Every finding on record at St Luke's Elmore Long Term Care

Based on observation, staff interview, and the FDA Food Code, the facility failed to ensure food was stored, prepared, and served under sanitary conditions to prevent contamination and ensure food was safe and unadulterated. These failures had the potential to expose residents to foodborne illness. Findings include:Food Code 3-101.11 stated food should be safe, unadulterated, and honestly presented.1.On 1/20/26 at 9:19 AM, during a brief kitchen tour a container of soft strawberries with fuzzy white substances was observed in the front kitchen fridge where fresh produce and snacks were stored.On 1/20/26 at 9:20 AM, the Food Service Manager stated the facility goes by visibility and if the produce appears spoiled, they will dispose of it. She confirmed the dietary staff should have disposed of the strawberry container.2. Food Code 3 302.11 - Separation and Protection documents ready to eat foods must be protected from cross contamination during preparation and service.Food Code 4 501.112 / 4 601.11 - Clean and Sanitized Food Contact Surfaces documented food contact surfaces (including gloves) must be clean and sanitary before contacting ready to eat food.On 11/23/26 at 11:40 AM, during a tray line observation, [NAME] #1 was observed preparing resident meal trays and reviewing dietary requests according to resident preferences. During preparation of one tray, [NAME] #1 left his workstation to obtain a serving of sorbet. He returned to the tray line without performing hand hygiene or changing gloves. Upon returning, [NAME] #1 immediately turned toward a plate, picked up a dinner roll with the same gloved hand, and placed it onto a resident's tray. He then placed the heat cover on the plate and proceeded to the next tray.As the tray line observation continued [NAME] #1 was later observed turning around and opening the refrigerator door to obtain a bowl of fresh fruit with his gloved hand. After placing the fruit bowl on the tray, he again turned around and retrieved a dinner roll with the same gloved hand that had contacted the refrigerator handle and other surfaces.On 11/23/26 at 11:57 AM, the Food Service Manager stated she was not concerned about [NAME] #1 touching other surfaces while handling ready to eat food. She also acknowledged that touching additional surface areas does increase the risk for cross contamination.

Based on observation and staff interview, the facility failed to ensure resident records were safeguarded to prevent unauthorized access. This failure had the potential to allow misuse or disclosure of resident information. Findings include:On 01/20/26 at 9:40 AM, a medication cart was observed in the hallway in front of room [ROOM NUMBER]. The medication cart contained a laptop that was logged into the electronic medical record system, displaying access to multiple resident records. No staff member was present at the cart at the time of the observation.On 01/20/26 at 9:45 AM, the Interim Director of Nursing stated the expectation is that resident records are to remain secured to prevent unauthorized access.

Based on record review and staff interview, it was determined the facility failed to ensure resident assessments accurately reflected their diagnoses and specialized services. This was true for 2 of 8 residents (#1 and #5) whose Minimum Data Set (MDS) Assessments were reviewed. This failure placed Resident #1 and #5 at risk for adverse outcomes if their needs were to go unmet. Findings include:The MDS Assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including dementia, Parkinson's disease, kidney failure, and obstructive sleep apnea. On 1/20/26 at 2:25 PM the Interim DNS stated Resident #1 had never needed an invasive mechanical ventilator (a tube inserted into your airway through intubation or a surgical opening called a tracheostomy so a machine can breathe for you) for his respiratory care and stated he currently used a CPAP machine (a continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open while you sleep).Resident #1's Quarterly MDS Assessment, dated 11/1/25, at item F1 in Section O, documented yes, documenting that Resident #1 used an invasive mechanical ventilator.On 1/22/26 at 3:54 PM the MDS Coordinator/ Patient Assessment Coordinator, stated Resident #1 used CPAP and did not have an invasive mechanical ventilator. She stated she marked item F1 in Section O of Resident #1's MDS as yes in error. 2. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. Resident #5's record included an Abbreviated Level 2 PASRR (a Pre-admission Screening and Resident Review is a federal required process that is designed to, among other things, identify evidence of serious mental illness and/or intellectual or developmental disabilities (ID/DD) in all individuals seeking admission to a skilled-nursing facility), dated 12/10/25. The Abbreviate PASRR Level 2 documented at item 33 Individual has a current diagnosis of severe mental illness per PASRR criteria and documented her diagnoses of bipolar disorder, depression, and anxiety. Resident #5's Admissions MDS Assessment, dated 12/17/25 documented no at item A1500, Is the resident currently considered by the state Level 2 PASRR process to have a serious mental illness and/or intellectual disability or a related condition? On 1/22/26 at 4:03 PM, the MDS Coordinator stated she was not aware about #33 on the PASRR Level 2 form needing to be reflected on the MDS and Resident #5's Admissions MDS was not accurate because of this.

Based on observations, record review, and staff interview, it was determined the facility failed to ensure a resident who was self-administering a medication was assessed to effectively do so. This was true for 1 of 1 resident (Resident #4), whose record was reviewed for self-administration of medications assessment. This failure placed Resident #4 at risk for adverse outcomes if she were to use the medication inappropriately. Findings include: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including leukemia and rheumatoid arthritis. On 1/22/26 at 8:34 AM, RN #1 was observed setting the single use vial of cyclosporine eye drops on Resident #4's bedside table and let her know she could use them whenever she wanted and to let him know later. On 1/22/26 at 9:44 AM, The Interim DNS stated Resident #4 had been observed by staff to appropriately self-administer her eye drops, but the facility did not perform or document a self-administration of medication assessment.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's care plan was comprehensive. This was true for 1 of 8 residents (Resident #5) whose care plans were reviewed. This failure placed Resident #5 at risk for her mental health needs to go unmet because her mental health diagnoses were not included in her care plan. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. Review of Resident #5's comprehensive care plan did not document her bipolar disorder, anxiety, and/or depression diagnoses or interventions for how staff were to care for her mental health needs. On 1/22/26 at 4:28 PM, the Resident Service Advocate, stated Resident #5's care plan did not have her bipolar disorder, depression, and anxiety disorders in her comprehensive care plan, and they were excluded in error.

Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 10 residents (Resident #4) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/24, documented if a PASARR (Preadmission Screening and Resident Review) level II determined a resident has a serious mental illness then section A1500 of the MDS should be marked yes. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (a mental health condition characterized by significant mood swings) and anxiety disorder. Resident #4's medical record documented a PASARR level II, dated 7/11/22, was completed. Resident #4's admission MDS assessment, section A1500, dated 7/20/22, documented, no, indicating Resident #4 did not have a PASARR level II. Resident #4's annual MDS, section A1500, dated 7/11/23, and 7/11/24 documented no, indicating Resident #4 did not have a completed PASARR level II. On 1/23/25 at 2:06 PM, the MDS Coordinator stated it appears EPIC (the facility's electronic health record) and the MDS are worded differently for section A1500. The MDS Coordinator stated, I should have marked, yes, based on the MDS wording, as Resident #4 did have a PASSAR level II.

Based on record review, review of facility policies and procedure, review of Incidents and Accidents (I&As) reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 3 residents (#14 and 170) reviewed for medication errors. This deficient practice created the potential for Resident #170 to experience harm when he was administered another resident's medications, and for Resident #14 when he received the wrong dose of insulin. Findings include: The facility's policy, Medications - Ordering, Dispensing, Administration, Monitoring and Storage, documented, medications will be administered according to the following rights of medication: The right patient, right medication, right dose, right time, right route, and right documentation. 1. A facility I&A report, dated 5/1/24, documented, during the morning medication rounds, Resident #170 received 8 medications meant for another resident. The medications included: Three medications Resident #170 was not prescribed: Vitamin C 500 mg, Vitamin B-12 100 mcg, and Ferrous sulfate 325 mg. Three medications at different doses than the ones he took: Vitamin D-3 1000 units (5000 units intended), Cymbalta (an anti-depressant) 20 mg (60 mg intended), and Metformin (an anti-diabetic) 1000 mg (500 mg intended). Two medications at different times than the ones Resident #170 took: Tamsulosin (a treatment for an enlarged prostate) 0.4 mg, and Finasteride (a treatment for an enlarged prostate). Immediately after discovering the error, the nurse notified Resident #170's physician and began monitoring for him for adverse effects. Resident #170's record documented no adverse effects manifested. Resident #170's family was notified, and nursing staff were re-educated on the 6 rights of medication and the procedure for scanning medications at the bedside. 2. A facility I&A report, dated 7/13/24, documented Resident #14 was administered 10 units of Semglee (a long-acting insulin) instead of his ordered dose of 14 units. Immediately upon discovering the error, the nurse notified Resident #14's physician, who recommended monitoring Resident #14 and no additional dosing to be given. Residents #14's record documented no adverse effects were noted during the monitoring. The report documented the facility's DON, Administrator, and Resident #14's family were notified of the error. The nurse was reeducated on the importance of following the 6 rights of medication administration. On 1/23/25 at 3:05 PM, the DON was interviewed. She confirmed Resident #14 and Resident #170 experienced medication administration errors. The DON stated the facility has an ongoing Quality Improvement project to address medication errors. She confirmed the project includes Resident #14's and Resident #170's error events.

Based on observation, staff interview, policy review and record review, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 1 resident (Resident #7) whose medications were observed in the medication cup inside the medication cart. This failed practice created the potential for residents to experience adverse effects when their medications were not administered according to the physician's order. Findings include: The facility's Medications - Ordering, Dispensing, Administration, Monitoring and Storage policy, revised 11/12/24 documented medications prescribed frequently than daily, but no more frequently than every 4 hours (ex: QID, TID, BID) may be administered within a window of 2 hours before or after the standardized scheduled time. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including stroke and dementia. A physician's order, documented Resident #7 was to receive the following medications: - Allegra (antihistamine) tablet 180 milligrams once a day, - Metformin tablet 1,000 two times a day with meals, dated 7/26/24, - acetaminophen 650 mg two times daily, dated 6/27/24, and - lactulose (laxative) 20 gram/30 ml (milliliter) three times a day, dated 3/6/24. -Vitamin D3 1,000 units daily. On 1/22/25 at 1:13 PM, during the inspection of the Long Hall Medication cart with ADON present, a medication cup containing two round white tablets, one oval pink tablet, one white oval tablet, one small tablet, and next to the medication cup was an unopened cup of lactulose 20 grams/30 milliliter was observed inside the medication cart. The medication cup was inside another container with Resident #7's name. When asked about the medications, ADON looked at the medications and paused before responding. ADON then stated she prepared Resident #7's medications and when she was about to administer them, Resident #7 stated he needed to go to the restroom. ADON stated when she went back to Resident #7's room, he was not in his room. ADON stated she put the medication cup back inside the medication cart with Resident #7's name. When asked what time the medications should have been given to Resident #7, the ADON stated it was due at 8:00 am. ADON stated she got distracted and was not able to give them to Resident #7.

Based on record review and staff interview, it was determined the facility failed to ensure there was documented evidence COVID-19 vaccines were offered to the staff, or documentation of staff decisions to accept or decline the vaccine and if declined, the reason they declined. This was true for 9 of 26 staff (RN #1, RN #4, CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, the Health Unit Coordinator, and the Activity Coordinator) reviewed for COVID-19 vaccinations. This failure created the potential for staff to have increased risk of exposing undetected COVID-19 to residents, visitors, and other employees. Findings include: The CDC website, accessed on 7/27/21, titled Frequently Asked Questions about COVID-19 Vaccination in Long-Term Care, stated employers offering vaccinations to workers should keep a record of the offer to vaccinate, the employee's decision to accept or decline the vaccination, and if declined, the reason they declined. This guideline was not followed. On 7/22/21 at 10:30 AM, the IP said she provided education to the staff regarding COVID-19 vaccination and provided them a copy of the COVID-19 vaccine information sheet which included the risks and benefits of receiving the COVID-19 vaccine. The IP said she offered the COVID-19 vaccine to the staff multiple times and 9 of the 26 facility staff did not receive the COVID-19 vaccine for various reasons. Some of the reasons given by the staff were due to religious reasons, some were concerned about the possible side effects of receiving the COVID-19 vaccine, and others declined due to medical reasons. The IP said she did not ask for more information if the staff declined due to medical reasons. The IP said she did not have documentation COVID-19 was offered to the staff. The IP said she verbally informed the staff they could get the vaccine any time. When asked if she had documentation of staff declination to receive the COVID-19 vaccine, the IP said she did not have documentation of staff declination to receive the COVID-19 vaccine.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans included individualized, resident-centered interventions and goals related to oxygen therapy. This was true for 5 of 11 residents (#2, #4, #7, #9 and #12) whose care plans were reviewed. This failure placed residents at risk for negative outcomes if services were not provided, or provided incorrectly, due to lack of information on their care plans. Findings include: A facility policy, Care Plan Policy, revised 6/21/21, stated, The care plan, in conjunction with care guidelines, addresses the patient/resident's care needs identified from assessments, including those not solely related to the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, it stated, The plan will contain individual goals and preferences which are reasonable, objective, measurable and achievable with time frames to meet the patient/resident's medical, mental and psychological needs. This policy was not followed. 1. Resident #7 was admitted to the facility on [DATE], with a history of hypertension, DM, and [CONDITION(S)] (progressive lung disease characterized by increasing breathlessness). Resident #7's record included an order, signed by her physician, which stated, PRN [as needed] .discontinue oxygen if SpO2 [measure of the percent of oxygen in the blood], remains above criteria and vital signs remain stable on room air for greater than 15 minutes .Notify Provider: If patient continues to need oxygen beyond 24 hrs from procedure or surgery .If oxygen is re-initiated after being on room air for more than 4 hours .Keep O2 Sat[uration] equal to or greater than: 90%. RN #2 was interviewed on 7/22/21, beginning at 1:31 PM. When asked if Resident #7 was on PRN or continuous oxygen, RN #2 stated, continuous. When asked how much oxygen Resident #7 was ordered, she stated, 3 liters per minute. Resident #7 was interviewed in her room on 7/22/21, beginning at 1:33 PM. When asked if she was on PRN or continuous oxygen therapy, Resident #7 stated, continuous. When asked how much oxygen she was to be on, she stated, 2 liters per minute. When asked what would happen if she stopped wearing her oxygen, Resident #7 stated, my oxygen drops to 68% and I can't breathe; sometimes it comes off at night and I've had to yell for help. Resident #7's room was observed during interview. Her supplemental oxygen was provided via a nasal cannula which was attached to a wall-mounted oxygen regulator. The nasal cannula tubing was attached to a humidifier and the wall-mounted oxygen regulator was set at 2 liters per minute flow. Additionally, Resident #7's wheelchair had an attached oxygen concentrator which she used when outside of her room. Resident #7's care plan did not include individualized, resident-centered interventions and goals related to her oxygen therapy. The CNO, DON, and MDS nurse were interviewed together on 7/22/21, beginning at 2:55 PM, and Resident #7's medical record was reviewed in their presence. They acknowledged Resident #7's oxygen order was not updated from PRN to continuous and her care plan did not include individualized, resident-centered interventions and goals related to her oxygen therapy. 2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 2/1/21 at 1:37 PM, documented Resident #4 was to receive oxygen at 2 LPM (liters per minute) or greater as her clinical status dictated. Resident #2's care plan did not include her use of oxygen. On 7/19/21 at 10:07 AM, Resident #2 was observed in bed receiving oxygen therapy via a nasal cannula at 2.5 LPM. On 7/20/21 at 2:14 PM, the MDS nurse said Resident #2's oxygen was not addressed in her care plan because it was in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's care plan did not have oxygen listed as part of his care regimen. On 7/22/21 at 11:35 AM, the Quality Specialist stated the facility philosophy was the entire chart was part of a resident's care plan. 4. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 was observed using oxygen at times, and other times she was not. On 7/20/21 at 12:45 PM, during an interview with Resident #12 and her husband, Resident #12 stated she was to use oxygen, but she did not always do so. Resident #12 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's care plan did not include her use of oxygen. On 7/20/21 at 2:30 PM, the MDS nurse stated Resident #12's entire chart was considered part of the care plan and thus the oxygen order should be considered part of the care plan.

