Every finding on record at St Lukes Home

Based on observation, policy review, and staff interview, the facility failed to follow infection control standards for 3 of 5 sampled residents (Resident #7, #12, and #71) observed during cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to spread infections throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/16/26. This policy, revised on 04/22/26, stated, . Staff will perform hand hygiene . using proper technique consistent with accepted standards of practice . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE) . Before and after handling clean or soiled dressings . Before performing resident cares . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site . After assistance with personal body functions . - Observation on 06/14/26 at 11:40 a.m. showed a nurse (#5) entered Resident #71's room, performed hand hygiene, and applied PPE. The nurse applied the prescribed medication patches to the resident's back, removed the gloves, and without performing hand hygiene, applied new gloves. The nurse removed a dressing from the resident's abdominal area, removed the soiled gloves, and without performing hand hygiene, applied clean gloves. Resident #71 asked the nurse for gloves; the nurse supplied the gloves the resident applied them. The nurse failed to offer or assist the resident with hand hygiene. The resident assisted the nurse to cleanse the wound and asked for a cotton swab. The nurse sprayed the swab with cleaning solution and the resident cleaned around the wound wiped wound debris on a facial tissue from the swab, and repeated the process. Resident #71 removed the soiled gloves. The nurse failed to assist or encourage the resident to perform hand hygiene. The nurse (#5) removed his/her soiled gloves, applied clean and applied a clean dressing to the residents wound. The nurse failed to perform hand hygiene between glove changes. During an interview on 06/16/26 at 7:03 a.m., an administrative staff member (#8) confirmed staff are expected to complete hand hygiene between glove changes and the nurse should have offered hand hygiene to resident#71. - Observation on 06/14/26 at 11:53 a.m. showed two certified nurse aides (CNAs) (#2 and #3) transferred Resident #7 from the bed to the wheelchair utilizing a full body mechanical lift. Following the transfer, the CNAs (#2) exited the room with the lift and placed it in the hallway alcove. The CNA (#2) failed to perform hand hygiene prior to exiting the room and failed to sanitize the lift. -Observation on 06/16/2026 at 1:44 p.m. showed a CNA (#4) enter Resident #12's room, completed hand hygiene, applied clean gloves, and transferred the resident from a wheelchair to the toileting utilizing a mechanical sit to stand lift. The CNA (#4) provided perineal care, and without removing the soiled gloves and completing hand hygiene, the CNA applied a clean brief, pants, and shoes, adjusted the resident's hands on the lift, and transferred the resident from the toilet to the wheelchair. During an interview on 06/17/2026 at 1:33 p.m., an administrative staff member (#1) confirmed nursing staff are expected to remove gloves and complete hand hygiene after completing perineal care and moving to a clean task. - Observation on 06/14/26 at 12:25 p.m., showed two unidentified staff members passed the noon meal to residents. Two staff members delivered drinking glasses to residents by touching the rims with their bare hands. The staff members failed to hold the drinking glass from the body of the glass. During an interview on 06/16/26 at 2:40 p.m., an administrative staff member (#7) confirmed staff are expected to pass glasses by holding onto the body of the glass.

Based on record review and staff interview, the facility failed to ensure the attending physician documented his/her rationale for continued use of a psychotropic medication for 1 of 5 sampled residents (Resident #3) reviewed for drug regimen. Failure to provide a rationale for continued use of an antianxiety medication may result in Resident #3 receiving an unnecessary medication and/or experiencing adverse consequences related to its continued use. Findings include: The facility failed to provide a copy of their policy addressing unnecessary medications per request. Review of Resident #3's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, anxiety, dementia with psychotic disturbance including hallucinations, and depression. Current physician's orders included an order for Buspirone (an antianxiety medication) 7.5 milligrams (mg) twice daily. The monthly pharmacy reviews for 01/05/26 showed the pharmacist identified/recommended an annual gradual dose reduction (GDR) for Resident #3's Buspirone. The attending physician failed to provide a rationale for the continued use of the medication and stated, Rejected. Need to continue. During an interview on 12/05/19 at 8:30 a.m., an administrative nurse (#1) confirmed the provider failed to provide a rationale for the continued use of Buspirone.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 3 of 6 supplemental residents (Residents #62, #68, and #77) observed during medication administration. Three medication errors occurred during staff administration of 37 medications, which resulted in an eight percent error rate. Failure to follow facility policy and failure to ensure correct labeling of medications may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Insulin Pens occurred on 06/16/26. This policy, dated 04/28/25, stated, . 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. h. Prime the insulin pen: . With the needle pointing up, push the plunger, and watch to that at least one drop of insulin appears on the tip of the needle. -Observation on 06/14/26 at 12:33 p.m. showed a nurse (#5) prepared an insulin pen for Resident #77. The nurse dialed two units of insulin, removed the cap, and primed the pen horizontally. -Observation on 06/14/26 at 12:40 p.m. showed a nurse (#5) prepared an insulin pen for Resident #62. The nurse dialed two units of insulin, removed the cap, and primed the pen downwards. The nurse (#5) failed to prime Resident #77 and #62's insulin pens correctly. -Observation on 06/15/26 at 8:50 a.m. showed a medication aide (MA) (#6) prepared a medication for Resident #68, labeled, ARIPIPRAZOLE 15 MG [milligrams] TAKE 1/2 [one half] TABLET (7.5 MG) BY MOUTH EVERY NIGHT AT BEDTIME. The MA explained staff administer the medication in the morning and could not explain why the label identified bedtime. The physician's order, dated 04/14/26, stated, GDR [gradual dose reduction] decrease Aripiprazole from 10 to 7.5 mg QAM [every morning]. Facility staff failed to clarify the pharmacy label. During an interview on 06/15/2026 at 1:52 p.m., an administrative staff member (#1) confirmed the nursing staff are expected to address the label error with the provider or the pharmacy and agree facility staff primed the insulin pens incorrectly.

Based on observation, review of facility policy, and staff interview the facility failed to follow standards of infection control for 1 of 4 sampled residents (Resident #62) observed for morning cares. Failure of staff to perform hand hygiene after removing gloves has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 04/10/25. This policy, revised 10/30/24, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Observation on 04/08/25 at 10:09 a.m. showed Resident #62 resting in bed wearing oxygen per nasal cannula and his upper denture sitting on the over the bed table. Two certified nurse aides (CNAs) (#1 and #2) entered the resident's room, performed hand hygiene, donned gloves, assisted the resident to sit on the edge of the bed, placed a gait belt, and transferred the resident from the bed to the wheelchair, and onto the toilet. The CNA (#1) removed Resident #62's wet incontinence brief and changed the resident's pants. The CNAs (#1 and #2) assisted the resident to stand, applied a new brief, pulled up the resident's pants, and transferred Resident #62 to the wheelchair. The CNA (#2) removed her gloves and washed her hands. The CNA (#1) removed her gloves, and without performing hand hygiene, transferred the resident from the bathroom to bed via wheelchair while holding the resident's oxygen tubing in her hands. The CNA (#1) donned new gloves, removed the gait belt, oxygen cannula, and Resident #62's shirt. The CNA (#1) washed and dried the resident's face and upper body and applied a clean shirt. The CNAs (#1 and #2) assisted Resident #62 to lay on the bed. The CNA (#1) opened the resident's brief, performed perineal cares, closed the brief, and pulled up the resident's pants. The CNA (#1) removed her gloves, and without performing hand hygiene, assisted the resident to sit on the edge of the bed, applied the gait belt, raised the bed, and with CNA (#2) transferred Resident #62 from the bed to the recliner. The CNA (#1) removed the gait belt, made the resident comfortable in the recliner, assisted with a drink of water, adjusted the resident's oxygen cannula, and with a tissue, removed the dentures from the table, and placed them in a denture cup. The CNA (#1) gathered the garbage and soiled linens, exited Resident #62's room, and entered the soiled utility room. The CNA (#1) failed to perform hand hygiene after removing gloves, before touching other surfaces, and before applying new gloves, and failed to perform hand hygiene prior to exiting Resident #62's room. During an interview on 04/09/25 at 2:00 p.m., an administrative nurse (#3) confirmed she expected staff to perform hand hygiene after glove removal and before touching other surfaces, and prior to exiting resident rooms.

Based on observation and review of facility policy, the facility failed to promote privacy and confidentiality of medication administration records (MAR) on 1 of 2 Units (Badlands Unit) observed for medication administration. Failure to close the MAR may result in unauthorized viewing of resident records by other residents, unlicensed staff, and/or visitors. Findings include: Review of facility policy titled Confidentiality of Social and Medical Information occurred on 02/08/24. This policy, dated 10/15/17, stated, . The facility should keep confidential all information contained in a resident's records, regardless of the form of storage or location of the record, . Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure . Observation during medication administration on 02/07/24 showed the medication cart unattended with a resident's MAR visible on the screen during the following times: * 12:16 p.m. to 12:18 p.m. * 12:20 p.m. to 12:22 p.m. * 3:50 p.m. to 3:53 p.m.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/09/23. Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 4 sampled residents (Resident #7 and #51) reviewed with alarms. Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, Section P: Restraints and Alarms, page P-10, stated, . Identify all alarms that were used at any time (day or night) during the 7-day look-back period.Code 0, not used: . Code 1, used less than daily: . Code 2, used daily: . Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident's clothing. Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing. - Review of Resident #7's medical record occurred on all days of survey. The care plan identified a tab alarm for a fall/safety intervention, dated 09/15/23. The quarterly MDS, dated [DATE], identified in Section P, alarms not used. Observation on 02/06/24 at 7:23 a.m. showed Resident #7 in bed, and a certified nurse aid (CNA) (#2) removed a tab alarm from the resident's clothing. Observation also showed an alarm on Resident #7's bed and wheelchair. During an interview on 02/08/24 at 8:25 a.m., an administrative nurse (#1) confirmed staff failed to code the alarms in Section P of the MDS for Resident #7. - Review of Resident #51's medical record occurred on all days of survey. The care plan identified an alarm to the bed and chair for a fall/safety intervention, dated 10/27/23. The quarterly MDS, dated [DATE], identified in Section P, alarms not used. During an interview on 02/07/24 at 3:00 p.m., an administrative nurse (#1) confirmed staff failed to code the alarms in Section P of the MDS for Resident #51.

Based on observation, record review, review of standing orders, and staff interview, the facility failed to follow professional standards regarding physician's orders for 1 of 2 sampled residents (Resident #4) and 1 closed record (Resident #82) reviewed for insulin orders. Failure to follow the physician's order regarding notification of high blood sugar levels has the potential to result in adverse events. Findings include: - Review of Resident #4's medical record occurred on all days of survey. Medical diagnoses included Type 2 diabetes mellitus. Observation on 02/07/24 at 11:05 a.m. showed a nurse (#3) checked Resident #4's blood sugar with a glucose meter and obtained a result of 336 milligrams per deciliter (mg/dL). Review of the Medication Administration Record (MAR) for sliding scale insulin identified . Per Sliding Scale . Special Instructions: Call PCP [primary care provider] if Blood sugar greater than 300 [mg/dL] . During an interview on 02/07/24 at 3:07 p.m., the nurse (#3) who obtained Resident #4's blood sugar and administered the sliding scale insulin stated she did not notify the provider as she did not see on the order to call if over 300 mg/dL. Review of Resident #4's blood sugar results from 09/01/23 to 02/07/24 showed six times the blood sugar results were above 300 mg/dL. The medical record lacked documentation staff notified the provider of the blood sugar results over 300 mg/dL. - Review of Resident #82's medical record occurred on 01/08/24. Review of the resident's blood sugar levels showed the following: * 01/06/24 at 7:17 a.m. blood sugar 408 mg/dL * 01/06/24 at 11:38 a.m. blood sugar 404 mg/dL * 01/08/24 at 7:42 a.m. blood sugar 421 mg/dL Resident #82's undated physician standing orders stated, Diabetic Treatment . Blood Sugar > [greater than] 400 mg/dL notify the MD [medical doctor] by telephone. The medical record lacked physician notification of the blood sugars over 400 mg/dL. 13101

Based on record review and staff interview, the facility failed to ensure residents' records contained the hospice election form for 2 of 2 sampled residents (Resident #72 and #189) receiving hospice services. Failure to obtain this document limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: - Review of Resident #72's medical record occurred on all days of survey and identified the resident elected hospice services on 12/06/23. The medical record lacked the hospice election form. - Review of Resident #189's medical record occurred on all days of survey and identified the resident elected hospice services on 01/30/24. The medical record lacked the hospice election form. During an interview on 02/08/24 at 10:33 a.m., an administrative nurse (#1) confirmed the medical record lacked the hospice election form for Resident #72 and #189. 13101

Based on record review and facility policy review, the facility failed to provide the resident's representative with a completed notice of transfer for 3 of 4 sampled residents (Resident #11, #23 and #72) with hospital transfers. Failure to provide a written notice of transfer which included an appeal date does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy titled Transfer and Discharge . occurred on 02/08/24. This policy, dated 01/02/17, stated, . 2. f. A copy of the original notice must be given to the resident (sent to hospital with resident and other pertinent papers see letter d.), with a copy given to the resident's representative and a copy placed in the resident's medical record. A review of medical records showed the following residents were transferred to the hospital and received a Notice of Transfer of hospitalization /Emergency Transfer that lacked a date by which to appeal: * Resident #11 on 01/03/24 * Resident #23 on 10/11/23 * Resident #72 on 08/11/23 and 10/07/23. Resident #72's medical record also identified the resident representative gave verbal permission for the transfers however lacked evidence the representative received a copy of the notice of transfer.

Based on record review, review of professional reference, review of facility policy, and resident and staff interviews, the facility failed to follow professional standards for medication administration for 1 of 1 sampled resident (Resident #33) who experienced adverse side effects as a result of a significant medication error. Failure of staff to administer medications utilizing safe administration practices resulted in an adverse reaction to Resident #33's physical health/safety, and affected the resident's psychosocial well being. Findings include: Berman, Snyder, Kozier, and Erb's, Fundamentals of Nursing Concepts, Process, and Practice, 10th Edition, Copyright 2016 by Pearson Education, Inc., New Jersey, page 769-771, stated, . Before administering a medication, identify the client correctly using the appropriate means of identification . Errors can and do occur, usually because one client gets a drug intended for another. Review of the facility policy titled Administering Oral Medications occurred on 02/09/23. This policy, revised October 2010, stated, . Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. 6. Check the label on the medication and confirm the medication name and dose with the MAR [medication administration record]. 10. Confirm the identity of the resident. During an interview on 02/08/23 at 3:38 p.m., Resident #33 stated, About two weeks ago a nurse gave me the wrong medications and after about an hour I started feeling sick to my stomach, having trouble breathing, became very weak and when they checked my blood pressure it was very low, like 77 or 75 over 44. One nurse (#13) kept saying we need to get her to the ER [emergency room ] and another nurse (#15) said we need to get her laid down in bed. The resident told the nurses she did not want to go to the ER. I was very scared and I don't want to ever experience that again or want anyone else to experience it. The resident indicated she had to stay in bed the day of the incident and the day after because I was very weak and felt fuzzy. She admitted feeling very anxious now when taking her medications. Review of Resident #33's medical record occurred on all days of survey and showed a blood pressure of 75/44 on 01/24/23 at 8:57 a.m. A quarterly Minimum Data Set, dated dated [DATE], identified the resident as cognitively intact. Review of the facility's incident report, dated 01/24/23, showed on 01/24/23 at 8:00 a.m. staff administered the wrong medications to Resident #33. Incorrect medications included the following: * Venlafaxine 150 milligrams (mg) (antidepressant) * Keflex 250 mg (antibiotic) * Carvedilol 25 mg (high blood pressure medication) * Isosorbide 24 hours [extended release] 30 mg (heart medication/high blood pressure medication) * Losartan 100 mg (high blood pressure medication) * Pantoprazole 40 mg (anti-reflux medication) The incident report stated a nurse (#13) . grabbed the . medications (sic) were sitting in (sic) side table, handed resident her medication cup, once she handed it back I noted the cup had a different resident and room # [number] written on the side. The incident report identified another nurse (#14) pre-dished the medications and left the wrong medications in Resident #33's room on the bedside table. Staff failed to administer medications utilizing safe administration practices and resulted in Resident #33 experiencing a hypotensive reaction (low blood pressure), weakness and trouble breathing. Resident #33 reported experiencing increased anxiety since the incident. During an interview on 02/09/23 at 7:51 a.m., an administrative nurse (#2) confirmed Resident #33 as cognitively intact, and stated, The resident recalls the events of the incident/medication error accurately. The nurse (#2) confirmed only the two nurses who were involved in the medication error received verbal education at the time.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to notify the resident's physician of a change in condition for 1 of 1 resident (Resident #33) who experienced low blood pressure, weakness and shortness of breath. Failure to notify the physician of these changes may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notify of Changes occurred on 02/09/23. This policy, dated 04/21/22, stated, . The purpose of this policy is to ensure the facility promptly . consults the resident's physician; . when there is a change requiring notification. Compliance Guidelines: The facility must . consult with the resident's physician when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical . condition such as deterioration in health . During an interview on 02/08/23 at 3:38 p.m. Resident #33 indicated about two weeks ago a nurse gave her the wrong medications. The resident stated, Now I am very anxious about taking any medications. The resident stated, After about 1 hour after they gave me the wrong medications I started having trouble breathing, became weak and when they checked my blood pressure it was very low, like 77 or 75 over 44. It was very scary and I don't want to ever experience that again or anyone else to experience it. Review of Resident #33's medical record occurred on all days of survey. The medical record showed a blood pressure of 75/44 on 01/24/23 at 8:57 a.m. Review of the facility's incident report, dated 01/24/23, showed on 01/24/23 at 8:00 a.m. staff administered the wrong medications to Resident #33. Incorrect medications included the following: * Venlafaxine 150 milligrams (mg) (antidepressant) * Keflex 250 mg (antibiotic) * Carvedilol 25 mg (high blood pressure medication) * Isosorbide 24 hours [extended release] 30 mg (heart medication/high blood pressure medication) * Losartan 100 mg (high blood pressure medication) * Pantoprazole 40 mg (anti-reflux medication) The medical record lacked evidence facility staff notified the physician of Resident #33's low blood pressure, weakness and trouble breathing as a result of receiving the wrong medications on 01/24/23. During an interview on 02/09/23 at 9:25 a.m., an administrative nurse (#2) confirmed staff failed to notify the physician of Resident #33's low blood blood pressure and decline in physical health conditions. See F-760

42397 THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 09/02/21 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to complete Minimum Data Sets (MDSs) that accurately reflected the residents' status for 2 of 18 sampled residents (Resident #34, and #63). Failure to accurately code the MDS may negatively affect the development of comprehensive care plans and the care provided to the residents. Findings include: Section A: Identification Information The Long-Term Care Facility RAI Manual, revised October 2019, pages A-21 to A-23, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding instructions: Code 0, no, and skip to A1550 . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . - Review of Resident #34's medical record occurred on all days of survey. Diagnoses included schizoaffective disorder. The record showed a PASRR Level I completed on 09/21/21, followed by the referral and a completed Level II screening. The annual MDS, dated [DATE], showed section A1500 coded 0, as No, which resulted in the staff member failing to code section A1510. During an interview on 02/08/23 at 11:20 a.m., a social services staff member (#4) confirmed staff failed to correctly code A1500. Section N: Medication The Long-Term Care Facility RAI Manual, revised October 2019, pages N-6 to N-7 stated, . Steps for Assessment . Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period . N0410F, Antibiotic: Record the number of days an antibiotic medication was received by the resident at any time during the 7-day look-back period . - Review of Resident #63's medical record occurred on all days of survey. Diagnoses included open wound left foot and diabetes. A physician's order dated, 09/16/22, stated, Mupirocin ointment [a topical antibiotic ointment] 2 % Once a day, PRN [as needed] Amount to Administer - Apply Mupirocin ointment with dressing on left foot callous as needed. The quarterly MDS dated [DATE], identified seven days of antibiotic use in section N0410F. The medication administration record (MAR) dated 11/26/22-12/02/22 lacked documentation of administration of an antibiotic during the 7-day look back period. During an interview on 02/09/23 at 8:54 a.m., an administrative nurse (#3) agreed the MAR lacked documentation of an antibiotic administration and staff failed to correctly code N0410F.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 6 residents (Resident #22 and #46) observed during medication pass. Three medication errors occurred during staff administration of 28 medications, resulting in a 10% error rate. Failure to ensure medications are administered correctly may result in an adverse side effects. Findings include: Review of the facility policy titled Use Of Insulin Pens occurred on 02/09/23. This policy, dated 12/14/16, stated, . Insulin pens will be prepared and primed prior to actual dose administration to ensure expelling of air and accuracy of dosage . After needle is in place, do an air shot before injection . To perform air shot do the following . Dial two units . Hold syringe with needle pointing up and tap reservoir gently to remove air bubbles to tip of needle . Press the push button on syringe . until a drop of insulin appears. - Observation on 02/09/23 at 6:53 a.m. showed a licensed nurse (#1) prepared Resident #46's Lantus insulin pen for injection. The nurse (#1) secured the needle on the insulin pen, and failed to perform an air shot to expel air from the pen prior to injection. - Observation on 02/09/23 at 7:07 a.m. showed a licensed nurse (#1) prepared Resident #22's Lyumjev and Toujeo insulin pens for injection. The nurse (#1) secured the needle on the insulin pens and failed to perform an air shot to expel air from the pens prior to injection. During an interview on 02/09/23 at 7:45 a.m., an administrative nurse (#2) stated she would expect the nurse to perform an air shot prior to administering the insulin.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 10 sampled residents (Residents #11 and #68) observed during perineal cares and/or dressing change. Failure to follow infection control standards has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: DRESSING CHANGE Review of the facility policy titled Wound Care Dressing Change occurred on 02/13/23. This policy, dated October 2022, stated, . remove soiled dressing. Remove soiled gloves. Perform hand hygiene. Put on clean gloves. Observation on 02/07/23 at 8:15 a.m. showed a nurse (#5) removed Resident #11's right foam heel protector and a blue absorbent pad, and without changing gloves, measured the pressure ulcer, opened the promogram prism (wound treatment), used gloved hands to form it to the open area, and then replaced the absorbed pad and the foam heel cushion. The nurse (#5) failed to remove her gloves and perform hand hygiene after removing the foam heel pad and absorbent dressing. PERINEAL CARE Review of the facility policy titled Hand Hygiene occurred on 02/13/23. This policy, dated October 2022, stated, . Staff will perform hand hygiene when indicated . Before applying and after removing personal protective equipment (PPE), including gloves . after assistance with personal body functions . - Observation on 02/07/23 at 8:30 a.m. showed a certified nurse assistant (CNA) (#6) donned gloves and provided perineal care for Resident #11. The CNA (#6) cleansed the rectal area of stool using a wet wipe. The CNA (#6) washed, rinsed, and dried the buttocks area with a washcloth and towel and the CNA (#6) placed the washcloth and towel directly onto the floor along with the resident's pajamas. The CNA (#6) removed her gloves and without performing hand hygiene, the CNA (#6) assisted in applying a clean brief, applied the right heel bootie, adjusted the resident's clothing, assisted with transferring the resident into the wheelchair, placed the foley catheter bag into a dignity bag, and performed hand hygiene. - Observation on 02/07/23 at 8:50 a.m. showed two CNA's (#7 and #8) assisted Resident #68 on and off the bedpan. The resident voided in the bedpan and the CNA (#7) completed perineal cares, removed her gloves, adjusted the resident's clothing, raised the head of bed, put a pillow under the resident's legs, gave her a drink of water, closed the blinds, and then performed hand hygiene. During an interview on 02/09/23 at 9:05 a.m., two administrative nurses (#2 and #5) confirmed they expect staff to remove gloves and perform hand hygiene after perineal cares before doing other tasks and to change gloves and perform hand hygiene after removing foam heel protector before applying wound treatment.

Based on observation, review of facility policy, record review, review of professional reference, and staff interview, the facility failed to ensure appropriate concentration levels of sanitizer solution and failed to ensure cupboards/appliances remained locked in 1 of 4 kitchenettes (Western Unit). