facility and investigating bruising on resident's hip and underarms. Attempted to evaluate resident and (Daughter #2) declined said the police would investigate .Paramedics called and took resident to the ER for evaluation . * 11:09 am (Late entry): Resident was discharged to the ED . * 11:30 am (Late entry): Called (Daughter #1) that before the resident returns to facility we would have to meet with family and facility administrator based on families (sic) concerns with bruising and facilities (sic) concerns for (Daughter #2's) impediment in care of resident. There was no documentation as to when the late entries were added to Resident #20's record. Resident #20's 6/10/17 Nurse's Notes continued: * 2:16 pm: Received call from ED physician and ED (nurse's name and title). Discussed concerns around ability to provide sufficient care with (Daughter #2's) impediment on care. ED states there are no significant injuries. Will hold resident until a meeting can be facilitated about resident's care. * 2:42 pm: (Daughter #2 asked) to have a confidential conversation regarding the bruises on her mother's arms, wrists, and hips. She stated she was going to talk with the Ombudsman and she was not angry but insisted that the bruises be investigated. * 5:59 pm: (Daughter #2) then stated she was taking pictures of the bruises and she stated she had called the Boise police and she was waiting for them states she wanted to have it investigated very well that is why she called the police. Police arrived and (officer's name) states that police protocol is to call the paramedics for an eval(uation). Paramedics arrived and then transported the resident to the (ED). Resident #20's ED Triage notes from 6/10/17 at 12:46 pm documented, Patient arrives via EMS (emergency medical services) with c/o (complaint of) possible abuse at her nursing home. Patient's daughter reportedly called the police after finding 'bruises on the patient's arms and hip' .patient herself is a poor historian. She was unable to reliably tell EMS how she got the bruises; she first stated 'I was ganged up on' and then 'It's from all the tests they do.' She was able to stand with minimal assistance .(Facility nurse's name) also called to give .report .She states the facility will not be able to take the patient back until 'we have a meeting with the patient's family to discuss her care .' In terms of tests, Resident #20's record documented she most recently had labs drawn on 8/15/16. An ED Plan of Care note for Resident #20, on 6/10/17 at 2:38 pm, documented, .the (facility) nurse reports that (Resident #20) currently lives in a secured dementia facility. The nurse also reports that the .daughter is very disruptive and they (the facility) had to call the police. EMS reports that they found bruises up her bilateral arms, right forearm, and right flank .I spoke with (facility nurse's name) who reports they will not be able to take the patient back until after a care conference occurs with their administrator/DNS (Director of Nursing) and herself to discuss ongoing care needs. She (the facility nurse) reports (Resident #20) resides on their locked memory care unit with a history of wandering and exit seeking behavior .also .has struck out at staff .I met with (Daughter #2) who reports that she visits 2-3 times/week .with her sister on alternate days .(Resident #20) is not noted to be on an anticoagulant .she reports the police were involved due to 'the large bruises' and 'concern for excessive use of force' used when (Resident #20) .'tried to escape at night.' She reports the police recommended involving EMS who recommended the ED visit for evaluation. (Daughter #2) reports their goal in reporting to police was to have an 'accurate documentation of what this is' .(Daughter #2) reports she and her sister were leaning towards taking (Resident #20) home to care for her unless she can stay here because (Daughter #2) understood from (Daughter #1) that the facility said (Resident #20) could not return there. I clarified the accuracy of this within the caveat that (Facility nurse) explained being a care conference clarifying goals of care would need to happen first . Resident #20's ED Plan of Care notes from 6/10/17 at 3:17 pm documented, Met with (Daughter #1 and Daughter #2). (Daughter #1) clarified that she was told they were not able to return (Resident #20) to facility until a care conference was done .I reviewed with them my discussion with the ED MD that there is no medical findings to support admission at this time . On 6/14/17 at 1:15 pm, Resident #20's Daughter #1 and Daughter #2 reported they had Resident #20 home with them since the ED visit on 6/10/17, and were exhausted. The daughters reported Resident #20 was complaining of constant pain from her bruises, was sleeping poorly, and not as mobile as she had been prior to the onset of the bruising. The daughters stated Resident #20 was requesting her walker, which was still at the facility, and the daughters were concerned if they returned to the facility it would not be given to them because of the way the resident had been discharged . The daughters expressed concern that they had done something wrong in calling law enforcement because, That's when everything (with the facility) went downhill and now (Resident #20) can't get the help she needs. We won't be able to keep this up for much longer. (Resident #20) always needs someone who can be awake to keep an eye on her, so we are each taking 12 hour shifts. The daughters reported the following timeline of events: * Daughter #2 reported she was in the facility, sitting with Resident #20 in the dining room prior to the dinner meal on Friday, 6/9/17 as it was customary for her to assist the resident with her meals several times weekly. Daughter #2 stated Resident #20 was wearing a long-sleeved shirt. At approximately 4:45 pm, Daughter #2 stated she saw a bruise on Resident #20's right wrist, peeking out from under her sleeve. Daughter #2 stated she notified LPN #2, who stated the bruise looked old, although had not been reported to him when he came on duty. LPN #2 stated he would look at the bruise later. * Daughter #2 stated that after Resident #20 had finished her meal, she again asked LPN #2 to assess the resident's bruised wrist. LPN #2 responded that he was busy supervising the dining room, and then had to pass medications. LPN #2 instructed Daughter #2 to go ahead and take Resident #20 to her room and get her ready for bed, and he would assess the bruise later. * Daughter #2 did as instructed and took Resident #2 to her room at 6:15 pm, and as she was undressing Resident #20 discovered a second bruise, this one on the resident's right upper arm. Daughter #2 reported this bruise to LPN #2, who again told Daughter #2 to continue assisting Resident #20 to get ready for bed, and the RN would assess the bruises later. At 6:20 PM, Daughter #2 discovered a third bruise and skin tear on Resident #20's left elbow, then a fourth and fifth bruise on the resident's left upper arm. Daughter #2 again reported these findings to LPN #2, who again stated he would assess the bruises later. When Daughter #2 returned to assist Resident #20, the resident was verbalizing pain and having difficulty maintaining a standing position, both of which were unusual for the resident. Daughter #2 then assisted Resident #20 to change her Attends, and discovered a sixth very large bruise on the resident's right hip. Daughter #2 alerted LPN #2 of the sixth bruise, and was told the bruises would be assessed later that evening when other work had been completed and a second staff person was available. Daughter #2 remembered the bruises as large, in places on her body (upper arms, around her wrist, and on her hip) that suggested to her that the resident had been engaged in struggle and thought the bruises may have been the result of facility staff handling Resident #20 with excessive force. * Daughter #2 stated she was not the Resident #20's POA (Power of Attorney), but Daughter #1 was. Daughter #2 stated the facility expressed sometimes they felt she interfered with care decisions, so she decided not to press the issue further at that time. Daughter #2 left the facility, drove home to charge her phone, then called Daughter #1 to inform her of Resident #20's bruises and that the facility had not assessed the bruises at the time Daughter #2 left the facility. * Daughter #1 stated Daughter #2 called her at approximately 9:00 pm on 6/9/17 to report she had found 6 bruises on Resident #20. Daughter #1 stated in her mind's eye she saw small bruises on extremities where the resident may have bumped into furniture, but did not imagine bruises in the locations or of the size ultimately discovered. Daughter #1 told Daughter #2 she would call the facility to find out what the results of the evaluation of the bruises were. * Daughter #1 stated she called the facility shortly after 9:00 pm and talked to ADCS #3. ADCS #3 assured Daughter #1 she would go evaluate the bruises, and called back at approximately 9:30 to report there was no need to be concerned, and the bruises had likely resulted from the pillows in Resident #20's wheelchair. * On Saturday, 6/10/17, Daughter #2 went to the facility at approximately 10:00 am to follow up on the evaluation of Resident #20's bruising. Daughter #2 stated she continued to be troubled by the size, number, and locations of the bruising. Daughter #2 approached LPN #1, who was the nurse caring for Resident #20. LPN #1 told Daughter #2 that the facility had started a skin sheet and would be investigating the cause of the bruising, so there was no need to worry. Daughter #2 stated she asked LPN #1 to have Resident #20 evaluated by a physician to rule out abuse as a potential cause of the bruising, and to assess for further internal injuries or fractures associated with the bruising. Daughter #2 stated LPN #1 told her she did not think that was necessary. Daughter #2 stated she began to wonder if the facility was trying to sweep the cause of the bruises under the rug, so took pictures of Resident #20's injuries with her cell phone so they would be accurately documented. * Daughter #2 stated that at that point, she felt she needed to consult with Daughter #1, who was Resident #20's POA. Daughter #2 stated she exited the memory care unit where Resident #20 resided each time she spoke on the phone with Daughter #1, as the nature of their conversations was private, and potentially upsetting to Resident #20. * Daughter #1 stated she remembered Daughter #2 calling her the morning of 6/10/17, and being upset about the extent of Resident #20's bruising. Daughter #1 stated she began to understand the bruising was more severe than she had previously imagined, and agreed she would like Resident #20 evaluated by a physician for abuse and/or other injuries. Daughter #1 stated since the facility had declined to have Resident #20 evaluated by a physician, they weren't sure how to proceed to get that done on their own. After discussion, the daughters decided if this discovery was made in the community, the police would be called. Daughter #1 stated it seemed reasonable to them at the time that calling the police was the best option given the facility's response to their request to have the resident seen by a physician. Daughter #1 told Daughter #2 to check with the facility to see if it was acceptable for them call the police. * Daughter #2 stated after this discussion, she approached LPN #1 and asked if it would be OK to call the police. Daughter #2 stated LPN #1 told her there was no problem with them calling the police, and went back to her work. Daughter #2 then called the police. * Daughter #1 stated within approximately 30 minutes, she was contacted by a police officer on site at the facility with Resident #20. Daughter #1 stated the police officer agreed the bruising was significant, and as such police policy was to summon EMS. Daughter #1 stated she gave permission to have EMS called. Daughter #1 stated that a few minutes later, a paramedic called and requested permission to transport Resident #20 to the ED for evaluation. Daughter #1 stated, I asked him if he thought that was really necessary and he told me, 'If it were my mom, she'd already be there by now.' Daughter #1 stated that based on this statement from the paramedic, she gave consent for Resident #20 to be evaluated at the ED, and set out from her home to meet the resident there. * Daughter #1 stated that while she was driving to the hospital to meet Resident #20, ADCS #1 called from the facility and told Daughter #1 that since the facility did not think the resident required evaluation at the ED, the facility's position was that Resident #20's family had chosen to discharge her. Daughter #1 stated that since the discharge was the family's choice and not a medical necessity, the facility considered the resident officially discharged and she would not be able to return to the facility that day. Daughter #1 stated ADCS #1 told her the facility would only be willing to readmit the resident after the family met with the Administrator, DNS, and herself to discuss care concerns. Daughter #1 stated she was stunned and confused by the call, but more focused on making sure the resident did not have underlying injuries related to her bruising, and that the resident had not been abused. * Daughter #1 stated that when she saw Resident #20's bruising for the first time in the ED, she agreed completely with Daughter #2's concerns and insistence that the resident be evaluated by a physician. * Daughter #1 stated the ED was unwilling to confirm or refute whether Resident #20 had been abused, but did find that the resident had not sustained internal injuries or fractures related to the bruising. Daughter #1 stated the ED informed them the resident did not meet criteria for admission to the hospital, and the facility had declined to let the resident return. Daughter #1 stated they had no choice but to take Resident #20 home and try to care for her until they could meet with the facility on Monday, 6/12/17. * Daughter #1 stated that between 6/10/17 and 6/12/17, Resident #20 complained almost constantly of pain related to her bruises, and was less independent with her mobility due to her pain levels. * Daughter #1 stated that by 6/12/17, they were exhausted trying to care for Resident #20 with just 2 family members, and called the Ombudsman first thing that morning to request she attend a conference with family and the facility to facilitate the resident's readmission. Daughter #1 stated she lived in a community quite some distance from the facility, and there was no one else to care for Resident #20 in their absence, so they decided the most prudent action was to bring the resident with them to the facility for the conference. Daughter #1 stated she presumed, since the facility had been the resident's home for the past year, there would be no problem with Resident #20 returning to her room in the facility that day. Resident # 20 was present when the facility met with the family and Ombudsman. * Daughter #1 stated, as POA, that she expected the facility would apologize for their response to the discovery of Resident #20's bruising, and discuss the results of their investigation into the root cause of the bruising during the meeting. Daughter #1 stated, Instead, it was like an interrogation of my sister and me. Like we were on trial. The Administrator told us (Resident #20) no longer had her bed at the facility and was no longer considered a resident. He (the Administrator) told us that he didn't appreciate us throwing an allegation of abuse around, or calling those people (police and EMS) in. He said he could really get in trouble with the state, have to do lots of paperwork, and cost the facility their licensing because (Daughter #2) had alleged abuse .he tried to make my sister a scapegoat because of how she responded to finding all those big bruises on (Resident #20). * Daughter #1 stated the Administrator then asked to speak with her privately, away from Daughter #2. Daughter #1 stated the purpose of that conversation was to inform her that since Daughter #2 had made an abuse accusation against the facility, no other facilities would be willing to accept Resident #20 for admission. Daughter #1 stated based on that, the Administrator said he was willing to consider letting Resident #20 back into the facility on the condition that Daughter #2 did not visit Resident #20 unless she was accompanied by another family member. * Daughter #1 stated she was becoming frightened for Resident #20's well-being, and ashamed that the family's response to the bruising may have jeopardized the facility's willingness to care for her. Daughter #1 stated she felt that she did not have a choice other than to go along with whatever the facility requested, so she agreed to the condition. * Daughter #1 stated that after she agreed to the condition, the facility said they still could not let Resident #20 stay there because they did not have the proper paperwork. The Administrator told Daughter #1 the family would have to take the Resident #20 back to the ED to get orders and a PASARR (Pre-Admission Screening and Resident Review). Daughter #1 stated once at the ED, there became a problem with the ED providing the PASARR. The ED called the facility to discuss the barrier, and the facility told them Resident #20 would not be able to come back. Daughter #1 stated, We had to take (Resident #20) home with us again. We don't have her walker, we don't have her medications, and we are absolutely exhausted. We don't know where to turn or what to do. On 6/15/17 at 8:15 am, the Ombudsman stated she was contacted by Resident #20's daughters on the morning of 6/12/17 regarding the above situation, and they requested that she meet them at the facility for the care conference later that morning. The Ombudsman stated the Administrator, SW (Social Worker), and DNS (Director of Nursing) were at the conference. The Ombudsman stated the Administrator told Resident #20 and her daughters that the resident would not be allowed to return to the facility and implied that decision had been made because the police had been called. The Ombudsman stated the daughters were upset with the news because they just wanted an investigation, and it felt like the bruising was being minimized by the facility. The Ombudsman stated the Administrator had asked to meet with her privately, and told her Daughter #2 was the problem. The Ombudsman stated some of the Administrator's comments and insinuations caused her concern. The Ombudsman stated the Administrator did require the family agree to supervised visits for Daughter #2 as a condition of readmission, and that she felt Daughter #1 agreed to this out of desperation. The Ombudsman described the situation and conference as, such a shock. On 6/15/17 at 9:35 am, ADCS #1 stated she had been the nurse on call on 6/10/17, and was notified at some point during the morning that the police were in the building. ADCS #1 determined the police had been called by Resident #20's family related to bruises that had been discovered. ADCS #1 stated Daughter #2 was present in the facility. ADCS #1 stated Daughter #2 had a long-standing history of interfering with Resident #20's cares, and interfered with facility cares that morning. ADCS #1 was not aware of any documentation or other evidence of Daughter #2's interference since Resident #20 was admitted to the facility approximately a year prior, but said there was documentation at the time of Resident #20's admission that Daughter #2 had been Resident #20's caregiver in the community, and had not given Resident #20 her antipsychotic medication as she thought it made Resident #20 drowsy. ADCS #1 stated Daughter #2 interfered with care in two ways on the morning the police were called. The first was Daughter #2 did not allow ADCS #1 to complete a skin assessment after the police were called, stating that she was not going to allow anyone from the facility to look at the resident until the police arrived. The second was as Resident #20 was sitting on the gurney being attended by the paramedics at 11:45 am, LPN #1 asked if Resident #20 would like her noon dose of Tylenol before going to the hospital. Resident #20 did not respond, but Daughter #2 declined on the resident's behalf. ADCS #1 confirmed that she had called both the ED and Daughter #1 to tell them Resident #20 could not return to the facility that day because, (Daughter #2) completely over-reacted to the situation and because of that I wasn't sure if we (the facility) could meet (Resident #20's) needs. ADCS #1 could not state which needs Resident # 20 had that the facility could not meet. ADCS #1 stated she thought the hospital would admit the resident due to this development, and keep her in the hospital until the facility could meet with the family. ADCS #1 was unable to identify the date the resident was considered discharged . ADCS #1 stated after Resident #20 left the facility, she started an abuse investigation. On 6/15/17 at 9:55 am, the SW stated her first awareness of the event was an email she had on Monday, 6/12/17, notifying her of a care conference with Resident #20's family, as the police had been called and the resident removed from the facility due to an allegation of abuse. The SW stated she was also informed that Daughter #2 had caused a commotion and was so emotional she had caused disruption in the (memory care unit). The SW stated the conference was facilitated by the Administrator. The SW stated the Administrator informed Resident #20 and her family in the conference that he was concerned about Daughter #2's reaction to the bruising, and he did not want Resident #20 to return to the facility. The SW stated the Administrator told Resident #20 and her family she had lost her bed and was no longer considered a resident at the facility. The SW stated Resident #20's family was very concerned about the resident's bruising. The SW stated historically Resident #20's family, including Daughter #2, was not unusually disruptive to the resident's care or the overall environment. The SW stated Resident #20's family needed guidance at times as to care options or the grievance process, but were receptive to such guidance. On 6/15/17 at 10:30 am, ADCS #3 stated she had been working on evening shift on a different unit on 6/9/17. ADCS #3 stated she received a call from Daughter #2 at approximately 9:00 pm, with a concern about Resident #20's bruising. ADCS #3 stated the bruises had not yet been assessed, so she went to assist with the assessment. ADCS #3 stated she recalled at that time finding bruising on Resident # 20's right upper arm that was fairly large, a bruise to the resident's right wrist, and a bruise to her left arm. ADCS #3 stated there was also a bruise to Resident # 20's right hip that she recalled as about 2 inches in diameter, however the resident's Attends was not removed for the bruise to be visualized or measured in its entirety. ADCS #3 surmised at the time that the bruising had come from the cushion in Resident #20's wheelchair. ADCS #3 stated she had no further interaction with Resident #20 or her family until a care conference on Monday, 6/12/17. ADCS #3 stated she recalled the Administrator told Resident #20 and her family during the care conference that she was no longer a resident in the facility and had lost her bed. On 6/15/17 at 11:55 am, the police officer who responded to Daughter #2's call on 6/10/17, stated he found Resident #20 with what he would consider severe bruising, and in his training the most important thing to do was to rule out further injuries. The police officer stated the family consented to summoning EMS, and upon EMS recommendation Resident #20 was taken to the hospital. The police officer stated, They were saying we were disrupting the unit, but that didn't make sense to me, because we were in her room or just outside her room in the hall. We were sensitive to where we were. On 6/15/17 at 2:20 pm, LPN #2 stated he was on duty when Daughter #2 started noticing bruising on Resident #20. LPN #2 stated though Daughter #2 reported several instances of new bruising, he was occupied with other, more pressing duties, and it was not until after 9:00 pm when the bruises were assessed. LPN #2 stated he had worked with Resident #20 for quite some time, and was very familiar with Daughter #2. LPN #2 stated Daughter #2 made odd requests at times, but was not disruptive to Resident #20's care. LPN #2 stated in his experience, Daughter #2 was not problematic in her demeanor on the unit, either prior to, or on, that night. On 6/15/17 at 3:15 pm, the DNS stated she was informed on Saturday morning, 6/10/17, that Resident #20's family had summoned the police, and that Daughter #2 had been walking back and forth on the floor, disrupting the unit. The DNS stated when she found out Resident #20 was being transported to the hospital, she informed ADCS #1, who was the nurse on call that day, that there would have to be a care conference when the resident returned to the facility to discuss Daughter #2's behavior. The DNS stated she was under the presumption that the resident was going to be held for observation at the hospital until such a conference could be arranged. On 6/15/17 at 4:00 pm, the Administrator stated Daughter #2 had created disruption on the memory care unit on the morning of Saturday, 6/10/17. The Administrator stated he was not present at the facility until after Resident #20 had been transported to the hospital and her family had left the premises. The Administrator stated the family demanded Resident #20 needed to go to the hospital, so the physician wrote the order and the resident was discharged . The Administrator stated he assessed the other residents in the memory care unit were not safe because of Daughter #2, and he made the executive director privilege decision to not accept the resident back that day. The Administrator stated he believed ADCS #1 and the hospital struck a bargain that Resident #20 would be kept under observation at the hospital until the facility could arrange a conference the following work week. The Administrator stated he learned when Resident #20 and her family came to the care conference on 6/12/17, that the resident had been home with her daughters since 6/10/17. The Administrator stated he initially declined to have Resident #20 return to the facility, but was able to work out an arrangement with Daughter #1 that Daughter #2 would only have supervised visits. The Administrator stated at that point, since the facility considered Resident #20 discharged , he instructed the family to take Resident #20 back to the ED to obtain orders and other admission paperwork. The Administrator stated the ED was unable to provide a PASARR for Resident #20, so the facility did not allow her to come back. On 6/16/17 at 8:55 am, LPN #1 stated she had been the nurse on duty on 6/10/17. LPN #1 stated she had received report that morning that Resident #20 had been restless during the night, and had high activity the past couple of days. LPN #1 did not recall being told of Resident # 20's bruising, so had not done an assessment. LPN #1 stated she was approached at one point by Daughter #2 due to concerns with Resident #20's bruising, and went to the room to observe the bruising. LPN #1 stated she did not do a formal assessment at that time, but checked the resident's record and saw that a skin sheet had been opened. LPN #1 stated no measurements were documented on the skin sheet at that time. LPN #1 informed Daughter #2 of this, and that the skin sheet would be completed later that day. LPN #1 stated Daughter #2 had an excited manner about her, requesting further evaluation of the bruises. LPN #1 stated she offered to eyeball the bruises, but Daughter #2 became more excited, going in and out of the building. LPN #1 described the impact of Daughter #2's behavior that morning as, It wasn't unusual or a big deal. LPN #1 stated when Daughter #2 requested further evaluation of the bruising, I didn't call the physician. I didn't even consider it. When I saw the 'skin sheet' had been started, I just presumed someone else had already let the physician know and there was nothing else to be done. Resident #20 was harmed when she was involuntarily discharged from the facility. Resident #20's family discovered several large bruises on her, and requested she be evaluated for further injuries and to rule out abuse. Resident #20's family summoned emergency responders and had her taken to the ED when the facility failed to respond to this request. The facility's refusal to allow Resident #20 to return to the facility resulted in her being discharged to her daughter's home without medications, medical equipment, or follow-up care, and without enough caregiver support to sustain the arrangement safely. The facility reaffirmed the decision by telling Resident #20 and her family two days later at a care conference that she had lost her bed and was no longer considered a resident.

Based on staff and physician interview, review of resident records and facility policy, it was determined the facility failed to: a) Ensure timely treatment for [REDACTED]. b) Ensure antibiotics were administered as ordered c) Ensure abnormal blood glucose levels were treated d) Ensure the policy for diabetic management provided direction for [MEDICAL CONDITION] management. This was true for 2 of 5 residents (#2 and #12) reviewed for falls, incidents and diabetic management. Resident #12 was harmed when she fell out of bed and fractured her jaw. Nursing interventions for pain management were not effective, her physician was not consulted regarding the fall or of ineffective pain management interventions, which resulted in unnecessary pain and suffering. Resident #2 was at risk for more than minimal harm when interventions for [DIAGNOSES REDACTED] were not consistently implemented and an antibiotic was not consistently administered as ordered. This had the potential to result in adverse complications for any resident that experienced untreated [MEDICAL CONDITION]. Findings include: 1. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A fall investigation report documented Resident #12 fell on [DATE] at 12:35 am. The report documented at a Thud was heard, the responding CNA ran to Resident #12's room and found her on the floor. She was described as lying on her left side facing the bed. Resident #12 was reported to state I rolled out of bed. A nursing progress note, dated 5/22/17 at 1:01 am, documented Resident #12 was complaining of left jaw pain and she was medicated with [MEDICATION NAME] 15 mg orally, at that time. The note documented the medication was effective at relieving her pain. Resident #12's Medication Administration Record [REDACTED]. A nursing progress note, dated 5/22/17 at 1:31 am, 30 minutes after the [MEDICATION NAME] was administered, documented Resident #12 was repeatedly yelling out Help me! even after needs met. The progress note and her MAR indicated [REDACTED]. A nursing progress note, dated 5/22/17 at 3:30 am, described Resident #12's fall. It included documentation of swelling on her chin and left side of lower jaw. The progress note documented a superficial abrasion on Resident #12's left knee, small bruises on her left knee, right knee, left upper arm and left elbow. The progress note documented a note for Resident #12's physician was left in the communication box, and her Interested Party would be called in the am. A nursing progress note, dated 5/22/17 at 4:12 am, documented Resident #12 was anxious since rolling out of bed, and did not calm down for any length of time. It stated staff attempted to feed her pudding and after 2 bites she refused to eat. The progress note stated Resident #12 was, Yelling so much she get (sic) mucous in the back of her throat that was suctioned. A nursing progress note, dated 5/22/17 at 6:38 am, documented Resident #12's Interested Party was notified of her fall. The progress note documented Resident #12's Interested Party was assured that a message was left to have the physician check on her. The message to Resident #12's physician on 5/22/17, stated At 00:35 (12:35 am) resident rolled out of bed. Found lying on her left side. She has some swelling on her chin and L (left) lower jaw. Ice pack applied. States I broke my jaw. Jaw feels the same on both sides. Has some bruises/abrasion L (left) knee, R (right) knee & L (left) elbow and LUE (Left upper extremity). Please check face. Neuro checks initiated. A nursing progress note, dated 5/22/17 at 12:31 pm, approximately 12 hours after her fall, documented Resident #12 received an additional dose of [MEDICATION NAME] for anxiety. Resident #12's nursing progress note, dated 5/22/17 at 1:30 pm, documented she was evaluated by a Nurse Practitioner and X-rays were ordered. A nursing progress note, dated 5/22/17 at 4:36 pm, documented an X-ray revealed a fracture of Resident #12's mandible (jaw). A nursing progress note, dated on 5/22/17 at 5:21 pm, documented Resident #12's Interested Party was notified of the X-ray results and made the decision to send Resident #12 to the ER for evaluation and treatment. The note documented the NP was notified and an order was received for non-emergent transport of Resident #12 to a hospital ED. A nursing progress note, dated 5/22/17 at 5:45 pm, documented Resident #12 was administered [MEDICATION NAME] 15 mg 1 tablet. Resident #12's MAR indicated [REDACTED]. Resident #12 was transported to the hospital and did not return to the facility. On 6/8/17 at 3:30 pm, Assistant Director of Clinical Services (ADCS) #3 stated Resident #12's clinical record indicated she was medicated for pain and anxiety twice after her fall. The ADCS stated Resident #12's MAR indicated [REDACTED]. She stated the [MEDICATION NAME] order was previously in place as needed for moderate pain, prior to Resident #12's fall. She stated Resident #12's MAR indicated [REDACTED]. ADCS #3 stated Resident #12's pain level documented was 10 of 10 prior to her transfer to the hospital. She stated the NP or physician were not called about Resident #12's injuries at the time of her fall. She confirmed there was a delay of approximately 13 hours before Resident #12 was evaluated by a physician or NP. 2. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's 5/15/17 admission MDS assessment documented his cognition was intact and he received insulin and antibiotics 7 of 7 days prior to the assessment. a. Resident #2's care plan documented a focus on the risk for hyper/[DIAGNOSES REDACTED] on 5/8/17. Interventions were to encourage him to report signs of hyper/[DIAGNOSES REDACTED], and to provide medications as ordered. Resident #2's Progress Notes and log of BG results, both dated 5/10/17 to 6/8/17, and Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR), documented his BG level was 60 or less on: * 5/16/17 4:56 am - Resident awoke around 3:20 am and said he felt shaky. His BG level was 41. Resident #2 ate a 1/2 sandwich and drank orange juice. He slept after that. At 4:40 am, an hour and 20 minutes later, his BG was 68. He drank more orange juice with a package of sugar in it but said he could not eat the rest of the sandwich. There was no documented evidence Resident #2's BG level was rechecked 15 minutes after he ate half of the sandwich and drank orange juice. * 5/20/17 at 12:20 pm - BG 60. There was no documented evidence interventions were implemented or that Resident #2's BG level was rechecked. The next BG level was documented 4 1/2 hours later at 4:50 pm and was 175. On 6/8/17 at 3:05 pm, Assistant Director of Clinical Services (ADCS) #1 reviewed Resident #2's Progress Notes and BG log records. She said the BG should have been rechecked on 5/16/17. The facility's diabetes management policy was requested at that time. Later in evening on 6/8/17, the Director of Nursing Services (DNS) provided a Nursing Care of the Resident with Diabetes Mellitus policy, dated 6/2012 as revised/reviewed. The policy documented the following: * Asymptomatic and responsive resident with [DIAGNOSES REDACTED] - give an oral form of rapidly absorbed glucose, recheck BG in 15 minutes; if still hypoglycemic, repeat the oral glucose and recheck the BG in 15 minutes; if no improvement, notify the physician. * Symptomatic but responsive resident with [DIAGNOSES REDACTED] who is able to swallow - give an oral form of rapidly absorbed glucose, recheck BG in 15 minutes; repeat juice if indicated, recheck BG in 15 minutes. * Symptomatic but responsive resident with [DIAGNOSES REDACTED] who is unable to swallow - administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME] (per facility protocol), recheck BG in 15 minutes; repeat intervention if indicated and recheck BG in 15 minutes; if no improvement, notify physician. The facility did not consistently implement interventions or recheck the BG after interventions when Resident #2 experienced [DIAGNOSES REDACTED]. The facility policy titled Nursing Care of the Resident with Diabetes Mellitus, revised 6/2012, stated the purpose of the guideline (policy) included recognition, management and documentation for the treatment of [REDACTED]. The policy stated [MEDICAL CONDITION] is not the same as having diabetes. The policy provided detailed management of [DIAGNOSES REDACTED], however, it did not include assessment or management of [MEDICAL CONDITION]. The Medical Director reviewed the policy on 6/8/17 at 11:20 am. He stated the policy should direct the staff to contact the resident's physician for a BG level less than 70 or greater than 400. He stated he would expect to be called for BG outside of the parameters except in cases of hospice, or other specified parameters. He stated It would be reasonable to add a statement to the policy to notify the physician for BG over 400. b. Resident #2's care plan documented a focus area for actual infection with [MEDICATION NAME] and serratia on 5/8/17. Interventions included medications per physician orders [REDACTED]. Resident #2's active orders documented a 5/24/17 order for an antibiotic, [MEDICATION NAME] 2 grams, 1 vial in 5% [MEDICATION NAME] in water 100 miliLiters, infuse IV over 30 minutes every night shift to treat the infection. On 6/6/17 at 1:10 pm, Resident #2 was observed in his room. He said said his IV antibiotic was not administered last night because it did not come from the pharmacy. On 6/6/17 at 1:20 pm, ADCS #1 said she was unaware Resident #2's IV antibiotic was not administered or that it was not available. Resident #2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In the space to document administration of the medication on 6/5/17 was NN and someone's initials. Chart Codes/Follow Up Codes at the bottom of the MAR indicated [REDACTED]. Resident #2's Progress Notes, dated 6/6/17 at 12:48 am, documented the IV antibiotic was not available. It documented that the pharmacy provider was called and the nurse was told the antibiotic would be shipped to the facility in the morning. On 6/6/17 at 4:05 pm, ADCS #1 said 7 doses of [MEDICATION NAME] were received from the pharmacy for Resident #2's initially. The ADCS said she did not know the number of doses received after that and she would review pharmacy receipts and/or call the pharmacy provider. On 6/6/17 at 7:45 pm, ADCS #1 provided pharmacy delivery records for Resident #2's [MEDICATION NAME] which documented 7 doses were delivered to the facility on [DATE], 3 doses were delivered on 5/30/17 and 4 doses were delivered on 5/31/17. The pharmacy delivery records documented enough doses of Resident #2's [MEDICATION NAME] were available for daily administration through 6/6/17. However, the IV antibiotic was not administer on 6/5/17 as ordered.

Based on observations, staff interview, review of clinical records and incident/accident reports, it was determined the facility failed to ensure residents received sufficient supervision, toileting assistance, resident repositioning as care planned, and care plan updates to prevent falls and injuries for 2 of 5 residents (#12 and #14) reviewed for falls. As a result: a) Resident #12, was harmed when she fell and sustained a fractured jaw, as well as, abrasions and bruising to both legs, left elbow and arm. b) Resident #14, was harmed when she fell and sustained a closed head injury and facial fractures. Findings include: 1. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Resident #12's MDS assessment, dated 5/1/17, documented she required extensive assistance with transfers, ambulation, bed mobility, and toileting. Resident #12's care plan revised on 8/25/16, identified her as at risk for falls and having behavior related to insomnia and dementia. Interventions included: - Bed mobility - 2 person assistance, sit-to-stand for transfer on and off the commode, toileting upon rising, before and after meals, at bedtime and every 2 hours and as needed. Additional interventions included a High/Low bed in lowest position, wearing of nonskid slippers with transfers and nonskid socks while in bed. - Resident #12's care plan revised on 8/25/16, included interventions related to skin integrity, which documented Prevalon boots (pressure reduction) were to be worn at all times except during transfers and she was to be repositioned in her bed every 1-2 hours. Her care plan documented a pressure reduction air mattress with bolsters was initiated on 3/31/16. A fall investigation report, dated 5/22/17, documented the following: - The fall investigation report documented Resident #12 fell on [DATE] at 12:35 am. The investigation report documented a thud was heard, the responding CNA ran to Resident #12's room and found her on the floor. The investigation report documented Resident #12 was lying on her left side facing the bed. The resident was reported to state I rolled out of bed. - The fall investigation report documented the last time Resident #12 was toileted was 5/21/17 at 4:46 pm, approximately 8 hours prior to her fall. She was documented as being incontinent of urine when she was found on the floor. - The fall investigation included a section titled Re-Creation of Last 3 Hours Before Fall. The statement was incomplete and stated Worked with two CNA's. First CNA checked on (Resident #12) around (time left blank) and I checked on her around 11:15 pm. She was laying on (right) side and sleeping. - The fall investigation included a section titled Fall Huddle. The statement, unsigned, documented, (MONTH) benefit from bolster mattress or 2nd bed cane. Resident #12's current care plan documented an air mattress with bolsters was initiated on 3/31/16. - The fall investigation included a section titled ROOT CAUSE OF THIS FALL which documented the following contributing factors: * amount of assistance in effect * Assistive/protective device * Medication * Medical status/Physical condition/Diagnoses * Toileting status * Vision or hearing - The fall investigation described initial interventions to prevent future falls: Left note for ADCS (Assistant Director of Care Services) for poss(ible) bolster or 2nd bed cane for visual boundary. A nursing progress note, dated 5/22/17 at 3:30 am, described Resident #12's fall. It included the following documentation: At 00:35 (12:30 am) resident rolled out of bed. Found lying on her left side. She has some swelling on her chin and L (left) lower jaw. Ice pack applied. States I broke my jaw. Jaw feels the same on both sides. Has some bruises/abrasion L (left) knee, R (right) knee & L(left) elbow and LUE (Left upper extremity). Nursing progress notes dated 5/22/17 at 4:36 pm, documented the X-ray revealed a fracture of her lower mandible (jaw). A nursing progress note, dated on 5/22/17 at 5:21 pm, documented Resident #12's Interested Party requested she be transported to a hospital for evaluation. She did not return to the facility. On 6/8/17 at 3:30 pm, ADCS #3 stated Resident #12's fall investigation recommended an air mattress with bolsters and her care plan documented she had one since 3/31/16. ADCS #3 stated it was unclear what kind of footwear, if any, Resident #12 was wearing at the time of the fall. She confirmed the care plan documented Prevalon boots were to be worn, but her clinical record did not include documentation whether they were used. ADCS #3 stated Resident #12's care plan directed staff to assist her with repositioning and toileting frequently, and she should have not had an 8 hour delay of toileting. ADCS #3 stated Resident #12's care plan interventions of bed position, the air mattress with bolsters, footwear type and resident repositioning every 1-2 hours would not be documented on a treatment record or other document. She stated If it is care planned, they should be doing it. The facility failed to ensure Resident #12 received the care and services necessary to protect her from falls. 2. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nursing Admission Assessment, dated 5/12/17, documented Resident #14 had poor balance, an unsteady gait, weakness, required assistive devices, had a fall in the last month, had a fall in the last 2-6 months, and had a fall resulting in a hip fracture 1 1/2 years ago. The Nursing Admission Assessment noted Resident #14 was a high fall risk. Interventions put in place included 15 minute checks for the first 72 hours, a red leaf (indicating high fall risk), a high low bed with bolster sheet, and a pressure sensitive call light. The MDS assessment for Resident #14, dated 5/26/17, documented she required extensive assistance of one staff for transfers. A Care Plan for impaired coordination, dated 5/12/17, directed staff to provide Resident #14 a one person assistance with constant guidance and physical assistance for transfers, and one person assistance with ambulation using a 4-wheeled walker. Resident #14's Fall Risk Care Plan, completed on 5/12/17, documented she was at risk for falls due to her acute medical condition, cognitive impairment, gait disturbance, weakness, history of falls, impaired balance, short term memory loss, and unsteady gait. Interventions included every 15 minute checks (no end date provided), Red fall risk, commonly used items within easy reach, high-low bed, (no position for height provided), perimeter mattress, reinforce with her the need to call for assistance, resident to wear nonskid shoes/slippers/socks, not leaving her unsupervised in room while she was up in her wheelchair; if she is awake please take out to an area of high visibility for closer supervision, and to seat her in an area of high visibility for supervision. A Fall/Post Fall Assessment, dated 5/18/17 at 6:30 pm, was completed Resident #14's unwitnessed fall from a wheelchair at the side of her bed. The Preventative Plan, the Social Service portion, and the RN follow up portion of the assessment were not completed. The Care Plan identified a revision date of 5/22/17 for high low bed and nonskid shoes/slippers. Both interventions were initiated on 5/12/17. No new interventions were noted. A Fall/Post Fall Assessment, dated 5/28/17 at 10:00 am, was completed for Resident #14's unwitnessed fall from a wheelchair. Resident #14 was in a common area of the facility watching TV. The assessment documented Resident #14's wheelchair brakes were on. The RN recommended anti-roll back brakes for Resident #14's wheelchair as an intervention. Resident #14's current Care Plan did not reflect the recommendation. The Care Plan identified new interventions, dated 5/31/17, which directed staff to encourage Resident #14 to use handrails or assistive devices properly and to adjust bed height and leave the bed in the lowest position when in bed. A Fall/Post Fall Assessment, dated 6/6/17 at 1:10 am, was completed when Resident experienced an unwitnessed fall from bed. The assessment documented Resident #14's bed was at normal height and her wheelchair was next to the bed. Resident #14 was transferred to the hospital and returned to the facility with [DIAGNOSES REDACTED]. Resident #14 participated in Physical Therapy from 5/13/17 to 6/7/17. Each Treatment Encounter Note documented Resident #14's precautions as being dementia, fall risk, and poor safety awareness. There was no Physical Therapy documentation or assessment of the three falls. There was no Physical Therapy documentation or assessment that placing Resident #14's high low bed in the lowest position would be the safest intervention to prevent falls. A Nursing Progress note, completed by ADCS #1, dated 6/7/17, documented per night shift aide reports resident slept all night without waking since starting Melatonin. On 6/8/17 at 10:55 am, Certified Nursing Assistant (CNA) #4 stated the communication section of the electronic medical system had updates for CNA's to see facility wide. CNA #4 stated there were no specific times specified to check on Resident #4. CNA #4 said, everybody works together, not just me. CNA #4 was not aware of updates on Resident #14. CNA #14 said, Physical Therapy put Resident #14 in bed 10-15 minutes ago. Resident #14 was lying in bed and appeared to be asleep. CNA #5 was asked if the bed was in the lowest position. CNA #5 pressed the control for the bed to lower until it stopped. CNA #5 stated, It was in a low position, but not the lowest. On 6/8/17 at 11:30 am, the DNS stated changes in resident care are provided on the electronic communication screen. Staff is to review at the beginning of their shift to note any new interventions they need to be aware of. The DNS was not able to find communication to staff providing care to Resident #14 following the recent fall with injury. On 6/8/17 at 12:30 pm, Therapy Staff #1 stated at 10:45 am the door to Resident #14's room was closed and the call light was on. Therapy Staff #1 found Resident #14 standing by the bed. Therapy Staff #1 stated she assisted Resident #14 with toileting and then to bed. Therapy Staff #1 stated Resident #14 was not to transfer independently because she is a fall risk. Therapy Staff #1 stated she knew it was communicated that the bed was to be in the lowest position and she thought it was.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents did not develop pressure ulcers. This was true for 1 of 6 (#3) sample residents reviewed for pressure ulcers. Resident #3 was harmed when a skin tear developed into a Stage III pressure ulcer. Findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances, altered mental status, and anxiety disorder. The 1/13/15 admission MDS coded moderate cognitive impairment, extensive two person assistance for toileting, always incontinent of bowel and bladder, at risk of developing pressure ulcers, no unhealed pressure ulcers, no MASD or other ulcers, wounds or skin problems, and pressure reducing device for the chair. The 2/9/15 significant change and 5/12/15 and 8/12/15 quarterly MDSs all coded the resident was at risk for pressure ulcers, and had no MASD or unhealed pressure ulcers. An 8/16/15 Skin Event Assessment documented a 3cm by 0.2cm skin tear injury to the coccyx and both bowel and bladder incontinence. The prevention plan section documented reposition frequently in the night and follow up with staff with turning and repositioning throughout the day and night, frequently incontinent of bowel and bladder and dependent on staff to anticipate needs. The Conclusion/Investigative Findings section documented a 3cm x 0.2cm MASD on the coccyx on 8/16/15, dementia, unable to communicate needs at times, and required staff to anticipate her needs. An 8/25/15 Nursing Summary documented the resident required extensive one-to-two person assistance with most ADLs and declined from frequent incontinence of bowel and bladder to total incontinence with rare continent/incontinent this quarter. The most recent Braden Scale score, 10, documented the resident was at high risk for pressure ulcers. The Nursing Summary documented the resident was assessed on 8/16/15 with MASD to the coccyx measuring 3cm by 0.2cm, and noted, A dressing will be placed on site and checked every shift. The 10/13/15 significant change and 1/12/16 quarterly MDSs both coded moderate cognitive impairment, always incontinent of bowel and bladder, and one unhealed Stage III pressure ulcer. A 12/1/15 - 12/19/15 Follow Up Question Report documented: 12/18/15 2:51 - Stage II length 1.0 cm, width 0.8 cm, depth partial thickness. Pressure Ulcer: Site: Coccyx, between gluteal folds, Stage III. A 1/27/16 - 2/17/16 Follow Up Question Report documented: 2/12/16 Stage III length 1.0 cm, width 0.5 cm, depth 0.25 cm. The resident's CP, with a 2/3/16 review date, documented: - Urinary and bowel incontinence: 1/6/15. Interventions, created 3/25/15, initiated and revised 4/20/15: Toilet upon rising, before and after meals, at bedtime, and every 3 hours. - At risk for actual skin impairment/pressure ulcer, created and initiated 1/6/15. Pressure reduction on bed, pressure reduction on chair, float heals when in bed, and notify charge nurse of skin impairment, bruises and rashes. The 1/11/16 Patient Wound Care Order Sheet documented: Coccyx pressure ulcer - Stage III, length 2.0cm by width 1.2cm and depth 0.1cm. - Pressure/Other Ulcer/Wound: 1/26/16: Pressure Ulcer: Site: Coccyx, between gluteal folds Stage III. The 2/12/16 Patient Wound Care Order Sheet documented a coccyx pressure ulcer - Stage III, length 1.2 cm by width 0.5 cm and depth 0.1 cm. Progress Notes documented: - 9/25/15 2:02 pm: Skin/Wound Note: Area to coccyx was not progressing towards healing. Area was open and measured 2.3cm by 1.0cm with about a 0.2cm measurable depth. - 11/13/15 12:12 pm: Skin/Wound Note: MASD to coccyx was not healing and had shown no improvement. - 11/20/15 3:45 pm: Skin/Wound Note: MASD to coccyx did not appear to be healing and there was no change in size. Most likely related to resident moisture risk. - 11/30/15 3:48 am: Behavior Note: CNAs offered to assist resident to bed, but resident refused. - 12/15/15 8:31 am: IDT Progress Note - General: returned from a 12/14/15 dermatologist appointment with a [DIAGNOSES REDACTED]. On 2/22/16 at 9:32 am, the dermatologist said the frictional folliculitis would not have affected the worsening of the pressure ulcer. He also said he was not asked to look at the pressure ulcer and was not made aware of the resident's MASD or pressure ulcer. - 12/16/15 4:34 pm: IDT Progress Note - General: Stage III noted to coccyx and covered with [MEDICATION NAME] foam dressing. - 12/18/15 3:02 pm: Skin/Wound Note: Coccyx still open measuring 1.0cm by 0.8cm and no measurable depth. CP updated to Stage II pressure ulcer. Area cleansed and new [MEDICATION NAME] foam dressing applied. - 1/6/16 10:52 pm: Resident refused to lay in bed or in her recliner. - 1/11/16 2:07 pm: Skin/Wound Note: Nurse in to evaluate resident's pressure ulcer to coccyx. Noted that ulcer was a Stage III rather than a Stage II. Care plan updated. - 1/16/16 10:44 pm: IDT Progress Note - General: Monthly head-to-toe, no concerns at this point, continue with current CP. - 1/31/16 4:06 pm: IDT Progress Note - General: Old dressing on coccyx soiled with stool. New dressing applied. - 2/1/16 1:25 pm: IDT Progress Note - General: POA does not wish to pursue an air mattress at this time. On 2/17/16 at 7:43 am: RN #2 said the resident's skin condition began as MASD with a slit to the coccyx. The RN said the resident's skin condition worsened due to the resident's refusals to relieve pressure by lying in bed or in the recliner. On 2/18/16 at 2:37 pm, Resident #3's dressing change was observed. When asked to measure the wound, LN #12 said measurements were taken only by the wound nurse.

Based on observation, staff interview and record review, it was determined the facility failed to ensure residents did not acquire pressure sores for 2 of 3 residents sampled for pressure sores (#3 & #9). Resident #3 was harmed when he acquired three successive Stage II pressure sores on his upper right thigh and the facility failed to provide appropriate interventions after the first two sores to prevent a third sore from developing. Resident #9 was harmed when he acquired a Stage II pressure sore on his right ischial tuberosity and an unstageable blister on his right heel which healed and then reoccurred. Findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Medicare 5 day MDS dated [DATE], coded the resident as: *Having an indwelling catheter. *Moderately cognitively impaired. *Does not have pressure sore. The resident's Care Plan (CP) dated 12/9/12, documented under Interventions for the Focus of Resident Care Standards, "Weekly Skin at Risk Assessment." The resident's CP dated 12/11/12, documented under Interventions for the Focus of Potential to Restore Function: Foley Catheter due to [MEDICAL CONDITION], "Maintain closed drainage system/secure catheter tubing to prevent pulling/trauma..." The resident's CP dated 5/11/12, documented under Interventions for the Focus of Resident Skin Impairment, "Pressure reduction on bed" and "Pressure reduction on Chair: w/c (wheelchair) cushion." The resident's Skin/Wound Integrity Admission assessment dated [DATE] documented the resident did not have pressure sores or blisters. The assessment also documented under Pressure Ulcer Definitions, "3. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." The resident's Progress Notes dated 12/11/12 at 4:03 PM and signed by RN#2, documented, "Blister found to residents right upper thigh by groin area during cath(eter) care this shift. Blister in (sic) unopened, fluid filled, 1.5 cm x (by) 1 cm. Covered area with clear film dressing and faxed MD (Medical Director)...Updated care plan and TAR. Resident put on alert charting. Will continue to monitor." The resident's Skin Event assessment dated [DATE] and signed by UCM #1 on 12/14/12, documented in the Conclusion/Investigative Findings section, "...Catheter tubing likely caused blister due to rubbing against skin. Resident does use a catheter securing device on his leg, which is his right leg. Skin is thin and fragile due to age. Resident hasn't had other blisters in the past due to catheter though on 10/17/12, he did develop an abrasion on his leg which was thought to be caused by catheter port. Will treat as ordered by MD and monitor for s/sx (signs and symptoms) of malhealing. Will continue with current POC (plan of care) for catheter use as ordered by MD." NOTE: The pressure sore was resolved on 1/1/13. On 12/18/12 a new blister was found on the resident's upper right thigh near the groin area and the resident's Skin Event assessment dated [DATE] and signed by UCM #1 on 12/21/13, documented: *The Skin Issue section, "Size 1.2 x 1.2 cm...Blister is intact, has serous fluid in it." *The form documented a history of a similar issue was found. *The Preliminary Findings section, "Resident currently has another blister approx(imately) 6 cm away from this blister. It may have been caused by his catheter rubbing against his skin" and "Placed clear dressing over blister. No changes to care plan at this time." *The Conclusion/Investigative Findings section, "Blister caused by catheter tubing. Foley catheter is in place due to [MEDICAL CONDITION]. Resident has another blister to R (right) thigh which was noted on 12/11/2012. CP includes intervention to secure catheter tubing and resident is compliant with this. Other than 12/11/12 blister, no hx (history) of blisters noted r/t (related to) catheter. Will treat as ordered by MD and monitor for signs of malhealing." Note: The pressure sore was resolved on 1/1/13. On 1/8/13 a new blister was found on the resident's upper right thigh near the groin area and the resident's Skin Event assessment dated [DATE] and signed by UCM #1 on 1/11/13, documented: *The Skin Issue section, "Size .5 x .5 cm...Blister itself is yellowish in color & fluid filled." *The form documented a history of a similar issue was found. *The Conclusion/Investigative Findings section, "This is the third blister that resident has had to his right thigh r/t catheter. Previous blisters were noted on 12/11/12 and 12/18/12. Resident has been using an adhesive leg strap that "tapes" to the leg and it is likely that strap doesn't hold catheter tubing off of leg well enough. Resident previously used a Velcro strap, though this has not been available in the facility, and no hx of blisters noted until recently. A request has been made to central supply to order these Velcro straps as when in use, resident didn't develop blisters (sic)." Note: The pressure sore was resolved on 2/12/13. The resident's Progress Notes dated 1/15/13 at 12:07 PM and signed by RN#3, documented, "Placed new catheter strap around resident's right leg and attached catheter to strap." The DNS and UCM #1 were interviewed on 5/22/13 at 10:50 AM regarding the skin issues. When asked other than medical treatment and securing the catheter tubing, why the facility did not implement interventions after the first pressure sore was discovered, UCM #1 stated, "It seemed like an isolated event." When asked why there were no interventions after the second pressure sore was discovered, UCM #1 stated, "The adhesive strap looked like it kept it (tubing) off the skin...so we continued to use the same holder (strap)...there weren't any options." When asked what had caused the third pressure sore, UCM #1 stated, "After looking at it...it was the adhesive leg straps." She indicated it was the same issue with the other pressure sores as well. When asked to clarify why it took three pressure sores to finally discover the problem, the DNS stated, "If we don't have a source, what interventions do we put into place when we don't know the cause?" He also said the facility discovered their supplier switched catheter securing products from a Velcro strap to an adhesive strap. Although the facility medically treated the pressure sores, it failed to find and implement appropriate interventions before two more Stage II pressure sores were discovered, causing harm to the resident. On 5/23/13 at 2:10 PM, the Administrator and DNS were informed of the pressure sore issue. No further documentation was provided by the facility. 2. Resident #9 was admitted to the facility on [DATE] and readmitted most recently on 8/23/11. The admission [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 6/13/12, documented the resident: - had severe memory impairment with a BIMS of 3, - required extensive assistance with transfers, dressing, eating, personal hygiene and bathing, - had a catheter, - had 2 unstageable pressure sores (M0300F1), that were not present on admission (M0300F2), - the sore had necrotic eschar tissue covering it (M0700 = 4), and - the sore measured 0.8 by 0.5 cm in size. The 6/13/12 CAA Worksheet for Pressure Sores documented, "Resident has a history of multiple pressure ulcers and does remain at risk for future pressure ulcer development. Goals and interventions directed toward reduction of risk factors to be addressed in skin integrity focus. As resident does have two unstageable pressure areas on right foot, pressure focus will be addressed in resident's plan of care with goals directed toward resolution of ulcers." The most recent quarterly MDS assessment, dated 3/16/13, documented the resident: - had a catheter, - did not have a pressure sore, - had moisture associated skin damage (MASD) (M1040H), and - had pressure reducing device in wheelchair and bed. The resident's care plan dated 4/8/13 documented: Focus: "Resident at risk for actual skin impairment/pressure ulcer related to: History of prior pressure ulcer, diabetes, immobility, incontinence." The interventions were: "- Do not push broda chair through doorways/over thresholds, please pull chair through instead to avoid injury to resident's feet (initiated: 3/29/12), - Ensure bedding is not touching resident's feet; ensure foot cradle is in place at all times when resident is in bed (initiated: 6/7/12), - Ensure that resident is one of the last residents up before meals and one of the first residents down after meals (initiated: 2/6/11), - Foot buddy to wheelchair to prevent injury(initiated: 6/7/12), - Foot cradle to foot of bed (initiated: 6/7/12), - Glove to left hand at all times: check for placement every 2 hours(initiated: 1/25/13), - Provide nail care once a week...(initiated: 4/3/13), - Refer to mobility plan of care for positioning (initiated: 9/9/11), - Resident to spend limited time up in wheelchair until resolution of pressure ulcers; new turning/positioning schedule until resolution of pressure ulcers, refer to schedule posted in resident's room...(initiated: 5/25/12), - Pressure reduction on bed; full air mattress (initiated: 6/14/10), - Pressure reduction on chair; Keen contour cushion (initiated:6/14/10), - Float heels: Utilize Prevalon foam boots at all times to float heels (initiated: 2/6/13), - Moisture barrier to buttocks and scrotum after each incontinence episode....(initiated: 6/14/10)." The care plan for mobility, initiated 9/9/11, documented: "Reposition resident with assistance of 2 staff members, turn and reposition every 2 hours." The resident's sores that were coded on the annual MDS dated [DATE], were resolved by September 2012. During the survey it was found the resident had two separate areas of pressure sores. One was on the right ischial tuberosity (NOTE: Sometime described as gluteal fold in the documentation) and the other was on the right heel. NOTE: The two will be described separately below. a) On 9/21/12 the facility completed a Skin Event Assessment that documented the resident had a MASD of the right gluteal fold. The size was documented as: 2.5 cm x 2 cm x 0.1 cm. The wound bed was described as, "75% slough, without drainage, surrounding skin looks healthy and pink." The Preliminary Finding for the sore was: "Resident is obese, with decreased mobility. He is diaphoretic with frequent bowel incontinence. Resident also has a history of skin issues." The facility documented Risk/Contributing Factors of: "Resident is at an increased risk for skin impairment as well as for development of pressure ulcers. Resident does have a history of previous pressure ulcers, as well as a history of similar skin impairments in the same area as this impairment." The resident was noted to be, "Compliant with the plan of care." Facility Progress Notes documented a dressing change on 9/25/12 then nothing was documented about the sore until: On 10/2/12 at 8:04 p.m. an LN documented, "Late entry: (NOTE: no date for the late entry) Residents (sic) coccyx dressing changed. Wound seems (to) have gotten worse since last dressing change. Feces was in dressing and interrupted with (sic) healing process. Wound was cleansed well with wound cleanser and redressess(sic) with foam dressing." NOTE: There was no documentation provided by the facility that described the wound progress or deterioration between 10/2/12 and progress note documentation by the physician assistant (PA) on 12/31/12. On 12/31/12 at 1:51 pm and 1:57 pm the PA documented, "Subjective: Pt (patient) doing well overall, nursing has no concerns. Pressure ulcer on buttocks has healed, as have the ulcers on heels (with) boots and cares. Pt reports mood is happy today... Objective: skin: heel ulcers are healed, now grade 1 with some [DIAGNOSES REDACTED] of skin... Plan: 4. skin ulcers, improved w/wound care, air boots. Continue current care, special bed..." On 1/8/13 at 10:13 p.m. the LN documented, "....We are currently treating and monitoring an abrasion to his inner gluteal fold as well as ones to his right toes, all of which appear to be healing without issues..." NOTE: It is unclear if this was the same wound that the PA documented was healed on 12/31/12 or if it was a new wound on the right gluteal fold. In addition, there was no description of the wound on the gluteal fold since the PA documented it was healed. On 2/22/13 at 3:07 a.m. the LN documented, "Dressing to resident's right gluteal fold became removed during peri care this shift. Wound is open with red irritated skin around. Faxed MD requesting change in dressing orders...." NOTE: There was no documentation about the open gluteal fold wound between 2/22/13 and 3/26/13. On 3/26/13 at 6:28 a.m. the LN documented, "Wound to (right) gluteal fold has macerated tissue approx 4 cm x 4 cm (with) 2 open areas. Open areas have red wound bed that has occasional bloody drainage. D/t (due to) maceration..." NOTE: The Mosby Medical Encyclopedia describes maceration as the softening and break down of skin from prolonged exposure to moisture. On 4/1/13 at 3:11 p.m. the LN documented, "Late entry...for 3/28/13 note that gluteal wound...area of approx. 3 x 3 (cm) of red macerated skin with a scab in middle of wound, cleansed and dressing applied. skin surrounding wound was white in color, area in center pink and viable, area outside of wound blanchable..." On 4/1/13 at 1:14 p.m. the LN documented, "Area of right gluteal, Measures at 3.2 x 3 (cm) with healthy skin surrounding, area inside pink and bloody with a noted 1.1 (cm) eschar area in middle of wound, notified RCM (UCM) and will continue to turn pt side to side...." Interpretive Guidance for F314 describes eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. On 5/16/13 at 3:06 p.m. the LN documented, "Pressure ulcer to right gluteal fold assess(ed) by this nurse; pressure ulcer no longer noted to be unstageable. No slough/eschar present. Wound bed has opened to reveal stage II pressure sore measuring 2 cm x 2.5 cm. Wound edges noted with [MEDICATION NAME] tissue accounting for approximately 10% of the wound granulation tissue comprising the remaining 90% of the wound bed..." On 5/21/13 at 8:30 a.m. LN#3 was observed while doing a dressing change to the sore on the right ischial tuberosity. (NOTE: This is the same sore that was identified as being located in the gluteal fold). The sore was a stage II and measured 1.7 cm x .8 cm. It had depth, but the LN did not measure it. The sore was pink and no redness or slough was noted. The dressing was applied and the resident was positioned to the left side. b) A Skin Event Assessment, dated 1/28/13, documented a blister on the right heel. The blister measured 4 cm x 5 cm and was described as being, "blue, purple, fluid filled, no drainage, no s/sx (sign/symptoms) of infection, intact." The Preliminary Finding of the investigation documented: "unable to give possible cause...Resident has current orders to float heels in bed, foam boots when out of bed, and skin prep to heels BID (twice a day). With that noted, pressure to heels is a possible cause." The Risks/Contributing Factors were, "Resident has a significant history of poor tissue tolerance. Resident has a history of multiple pressure ulcers. Resident is at increased risk for development of skin impairment secondary to immobility as well as obesity. Friction as well as shear continue to remain risk factors as well." The Conclusion was, "It is likely that friction is the causative factor in the development of the blister. It is likely that resident's heel rubbed against an object, likely the mattress, thereby causing the blister." The Plan of Prevention was to place a, "protective dressing over blister. Plan of care updated to include that Prevalon boots are to be worn when resident is in bed to alleviate the possibility of friction between the resident's feet and the mattress." On 3/22/13 at 2:28 p.m., Facility Progress Notes documented, "This nurse also assessed blister to right heel. Blister is no longer intact; pink, healthy tissue noted. Dressing to site discontinued as treatment is no longer indicated. Skin to right heel continues to appear fragile; will continue to float bilateral heels when in bed as well as apply skin prep twice daily for additional protection." A Skin Event Assessment, dated 4/14/13, described a blister to the right heel. It measured 4 cm by 5 cm and was a, "fluid filled blister, red and purple with some white color r/t moisture. Blister is weeping." The Risk/Contributing Factors were documented as, "Resident is at an increased risk for development of skin impairment. Resident does currently have an unstageable pressure ulcer to his right gluteal fold, and does have a history of previous pressure ulcers." The Conclusion/Investigation Findings were, "Blister is likely the result of friction between the resident's foot and the mattress. It was noted that Prevalon foam boots were not in place which likely would have protected resident's foot from friction." On 5/21/13 at 11:10 a.m. LN#3 was observed to remove the dressing from the right heel of Resident #9. The sore was 2 cm x 1.5 cm and had pink granulated tissue. There was no depth to the sore and it was almost healed. The LN replaced the dressing and put the Prevalon boots on. The DNS and UCM were interviewed on 5/22/13 at 1:50 p.m. They indicated that the wound on the resident's gluteal fold was unavoidable because it was caused by moisture from the resident sweating and his incontinence of stool. However, the resident had a suprapubic catheter that aided in moisture prevention. The pressure sore on the right heel was healed and broke down a second time because a staff member did not apply the Prevalon boots as care planned. No further information was provided. The resident was harmed due to a history of skin breakdown and then having a new pressure ulcers develop. The facility had the resident on a every 2 hour turning schedule since 9/9/11 and the resident continued to have skin breakdown. In addition, a right heel stage II pressure sore developed then healed, but when staff failed to apply Prevalon boots, it reoccurred in the same area.

Based on resident and staff interview and record review, it was determined that the facility failed to ensure that two residents that were admitted to the facility without pressure sores did not acquire them. This was true for 2 of 13 (#s 7 and 8) sampled residents. Residents #7 and #8 both had facility acquired pressure sores. Resident #7 had a history of [REDACTED]. The facility harmed the resident by not having adequate interventions in place to prevent the resident's right heel sore from occurring and getting infected. Resident #8 had a history of [REDACTED]. The resident sustained [REDACTED]. The resident was harmed when the facility failed to have adequate interventions in place to prevent the skin breakdown. Findings include: 1. Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent annual MDS assessment dated [DATE], documented the resident: * Was cognitively intact (BIMS = 15), * Required extensive assistance of one staff for transfers, personal hygiene and bathing. * Had an unstageable deep tissue pressure ulcer. The most recent quarterly MDS assessment dated [DATE], documented the resident: * Had an unstageable deep tissue pressure ulcer. The resident's care plan, dated 1/27/12, documented several areas identified for staff to "Focus" on. One issue documented: "Resident at risk for actual skin impairment/pressure ulcer related to: Hx (history) of Prior pressure Ulcer, Diabetes, incontinence, nutritional deficit. (Initiated: 3/8/11)" The interventions were: "* Encourage the res(ident) not to scratch or rub(Initiated: 3/8/11) * Pressure reduction on bed; low airloss mattress (Initiated 9/20/11) (Initiated: 4/18/11) NOTE: Unable to determine which date it was actually initiated. * Pressure reduction on Chair: w/c (wheelchair) cushion (Initiated: 4/18/11) * Float heels at all times (Initiated: 9/20/11) * RD referral (Initiated: 9/20/11) * Treatment per MD orders. (Initiated: 6/20/11) * Assess circulatory status: PRN (as needed) (Initiated: 4/18/11) * Notify charge nurse of skin impairment, bruise, rashes (Initiated: 3/8/11)" Another area that the staff was to "Focus" on documented: Pressure/Other Ulcer/Wound Documentation: (Initiated: 5/5/11) The interventions were: "* While in bed, resident's heels need to be floated but also position pillows so she stays toward center of bed - to avoid rolling off to the floor. (Initiated: 10/4/11) * Check placement of supports and reposition res Q 2 hours (resident every 2) while in bed. (Initiated: 10/5/11) * 1. Pressure ulcer to right heel; suspected deep tissue injury. 2 cm x 2.5 cm dark purple/maroon area partially surrounded by 3 cm x 4 cm area of slough. Entire area is surrounded by 6 cm x 5 cm non-blanchable reddened area; please complete Ez Graph with each weekly assessment. (Initiated: 9/20/11)" On 9/20/11 at 2:00 p.m. a Skin Event Assessment was started on the resident because of a pressure sore on the right heel. The form documented the stage to be "Suspected Deep Tissue." The size was 4 cm x 5 cm. Wound bed description was: "Wound Bed is yellow/white, surrounded by dark purple skin area, This area is open, partial thickness skin loss." The surrounding tissue description was: "Tissue surrounding open area is yellow, intact skin. Skin surrounding yellow skin area is red." The resident indicated that "it hurts slightly." In the "Risk/Contributing Factors" section there was documentation at Acute Clinical Conditions that stated: "Resident has a hx of previous ulcerations. Resident is primarily bed/wheelchair bound." Progress Notes documentation provided by the facility began on at 9/1/11, however there was no documentation about pressure issues until 9/20/11 at 2:17 p.m. when an RN documented an IDT Progress note: "During toileting of resident, saw that there was serosanguinous bloood (sic) on her socks. Noticed pressure ulcer on right heel. Cleaned wound, placed allevyn gentle foam heel dressing on wound with [MEDICATION NAME]." On 9/20/11 at 2:27 p.m. an RN documented an IDT Progress Note: "Resident unsure how pressure ulcer happened. Asked resident if she had any pain, she said it had been hurting slightly for a few weeks but didn't tell any staff...." On 9/21/11 at 9:59 an RN documented in an IDT Progress Note: "Resident continues to wear foam boots while in bed so that heels are elevated off of the bed. Shoes are not being worn...." On 9/22/11 at 12:08 p.m. the RCM documented in an IDT Progress note: "Spoke with the resident regarding her refusals to shower. Resident's reply was that she didn't shower because 'I have sores on my feet.' Informed resident that it is ok to shower...Also spoke with resident regarding wound on right heel. Resident states, 'oh, it's not that bed, it will heal. I have good circulation.' Educated resident on the severity of the wound..." On 9/24/11 at 11:40 a.m. an LPN documented in a IDT Progress note: "...R(ight) heel PU (pressure ulcer) open drsg (dressing) reapplied....new order for Foot/Ankle Orthosis boots at all times, and also cont(inue) to float heels to decrease pressure...." On 9/30/11 at 11:25 a.m. an LPN documented in an IDT Progress note: "New order received from wound clinic. PU (Pressure Ulcer) to R heel positive [MEDICAL CONDITION], [MEDICATION NAME] 100 mg po BID x 14 days (an antibiotic -100 milligrams orally twice a day for 14 days)...." NOTE: The nursing documentation continued with the facility using Orthosis Boots, floating heels and using an antibiotic due to [MEDICAL CONDITION] in the heel. On 10/7/11 at 11:09 a.m. an RN documented in a Skin/Wound note: "During diabetic foot check resident's L(eft) heel noted to be slightly boggy. Due to resident's mostly sedimentary (sic) status, and stage II to R heel we need to ensure both heels floated!! Applied cpefoam for padding-secured with [MEDICATION NAME]" NOTE: Type to dressing. On 10/9/11 at 9:49 p.m. an RN documented an IDT Progress note: "....Both heels floated throughout the shift with heel protectors on, drsg (dressing) to foot ulcer intact and foam in place for left heel...." On 10/11/11 at 2:41 a.m. an LPN documented an IDT Progress note: "...BLE's (bilateral lower extremities) elevated on pillows & boots on bil(ateral) feet. Dressing dry & intact on right heel wound. Continues to receive [MEDICATION NAME] in heel wound. No adverse effects noted. Foam Dressing in place on boggy left heel. Left heel without redness. Less boggy compared to a couple days ago..." The facility monitored the right heel pressure sore on an "Intervention/Task" form. NOTE: Monitoring varied fron every 3 days to once a week. Some of the measurements documented were: 9/21/11: Stage 2, length 4 cm, width 5 cm, depth no response. NOTE: "no response" indicated that there was no data input into the computer program. 9/25/11: Stage unstageable, length 3 cm, width 4 cm, depth no response. 9/28/11: Stage 2, length 2 cm, width 3 cm, depth no response. In November the documentation was: 11/2/11: Stage unstageable, length 2 cm, width 2 cm, depth 3 cm. 11/15/11: Stage unstageable, length 1.5. cm, width 2 cm, depth no response. 11/29/11: Stage 2, length 0.5 cm, width 0.5 cm, depth no response At the time of the survey the heel wounds had resolved and the resident was in new diabetic shoes. The DON and Unit Manager were interviewed on 3/1/12 at 10:45 a.m. The DON indicated that the Right heel originally was unstageable and the next day it was a stage III sore. The left heel never became a sore before it resolved. When questioned what was in place prior to the right heel breakdown, the DON indicated that the resident "was up out of bed." "She started to refuse to take her shoes off and preferred to wear shoes to bed.." The facility staff did "education and reminded her because she was prone to skin breakdown." The DON also indicated that the resident "refuses lots of things." The DON also indicated that the RN's currently were the only ones doing pressure sores staging. The DON said he had a challenge with the accuracy of the staging that was currently in place and had been educating the RN staff to become more accurate and consistent. The Unit Manager stated that the resident had a decline in compliance after the antidepressant was discontinued. There was discussion about social services involvement in refusals of care and putting the resident at risk. The Unit manager indicated that there was not a behavior plan for the resident. As a result the behaviors that caused the pressure sores were not addressed by the facility. The resident was harmed due to: - The facility's failure to identify and address risk factors for developing a pressure ulcer, e.g.. wearing shoes to bed; - The resident's history of previous pressure sores that put the resident at risk for developing pressure sores; - The facility's failure to provide appropriate care to minimize infection which resulted in the resident's sore became infected [MEDICAL CONDITION]; and, - The facility's failure to accurately stage the pressure sore which varied from unstageable to Stage III and to Stage II. 2. Resident #8 was admitted to the facility 2/17/07 with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 2/7/12 documented the resident: * Was cognitively intact (BIMS - 14), * Required extensive assistance for transfers, dressing, personal hygiene and bathing, * Did not have a pressure sore. Resident #8's care plan, dated 11/22/11, documented several areas identified for staff to "Focus" on. One issue documented: Resident at risk for actual skin impairment/pressure ulcer related to: Mobility and skin folds. (Initiated 9/1/10) The interventions were: "* Cleanse and thoroughly dry folds of abdomen, breasts, and groin daily; apply pillowcases as needed to prevent moisture buildup (Initiated: 2/13/12) * Encourage resident to lie down between meals and activities (Initiated: 2/17/12) * Encourage and assist resident to change position every 2 hrs when in bed and when in her wheelchair (Initiated: 2/17/12) * Pressure reduction on bed: pressure reducing mattress (Initiated: 9/1/10) * Pressure reduction on chair: Pressure reducing cushion (Initiated: 9/1/10) * Float heels: on pillows (Initiated: 9/1/10) * Moisture barrier Q shift PRN (every shift as needed). (Initiated: 9/1/10) * Assess circulatory status PRN: lung status, color/temperature, pedal pulses, and sensation. (Initiated: 9/1/10) * Notify charge nurse of skin impairment, bruises, rashes. (Initiated: 2/17/12) * Abdominal fold need to be kept clean and dry under breasts. (Initiated: 9/1/10) * 1. Bruise: Location: Left posterior thigh/left ischial tuberosity Size: 3.7 cm x 6.5 cm red/purple surrounding skin tear. (Initiated: 1/26/12) * 2. Rash/Excoriation: Location: generalized redness in pannus and groin. (Initiated: 2/7/12) * 3. Rash/Excoriation: Location: Reddened area underneath right breast Size: 4.5 x 3 cm. (Initiated: 2/7/12)" Another area that the staff was to "Focus" on documented: Pressure/Other Ulcer/Wound: (Initiated: 2/15/12) The interventions were: "* 1. Pressure Ulcer: Site: Greater Trochanter, left Stage: Pressure - Suspected DTI (deep tissue injury). (Initiated: 2/15/12) * 2. Pressure Ulcer: Site: Ischium, right Stage: Pressure - Suspected DTI. (Initiated: 2/15/12) On 2/15/12 at 11:42 a.m. a Skin Event Assessment was initiated for Resident #8 due to the discovery of two pressure ulcers. The Site of the Skin Issue documented, "Right ischium, and Greater Trochanter, left." The form documented the Stage to be "Suspected deep tissue." The Size was "Right ischium is 5 cm x 7 cm; Left greater trochanter in 3.5 cm x 8 cm." The Wound Bed description was, "Right Ischium wound bed is red, serosanguinous drainage. Left greater trochanter wound bed is red, serosanguinous drainage." The Surrounding Tissue description was, "both areas of (sic) purple/red." The Preliminary Determination of Cause of Skin Issue documented, "Resident lies exclusively on left side, Resident is resistive to lying on right side. Resident prefers to sit on commode for 30 minutes or more each time she is toileted. Resident does not want to be 'rushed' while she is being toileted. Possibly occurred from sitting on commode." The Social Service Follow-up and Comments documented: "Resident not aware of how skin impairments occurred. Resident is able to communicate with staff and family. Resident encouraged to change her position in bed and when on the commode to prevent further impairments. No abuse or neglect suspected. No changes to care plan." Progress Note documentation provided by the facility beginning on 12/1/11 was reviewed. The resident had several skin issues prior to the 2/15/12 documentation of a pressure sore. The documentation for skin related issues were: On 12/20/11 at 1:57 a.m. an RN documented in an IDT progress note: "A skin tear was found on res's (resident's) rt. (right) back of thigh, it appears it was pinched by the seat of the commode. Res says this is possible, but doesn't know for sure, however it hurt her through the day. Wound bed red with slight serosanguinous drainage. Tissue around skin tear in bruised and slightly raised 4.5 cm x 4.5 cm. Res stated it hurts when touched...." On 1/3/12 at 1:57 p.m. an RN documented in an IDT Progress note: "Resident doing well today...shower revealed O (no) new skin issues, area in posterior R(ight) thigh healing appropriately..." On 1/9/12 at 11:07 a.m. an LPN documented in an IDT progress note: "back of right thigh healed - resolved, order dc'd." On 1/22/12 at 9:03 p.m. an LPN documented in an IDT progress note: "No latent injuries noted from previous fall. Resident (complains of) pain to posterior area of left upper leg....Two person transfers needed throughout shift..." On 1/24/12 at 9:01 p.m. an LPN documented in an IDT progress note: "Resident doing well today. no (complaints of) pain or discomfort. Found abrasion to back of Left thigh with bruising around it..." On 1/25/12 at 2:27 a.m. an LPN documented in an IDT progress note: "Dressing intact over abrasion left posterior thigh...Has been sleeping well thus far this shift..." On 1/25/12 at 11:56 a.m. an LPN documented in an EMAR note: "Skin tear to left hip/ischial tuberosity: Cleanse with dermal wound cleanser and 4 x 4 gauze. Cover with allevyn gentile boarder. Change every 3 days and PRN (as needed). Monitor for signs of mal-healing/non-healing..." On 1/25/12 at 2:41 p.m. an RN documented in an IDT Progress note: "Resident (complains of) L(eft) hip pain and did not get out of bed until 1130. Pain subsided with PRN APAP, encouraged resident to lie on R side to ease pressure on L hip. Dressing to L buttock intact, site blanchable will monitor for changes. Resident assessed ROM (range of motion)...." On 1/25/12 at 9:23 p.m. an RN documented in an IDT Progress note: "When asked about hip resident states that it feels a little soar (sic) but it doesn't (sic) hurt when she stands on it...." On 1/26/12 at 1:48 a.m. an LPN documented in an IDT progress note: "Resident c/o (complains of) pain to lt (left) buttocks. Medicated with PRN tylenol with good results as resident is currently sleeping. Also c/o being uncomfortable, wanting to lie on Lt side. Encouraged resident to lie on Rt side, placed a pillow behind back and between legs. Compliant thus far this shift..." On 1/29/12 at 3:12 a.m. an LPN documented in an IDT progress note: "....Had given Tylenol on evening shift to help her sleep. Needs encouragement to lay on right side to allow LLE (Left Lower Extremity) abrasion to heal. Resident has requested staff repos(ition) her numerous times. States 'I can't get comfortable.' Prefers to lay on her left side. Has been sleeping at intervals." On 2/6/12 at 1:50 p.m. a nurse documented a Behavior note: "Resident was placed on the commode at 0555 (5:55 a.m.) and refused to get off until 0730 (7:30 a.m.). She did not have a (bowel movement) or void. She resisted getting dressed and told staff to shut up. When staff told her she would be late for breakfast, she stated that she didn't care and continued to adjust the sheets on her bed as she sat on the commode." On 2/14/12 at 9:31 p.m. an LPN documented an IDT Progress note: "Dressing to thighs posterior applied this eve(ening). Areas of concern were raw and allevyn gentle border was placed over them. PT.(patient) did wxpress (sic) pain as wounds were being cleansed. Lt side is the sorest and an opsite was placed over the bandage to ensure it's placement. The terrain and flaccidity of her skin makes it impossible to apply the type of dressing the would be ideal without a major undertaking but they are sufficiently covered. It was evident that the right sided wound was caused by the skin folding over on itself and a long legged girdle of sorts may be the ideal solution. The left sided wound is definitely from to (sic) much time on the toilet seat." On 2/15/12 at 11:28 a.m. an RN documented a Skin/Wound note: "This treatment nurse assessed new skin issue with wound nurse. Determined that area in left hip is possible deep tissue injury, stage 2 wound. Skin area around open areas is purple/red in color. Area measures 8 cm x 3.5 cm. Resident has been encouraged to lie on her right side while in bed. Resident is somewhat resistive to this as she is used to and prefers lying on her left side. Resident also prefers to sit on the commode for at least 30 minutes at a time. Resident has been resistive to getting off the commode sooner than she is 'ready.'" On 2/15/12 at 11:29 a.m. an RN documented an IDT Progress note: "This treatment nurse assessed new area on right side of hip at ischium. Area of concern is 5 cm x 7 cm. There are 3 small open areas within the borders of the wound. Wound nurse described as pressures wound. suspected DTI (Deep tissue injury)...." On 2/18/12 at 7:06 a.m. an RN documented a Skin/Wound note: "Pressure ulcer to left trochanter is 6 x 7.9 cm, with an open area of 1.7 x 1 cm. Open area has a pink wound base, and is draining scant amounts of serosanguinous fluid. Surrounding tissue to open area is dark purple, and slightly boggy. Area is tender to touch, resident states 'it hurts right there.' Pressure ulcer to right ischium is 3.5 x 4.9 cm, with an open area of 0.5 x 0.6 cm. Open area has a pink wound base, and is draining scant amounts of serous fluid. Surrounding tissue to open area is dark purple, and slightly boggy. Suspected deep tissue injury. Area is not tender to the touch." On 2/19/12 at 2:20 a.m. an LPN documented an IDT Progress note: "Resident has been allowing staff to turn her side to side during the night to allow pressure sores to heal. resident is reluctant to change position as she prefers to lay on her left side. Staff has explained the importance of keeping pressure off areas & resident has allowed cares with encouragement." The DON and Unit Manager were interviewed on 3/1/12 at 10:45 a.m. When questioned on how the pressure sores occurred and what systems were in place to prevent the sores the responses were that the resident preferred to sit on the commode for long periods of time. Sometimes the resident would sit for 30 minutes or more. Also the resident's preference was to sleep on her left side at night. When questioned about these behaviors and why the resident's skin broke down now since these were long time preference, they both indicated that the resident had a recent weight loss and now had a lot of loose skin that would overlap when sitting or lying. This issue contributed to the pressure sores. The facility had not care planed for the excessive skin issue and the ongoing behaviors. On 3/2/12 at 7:45 a.m. the Administrator, DON, Activity Director, Social Service Director and Unit Manager met with the survey team. The facility provided further information. * The DON indicated that the CNAs have a "Standard of Care" that was to be their guidance with resident cares. Number 14 was highlighted and it stated: "Skin check with morning and evening care and on bath days. Report to licensed nurse any bruises, red, rashes or open areas." * The DON also stated that the staff "provided education" to the resident for turning off the side and prolonged sitting on the commode. (Note: The nursing progress notes do not have documentation that the education occurred prior to the skin breakdown.) * The Unit Manager did indicate that the resident "after seeing the consequences of the action, she changed her behaviors and started to get better." * The Social Service Director did indicate that there was not a care plan for the resident's behaviors and putting herself at risk for harm. The resident was harmed due to: - The facility's failure to develop a care plan intervention related to sitting on a commode for long periods of time; - The facility's failure to develop a care plan intervention for refusing to turn off the left side in bed. - The facility's failure to identify the resident's increase in risk for skin breakdown when the resident lost weight and had excessive skin. - The resident had multiple skin issues prior to the pressure sores. The facility failed to use the information to develop a plan for preventing further skin breakdown. The facility provided further information after the exit and the information was reviewed. There were interviews from staff that reinforced the fact that the resident sat on the commode for long periods and slept on the left side. The staff educated the resident but it did not change the resident's behaviors.

Based on observation, record review, and staff interview it was determined the facility failed to ensure that Resident #9 received supervision to prevent her from falling and fracturing her left hip. The resident had multiple medical complaints and showed a decline in cognition and gait prior to the injury. The facility failed to increase supervision of the resident which resulted in harm to the resident. The resident returned to the facility after the hip fracture and continued to fall from multiple attempts to self transfer without assistance. This was true for 1 of 13 (# 9) sampled residents. Findings include: Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent significant change MDS, dated [DATE], documented the resident: * Was severely cognitively impaired (BIMS = 3) * Required extensive assistance of one to two staff for transfers, dressing, eating, personal hygiene and total care for bathing, * Had a fall in the past month, * Had falls in the prior 2-6 months, * Had a fracture related to a fall in the past 6 months, * Had a non injury fall since re-admission to the facility. The most recent care plan, with a review date of 2/22/12, documented several areas related to mobility and falls. One that was initiated on 10/24/11 documented: "Requires assistance for MOBILITY characterized by the following functions; positioning, transferring, locomotion/ ambulation related to: Cognitive impairment, Pain, post surgery." Interventions were: "* Transfers: Provide two persons for constant supervision and physical assist with transfer belt; ensure toe touch weight bearing is maintained to right lower extremity.(Initiated: 1/27/12) * Encourage Resident to not ambulate without assistance. (Initiated: 1/27/12) * POSITIONING: Side rails type: Bilateral, full rails with pads When: Up at all times when in bed. (Initiated: 2/11/12)" Another care plan item that was initiated 10/26/11 documented: "Problematic manner in which resident acts characterized by inappropriate behavior; Resistive to treatment/care related to: refusal and decreased communication therefore cannot be persuaded to comply." Interventions were: "* Resident Specific Interventions: 1. offer ice cream 2. Enjoys Dr Pepper 3. One to One visits. (Initiated: 10/10/11) * Resist Care Behaviors: 1. Poor safety awareness 2. Long standing concerns regarding bowel habits. (Initiated: 10/7/11)" Fall care plan item that was initiated 10/24/11 documented: "Risk for falls related to: Weakness Acute Medical Condition (right femoral fracture with repair), Hx (history) of falls, Pain." The interventions were: "* Keep room clear of clutter, extra blankets, oxygen tubing extended along floor, etc., all of which are items that increase falls in res. room. Keep room neat, tidy, and as organized as res. will allow. (Initiated 12/28/11) * Resident not to be in W/C (wheelchair) while alone in room (Initiated: 1/30/12) * Hourly checks (Initiated: 2/8/12) * Fall risk (Initiated: 12/28/11) * Have commonly used items within easy reach (Initiated: 10/24/11) * Reinforce need to call for assistance (Initiated: 10/24/11) * Resident to wear non skid shoes/slippers with all transfers (Initiated: 10/24/11) * Do not leave unsupervised in room when up in wheelchair (Initiated: 2/8/12) * See mobility Plan of Care. (Initiated: 2/8/12)." The resident had multiple Progress Notes starting 11/1/11 related to "burning," "fire" and "pain" in the "lower abdomen," "rectum," "back," "mouth," "throat" and "vaginal" areas. The facility was treating these complaints with Benadryl every 4 hours and Norco one tablet every 6 hours. The resident could receive Valium 5 milligrams every 12 hours for anxiety. The resident received these medications multiple times a day because the resident was concerned about the "burning" and "fire." On 11/21/11 at 5:10 p.m. a Social Service Note documented: "Resident has become increasingly agitated and frustrated with her pain management. Talked extensively with resident that I would like her to be on board with medication adjustments to help alleviate some of this pain. Resident fearful of change at this time...." On 11/24/11 at 7:25 p.m. an LPN documented a Behavior Note: "Pt. (patient) awake and wondering (sic) hall way yelling out "(Name)" pt. with increased anxiety and agitation. Pt. follows this nurse around up and down hall way yelling out 'You need to help me im (sic) sick, You need to come to my room and help me.' When asked what she needs help with pt. states 'you know im (sic) sick and you need to help me. why dont (sic) you care? You need to give me something for the burning in my vagina and my rectum.' When this writer reminds pt. that she just medicated with Norco and Benadryl and that this writer would bring her her morning medications Valium and celexa pt. became more anxious and agitated....Pt cont.(inued) to threaten to leave and go to hospital...." On 12/4/11 at 2:50 a.m. an LPN documented a Behavior Note: "This LN received in report from eve(ning) shift that resident had been wandering the hallway with no pants on. At beginning of this shift I was alerted by CNA to come to residents room. Resident had accidentally dragged some trash out into the hall with her foot. Upon entering room found resident with no pants or brief on coming out of bathroom....Resident was confused....Cleaned up resident and helped her back in bed. She was moaning lightly but denied pain. Lethargic. Checked O2 sats (oxygen saturation), they were 78%. Applied O2 at 3LPM (oxygen at three liters per minute) via nasal cannula....Temp 95.7, feet and hands cold, put heat pack on feet....Called Dr (name)r/t (related to) change in condition, 02 sats and low temp..." On 12/5/11 the resident had a chest X-Ray and had a Right lower lobe infiltrate that the physician treated with an antibiotic. On 12/10/11 at 10:45 p.m. an IDT Progress note documented: "Resident with no newly noted ASEs (adverse side effects) of past admin(istration) of Doxycycline. Nystatin given vaginally for yeast infection thought to have been caused by ABX (antibiotic) therapy...." On 12/21/11 at 5:50 a.m. the resident reported a fall to staff. The Fall Assessment description of the event was: "Immediately after fall, resident stated that she had tangled her feet in the covers and tried to get out of bed and 'slipped and fell in the corner.' She pointed, the corner she was referring to was on the window side of the bed near the bed stand..." A computer generated Fall Report indicated that the facility's plan to prevent recurrence was to update the care plan. NOTE: The care planned intervention to "Keep room clear of clutter..." was initiated on 12/28/11. She had another fall on 12/27/11. On 12/22/11 at 12:30 a.m. an LPN documented an IDT progress note: "Resident awake at start of this shift asking for pain meds for her arms...Gave pain med with schd (scheduled) med in chocolate pudding and asked resident to use call light if she was getting up, so that we could make sure she was safe. Resident agreed. 30 minutes later LN found her in the bathroom. Resident states she forgot...." On 12/24/11 at 2:15 a.m. an LPN documented an IDT note: "....Resident did c/o (complain of) pain in the back of her head and stated that her legs hurt....Resident also stated that she felt light headed the last few mornings. Educated to sit on side of bed for a few minutes before getting up. Encouraged to use call light but resident has been noncompliant with call light in the past...." On 12/25/11 at 8:49 p.m. an LPN documented an IDT note: "....Resident was observed by this nurse ambulating in room and hallway x3 with unsteady gait. Resident redirected x5 to use call light for assistance when needing to transfer or ambulate to prevent falls. Resident remains non-compliant with call light. Non-skid mat in place....resident checked q 15 min (every 15 minutes), as this nurse keeps med cart parked near room...." On 12/27/11 at 6:34 a.m. an LPN documented a Fall note: "CNA notified LN that resident was found on the floor crawling to her bathroom, When asked why she was on the floor resident stated she fell . Resident blankets were twisted and hanging on the floor next to the bed. Residents (sic) floor was free of debris, room was well lite (sic), call light was attached to the bed and in reach. Resident had non skid socks on. This LN had made rounds 10 min. before and resident was sleeping with a slight snore....Resident needed a lot of support while doing orthostatic BPs...." A computer generated Fall Report indicated that the facility's plan to prevent recurrence was to update the care plan. See NOTE above related to the 12/21/12 fall. On 1/4/12 at 2:20 p.m. an RN documented a behavior note: "Resident came out of her room, as this writer was exiting room across the hall, with pants and pull-ups down around her knees. When asked what she was doing she responded 'I don't know.' Resident was redirected back to her room, assisted to pull her pants up, then she sat down on her bed and O2 cannula was re-applied. A few minutes later resident again came out of her room with pants and pull-ups down around her knees. She again stated 'I don't know,' when asked what she was doing. When asked if she needed something she stated 'I don't know." Resident was assisted back to room as before. A few minutes later resident once again came out into hallway with pants and pull-ups around knees. Only this time was attempting to get into another residents room. As this writer assisted resident back to her room again, I asked if she would like to use the restroom. Resident very pleasantly replied 'why yes, I think so.' resident was assisted to bathroom...." On 1/5/12 at 2:35 a.m. an LPN documented a behavior note: "During first rounds this shift, resident was found in another residents room...Directed to her room and offered assistance. Resident stated she didn't know what she needed, as she read the name on this LN uniform. She than stated 'I don't know what this Marquis is about....This LN then left room to get pulse ox(imeter) and upon my return resident was in her room without her pants on. Assisted to bathroom...." On 1/5/12 at 11:30 a.m. an RN documented a behavior note: "Resident noted wandering in the hallway, approaching several different staff members and demanding to know 'what's going on here?' Resident approached this nurse, appearing somewhat confused....resident's complexion appeared slightly dusky....upon checking O2 saturation , it was noted that saturation was 85% on room air....O2 initiated via nasal ..." On 1/6/12 at 5:27 a.m. an LPN documented a behavior note: "Resident was just found down banging and attempting to open storage room door across from the maint.(enance) room door....While assisting resident to her room became agitated and attempted to stop in another residents room....The LN asked her if she would hold this LN arm d/t (due to) I was worried because she was so wobbly..." On 1/9/12 at 1:20 a.m. an LPN documented a Behavior Note: "Resident found wandering into another residents room. When asked what she needed she stated she wanted to take care of herself. Explained that the room across the hall was somebody else residence and her belonging were in her room. O2 sats checked again and 82% on RA(room air) ...." On 1/10/12 at 4:15 a.m. an LPN documented an IDT progress note: "Resident exited out wrong door into another residents room....As this LN was attempting to escort (Resident #9) from other residents room she was not easily directed. This LN asked if I may hold her arm as she looked very unsteady and I would not want her to fall..." On 1/17/12 at 9:42 p.m. an LPN documented: "Resident noted to be more lethargic this evening....When examined res has very wheezy lung sounds...Resident O2 sats were 75% on ra. encourages(sic) res to wear O2...." On 1/19/12 at 2:27 a.m. an LPN documented an IDT Progress note: "O2 sats at the start of shift were in normal range. After walking halls for awhile and having increased confusion this LN re-checked sats and they were 83% on RA... On 1/19/12 at 4:42 a.m. an LPN documented a Fall note: "CNA notified this LN that resident has reported she had fallen in her room. CNA stated resident came into another residents room to tell her this and show her her arm. When this LN entered room her O2 tubing was strung across the floor along her bedside. Her blankets were all pulled to the RT(right) side (side near door) of her bed. She had trash she had tossed on the floor in front of her bed. She was wearing regular socks on her feet and no shoes...Her O2 was re-applied as her O2 sats was 83%...." A computer generated Fall Report indicated that the facility's plan to prevent recurrance was to update the care plan. NOTE: It could not be determined that the care plan had been updated. On 1/19/12 Fall Assessment summary documented: "Residents confusion has seemed to increase with her stay here at (Facility), this is unrelated to infection, rather this writers thought that dementia may be progressing. Lately resident has been found in other res. rooms because she was unable to find the bathroom in her own room she is often found roaming the hall in search of a nurse because she is 'so sick' but does not know with what. Res chooses to not wear non-skid socks. Res care-plan reads 'Keep room clear of clutter, extra blankets, oxygen tubing extended along floor, etc., all of which are items which increase falls in res. room. Keep room neat, tidy, and as organized as res will allow.' However res clutters room herself, and staff cannot clean behind her fast enough. Res has had two previous falls in facility, as above..." On 1/23/12 at 9:04 a.m. an LPN documented an IDT progress note: "Pt up in room, entered pt room to find her sitting on floor with her back against the drawers by the sink. Pt states 'I was coming to get a hot cup of tea' 'I dont (sic) know what happened' ROM (range of motion) done pt. complains of pain 'All over', Neuro checks wnl (within normal limits). Pt complains of left hip pain, pt. not able to bare (sic) wt. on this leg. able to bend knee and rotate foot, but unable to bare wt. will contact MD and get an order for [REDACTED]. On 1/23/12 at 9:43 p.m. an LPN documented an IDT Progress note: "Examined resident post fall at change of shift. Res had co (complained of) R(ight) leg/hip pain. Res had difficulty describing pain but showed extreme tenders when palpated or when res attempted to move. Also noted res Rt leg 7-9 cm shorter that left 70% outward rotation to l leg. Top of rt (right) leg 4 inches below hip had a extremely tender mass of very hard tissue. approximately 2/12 in by 4 in. no bruising noted but site extremely tender....Resident transported by non-emergent transport to (local hospital) at 1730 (5:30 p.m.)." A computer generated Fall Report for the fall on 1/23/12 indicated that the facility's plan to prevent recurrence was to update the care plan. NOTE: The care planned intervention to, "Encourage Resident to not ambulate without assistance" was initiated 1/27/12. The resident had surgical repair of a fractured right hip and returned to the facility on [DATE] at 4:00 p.m. Resident #9's admission orders [REDACTED]. The physician's orders [REDACTED]. On 1/27/12 at 9:35 p.m. an LPN documented a behavior note: "Resident refused dinner in Assisted stating 'it is too much!' meaning all the people in the dinning room. when the aid (sic) brought the resident back to her room the resident immediately started to attempt to self transfer. Despite aid (sic) telling the res to not wt (weight) bare on rt (right) leg....unit manager advised to start pressure alarm in bed and tag alarm while in W/C.(wheelchair)" On 1/30/12 at 6:45 p.m. the resident had a fall. The IDT progress note documented: "Resident slid out of her wheelchair on to her foot peddles when she was in her room. Staff noted resident sitting on her foot peddles (sic) of her wheel chair and assisted resident back into her chair before resident went completely to the floor...." A computer generated Fall Report for the fall on 1/30/12 indicated that the facility's plan to prevent recurrence was to update the care plan. NOTE: The care planned interventions for "Hourly checks" and " Do not leave unsupervised in room when up in wheelchair were initiated on 2/8/12. On 2/1/12 at 1:27 a.m. an LPN documented a SNF Progress note: "Resident found with left leg hanging off bed at beginning of shift. Resident repositioned in bed Moaning of pain to right hip and leg...." On 2/1/12 at 9:42 p.m. an LPN documented a IDT Progress Note: "Resident cont(inues) to be very confused at times....resident cont(inues) to be very anxious attempting to stand an (sic) bear (sic) wt on Rt leg...." NOTE: The resident's "Progress Notes" document the resident continued to attempt to stand and bear weight on the right leg until the next fall. On 2/10/12 at 10:59 p.m. an LPN documented in an IDT progress note: "Fall: Resident found on floor in her room during Q 15 min (every 15 minute) checks by CNA. Resident was lying face down an her knees (sic) with her right arm outstretched by the foot of the bed facing toward window side of the room....when asked why and where resident ws (sic) up she stated that she was trying to walk to the bathroom despite non wt (weight) bearing status..." NOTE: According to the Fall Assessment, the fall occurred at 9:00 p.m. On 2/11/12 at 6:42 a.m. an LPN documented in an IDT Progress Note: "Resident had a unwitnessed non injury fall. CNA just checked on resident 5 minutes prior to fall. See fall assessment for more information...." NOTE: According to the Fall Assessment, the fall occurred at 1:35 a.m. During the survey the resident was observed in bed, except for a short time around 11:00 a.m. on 2/28/12. At that time, the resident was up in a Broda chair and went outside for fresh air. Subsequent observations during the survey until 3/1/12 the resident was observed in bed with her eyes closed. On 3/1/12 at 11:00 a.m. the DON and Unit Manager were interviewed about the resident's fall with fracture and subsequent falls. Information was requested for documentation regarding the supervision and/or assistive devices that was in place prior to and after the injury to prevent the resident from repeated falls. The DON stated that prior to the fall with fracture, the resident was educated to use the call light. The resident was constantly reminded to use the oxygen. The "oxygen was a new thing and she did not use it consistently." The resident was "independent in her own mind for day to day activities." The DON and Unit manager when asked about behavior planning due the resident's disregard for her safety. It was stated that Social Services had not developed a plan for Resident #9 for the behaviors exhibited. The documentation provided indicated the resident was started on 15 minute checks on 2/10/12 at 3:43 p.m. (after the injury of 1/23/12 and re-admission on 1/27/12). The 15 minute checks continued until 2/23/12, when it was changed to hourly checks. Resident #9 was harmed when she fell on [DATE] and sustained a fracture of the right hip. The facility failed to: - Develop a plan for dealing with her non compliance for using her oxygen. - Develop a plan for monitoring the resident's safety when up and about when her gait became unsteady. - Develop a plan for assisting the resident to cope with the multiple somatic illnesses that stressed the resident into searching for help. - Implement an effective supervision plan to prevent multiple falls prior to, after and including the fall with fracture. The Administrator, DON, Activity supervisor, Social Service supervisor and Unit manager met with surveyors on 3/2/12 at 7:30 a.m. Further information was provided and was incorporated in the citation.