Based on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure beds and bed rails were inspected and maintained as part of an ongoing program. This was true for 1 of 6 residents (Resident #2) reviewed for bed rails and created the potential for harm if residents relied on loose mobility bars to prevent a fall from bed. Findings include: Resident #2 was admitted to facility on 10/8/18 with multiple diagnoses including CHF and DM. Documentation provided by the facility included the side rail policy and the user manual for the Invacare® hospital bed. The documentation provided made no recommendation for periodic safety checks of side rails installed on residents' beds. On 7/19/21 at 9:27 AM and 7/20/21 at 12:48 PM, Resident #2 was observed resting in bed. Resident #2 had both upper side rails in the raised position. On 7/21/21 at 8:50 AM. with the MDS Nurse present, Resident #2 was asked if she was using her bed rails. Resident #2 said Yes but it was broken and started to wiggle the right upper bed rail. The MDS Nurse said it was too loose and needed to be tightened. The MDS Nurse then checked Resident #2's upper left bed rail and said it was also loose. On 7/21/21 at 9:10 AM, the Facility Maintenance Mechanic checked both upper bed rails and said they were super loose. On 7/21/21 at 2:10 PM, the Facility Maintenance Mechanic stated he completed the initial bed rail evaluation. He said bed rail evaluations were completed when the beds were installed (8 months prior) and with new resident admissions. The Facility Maintenance Mechanic also said everything in the resident's room was checked annually to ensure safety and proper functioning as part of the facility's life safety requirements. On 7/21/21 at 2:10 PM, the Building Services Manager stated repair requests came from the MDS nurse or the RSA. She stated all equipment in resident rooms was checked annually to ensure safety and proper functioning as part of the facility's life safety requirements. On 7/21/21 at 9:53 AM, the MDS Nurse stated there should be an assessment for bed rails documented. She stated the nurse checked the bed rails for safety daily, but could not state what was being checked. The facility did not ensure bed rails were repaired as needed and functioning properly on an ongoing basis.

Based on observation, staff interview and policy review, it was determined the facility failed to ensure the antibiotic stewardship program was implemented. This was true for 1 of 8 residents (Resident #2) whose records were reviewed for antibiotic use. This deficient practice created the risk for Resident #2 to develop resistance to antibiotics resulting in ineffective or difficult treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Antimicrobial Stewardship Program (a coordinated program that promotes the appropriate use of antibiotics and antifungals to improve clinical outcomes in patients), effective date 1/28/21, stated a rationale should be provided for use of formulary restricted antimicrobials (certain restricted antimicrobials which pharmacists are required to confirm Microbiology approval or formulary indication before dispensing). Resident #2 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's care plan, documented she was taking prophylactic antibiotics to help reduce the frequency of her urinary tract infections (UTIs). A nurse's note, dated 7/6/21 at 8:41 PM, documented Resident #2 stated she had a burning sensation a few times that day when she urinated. The note stated Resident #2 was encouraged to increase her oral hydration and to drink some cranberry juice. A nurse's note, dated 7/7/21 at 5:45 AM, documented Resident #2 stated she really thought she had another bladder (urinary tract) infection. The note stated Resident #2 denied she needed to urinate at that time. The note stated fluids were encouraged and Resident #2 drank 120 cc (cubic centimeters) of apple juice with her medications and another 60 cc of water. A nurse's note, dated 7/8/21 at 1:57 PM, documented Resident #2 had no complaints of burning with urination. A physician order, dated 7/8/21 at 3:10 PM, directed staff to obtain a urinalysis (UA) with a culture and sensitivity (C&S - a test used to determine bacterial or fungal presence and identifies what antibiotic will inhibit the growth of the bacteria or fungi causing a specific infection) for Resident #2. A nurse's note, dated 7/8/21 at 9:54 PM, documented staff were unable to collect a clean catch urine (method of collecting a urine sample without germs) to be tested for a UA due to Resident #2 having a bowel movement each time she was on the bedpan. A UA report, dated 7/9/21 at 8:13 AM, documented the following were present in Resident #2's urine: nitrites (its presence in the urine commonly means there is a bacterial infection in the urinary tract) and leukocytes (white blood cells that are typically present when there is an infection). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 7/9/21 at 3:02 PM, documented Resident #2's urine sample was sent to the laboratory for a UA. The note stated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2. The nurse's note documented Resident #2 tolerated the new medication well. A nurse's note, dated 7/9/21 at 8:59 PM, documented Resident #2 was started on an antibiotic for a UTI and no adverse effects were noted. Resident #2 reported bladder spasms and was administered [MEDICATION(S)] (a bladder relaxant). A urine culture report, dated 7/10/21 at 9:34 AM, documented presence of mixed peri-urethral flora (bacteria in and around the opening outside the body where urine is eliminated) in Resident #2's urine, probably due to contamination during the collection process and susceptibilities (a test used to determine which antibiotic will inhibit the growth of the bacteria or fungi causing a specific infection) were not indicated. The report suggested a repeat specimen if Resident #2 had symptoms suggesting a UTI. A nurse's note, dated 7/10/21 at 2:37 PM, documented an antibiotic was administered to Resident #2 and she stated the antibiotic made her slightly nauseous. The note stated Resident #2 was educated [MEDICATION(S)] (an anti-nausea medication) was available if she needed it. A nurse's note, dated 7/11/21 at 2:30 PM, documented Resident #2 was receiving [MEDICATION(S)] for a UTI and there were no adverse effects noted. Resident #2 denied nausea and diarrhea. A nurse's note, dated 7/12/21 at 1:43 PM, documented [MEDICATION(S)] was discontinued, and a new order was received to administer [MEDICATION(S)] (an antibiotic) to Resident #2. Resident #2's record documented she received seven doses of [MEDICATION(S)] and it was discontinued on 7/12/21 at 10:45 AM, and a new order for [MEDICATION(S)] 875-125 mg was to be administered to Resident #2 two times a day. Resident #2's record did not include documentation why the [MEDICATION(S)] was discontinued and changed to [MEDICATION(S)]. A nurse's note, dated 7/14/21 at 4:33 PM, documented Resident #2 refused to take the [MEDICATION(S)] due to nausea. The note documented the physician was notified and a new order for [MEDICATION(S)] (an antibiotic), for Resident #2 was received and the first dose was administered at 12:00 PM. The note stated Resident #2 did not complain of nausea. Resident #2's representative was notified of her new ordered medication. Resident #2's record documented she received five doses of [MEDICATION(S)] and it was discontinued on 7/14/21 at 11:31 AM. A new order for [MEDICATION(S)] two times a day was received for Resident #2 for 14 doses which she completed on 7/20/21. On 7/9/21 at 9:17 AM, the MDS nurse said Resident #2's urine culture result had mixed peri-urethral flora and the laboratory suggested a repeat specimen if Resident #2 had symptoms of a UTI. The MDS nurse said Resident #2 did not have a repeat urinalysis. The MDS nurse said Resident #2 was started on [MEDICATION(S)], was changed to [MEDICATION(S)], and later changed to [MEDICATION(S)] due to Resident #2's complaints of nausea. When asked why Resident #2's [MEDICATION(S)] was changed to [MEDICATION(S)], the MDS nurse reviewed Resident #2's record and said she could not find documentation on why her [MEDICATION(S)] was discontinued by the physician. When asked what other signs and symptoms of a UTI Resident #2 had, the MDS nurse reviewed Resident #2's record again and said she did not find documentation Resident #2 reported any signs or symptoms of a UTI after 7/9/21. On 7/21/21 at 11:53 AM, the IP said the facility used the National Healthcare Safety Network (NHSN) surveillance protocol for UTIs. The IP said when she reviewed her record, Resident #2 started on [MEDICATION(S)]. The IP said Resident #2 did not meet the NHSN criteria for a UTI and she should have a repeat urinalysis. The IP said the physician may have started Resident #2 on antibiotics due to her clinical signs and symptoms of a UTI and it would take about two days for the urine culture results to come back. The IP also stated the physician should have written the reason for the antibiotic use according to their policy. On 7/21/21 at 1:21 PM, the Pharmacist said she reviewed the residents' antibiotic use for correct dosage, whether residents had history of an allergy to the antibiotic, and made sure the antibiotic was appropriate for the bacteria causing the infection. The Pharmacist said she was unable to find documentation why Resident #2's [MEDICATION(S)] was changed to [MEDICATION(S)]. The Pharmacist said Resident #2 had history of prior UTIs due to enterococcus (bacteria) which was sensitive to [MEDICATION(S)] and that could be the physician's reason for changing her antibiotic to [MEDICATION(S)]. The facility did not implement their Antibiotic Stewardship Program for Resident #2.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure drugs were appropriately labeled and stored for 1 of 1 medication cart observed. This deficient practice placed residents at risk for receiving ineffective medication or the wrong medication with the potential for adverse effects. Findings include: The facility's policy, Medications - Ordering, Dispensing, Administration, Monitoring and Storage, revised 6/23/21, stated, Medication storage areas will be routinely inspected (quarterly) by pharmacy or designee to assess for cleanliness, outdated medications and appropriate storage conditions. This policy was not followed. On 7/21/21 at 1:18 PM the facility's medication cart was observed in the presence of RN #1, the DON, and the Administrator, The following was observed: - An unlabeled [MEDICATION(S)] tablet (medication used to treat fluid retention) was found in an unlabeled medication drawer. There was no label identifying which resident the tablet belonged to or how long it had been there. - Multiple antibiotics which required reconstitution (process of adding liquid, such as sterile water, to a dry ingredient to make it a liquid) were found in an unlabeled medication drawer for residents who had discharged from the facility. On 7/21/21 at 1:18 PM, RN #1, the DON, and the Administrator were interviewed. They confirmed all medications for residents no longer on the unit should have been returned to the pharmacy. They also confirmed all medications should include a label identifying which resident the medications were intended for. On 7/21/21 at 2:22 PM, Pharmacist #1 stated all discharged resident medications should be returned to the pharmacy and all medications should be labeled for the intended resident. Pharmacist #1 stated pharmacy technicians were to remove medications from the medication cart after being alerted by nursing staff. She also confirmed the facility did not have a medication bin to place medications that needed to be returned to the pharmacy. On 7/21/21 at 3:24 PM, the Pharmacist and the Administrator were interviewed. They confirmed the pharmacy policy was for medication storage locations to be inspected quarterly. They stated the inspections were done, but were not documented. It could not be determined the last time the facility's medication cart was inspected. Medication cart drugs were not appropriately labeled and stored.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for neurological examinations and bowel care. This was true for 2 of 11 residents (#4 and #9) reviewed for quality of care. These failed practices placed residents at risk of undetected and untreated neurological changes after falls and ongoing constipation or fecal impaction. Findings include: 1. The facility's policy for Post Fall Assessment Algorithm for Adult Patient, dated 3/2/21, stated high risk for injury included those residents with unwitnessed fall and following an unwitnessed fall neurological assessments were to be completed every hour for four hours, then every four hours for 24 hours, and then every eight hours for 24 hours. This policy was not followed: Resident #4 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident and Accident (I&A) report, dated 4/9/21, documented Resident #4 was heard talking to herself in her bedroom via her audio monitor, then she was heard grunting and moaning. A CNA entered Resident #4's room and found her sitting on the floor between her bed and the window near the foot of her bed and facing towards the head of the bed. Resident #4 was assessed for injury. She did not complain of pain and no facial grimacing was noted when range of motion was performed on her. Resident #4 stated she went to the bathroom and on her way back, she slipped. The grippy part of the non-skid sock on Resident #4's right foot was on top of her foot and the non-skid sock on her left foot was placed correctly. An I&A report, dated 5/31/21, documented staff were alerted to check on Resident #4 due to lot of noises heard from her audio monitor. Resident #4 was found sitting on the floor in front of her toilet chair in the bathroom. Resident #4 leaned against the wall with the toilet on her left side. Resident #4 wore a non-skid sock and there was not any liquid on the floor. Resident #2 was assessed, and no injury was noted. Two staff members assisted Resident #4 off the floor and she was able to walk without any difficulties. The nurse's note documented a neurological exam was not completed due to Resident #4's inability to follow or understand the nurse's commands at all. On 7/22/21 at 1:40 PM, the MDS nurse said neurological assessments should be done after an unwitnessed fall. The MDS nurse said she was unable to find documentation of neurological assessments completed for Resident #4 when she fell on [DATE] and 5/31/21. 2. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If he had no bowel movement, give a second dose of MOM and encourage fluids. The order stated to repeat giving 2 doses of the MOM daily on an as needed basis daily if no bowel movement for 2 consecutive days. The order documented Resident #9's physician was to be notified if he did not have a bowel movement for 3 days. Resident #9's bowel movement records, dated 5/2/21 through 7/18/21, documented he did not have a bowel movement the following days: *Between 5/4/21 and 5/11/21 (7 days) Resident #9 received MOM on 5/7/21 and 5/8/21. *Between 5/13/21 and 5/21/21 (7 days) Resident #9 received MOM 5/14/21 and 5/19/21. *Between 5/21/21 and 5/26/21 (4 days) Resident #9 received MOM 5/22/21 and 5/24/21. *Between 5/27/21 and 6/1/21 (4 days) Resident #9 received MOM 5/30/21 and 5/31/21. *Between 6/12/21 and 6/16/21 (4 days) Resident #9 received MOM 6/15/21. *Between 6/17/21 and 6/22/21 (5 days) Resident #9 received MOM 6/20/21, 6/21/21 (2 doses), and 6/22/21. *Between 7/9/21 and 7/13/21 (4 days). Resident #9 received MOM 7/11/21. *Between 7/13/21 and 7/17/21 (4 days). Resident #9 received MOM 7/14/21 and 7/15/21. Resident did not receive 2 doses of MOM daily when he did not have a bowel movement for 4-7 days. Resident #9's record did not include documentation his physician was contacted for further orders when his lack of bowel movements continued. On 7/22/21 at 10:31 AM, the Quality Specialist reviewed Resident #9's record for bowel movement and medication administration. She stated there was no documentation the physician was notified of Resident #9's lack of bowel movements. On 7/22/21 at 1:10 PM, Resident #9's physician stated her order was to be notified after three days with no bowel movement and she expected she would be notified within 3-4 days. If medications were given and no bowel movement occurred, she wanted to be notified no later than the 4th day so she could intervene with further medication orders.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their needs. This was true for 1 of 12 residents (Resident #3) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment due to lack of personal hygiene. Findings include: The facility's resident care guideline documented residents should receive a bath or shower twice a week, as needed, or per the resident's preference. This policy was not followed. Resident #3 was admitted to the facility on [DATE] at 12:15 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's bathing record documented she was bathed on 5/30/21 and her next bath was completed on 6/6/21, 7 days later. Resident #3 received a bath on 6/6/21 and her next bath was completed on 6/13/21, 7 days later. Resident #3's bathing record documented she received a bath on 6/30/21 and her next bath was completed on 7/11/21, 11 days later. On 7/21/21 at 3:27 PM, the MDS nurse was interviewed regarding Resident #3's bathing documentation. She stated she was unable to find documentation of baths or showers within the time frames above. She stated Resident #3's scheduled bathing days were Wednesdays and Sundays, and Resident #3 should have been bathed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised to accurately reflect services provided and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed residents at risk of adverse outcomes if cares and/or services were not provided appropriately due to inaccurate information in the care plan. Findings include: The facility's care plan policy, revised 7/13/20, documented the interdisciplinary team monitored each resident's condition and effectiveness of the care plan interventions. The care plan was reviewed and revised as indicated by the resident's medical and psychological needs and by changes in treatments and interventions and contained individual goals and preferences. The daily care plan was updated as needed based on assessment needs, progress and/or change in the resident's condition. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 was admitted to hospice services for end of life care. Resident #9's care plan was not updated to reflect his current status, as follows: * A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's care plan documented he received hospice services. On 7/21/21 at 10:50 AM, the Clinical Informatics nurse stated Resident #9's care plan should have been updated to reflect he no longer received hospice services. * A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's care plan included an entry dated 3/11/20, which documented his physician should be notified if he did not have a bowel movement for 5 days. Resident #9's care plan included an entry dated 3/26/20, which documented his physician should be notified if he did not have a bowel movement for 4 days. Resident #9's care plan did not reflect his physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/21 at 2:30 PM, the MDS nurse stated Resident #9's care plan did not follow his physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff interview and record review, it was determined the facility failed to ensure a Pre-Admission Screening and Resident Reviews (PASARR) was completed for 1 of 1 resident (Resident #12) reviewed for PASARR screenings. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Resident #12 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's admission MDS assessment, dated 1/4/21, documented she had symptoms of depression and exhibited verbal behaviors directed toward others. Resident #12's PASARR Level I screening, dated 11/11/20, documented she was taking 25 mg (milligrams) of [MEDICATION(S)] daily for depression. A PASARR Level II screening was not in Resident #12's record. On 7/21/21 at 10:24 AM, the Administrator stated Unfortunately, only a PASARR I was done. She said Resident #12 should have had a PASARR Level II screening completed.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives were provided with the bed-hold policy upon transfer to the hospital. This was true for 1 of 1 resident (Resident #3) reviewed for discharge. This resulted in the potential for residents to be unaware of the duration of a bed-hold, the bed payment policy, and the ability to return to their former bedroom at the facility within a specified time. Findings include: The facility's bed-hold policy, undated, stated the resident or the resident's family member or legal representative must be provided written notification of the facility's bed-hold policy. The policy stated notice was to be provided at the time of transfer, within 24 hours of an emergency transfer, or at the time of a scheduled transfer. This policy was not followed. Resident #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/21 at 3:26 PM, Resident #3 was discharged to the hospital, following a urinary tract infection with worsening of her CHF. No bed-hold form was provided to the resident or her family. On 7/22/21 at 1:30 PM, the Administrator stated the facility did not use an actual bed-hold form. She stated they verbally agreed to hold the resident's bed, and the resident's belongings are still in her room.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' preferences for bathing/showering schedules were honored. This was true for 1 of 11 residents (Resident #7) reviewed for choices. This deficient practice had the potential for residents to experience a decreased sense of well-being, lack of self-worth, and frustration when preferences for bathing/showering were not accommodated. Findings include: A facility policy, Resident Care Guidelines, dated 7/13/20, stated, Bathing - Bath/shower twice a week, PRN, or per resident's preference. This policy was not followed. Resident #7 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 was interviewed in her room on 7/19/21, beginning at 9:07 AM. Resident #7 stated she was not allowed to choose what days she was given her showers and how that upset her. Resident #7 stated she was only allowed to have showers on Mondays and Wednesdays, but she did not know the reason why. Resident #7's record was reviewed and documented she received 2 showers per week, on Mondays and Wednesdays. Resident #7 was interviewed a second time in her room on 7/20/21, beginning at 1:05 PM. She stated she attempted to have her assigned shower days moved/adjusted, but was told, there were no openings. Resident #7 stated she gets, [MEDICATION(S)] infections under my breasts due to waiting so many days between shower times. She stated she had spoken to the RSA and CNAs about showering 3 days per week. Resident #7 stated she was told an option for a Sunday shower was available, but would have to be done by a male CNA, which she stated she did not want. Resident #7 stated she had a [MEDICATION(S)] infection to folds underneath her right breast which she attributed to her shower schedule. RN #1 was interviewed on 7/20/21, beginning at 1:27 PM. She stated she was previously aware of Resident #7's shower modification request. RN #1 stated she was unsure if anyone had offered her an alternative shower schedule. She stated she was unsure if there was a process that needed to be changed, and confirmed Resident #7 should receive showers based upon her preference. The RSA was interviewed on 7/20/21 at 2:45 PM, and Resident #7's concerns were reviewed in her presence. She stated she assisted in changing residents' shower schedules, but it was not her job duty exclusively. The RSA stated she had not heard about Resident #7's shower requests. Resident #7's right to choose her shower schedule was not upheld.

Based on staff interview and policy review, the facility failed to ensure a pneumococcal policy and procedure was developed. This failure created the potential for harm if residents did not receive pneumococcal vaccines and acquired, transmitted, or experienced complications from pneumococcal pneumonia. Findings include: The facility's Immunization policy, effective 7/8/21, documented the following: *Vaccination requirements were subject to change based on the most current CDC recommendations. *Any vaccine series must be completed within six months of start date (an alternate schedule might be necessary under extenuating circumstances and was at the discretion of the vaccine provider). On 7/22/21 at 3:23 PM, the Administrator said the facility was part of the hospital system and the policy and procedure was an enterprise-wide perspective. An addendum or exception was added to meet the needs of each particular unit. The Administrator said she was unable to provide a unit-specific pneumococcal immunization policy for the facility. The Administrator said the facility met the residents' needs because they followed the national standard of guidance. On 7/23/21 at 10:23 AM, the IP said she was unable to provide a specific policy for pneumococcal immunizations. The IP said the facility had a process to follow for pneumococcal immunizations and their policy for immunizations was system-based. The IP said the facility was part of the entire system and thus the policy applied to the facility as well as the entire system. There was no policy specific to the facility for pneumococcal immunizations.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents at risk for falls were provided the supevision and interventions necessary to prevent falls. This was true for 1 of 5 (#1) residents sampled for falls. Resident #1 was harmed when she fell in the day room and sustained a pelvic fracture. Findings include: 1. Resident #1 admitted to the facility 8/10/15 with multiple [DIAGNOSES REDACTED]. Resident #1's 8/10/15 long term care H&P documented she had a history of [REDACTED]. On 8/10/15, Resident #1's fall risk assessment documented she had an overall score of 21. The assessment form instructed an overall score of 10 or higher meant the resident was at risk for falls. On 8/17/15, Resident #1's admission MDS assessment documented she had at least one fall in the month prior to her admission. On 8/20/15, Resident #1's Care Plan documented he was at risk for injuries related to a history of falls. Interventions included to remind her to call for assistance with mobility/transfer as needed, proper use of assistive devices, and to observe for safety. On 9/7/15, the Physical therapy Discharge Summary documented Resident #1 continued to require supervision for all transfers and with walking using a quad cane due to her advanced dementia and poor insight. Resident #1's 11/17/15 quarterly MDS assessment, documented she had severe cognitive impairment. Resident #1 also required limited assistance of one person for transfer, bed mobility and ambulation; was not steady with moving from a seated to a standing position and walking with an assistive device; needed staff assistance to stabilize if turning while walking; and required a cane for ambulation. On 11/17/15, Resident #1's fall risk assessment score was documented at 15. A nursing note dated 11/26/15 at 9:30 am, documented Resident #1 fell in the day room and was transferred to the ER for an x-Ray. The x-ray report indicated possible pelvic fracture. An MD progress note, dated 11/27/15 at 5:00 pm, documented Resident #1 was diagnosed with [REDACTED]. The fall incident report, dated 11/30/15, documented Resident #1 was sitting in the day room and nursing staff was behind the desk. Staff heard a noise and Resident #1 was on the floor on her bottom. Resident #1 complained of her back and butt hurting. The nurse got her up and her legs gave out. The nurses moved her to her bed where they assessed for injury. The doctor was called and he ordered an x-ray. Resident #1's updated Care Plan, undated, documented Resident #1 fell on [DATE] and she hurt her left hip, and x-rays were ordered. Interventions included a bed alarm and landing pads at night, a wheelchair for locomotion, and for PT to evaluate and treat. On 4/26/15 at 2:30 pm, Resident #1 was sitting in the day room participating in an activity. CAP #6 was conducting the activity and was supervising all residents in attendance, including Resident #1. At 3:15 pm, CAP #6 left the room briefly and returned several times. At 3:21 pm, CAP #6 left the room and returned at 3:38 pm. At 3:26 pm, Resident #1 moved her chair back from the table where she had been sitting and tried to stand from the chair. At 3:31 pm, CAP #6 briefly entered the room and left again. At 3:38 pm, Resident #1 was unattended in the day room. She stood completely on her own. Resident #1's walker was approximately 6 feet behind her at another table. Resident #1 had taken two steps away from the table without her walker, when CAP #6 returned to the day room to assist her. On 4/26/16 at 4:55 pm, Resident #1 was sitting in a stationary chair along the wall of the day room. No staff were present in the area. At 5:07 pm, she attempted to stand. At 5:08 pm, she asked CAP #6 for assistance as he passed her chair. CAP #6 did not assist Resident #1 and left the area. Resident #1 was unsupervised. At 5:12 pm, Resident #1 again attempted to rise from her chair. Over the next 3 minutes multiple staff passed by Resident #1. Each staff told her to sit back down or stated not now. At 5:24 pm, Resident #1 stood on her own, grabbed the walker next to her chair, and took 5 steps towards the dining room. CAP #4 took Resident #1 by the arm and told her to sit back down. At the same time CAP #5, who was approaching the nursing station, called out from the nusing station for Resident #1 to sit down. CAP #5 was around the corner and behind a glass wall from where Resident stood. CAP #4 escorted Resident #1 to the dining room. On 4/27/16 at 11:00 am, the DNS stated Resident #1 was admitted with a history of falls. The DNS stated she talked to Resident #1's family to get a fall history at the time she was admitted . The DNS stated the family had Resident #1 sit in a chair at home and tell her to stay in the chair. However, as soon as they left the room she would stand and fall. The DNS stated Resident #1 had multiple falls at home in this manner. The DNS further stated nurses seated at the nurses' station can see the residents in the day room because the day room is bordered by a glass wall. The DNS stated there was typically an activity being conducted in the day room after breakfast for additional supervision. On the day Resident #1 fell , the DNS stated it was Thanksgiving Day so no activites were in progress. Resident #1 was admitted to the facility with a history of falling from her chair at home. This information was not incorporated into her care plan to ensure increased supervision when she was sitting in a chair. Resident #1 was observed to promptly stand from her chair when left unsupervised for short periods of time (minutes). Resident #1 did not receive the supervision necessary to protect her from falls.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure a) residents were assessed, and care plans developed, for residents with potential suicidal behavior; b) care was provided in a way to minimize resident distress; and c) advanced directives were enacted per resident wishes. This was true for 2 of 6 (#2 and #5) residents sampled for the provision of social services. Resident #5 was harmed when she had expressed ongoing feelings that she would be better off dead, or of hurting herself in some way, without response from the facility. Resident #5 was at further risk for harm when the facility did not secure copies of her advanced directives. Resident #2 was at risk of harm when she verbalized intent and a plan to take her own life. Findings included: 1. Resident #5 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #5's admission MDS assessment, dated 7/8/15, noted she rarely/never understood and had severely impaired decision making abilities. Staff assessed her as having no signs of depression. a. The 9/9/15 OMRA MDS assessment stated Resident #5 had delusions. On 9/10/15, a social services progress note documented the possibly of depression. The progress note stated behaviors were noted and her care plan was updated. On 9/11/15, Resident #5's care plan was updated to include mood disturbances and delusions. Resident #5's documented behaviors included depression, negative thoughts, disrobing, delusions of delivering twin babies, and paranoia that her daughter is out to get her. She was noted to be uncooperative and made verbal threats. The MD was notified and declined orders for an antidepressant at that time. No further social services documentation was noted from 9/11/15 to 10/21/15. On 10/15/15 a quarterly MDS assessment indicated Resident #5 had moderately impaired cognition and she could participate in a mood assessment. During the mood interview, Resident #5 reported feeling down, depressed, or hopeless. The overall mood score was 21 out of 27 indicating possible severe depression. Resident #5 also reported that she had thoughts she would be better off dead or hurting herself in some way more than half of the days in the previous two weeks. The MDS assessment indicates that for residents with those thoughts, the facility is make a safety notification to the responsible staff or provider that Resident #5 was at risk of harming herself. The response on the MDS assessment documented this had been done. Resident #5's record did not contain documentation of physician notification or further evaluation of her psychosocial needs. Her care plan was not updated to include further interventions related to her psycho-social and mood status. In a social services progress note, dated 10/15/15, the RSA (unlicensed personal) documented Resident #5 was afraid the bed alarms and toilet alarms she was hearing were fire alarms. No further evaluation was conducted of this fear. New care plan interventions were not documented. There was no further social services documentation between 10/21/15 and 1/18/16. On 1/15/16 a quarterly MDS assessment indicated Resident #5 continued to have thoughts of being better off dead, or hurting herself in some way, several days out of the previous two weeks. The assessment documented the responsible staff or provider was informed of the potential for Resident #5 to harm herself. Resident #5's record did not contain documentation of physician notification or further evaluation of her psychosocial needs. New interventions were not identified on her mood care plan. On 1/18/16, the RSA documented a care conference was held with Resident #5's daughter and the facility had no identified concerns at that time. On 4/26/16 at 4:55 pm, Resident #5 was observed talking with Resident #1. She asked if Resident #1 had seen the baby. Resident #1 directed Resident #5 to go talk to the nurse. Resident #5 approached RN #10, asked about the baby, was told, not now, and taken back to the day room. Resident #5 reaproached the nurses' station and asked RN #10 about the baby. RN #10 returned Resident #5 to the day room. Resident #5 was observed to be crying. She was escorted to a quiet area in the day room with CNA #8. At 4/26/16 at 5:20 pm, Resident #5 was observed propelling her wheelchair towards the nurses' station. Resident #5 stated, I'm looking for my babies, and began to cry. On 4/27/16 at 4:55 pm, the MDS nurse stated, Resident #5 used to live alone, was fearful of being alone, and wanted to die. The MDS nurse stated, there was no further documentation regarding these issues. She said she simply knew Resident #5 well enough to know that. b. On 8/5/15, the MDS nurse documented in the social services progress notes, PT staff came to this nurse and said, '(Resident #5) is anxious today because she's fearful of being raped in the shower potential. Resident did receive shower by male CAP on 8/5/15 .will care plan her for female showers only to decrease anxiety. Resident #5's care plan did not contain documentation of her preference for female shower aides. One note was documented on Resident #5's behavior monitor for the month of August, on 8/7/15, for attention seeking-see nurse's notes. No documentation related to this behavior was found in the nurses' notes. There was no further documentation found regarding the use of female shower aides only. On 4/27/16 at 4:55 pm, the MDS nurse stated Resident #5's concern was not an allegation of rape, but more a fear that something might happen. The MDS nurse stated she believed the information was added to Resident #5's care plan. She had no additional documentation to offer. The MDS nurse stated if the item was no longer on the care plan, that meant that the facility had determined that the item may be removed. The MDS nurse stated, per her recollection, Resident #5 had only mentioned the fear of rape once and Resident #5's daughter had no concerns with male aides showering her mother. On 4/27/16 the LSW stated she had no memory of the incident on 8/5/15. The LSW stated the facility did not have a permanent social worker from March 2015 to end of August 2015. c. Resident #5's record contained a photocopy of a wallet sized Notice to Health Care Providers that she executed advanced directives designating a primary and secondary agents for health care decisions. The notice documented where the directive could be located. The photocopy contained a hand written addition stating the primary agent had passed away and the secondary agent is the surrogate health care decision maker. The photocopy documented the secondary health care agent was to provide a copy of the advance directives. The photocopy was dated 7/8/15. On 4/27/16 at 1:30 pm, the LSW and RSA stated Resident #5 expressed paranoia that the secondary agent was going to, take all her stuff and that the secondary agent had not provided a copy of the advance directive. The facility had not followed up to obtain the document. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including depressive disorder, diabetes mellitus, and hypertension. An MDS assessment, dated 8/14/15, documented Resident #2 felt bad about herself 2-6 days out of the week and had thoughts that she would be off better dead or thoughts of hurting herself 7 of 11 days. A Suicide Screening Form, dated 8/17/15, documented Resident #2 as high risk with a score of 13. In the question, In your lifetime: Did you ever make a suicide attempt? Resident #2 answered, No, but wanted to. The interventions included: *Charge Nurse will notify DNS, MD, and family of Suicidal Screening Form results within 24 hours after completion. *Safety monitor to be placed in MARS for 72 hours. *Nursing staff will place patient in protective environment with continuous observation. Continuous observation will be provided by hospital staff . The Suicide Screening Form documented staff were to provide continuous observation of the resident if the score was greater than or equal to 10 (high potential). Resident #2 scored 13. Social Services Progress Notes, dated 8/17/15, documented Resident #2 had feelings of hurting herself every day and had planned to use a gun. The progress notes also documented the LN and MD were notified and suicide prevention was initiated. A CP regarding Resident #2's daily feelings of hurting herself was not found in her clinical record. On 4/28/16 at 10:30 am, the RSA said she notified the LN on duty about Resident #2's feelings of hurting herself and told the LN to notify the MD. When asked if she had notified the LSW, the RSA said Yes, her advice was to continue observing the resident and to continue the safety monitor for 72 hours. On 4/28/16 at 10:40 am, the LSW said she provided guidance to the RSA on how to deal with Resident #2's situation and to follow up with her, if needed. When asked if she had visited and assessed Resident #2, the LSW said she did not. She said she was told Resident #2 did not show signs and symptoms of depression and her family said she would make comments about hurting herself when she was in pain or would be mean to people when she was upset. The LSW said there was no urgency to see Resident #2 at that time. The LSW indicated Resident #2 had dementia with short term memory loss and it would be difficult for her to retain therapy information and participate in therapy sessions. The LSW was requested to provide the documentation of the referral made by the RSA to her. She said she would check her email and would give it to the surveyor. When asked about the continuous observation as documented on Resident #5's Suicide Screening Form for a high risk score, the LSW said, That is confusing, it didn't say one to one. She was monitored every 30 minutes. At 12:20 pm on 4/28/16, the LSW indicated she was unable to provide documentation of the consultation she provided to the RSA. She said it was a verbal consultation and if there was an email sent during that time their computer system cleared everything after three months unless they saved it. On 4/28/16, LN #1 said she had notified the MD at 2:30 pm on 8/17/15, and was told to continue the safety monitor in place, but said Probably I did not write it. She said Resident #2 was monitored every 30 minutes and was kept in line of sight of staff during the daytime by putting her in the day room; and then in the evening, staff made rounds every 30 minutes, and also in between the 30 minute checks, to make sure Resident #2 was safe.

Based on observation, record review and staff interviews, it was determined the facility failed to provide the necessary nursing care and services to promote healing and to prevent a pressure ulcer from reopening after it had closed. This was true for 2 of 2 (#s 3 and 5) sampled residents reviewed for pressure ulcers. Resident #5 was harmed when the facility failed to assess and monitor a recently closed Stage II pressure ulcer from 11/8/13 to 11/16/13, allowing a Stage II pressure ulcer to redevelop. There was potential for harm to Resident #3 when staff applied a barrier cream starting at a contaminated area, introducing bacteria, to a Stage II pressure ulcer. Findings included: 1 a. Resident # 5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Admit MDS, dated [DATE], documented in part: *Moderately impaired with a BIMS Score of 9. *Total assist with 2+ persons for bed mobility, transfer, and toilet use. *Total assist with 1 person for locomotion on and off the unit, personal hygiene and bathing. *Functional limitation in range of motion with impairment on both sides. *Indwelling catheter. The Admission Nursing Assessment, dated 10/15/13, documented in the Skin Assessment section, the resident had a Stage II pressure ulcer, was placed on a Stat II Mattress and had a MD order for Barrier Cream. The Skin Impairment Score section had a box marked "X" by "score of 12 or less OR has any High Risk Indicator." The Resident Status/Condition section documented the resident had an indwelling catheter and the reason for the catheter was due to the pressure ulcer. The care plan for risk for skin impairments, dated 10/28/13, documented interventions in part: " LN (licensed nurse) to do skin assessment with showers and prn (as needed) indicated." "CNA to observe and changes promptly with daily cares." "Anti pressure relieving Stat 2 Air Mattress and cushion in WC (wheelchair)." "Heel boots as she will allow." "Skin barrier with each incontinent cares and BID (twice daily)." "Use of Skin Barrier as ordered - Dimethicone - [MEDICATION NAME]." "Turn and reposition every 2 hours day and night and PRN (as needed)." "Cleanse daily with NTWC (non-toxic wound cleanser) - [MEDICATION NAME] and peri cares." The Braden Scale for Predicting Pressure Sore Risk, dated 10/15/13, documented the resident's total score at 14 and was at moderate risk for developing a pressure ulcer. The adjustment scoring indicated the resident was "automatically at high risk if one or more areas were indicated." A box marked with an "X" by "has a current pressure sore or has had one in the last 90 days." A second box was marked with an "X" by "is in an end stage disease process." The Treatment Record for November 2013, documented "barrier cream for coccygeal decubitus ulcer" was applied three times per day. The Skin Impairment sheet for Resident #6 documented the following: Date Length/width Stage Comments in cm 10/15/13 4 x 3 II Turn and reposition every 2 hours, Stat II air bed, moisture barrier cream. 10/19/13 4 x 3 II Blanches, otherwise no changes, continue treatment. 10/25/13 2 x 1 II Improved, smaller in size, total .5 cm x .5 cm red open area. 11/8/13 0 Pink intact skin, will monitor for 1 more week resolving. 11/16/13 .5 Small skin split at gluteal cleft, continue treatment. The skilled nursing charting sheet, dated 10/21/13, documented orders were received for Ensure and a multivitamin daily to help increase protein for wound healing and health. The skilled nursing charting sheet, dated 10/26/13, documented, "coccyx area improving with use of air mattress and barrier cream. No pain at site. Continue to monitor sight (sic)." On 11/4/13 at 8:25 AM, the nurse's notes documented the foley (catheter) was found out with the balloon inflated. The resident stated she did not know how it came out and wanted it left out. At 9:00 AM, the nurse's notes documented the resident was "voiding both continent and incontinent adequately." On 11/6/13 at 12:55 PM, the physician wrote an order to DC (discontinue) Foley and monitor bedsores. Note: There was no documentation the pressure ulcer was assessed or monitored by licensed staff from 11/8/13 until 11/16/13, when it was documented on the Skin Impairment sheet as reopened. On 11/19/13 at 9:35 AM, the surveyor asked the DNS to come into the resident's room to observe and measure the Stage II pressure ulcer. The DNS measurements were 2 cm (length) x 1 cm (width), which meant the pressure ulcer had continued to increase in size the last three days. On 11/20/13 at 1:45 PM, the DNS was interviewed regarding Resident #5's Stage II pressure ulcer on her coccyx. The DNS stated the resident's nutrition and pain were better. The DNS stated the resident pulled out her catheter and the DNS thought the pressure ulcer was probably due to moisture. The DNS stated the resident needed to be watched more carefully. 1 b. On 11/18/13 at 2:40 PM, Resident #5 was observed to be in the Activity Room sitting in her WC. The foot pedals had padding which was duct taped vertically and horizontally to the pedals (like a wrapped package) to hold them in place. On 11/18/13 at 2:50 PM, the AC (Activities Coordinator) stated, the resident kicked off her "problem boots" so they padded the foot pedals with old heel protectors. She stated they spoke with PT (physical therapy), OT (occupational therapy) and the DNS about the problem and they decided to use these for now until they came up with something better. On 11/18/13 at 3:05 PM, the DNS stated the resident was admitted with "mushy heels." She reported they care planned for Prevalon boots and the resident would not leave them on and would tear them off. The DNS stated she spoke with OT who stated just to put something on the foot pedals. The DNS stated the duct tape doesn't look very good, probably wasn't very sanitary, and stated she will check into something else for the resident's feet to rest on. On 11/18/13 at 4:20 PM, the resident was observed sitting in her WC by the nurses station with padded foot pedals, however, no duct tape was observed on the foot pedals. The care plan for skin impairment, with a start date of 10/28/13, documented "heel boots as she will allow." The skilled nursing charting sheet, dated 10/24/13, documented, "heel med-ex boots applied as heels are fragile. Resident does not keep heel booties on at present, she's trying to remove heel med-ex boots. Reminded to leave on for protection. Resident needs constant cuing and reassurance and direction." The skilled nursing charting sheet, dated 10/27/13, documented "fragile skin - heels." On 11/19/13 at 2:20 PM, the surveyor interviewed the PT who stated she "would not recommend using duct tape for any pressure issues." The facility failed to assess and monitor potential changes in skin condition for a resident who was at an increased risk of redeveloping a pressure ulcer. Additionally, the facility failed to adjust interventions when the catheter was removed and the resident experienced increased moisture. The facility failed to promote proper heel protection for a resident who had fragile heel skin by using duct tape, a slick, hard surface, which came in contact with the resident's heels. 2. Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 9/19/13 annual MDS coded cognitively intact, one sided upper and lower functional ROM limitations, and no pressure ulcers. Section V of the MDS triggered for Pressure Ulcers and the subsequent CAA documented, will proceed to plan of care as needs arise and for preventative cares against pressure ulcer formation. The resident's 11/14/13 "Skin Impairment" form documented a Stage II pressure ulcer. The comments column documented, "Open bleeding area @ rt (at right) of gluteal cleft. [MEDICATION NAME] Ongoing." The resident's Care plan identified the 10/27/10 problem of at risk for skin impairments related, in part, to incontinence and decreased mobility and functioning. The problem interventions included, in part, CNA to notify the LN of any changes to skin promptly. On 11/20/13 at 1:50 p.m., the survey team observed two CNAs providing cares for the resident. CNA #4 apply [MEDICATION NAME] to the affected area of the resident's gluteal cleft. The CNA applied the [MEDICATION NAME] by applying in the direction from the rectum area to the gluteal cleft. The CNA did not apply the [MEDICATION NAME] from the gluteal cleft toward the resident's rectum area. Note: This practice created the potential to contaminate the open area at the right of the resident's gluteal cleft. On 11/20/13 at 2:00 p.m., the survey team informed the DNS of the CNA applying [MEDICATION NAME] from the resident's rectum area to the gluteal cleft. The DNS indicated that was not the correct procedure to use and the CNA may have been nervous because the surveyors were in the resident's room. On 11/22/13 at 1:20 p.m., the Administrator was informed of the observation. The facility did not provide any additional documentation.

Based on observation, staff interview and record review it was determined the facility did not ensure pressure sores did not develop for 3 of 3 sampled residents (#1, 2 and 5) reviewed for pressure sores. *Resident #2 was harmed when he developed multiple/recurrent Stage II pressure sores and a stage IV pressure sore which became infected [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphylocaccus Aureus) and pseudomonas. *Resident #1 was harmed when an avoidable Stage III pressure sore developed and timely interventions were not implemented. *Resident #5 was harmed when she developed multiple avoidable Stage II pressure sores. The facility had not implemented preventative interventions in a timely manner to prevent these pressure sores. Findings include: 1. Resident #2 was re-admitted to the facility on [DATE] with a Stage II pressure sore. The resident also had a [DIAGNOSES REDACTED]. The resident's readmission "Nursing Full Assessment" was dated 6/2/11 and documented the resident had a pressure sore upon readmission. This was described as a Stage II pressure sore with "open blister" and measured 8 cm (centimeter) x 5 cm. The wound was red and yellow in color and had 1 cm of extra loose skin around the wound. There was serosanguinous drainage without odor. "Nurse Treatment Notes" documented the following information: 6/05/11- Concurred with above that resident had a open blister to his left heel. No other description of the pressure sore. 6/26/11- Documented the size of the wound as 3.8 x 2.5 cm. No drainage or odor. 7/03/11- The left heel wound measured 3.6 x 2.5 cm with "superficial depth" and no drainage or odor. 7/31/11- "Has 1 cm x 1 cm red center. There is yellow border surrounding entire wound that 2 cm thick (sic). The skin surrounding the border is thick rough & yellow. No drng (drainage) no odor..." 8/04/11- "Bed of wound is red. No drainage noted, no odor. Has thick yellow boarder (sic) 1 cm around wound bed..." 8/28/11- "...Right (error should be left) heel drsg (changed). (No drainage, no odor). Wound measures 2.4 x 1.7 cm. Slough tissue present in wound bed. Surrounding tissue pink, blanchable..." 9/01/11- "...L(eft) heel drsg (changed). Wound measures 2 cm x 2 cm & unstageable at this time. There is a hard brown callous - like area over center of wound. Skin is soggy & sloughing 1 cm around the entire wound. No drainage, no redness, or odor detected." 9/29/11- "...L heel dressing (changed). Wound measures 1.5 cm x 1 cm. (No) depth. Bed of wound is purple with no drainage. No odor. Wound appears to be improving." This was the last of the Nurse Treatment Notes provided. The DON was advised on 10/12/12 at approximately 10:45 am, that documentation of treatment notes indicating when the facility determined the wound was healed was not provided. However, a Wound Care Evaluation form had been provided with documentation from a wound care center as follows: "...Date of Service: 11/08/11. Reason for referral: Evaluation of a right plantar 5th MTP (metatarsal) ulceration and a left posterior heel ulcer in the setting of [MEDICAL CONDITION]. History of present illness: The patient is a (age provided) gentleman with a history of [MEDICAL CONDITION] and functions essentially has (sic) a quadriplegic. He resides in a wheelchair. He developed an ulceration that was first noticed on the right plantar 5th MPT region approximately 10 days ago. Since that time, they are protecting the area and not allowing him to be up in his wheelchair, and the facility has Prevalon boots on him as well as using Allevyn cover dressing. The area originally started out has (sic) a blister that spontaneously ruptured. the patient also has developed a left posterior heel ulcer that they are treating the same way, and this is essentially resolved on today's evaluation. The patient does have some sensation in the affected right foot plantar 5th MTP region. He has had no fevers or chills, no nausea or vomiting...On the right plantar 5th MTP region, there is an ulceration that is 1 x 0.8 cm with a pre-debridement depth of 0.1 cm, post debridement depth is 0.4 cm down to the tendon level... Diagnosis: [REDACTED]. We will continue with Allevyn to protect the left heel as..." In addition, documentation indicated a culture of the wound would be obtained. The wound care progress note, dated 11/29/11, documented the resident [MEDICAL CONDITION] and pseudomonas growth from the wound. He was placed on a "course of [MEDICATION NAME]." Also, the resident had stated he wore footwear when in his wheelchair at times but often only wore socks. The assessment by the writer indicated the foot rests were too hard and the resident was getting too much pressure. These two wound clinic progress notes were the only notes provided by the facility that were documented by the wound clinic. Information as to the date the Stage IV pressure ulcer was healed was not provided. The MDS assessment dated [DATE] did not document any pressure sores. However, the significant change MDS, dated [DATE], documented the resident had a Stage II pressure sore. Nurse Treatment Notes for April 2012 documented the following: 4/04/12- "...Pt. (Patient) has 1 x .6 cm black/red blister on back lower left heel. Black/red area is boggy and intact with surrounding tissue blanchable..." 4/24/12- "L(eft) heel measures redness 1 cm x 0.2 cm decreasing in size still blanches. Pink skin to surrounding area." 5/14/12- "0.6 cm x 1 black/red blister on L heel resolved...Continue with Prevalon boots at all times." A facility "Skin Impairment" form for the above time period 4/4 through 5/14 incorrectly staged the pressure sore as a Stage I. The blister indicated the pressure sore was a Stage II. A nurse progress note, dated 4/5/12, documented: "Dressing (changed) to L heel area. Area is red but intact. It is blanchable around the area. No discomfort assessed. Prevalon boots on. Foot pedal may be the cause. PT (Physical Therapy) to assess seating/footing placement and make recommendations..." A Physical Therapy note, dated 4/5/12, documented the following: "...PT screen due to pressure ulcer on L heel...Pressure point coming from foot plate on foot rest...disease had progressed significantly...increased tone in both lower extremities making it difficult to maintain hip/knee/ankle flexion required for foot placement on foot rest. Prevalon boots are not providing enough cushioning to protect this pressure point..." Recommendations were made by PT for ensuring the residents legs were supported and foot plates were out of the way. These recommendations were acted upon and a note documented by PT on 4/13/12 indicated the wound was healing and recommended the continued use of the padding devices recommended for the resident's chair. The resident's care plan was dated April 2012. The care plan identified the development of a Stage II pressure ulcer on the resident's heel and that it had resolved on 5/14/12. The use of the Prevalon boots, every 2 hour repositioning and recommendations for wedge cushion under his legs to prevent pressure to his heels were included for interventions. None of the interventions were dated as to when they were implemented. A care plan prior to the development of the pressure sore in April 2012 was not provided. The DON was interviewed on 10/11/12 at approximately 10:45 am. When asked what was done to prevent pressure sores for Resident #2 she indicated they had gotten a new wheel chair that positioned the resident differently. She indicated it had taken an extended amount of time to get improvement for the new J-back wheel chair. She indicated the nursing staff who work at the facility were directed to check skin with every shower. She said the resident had been placed on hospice and they (hospice) sometimes showered the resident, which may have caused a lack of communication. (NOTE: The nurses' notes documented Hospice assessed the resident on 4/10/12 and Hospice was in place by 4/13/12. The resident's pressure sore was identified on 4/5/12). The resident was observed up in his wheel chair on all observation days of the survey (10/9 through 10/11/12). His wheel chair reclined and it did have cushioning under his legs held in place by gait belts. The resident preferred to spend most of his time up in the wheel chair. The facility failed to prevent pressure sores for Resident #2 who developed recurrent Stage II pressure sores on his foot and developed a Stage IV pressure sore also on his foot that became infected. The facility had information regarding positioning of the resident's feet while in the wheel chair from 2011, that had caused pressure sores. However, he again developed a pressure sore on his foot related to his wheel chair, in April of 2012. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 7/23/12, documented she was severely cognitively impaired, and required total assistance by 2 staff for most ADLs. She was documented as frequently incontinent of bladder and bowel and had unavoidable weight loss. No pressure sores were documented. The care plan was not dated. A problem was identified for risk of skin impairments related to: "History of healed pressure ulcers. Risk of pressure ulcer per Braden. Dependent on staff for mobility and positioning. Incontinence of bladder and bowel. Expected unavoidable weight loss. [MEDICATION NAME] level low. Candidiasis history. Seborrheic [MEDICAL CONDITION]." Interventions included: * "Stat II mattress with (baffled overlay was crossed out and documented as discontinued 8/30/12.)" * "Cushion to w/c (wheel chair) seat" was replaced with "Roho cushion 7/24/12." * "J back support to w/c." * "Reposition and off load every 2 hours" (and rounds at night, was crossed off list). * "Pillow between her legs when in (sic) as she will allow or bone pillow." * "Blue padding to arm rest of w/c." * "7/2 One of the last up & first down (after) meals." * "8/30/12 Use of body pillow for positioning in bed - she doesn't move about unless assisted." A facility conference summary was dated 7/23/12 and was documented as a "Look back time frame of 4/23/12 to 7/23/12." The following was documented under the nursing section: "...On 7/1/12 she was found to have 2 Stage 2 pressure ulcers- 1 at her coccyx/sacrum area the other to her hip. The MD (Medical Doctor) was notified and interventions were in place with new wound care treatments. These areas have healed as of 7/11/12 and now have continuation of the preventative dressing in place due to Stage I scar tissue present. (Resident #5) has had w/c evaluation for seating and positioning on 7/13 and 5/21. On 5/21/2012 it was advised that she have a pillow between her knees- maintain a neutral positioning of her hips and legs and no sleeping in her w/c- either have her sleep in her bed or recliner for comfort and positioning needs. On 7/13/2012 she was given a new w/c Bentley with a Jay Focus Back and a J2 Jell cushion. (Resident #5) continues to be dependent on staff for all of her ADL's..." Record review revealed the physician and family were notified of the pressure ulcers and the resident was evaluated by PT on 7/13/12 (Late entry dated 7/27/12). PT evaluated the w/c as a good fit for the resident and with improved lateral and trunk support. Recommendations were made to lay the resident down when sleeping or have her sleep in a recliner. Also, to have a pillow between legs when up in her wheel chair. Any similar evaluation by PT for May 2012 was not provided. The current care plan did not contain specifics about sleeping only in bed or a recliner and the cushion in her wheel chair had been changed to a Roho. The resident's family member and representative was interviewed on 10/11/12 at 8:10 am. He said he had been notified about the pressure sores that developed in July. When asked why he thought she developed the pressure sores he stated that the resident was so thin that her bones do not have any padding. He indicated she refuses to eat and had declined greatly with her disease process. The DON was interviewed on 10/11/12 at approximately 10:45 am. She was asked how the pressure sores were caused and could have been avoided. The DON stated that the resident was at high risk since admitted and had always been on a Stat II air mattress. She said it was possible the resident was sitting too much and had a new wheel chair. She indicated they had been laying the resident down more frequently. The facility did not prevent multiple Stage II pressure ulcers for Resident #5. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Nursing assessment on 8/23/12, documented the resident was high risk for skin impairment and did not have any pressure areas. The admission MDS assessment dated on 8/29/12, documented the resident: * had no pressure sores * was severely impaired for decision making skills * required assistance of one-to-two staff for bed mobility, transfer, dressing, personal hygiene and bathing. The nurses notes on 8/28/12 at 11:30 pm, described a newly discovered skin issue, "Open area 1 skin tear to L (left) buttock near anal crease. Measures total area 5 cm (centimeter) x 3 cm with 4 cm x 3 cm opened skin area. Looks like a blister that popped open. Center is beefy red. No drainage, no odor. Approximated edges, placed [MEDICATION NAME], covered w/(with)[MEDICATION NAME] and secured w/ [MEDICATION NAME] tape." The "Skin Impairment" notes documented the following: 9/12/12- "Length/Width 4 cm x 2.5 cm" and "There is a small area inside of wound bed 1.5 (cm) x 1.5 (cm) purple area like a blood blister that is intact. Scant amount of drainage." 9/18/12- "Length/Width 2 cm x 1.5 cm" and "Measurements done by doctor (after) debridement." 9/25/12- "Wound vac (vacuum) applied." 10/8/12- "Length/Width 2 cm x 1.5 cm" and "Wound vac reapplied." (Note: None of the skin notes staged the sore, however, a "Wound Care Progress Report" from a local Wound Center stated it was a stage III pressure sore, when the resident was seen there on 9/20/12.) Resident #1 was observed in the dining room on 10/10/12 at 11:50 am with a [DEVICE] in place. The care plan on 9/4/12, documented the skin issue as a stage III pressure sore, with a treatment plan which included a, "Stat 2 (air) mattress." The nurses notes on 8/29/12 documented, "Discussed an air mattress for fragile skin. Family is concerned about resident slipping from bed and sustaining another fall and injury occurring (due) to confusion." Doctor orders on 9/18/12 documented, "Low air loss mattress." The nurses notes on 9/18/12 documented, "Will move resident onto a Stat II mattress." The resident's room was observed on 10/9/12 during the initial tour, which included an air mattress on the bed. The DON was interviewed on 10/11/12 at 10:35 am. When asked why there was a delay for an air mattress, the DON stated, "The son did not want it because of the resident's falling issues." The DON said the resident was on a pressure reducing mattress and they had to weigh the risk of the resident falling versus the risk of the resident developing pressure sores. When asked what was the cause of the resident's pressure sore, the DON said it might have been during a slide board transfer at the facility. The facility failed to prevent pressure sores by not acting in a timely manner to assess the cause of the sore and a delay of implementing an effective plan before a Stage III pressure sore developed, causing harm to the resident. No other documentation was provided by the facility.

Based on observation, record review, family interview, and staff interviews, it was determined the facility failed to provide adequate supervision to prevent accidents. This was true for 4 of 9 residents (#s 2, 4, 6, and 8) reviewed for falls and safety, and all independently mobile residents who could enter the Beauty Shop unsupervised. Specifically: Resident 2, who was at risk for choking and care planned to not have water at the bedside or unsupervised, was observed to have a cup of water on his bedside table on 2 occasions; the Beauty Shop, which was observed to have an open door at all times during survey, was observed to have hot water temperatures in excess of 120 degrees Farenheit in the hair washing sinks on multiple occasions; and Residents #2, 4, 6, and 8 fell multiple times at the facility without adequate changes to care planned interventions. Resident #4 was harmed on 7-22-11 when her left wrist fractured during her 18th fall in a 6 month period. Findings include: 1. Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included dementia, anxiety, sleep disorder, gait instability, urinary retention, incontinence, a history of fracture, and pain. The resident's 5/23/11 Significant Change MDS assessment coded: * Severely impaired cognition * Trouble falling or staying asleep, or sleeping too much - 7-11 days of the prior 2 weeks * Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that she had been moving around a lot more than usual - 1 day in the prior 2 weeks * Limited assistance by 1 person for bed mobility, transfers, and personal hygiene * Supervision and setup for walking and locomotion * Extensive assistance by 1 person with dressing and toilet use * Not steady but able to stabilize without human assistance during transitions and walking * Walker used for mobility * Depression and psychotic disorder * Falls since admission to the facility: without injury and with injury other than major; no falls with major injury including bone fractures * Antipsychotic and antidepressant medications administered in the prior 7 days CAAs associated with the 5/23/11 MDS assessment documented: * "During this look back time frame, has shown an improvement in her ability to ambulate about her room and the corridor independently with her FWW (front wheeled walker) and generalized staff supervision. (The resident) has been noted to have an improvement in her behaviors, mood and impulsiveness since the starting of her Depakote medication on February 2011 (sic)." * "Has taken multiple falls during this look back time frame. She is being supervised with her ambulation using her FWW due to her over all physical improvement. It was felt that she could have been tripping over her shoe strings so her daughter was asked and brought in a pair of supportive tennis shoes with a Velcro strap in place of the shoe strings. All of her falls have occurred with her doing her routine activity, mostly getting up either from her chair or from her bed. She does have a blood pressure that runs hypotensive and the MD (physician) is aware. She has ben encouraged to stand up slowly and stand erect and maintain that position for 1-2 minutes prior to ambulation. She is not able to remember this on her own due to her dementia process and short term memory loss. She does have many medications that cause hypotension as a side effect but currently these medications are effective in improving her mood and behaviors. Her family and her are aware of the risks related to her medications but at this time they feel that the improvement out weighs (sic) the risks. Will proceed to her plan of cares for the prevention of falls and for safety issues/concerns." The resident's Plan of Care, dated May 2011, documented the following related to accidents and supervision: * "At risk of health maintenance (due to) confusion - dementia - but pleasant; impulsiveness - fall risk high; decrease in her physical functioning; decreased safety awareness; pigeon toed gait / scissor gait; decrease in her mobility; discomfort - pain... Alert with confusion. Is very impulsive with behaviors (at) times... (independent) on unit with her FWW and staff supervision. 1 assist with ADL needs... transfers, locomotion... have gray chair close within reach - when she sits she plops down quickly." - Occupational Therapy evaluated and treated on 7/24/11 for use of wheelchair. - Physical Therapy evaluated for gait, ambulation, and balance on 6/2/11. - Restorative assistance was re-started on 7/2/11, to prevent decline in her range of motion, ADL level, and general exercises. * "Is a high fall risk (related to): She is very impulsive behaviors (sic); has decreased safety awareness; history of falls with injuries in past; is independent on unit with FWW with supervision; does require 1 assist with toileting.... Call light within her reach and answer promptly; staff to anticipate her needs due to dementia process (and) check on her every 1 hour and PRN (as needed); encourage her to wear her white Velcro tennis shoes for support; monitor for safety at all times; keep environment clean and free of clutter that could cause tripping; have adequate lighting in room - night light if indicated; monitor medications for side effects that could cause falls; use of bed alarm on at all times; bed is to be in position where she can put her feet flat on floor when she sits up; landing pads when in bed; keep gray chair in room within reach by sink - she tends to plop without warning when she sits down; offer to take her for a walk 1-2 hours PRN; she likes to go outside weather permitting for walks; she will sometimes ask for assist when she goes to the bathroom - offer her toileting every 2-3 hours and PRN; encourage her to ask for assistance as needed; sits in green chair within view of (unit clerk) most always, with padded armrests." - Falls were documented with handwriting on the typed Plan of Care on 5/30/11, 6/2/11, 6/7/11, 6/30/11, 7/8/11, 7/11/11, and 7/22/11. - Physical therapy evaluation was done 6/3/11. - Side rails when in bed, added 6/28/11. - X-rays as ordered, added on 7/12/11. The resident's July 2011 Physician order [REDACTED]. * Aricept 10 mg (milligrams) PO (orally) daily for Alzheimer's disease - started 12/3/10 * Depakote 500 mg PO at HS (bedtime) - No [DIAGNOSES REDACTED]. * Zyprexa 5 mg PO daily at HS for dementia with behaviors - started 2/27/11 Physician order [REDACTED]. * 6/30/11 - Ambien 5 mg PO at HS for sleep aid * 7/12/11 - Pelvis and spine X-rays * 7/15/11 - Decrease Ambien to 1/2 dose, 2.5 mg PO at HS for sleep * 7/22/11 - Xray left wrist status [REDACTED]. The resident's 3/1/10 Discharge Summary related to her stay at the hospital from which she was admitted to the facility documented: "The patient had been residing at assisted living... where she had a couple of falls starting back in January... approximately 3 weeks ago she... (had) a... fracture... the patient was sent back to assisted living to watch her ambulation. She continued to be a little bit unsteady, fell a couple of more times... the patient was very agitated, was on the bed and up in the chair and then sitting... the patient is going to need long-term care... so we looked at placement at the long-term care unit." The resident's 3/1/10 Admission Nursing Assessment documented: Disoriented daily, fair impulse control, shuffled gait/balance problems, previous falls within 6 months, exhibits unsafe ambulatory transfer skills daily; safety devices of landing pads, bed alarm, and tag alarm. NOTE: Although the above documents predate the facility's date of alleged compliance from the prior survey, they are included to document that the facility was aware of this resident's high fall risk and history of falls with injury. The resident had at least 23 falls between 7/28/10 and 7/28/11. On 7/22/11 she sustained a fracture during a fall. The resident's medical record contained the following documents related to accidents and supervision: * 8/3/10 Nurse's Note (NN) - "(Physical Therapy) recommends 3 day trial for all (ambulation) off unit (with) FWW (and) 1 assist (and) use of w/c in day room only. Encourage ambulation at all times (with) staff to and from bathroom." * 8/31/10 Resident At Risk Committee (RAR) - Change in Condition/other Concerns: Self transfers - found on floor. Safety/Risk: Self transfers, Fall. Plan of Care: As written. * 9/7/10 RAR - Change in Condition/other Concerns: Positioning in w/c. Safety/Risk: Fall, self transfer. Plan of Care: As written. * 9/9/10 Care Conference Summary (CCS) - "She continues to be a high fall risk as evidenced by the frequency of her falls. She is a very impulsive lady with poor safety awareness due to her dementia process. Because of her falls, her bed is placed as low to the floor as possible plus she has a bed alarm. There are bilateral landing pads down. The call light is within her reach but she does not use it due to her confusion. The staff checks on her every 1-2 hours in anticipation of her needs due to the fact that she is unable to use her call light appropriately. Despite all the interventions that are in place for the prevention of falls and injuries, she goes from her bed to the floor and then has started crawling from one area to another... I will continue to update her POC as things change for her... She is very impulsive and has poor safety awareness... (she) is working with the (Restorative Aide) staff on her exercise program to encourage her to ambulate more and be active at her current level of functioning. Will continue to encourage her to be up more as she is willing, with the goal of having her walk about the unit with staff assistance and her FWW." * 9/14/10 RAR - Change in Condition/other Concerns: Tolerating change in ambulation well. Safety/Risk: Fall 8/31. Plan of Care: As written. * 10/27/10 RAR - Change in Condition/other Concerns: Removes tag alarm, ambulating (without standby assist). Safety/Risk: Fall. Encourage her not to remove tag alarm - have standby assist with ambulation and FWW... Consider tag (alarm) removal with safety check every 30 minutes. Plan of Care: As written. * 11/2/10 RAR - Safety/Risk: Fall. Tag alarm remains in place on pants. Plan of Care: As written. * 11/3/10 NN - "Attempted to get (up) by self 36 (times) during the 1 (hour) in the day room. (Social Services referral) done." * 11/8/10 NN - "Resident has set (off) tag alarm many many times this shift - attempts to walk alone. At times angry affect." * 11/9/10 RAR - Safety/Risk: Fall. Encourage Restorative Aide to ambulate more frequently. Plan of Care: As written. * 11/15/10 NN - "Resident impulsive today. Sets off tag alarm repeatedly. Attempts to walk independently. Attempts to re-direct are usually successful. Resident is toileted (every hour)... Reminded of frequent falls and past (fracture), reminded that safety measures are to help her. MD was phoned today, asked to review paperwork concerning behaviors. MD agreed." * 12/3/10 Return Admission Nursing Assessment - Disoriented daily, poor/no impulse control, decreased sensation or coordination in extremities, poor/no awareness/judgement, shuffled gait/balance problems, previous falls within 6 months, exhibits unsafe ambulatory transfer skills daily; and safety devices of bed and tag alarms. * 2/12/11 at 9:30 PM Event Report (EVENT) - fall in resident's room - "Went to use the bathroom and I was helping her and she went to sit down and I told her to move over more first and she still sat and the chair pushed away and she fell ... (Resident) is very impulsive and gets up instantly. She forgets immediately and lots of time is very obstanet (sic)... Landing pads were in place at bedside. (Resident) falls frequently because of her instantaneous (sic)... Impulsive dementia (with) inability to respond to (cueing) or directions from staff. (Family member) states resident has always been very stubborn." *2/17/11 at 12:20 PM EVENT - fall in resident's room - "Called into room... observed resident on floor in sitting position - states 'tripped on my sweater'... is very impulsive (with) no thought. She just gets up (and) goes. Because she is weak, unbalanced and unsteady she falls easily. When redirected she appears to understand but her Alzheimer's is advancing. Bed alarm in place, landing pads placed, tag alarm in place... Sweater was left on bed (and) resident threw off bed linens (and) they fell on floor causing her to fall. Call light in reach. Did not use. Reminded to. Impulsive." * 2/18/11 at 8:30 AM EVENT - fall in resident's room - "Observed in sitting position upright next to bed on landing pad. Hit head on end table. Quarter sized red area to (left) region of forehead. Hematoma x 2 to (left) inner wrist. Bruised quarter size area to (left) knee. Observed minimal shuffle to gait (with left) foot... Keeps getting out of bed and is found on the floor sitting. This time (with) hematomas to knee, wrist and forehead. Landing pads in place. Extended fall charting (and) extended safety monitor. She instantaneously gets up from bed and is too weak to stand (and) falls. Very impulsive behavior. Put on list for specialist (nurse practitioner) from (behavioral facility) to see (and) possibly (change) meds. Resident on safety monitor to be assessed (checked) every 30 (minutes). Verbal (cueing) for call light use - may be moved to day room for safety (and) supervision if resident will not stay in bed." * 2/18/11 at 9:50 AM EVENT - fall in resident's room - laceration to (right) eyebrow - 5 stitches. "I was cleaning (the resident's) chair in her room and told her wait before she sat so she didn't sit on anything on the chair and I went to throw the wipes in the garbage on the other side of her and grabbed more wipes by the garbage and I think she thought I was done and went to sit down and fell and her walker hit her in the face. Sent to (emergency room secondary to) laceration to mid forehead... This fall is less than 12 (hours) (sic), she has been getting more aggressive and angry at the staff (with) the redirections and the rules. She takes off the tag alarms and is very impulsive in actions. Does not follow instruction. Was with a new CNA and was confused on the verbage (sic). As she grabbing (sic) her walker she fell and the walker hit her in the forehead causing a laceration, sent to the (emergency room ) for 5 stitches. Will continue to treat (and) dress the wounds... (Physician) to come (and) see (resident)... Resident fell while CNA present (with) her. Very impulsive not following verbal cues. (Care Plan changed) to have chair readily available by sink at all times. Very forgetful (and) impaired sleep patterns. Some changes to meds to help impulsivity. Resident's shoes to be changed due to (right) foot scizzoring (sic). Family to bring in better supportive shoes." * 3/1/11 RAR - Safety/Risk: Fall 2/18/11. Plan of Care: As written. * 3/21/11 at 2:15 AM EVENT- fall in resident's room - "Bed alarm sound - staff to room found resident on floor in sitting position a couple of feet from the bed towards the bathroom - walker was tipped over in front of her. None of the staff had heard any type of crash sound (like a walker would have made tipping over)... (Resident) is very impulsive and also attention getting. Staff and nurse feel like this could have been the (resident) sitting on the floor herself and laying her walker down to look like a fall. (Resident) showed no injury or anxiety. All alarms were in place (and) worked. She falls (frequently), usually (with) no injuries. Safety mechanisms in place (bed alarm, landing pads), call light was in reach and not used. Resident is impulsive and forgetful (due to) dementia." * 3/22/11 NN - "Resident not cognasant (sic) of her impulsivity. Safety monitor in place. Many verbal cues given to resident today for safety." * 3/28/11 at 2:15 PM EVENT - fall in resident's room - "Was on her way to her room to use the facilities. CNAs to follow. In the door way of her room her (left) foot turned inward (and right) foot hit it in forward motion (and) caused the fall. Landed on buttocks... (Resident) gets up out of chair and was walking (with) walker to room to use the facility. Her (left) foot turns inward and as the (right) foot is in motion forward it hits the (left) foot and she falls. When the CNA reached the door she was sitting on the floor and she said, 'that damn foot is in the way'... Landing pads on floor at bedside. (Resident) is frequently falling and is on the list to be seen by... nurse practicer for (medication) review." * 4/6/11 at 6:30 PM - fall at nurse's station - "Went to walk away from nurse's station and tripped over her own feet... Continues to be very impulsive, self centered, asking repetitive questions. Tag alarm (and) bed alarm are all on. Her time frame, even when looking at the clock, is so small (sic). She is (up and down) quickly. Her (left) foot turns in (and) when her (right) foot pulls (through) she trips easily." * 5/12/11 at 6:15 PM EVENT - fall in the day room - "Sitting in big green chair in day room and impulsively decided to stand up. She did not ask for any help. As she stood she knocked over her walker and she fell to the floor with it. She was laying on her (left) side... she stated, 'I'm not hurt.' She was picked up by 2 assist and sat back in her chair after complete (exam)... Resident is very impulsive. Upon interview she remembers she thinks she 'got up too fast.' Resident has a history of low (blood pressure)... No big changes in (blood pressures). Resident apparently moved faster than her walker and tumbled over it. Staff will prompt her to dangle and move carefully (and) purposefully." * 5/17/11 RAR - Change in Condition/other Concerns: Fall - impulsive, using FWW - good supportive shoes. Safety/Risk: Fall. Continue to do frequent observation to maintain her safety. Plan of Care: As written. * 5/24/11 RAR - Change in Condition/other Concerns: Fall frequency. Safety monitor PRN. Plan of Care: As written. * 5/25/11 NN - "Quarterly changed to significant change related to improvement in her ADL ability going from limited to supervision in her ambulatory ability... Her behaviors during the look back time improved as evidenced by (no) symptoms of behaviors either physical or verbal or directed towards self. Reasons for her improvement due to medication changes.... Decline in her ability to recall (due to) confusion caused by her dementia process. Will complete new POC for her (due to) an over all improvement in her functional ability, mood (and) behaviors." * 5/30/11 at 2:20 PM EVENT - fall in resident's room - "Resident ambulated (with) walker from day room to room to get cookies, turned on landing pads beside bed (and) fell to knees... (Resident) turns (with) her walker and her feet don't move. Therefore when her walker goes, she falls. Her walker got stuck on landing pads causing her to go to her knees. Her (doctor) wants her to stay as mobile and independent as (possible). She has better, more sturdy shoes now but she is still so very impulsive causing multiple falls." * 5/31/11 CCS - "During this look back time, (the resident) was found to have experienced a significant change in her condition. The change was for the best as far as what she is able to do for herself; she is independent on the unit, with supervision only, using her FWW. She continues to be very impulsive and falls frequently due to her decreased in (sic) safety awareness, scissor type gait with her right foot in particular, plopping down, into her chair, without looking where she is going to sit down and hitting the arms of the chairs. For this gait balance issue that she has, (a family member) did bring her in supportive tennis shoes with Velcro closure to avoid having shoe strings to trip over. Her chair was given extra padding in the dayroom and her gray chair in her room is to remain free of clutter so staff can grab it quickly in the event that (she) decides to sit down. Due to her falls possibly, she has required an increased usage of her pain medication. The MD is aware of this and there are no new order changes in relationship to this pain... She has experienced bruising due to her falls but there has not been any significant injury to her. (The resident) does work with the (Restorative Aide) program to prevent any decline in her physical balance and ability. Will provide her with a new POC and adjust it PRN as things change and or arise... (The resident) has had an improvement with her behaviors. She has been friendlier with less combative behaviors... There are no further concerns... at this time... (A family member) feels (the resident) is just existing - (encourage) to vary her visits/times." * 5/31/11 NN - "After care conference daughter voiced concern over (amount) of pain med she's needed this past month... multiple falls bruising as results. Message left on answering machine at (physician's) office... (No) new orders (at) this time." * 6/2/11 at 5:15 PM EVENT - fall in hallway by nurse's station - "Was attempting to turn herself around to return to her chair in dayroom... tripped over her (right) foot with the left foot. fell on to her (right) side... (Physician) ordered a Physical Therapy (evaluation) for her feet turning inward (and) stability (and) balance. She is so very impulsive in ambulation that she falls a lot. Also (physician) ordered a (urinalysis) for (culture and sensitivity) in case she might have a (urinary tract infection) and contribute to her behaviors. Chronic scizzoring (sic) gait. (Physical Therapy) to assess if this is a physical or cognitive change." * 6/8/11 at 12:30 AM EVENT - fall in resident's room - "Had set her bed alarm off and asked to go to the bathroom. I took her, put her back to bed and came back to the nurse's station. Not 3 minutes later her bed alarm went off again and when I entered the room she was sitting on her landing pad with a big bump on her head. (Resident) stated, 'I was getting up to shut my door and I fell and hurt myself'... Confusion (with) recent (urinary tract infection) and on (antibiotics). Call light was in reach (and) resident did not remember to use it. She had just been checked and toileted. When interviewed resident states, 'I forgot my buzzer." Resident has history of impulsive behaviors. Hit back of head on bed when she fell . She was found sitting on landing pad. Reminded to use call light or 'buzzer' when she needs help." * 6/30/11 at 7:45 PM EVENT - resident fell while ambulating in the facility with her family member. No further information. * 6/30/11 Physician's Note - "She is still able to kind of get up and walk with her walker although when she is walking in the middle of the night she is at a littler higher fall risk." * 6/30/11 NN - "Resident fell while ambulating (with) her daughter while in her room... Fall precautions in place including bed alarm, bed in (low) position, landing pads in place, call alarm within reach." * 7/8/11 NN - "Resident a bit aggitated (sic) tonight (due to) use of gait belt (and) the loss of independence, she had to be encouraged to be careful, she was standing frequently at her chair in the day room." * 7/8/11 at 5:30 AM EVENT - fall in resident's room - going to/from bathroom - dizzy - unsteady gait - reaching/leaning. "After resident stood she said she felt dizzy and hit her face in (sic) the wall... CNA to be (with) resident during all of (bathroom) time. (Frequent) reminders... CNA to be (with) resident at all times during and after bathroom use. She is so very impulsive that she just pops up off the toilet or chair (and) then becomes dizzy or woozy. Monitor (blood pressure) daily for (fluctuations). Supervise (and frequent) cueing for 'how she feels' and 'dizziness'." * 7/8/11 at 11:30 AM EVENT - Fall in the day room - ambulating - found on floor - witnessed by staff - assisted by staff - loss of balance. "History of falls with and without injury. All safety mechanisms in place and on care plan. Resident needs (cueing) for compliance. Recent (Physical Therapy) evaluation - no new recommendations. Continue work (with restorative aide) for strengthening of scissoring gait (and left) foot cross-over. Resident very impulsive and cognitive deficits... Unsure, resident does her own thing regardless (of cueing). Keep near nurse's desk for supervision. * 7/8/11-7/11/11 - 3 separate Social Services Referals (SSR) were made related to the resident's standing without assistance or gait belt, falls, self transfers, and refusals to allow the CNAs to use a gait belt. The Social Services Assistant (SSA) responded: - "Due to recent fall she needs to have (stand by assistance) of (1 with) all ambulation despite the fact that she's unhappy (with) this. DON aware of above. Frequent reminders of fall prevention." - "(The resident) received follow up X-rays, MD aware. She is having (decreased) safety awareness and (increased) impulsivity. Staff will monitor for further (signs and symptoms) of injury and (increased) pain." - "Dementia is progressing and she is becoming more impulsive and less aware of her safety. Staff will continue to monitor her and she may need to start using a wheelchair." * 7/11/11 at 9:53 PM EVENT - Fall in the day room - found on floor - ambulating - witnessed by staff - assisted to floor - loss of balance. "Lost balance, got (up after) being told to please stay seated until a CNA could assist her to bed... Xray done of her spine (and) pelvis which results are negative for any injury. (Restorative Aide) continue to work (with resident) ambulating techniques and (with Physical Therapy) about her turned in (left) foot. After sleep meds given more supervision needed. Constant cueing and reminders to remind (resident) to follow directions." * 7/14/11 at 12 PM EVENT - fall in dining room - witnessed by staff - assisted to floor. "Was trying to sit in her chair at the dining table and missed the edge of the chair. Assisted to the floor by CNAs. No fall. Assist of CNAs for all sit downs and ups to a chair. More close attention to supervision... (Resident) is so impulsive and she stands up instantly and then tries to sit right down and backs up to chair (and) thinks she can just sit down. Care planned added (sic) for supervision of CNA to supervise all sit downs (and) ups then follow care plan." * 7/15/11 NN - "(Increased) falls since Ambien initiated. Will monitor sleep patterns and safety (and) report to MD. Resident remains ritualistic, impulsive and determined to have things her way; being unaware of safety concerns or limits." * 7/22/11 at 5 PM EVENT - fall in the day room - ambulating - going to/from bathroom - from chair - witnessed by staff. "Observed (resident) getting up from chair, using walker, tripped over feet and fell hitting head on wall, landing of (sic) (left) wrist. Resident placed in w/c, unable to use walker (due to left) wrist pain... Resident's ambulation continued problem. Placed in w/c for safety. Continues (with) impulsive behaviors, forgetful. At view of nurse's desk... Ambulation no longer safe. Very impulsive, forgets to ask for assistance. Unsteady balance. (Physical Therapy) has recently evaluated... Resident continues to be impulsive (and) noncompliant (secondary) to dementia and advancement of (sic). (Care Plan) was in place to address safety issues, but resident unable to comply (with) plan. We will place in w/c (with) tag alarm in day room during the day for (increased) safety." Every event report documented: "Interventions implemented immediately to prevent further problems," "Long term plans, recommendations to prevent new occurrences and safe environment present," and "Care Plan addendum added." * 7/22/11 Radiology Report - "Patient fell today and injured left wrist. She has wrist pain... Comminuted fracture of the distal radius with some impaction, as well as lateral displacement of fracture fragments. Fracture lines extend into the radiocarpal joint. Undisplaced fracture of the ulnar styloid. Widening of scapholunate interval consistent with ligamentous disruption. Fracture of the waist of the scaphoid bone not excluded." * 7/22/11 NN - "(Up) to void, grimacing, (complains of) pain." * 7/23/11 NN - "Resident (up) in w/c. (Complains of) pain in (left) hand." * 7/24/11 NN - "(Resident) up w/c. (Complains of) pain to (left) wrist. * 7/25/11 NN - "Pain controlled (with) PO PRN meds (and) ice pack. Has been requiring 2 max (assist with) transfer - not using legs to help stand during transfers." * 7/25/11 NN - "Remains impulsive (with) very poor safety awareness. Tag alarm (and) bed alarm in place." Fall Risk Evaluations, in which a score of 10 or higher indicates risk for falls were completed and documented scores of 15-26 on 7/28/10, 7/29/10, 8/28/10, 8/30/10, 9/14/10, 9/25/10 , 11/3/10, 11/7/10, 12/3/10, 12/7/10, 2/12/11, 2/17/11, 2/18/11, 2/28/11, 3/4/11, 3/21/11, 3/28/11, 4/6/11, 4/9/11, 5/12/11, 5/24/11, 5/30/11 (twice), 6/2/11, 6/8/11, 6/30/11, 7/8/11, 7/11/11, 7/14/11, and 7/22/11. The resident's medical record contained many Social Services Referrals (SSR), reporting physically abusive behavior, insomnia, resisting care, verbally abusive behavior, and persistent anger. SSA responses included: "Consider removing tag alarm completely (and) staff to (check) on her activity every 30 minutes to maintain her safety. Remains high fall risk (due to) behaviors, decrease (sic) safety awareness, (increased) dementia (and) impulsive." The resident's July 2011 Medication Record had 5 informational stickers adhered to it, which documented side effects including: * Antidepressants: sedation, drowsiness, blurred vision, urinary retention, muscle tremor, and agitation. * Antipsychotic: sedation, drowsiness, blurred vision, extrapyramidal reaction, postural hypotension, urinary retention. * Hypnotics: sedation, drowsiness, morning hangover, ataxia "(drunk walk)". NOTE: Although the resident was documented to be at high risk for falls, had frequent Fall Risk Evaluations and SSR, and had warnings of medication side effects on her Medication Record; was frequently reviewed by the RAR Committee, and documented to be impulsive and have multiple falls, her Plan of Care was not adequately updated with relevant and effective interventions when the interventions already in place were demonstrated to be ineffective in protecting her. Each of the RAR notes documented that the Plan of Care was to be continued, "as written." The DON and Administrator were informed of the findings on 7/27/11 at 3:40 PM. No further information was received from the facility. 2. Resident #2 was admitted to the facility on [DATE], with diagnoses which included supranuclear palsy, anxiety, depression, pain, constipation, incontinence, and peripheral neuropathy. The resident's 7/15/11 Significant Change MDS assessment coded: * Cognitively intact * Highly impaired vision * Extensive assistance by 2 or more staff for bed mobility, transfers, walking in room, and toilet use * Extensive assistance by 1 staff for locomotion on and off unit, and dressing * Limited assistance by 1 staff for eating and personal hygiene * Not steady and only able to stabilize with human assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfers * Functional impairments of upper and lower extremities on both sides * Walker and wheelchair used for mobility * Frequently incontinent * Two or more falls without injury since admission or prior assessment * Antipsychotic, antianxiety, antidepressant, and diuretic medications administered in prior 7 days * Hospice care * Bed rails used in bed, daily * No signs or symptoms of swallowing disorder * Mechanically altered diet CAAs associated with the 7/15/11 Significant Change MDS assessment documented: * "The noticeable change here is that his balance is not like it had been previously and staff are providing more and more of the weight bearing support." * "(The resident) continues to believe that he can

Based on observation, interview and record review, it was determined the facility failed to ensure pain was adequately assessed, treated and care planned and that interventions were implemented for bowel care for 2 of 10 sampled residents (#s 1 & 6.) The lack of assessment and intervention resulted in harm to Resident #1 who experienced pain, contributing to a decline in function. Interventions were not implemented as ordered for Resident #6's bowel protocols. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's 4/11/11 annual MDS assessment documented the resident required limited assistance with personal hygiene and bed mobility, was always continent of bowel and bladder, and experienced no shortness of breath when lying flat. Mood indicators all were marked "0", assessing the resident did not experience; little interest or pleasure, feeling down, depressed or hopeless, tired, little energy, poor appetite. Use of a walker and wheelchair were documented. No frequency of pain was documented. A 7/11/11 significant change MDS assessment document the following: Mood - little interest or pleasure, feeling down, depressed or hopeless, tired, little energy, poor appetite. Pain - frequent moderate pain, no scheduled pain medications, no non-medication interventions for pain. The assessment also documented a decline in the resident's ability to participate in personal hygiene and bed mobility, requiring extensive staff assistance. The resident was also assessed as being occasionally incontinent of urine, and only a wheelchair was documented as being used by the resident. Care Area Assessment Documentation Notes (CAA) corresponding to the pain category, dated 7/13/11, stated "(Resident #1) complains of moderate pain usually on a daily basis. She does have prn (as needed) medications that when it is given this medication is effective against the different types of pain she can have. At this point, when she was asked about where her pain is, she just says "all over". She is having a decrease in her appetite, frequent tearfulness when speaking of past and present events in her life, she is no longer coming out of her room and joining in the daily activities of the unit. She is requiring more staff extensive to dependency with her ADL's on a daily basis. Refusing to ambulate using her FWW(front wheel walker) to and from meals like she had been doing in the past. She is wanting to stay in her bed and withdraw from others more but she continues to want staff to come into her room and visit her. There are no referrals in this area for her at this time. The MD has been made aware of her pain level, use of her prn pain medications and it is his desire not to have her receive any scheduled pain medication and that she can ask for pain meds as she needs it." The CAA for Falls documented in part, "...Last quarter she was able to ambulate with her FWW and staff assistance and now she is no longer ambulating due to increased weakness, respiratory distress with minimal effort even with the use of her oxygen at 2L/NC(2 liters via nasal cannula), which resolve after she is able to rest..." The CAA for Functional/Rehabilitation Potential documented in part, "...(Resident) #1 has changed over this past quarter significantly per the MDS. She is now requiring extensive assistance from staff with the majority of her ADL's...She has also stopped the ambulation of 5 - 10 feet that the RA staff were attempting to provide her with." Physician Orders, recapitulation, for 7/1/11 - 7/31/11 document the use of the following medications: [REDACTED] [MEDICATION NAME] SR 150 mg by mouth daily for depression. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg 1 tablet by mouth 4 times daily prn for anxiety. [MEDICATION NAME] 10/325 (325 mg [MEDICATION NAME] with 10 mg [MEDICATION NAME], narcotic [MEDICATION NAME]) by mouth every 4 hours prn for pain. Start date 2/23/11. Medication Administration Records (MAR) were reviewed for the months of 3/11 - 7/11. The front of the MAR indicated [REDACTED]. The back of the form had lines to document each dose of prn medication administered, including the reason for the medication and the effectiveness, as assessed after administration. The following prn medication administration and effectiveness were noted: 3/11 [MEDICATION NAME] - 41 doses documented as given on the front of the MAR. Of the 41 doses given, 33 doses were documented on the back of the MAR. Of those 33 doses documented, no documentation of effectiveness was present for 8 doses. [MEDICATION NAME] - 33 doses documented as given on the front of the MAR. 31 doses documented on the back. Of the 31 doses documented, no effectiveness documented for 6 doses. 4/11 [MEDICATION NAME] - 37 doses given as documented on the front of the MAR. Of the 37 doses given, 36 documented on the back of the form. No effectiveness documented for 6 doses. [MEDICATION NAME] - 34 doses documented as given on the front of the MAR. 32 doses documented on the back. No effectiveness documented for 7 doses. 5/11 [MEDICATION NAME] - 35 doses documented on the front of the MAR. 33 documented on the back. No effectiveness for 6 doses. [MEDICATION NAME] - 29 doses documented on the front 26 doses documented on the back No effectiveness documented for 2 doses. 6/11 [MEDICATION NAME] - 38 doses documented on the front of the MAR 36 doses documented on the back No effectiveness documented for 4 doses. [MEDICATION NAME] - 29 doses documented on the front of the MAR. 26 doses documented on the back No effectiveness documented for 2 doses. 7/1/11 - 7/26/11 [MEDICATION NAME] - 23 doses documented on the front of the MAR 21 doses documented on the back No effectiveness documented for 5 doses. [MEDICATION NAME] - 25 doses documented on the front of the MAR 20 doses documented on the back No effectiveness documented for 6 doses. Of the 174 doses of [MEDICATION NAME] for pain documented as given, the effectiveness of 44 doses was not documented. Of the 150 doses of [MEDICATION NAME] for anxiety documented as given, the effectiveness of 38 doses was not documented. These numbers indicated that approximately 25% of the medications given were not assessed for effectiveness. The MAR indicated [REDACTED]. The monitor stated "Monitor for pain q(every) shift (+) intact (-) not intact." For the months reviewed, 3/11 - 7/26/11, every monitor contained a combination of entries, some staff using the "+" "_" symbols to indicate pain presence/absence, and some entries using a number, 1-10, to indicate the severity of the resident's pain. Assessments of the resident's pain were not documented as having been conducted for: 3/11 - 8 shifts 4/11 - 11 shifts 5/11 - 5 shifts 6/11 - 12 shifts 7/1 - 7/26/11 - 12 shifts Quarterly Pain Assessment Updates were reviewed and revealed the following information: 10/19/10 - "Rates pain 5/6 out of 1/10...pain mostly in her back." Daily, moderate pain was documented. 1/17/11 - "MD asked about scheduling pain med but he refuses (at) this time...will continue to observe effectiveness 2(hours) to (sic) [MEDICAL CONDITION]." No pain level or frequency documented. 7/13/11 - "[MEDICATION NAME] used at least daily...pain continues to be all over in nature." Daily, moderate pain was documented. On 7/25/11 at 9:35 a.m. the resident was observed in bed in her room. When asked how she was feeling, she complained of discomfort and stated, "I could use another pill." The LN was informed and came into the room to speak with the resident. She informed the resident it was too early for another pill. The LN assisted the resident to reposition, spoke soothingly to her and left the room. The resident was observed again at 10:25 a.m., at which time she appeared to be resting comfortably in bed. According to the MAR, The resident had been medicated for pain with [MEDICATION NAME] and anxiety with [MEDICATION NAME] at 8:00 a.m. on 7/25/11. The effectiveness of the medications was not documented for either medication. On 7/26/11 at 12:00 noon the resident was observed seated in front of the television in her room with the over bed table in front of her. Reading materials were on the table. When asked how she was feeling, the resident stated she felt too sick to talk and that she "hurt all over." She then requested to be put back to bed. A staff was summoned to assist her. According to the MAR, the resident had been medicated for pain and anxiety at 7:45 a.m. The effectiveness of the medications was not documented. Despite the resident's complaints of pain at 12:00 noon, more than 4 hours after her last dose of pain medication, no further pain medication was documented as having been administered for the remainder of the day. The following Behavioral/Psychopharmacological Review reports were reviewed and revealed the following: 9/23/10 - "PRN [MEDICAL CONDITION]/s: [MEDICATION NAME] 0.5mg QID(4 times daily) PRN." Resident target behaviors were listed as sadness, tearfulness, feelings of helplessness, periods of weakness, very anxious in the AM and PM. 4/7/11 - "PRN [MEDICAL CONDITION]/s: [MEDICATION NAME] 0.5mg 1 tab QID PRN for anxiety." The committee recommendation to the physician was to request the [MEDICATION NAME] 0.5 mg be given routinely, twice daily, because she was taking it consistently twice a day. The physician wrote in response, "Please quit asking the same question over + over again. The [MEDICATION NAME]/[MEDICATION NAME] prn. Per client she doesn't ask for it, she will not get it which will be fine." The date of the physician signature was 5/20/11. Resident #1's current Plan of Care, dated 4/12/11 and updated 7/11/11, failed to identify pain as an area of concern and contained no plan for the resident's pain management. Pain was not identified as an issue in any other areas of the plan, including health maintenance, physical function or depression. The Plan of Care did identify the problem of mood related to her anxiety and depression. Interventions by nursing included "Review frequency/effectiveness of PRN medications." The DON was interviewed on 7/27/11 at 11:00 a.m. The DON was informed of the following issues: * The resident's Plan of Care did not include interventions to address pain. * The MDS identified pain as a concern but the CAA didn't recommend care planning for it. * Pain monitoring was incomplete and inconsistent, with some staff using "+/ -" and some a numeric pain scale. * Medication administration and effectiveness for both pain and anxiety were inconsistantly documented. * No comprehensive plan in place for non-pharmacological interventions to address pain and anxiety from air hunger. The DON confirmed the identified issues as being present. A discussion ensued about the resident's relationship with her physician, and the IDT's (interdisciplinary team) efforts to problem solve issues. The DON stated Hospice services had been discussed with the resident in the past, but the physician did not recommend it, so the resident declined. The DON also stated the discussion should be held again, as the resident's abdominal aortic aneurism had recently grown larger. On 7/27/11 at 3:00 p.m. the MDS coordinator provided the surveyor with a copy of a generic pain care plan. The plan did not contain a resident name, and the MDS co-coordinator stated it was one she could use. She further stated Resident #1's care plan had not been updated with the most recent significant change MDS because, "The Dr. didn't make any changes to her med(ications)s." A short time later, the MDS co-coordinator provided a copy of the resident's previous Plan of Care for pain, dated 4/12/10. The only pain related plan was in relation to the 2/23/11 extraction of 4 teeth. The problem was documented as having resolved on 4/1/11. The facility failed to address Resident #1's pain and anxiety with a comprehensive plan of care incorporating both pharmacological and non-pharmacological interventions. Without the use of a consistent pain assessment/monitoring system, the resident's pain levels could not be adequately evaluated. An accurate assessment of the effectiveness of current medications for pain and anxiety could not be obtained due to the lack of effectiveness documentation for the medications. The facility's failure to consistently evaluate Resident #1's daily, moderate pain, to develop interventions to address pain to the greatest extent possible, and to monitor the effectiveness of interventions resulted in harm to the resident, as demonstrated by the decline in both physical and psychosocial function. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 2/12/11 Admission MDS assessment coded: * Moderately impaired cognition * Extensive assistance by 1 staff for dressing and personal hygiene * Extensive assistance by 2 staff for toilet use * Always incontinent of bladder and bowel The resident's 5/9/11 Quarterly MDS assessment coded: * Severely impaired cognition * Total dependence on 2 or more staff for toilet use * Extensive assistance by 1 staff for dressing and personal hygiene * Always incontinent of bladder * Frequently incontinent of bowel CAAs associated with this assessment documented: * "Will proceed to her plan of cares for toileting, use of adult briefs/pad on her bed, hygiene and clothing management." * "Will proceed to her plan of cares for ADL support." Resident #6's February 2011 Plan of Care did not initially address her bowel care or constipation. On 6/3/11, "Constipation risk" was added with the goal, "Will have BM (bowel movement) every 3rd day." Interventions were, "Start of facility bowel care PRN (as needed). (Encourage) fluids - likes ice water (at) care times. Observe for any (gastrointestinal) distress. Accurately (sic) charting of BMs." The resident's July 2011 Physician order [REDACTED]. * [MEDICATION NAME] 1 packet PO (orally) daily for constipation, started 2/7/11 * Bowel care protocol: 1) if no BM in 3 days give [MEDICATION NAME] S 2 tabs PO. 2) If no BM in 4 days give [MEDICATION NAME] S PO TID (three times daily). 3) If no BM in 4 days do rectal exam. If resident is impacted, call MD; if not impacted give [MEDICATION NAME] (suppository) PR (per rectum). In 1 (hour) if no results give Fleets enema. If no results, call MD. - started 6/3/11 * [MEDICATION NAME] suppository PR 1 daily PRN for constipation CNA Flow Sheets documented that Resident #6 did not have a bowel movement for greater than 3 days during the following periods: * April 23-27, 2011 (5 days) * May 19-22, 2011 (4 days) * May 26-29, 2011 (4 days) * June 15-18, 2011 (4 days) Medication Records documented that PRN bowel medications and/or the bowel care protocol medications were not administered as ordered for constipation during the listed times when the resident exceeded 3 days without a BM. The DON and Administrator were informed of the findings on 7/27/11 at 3:30 PM. No further information was received from the facility.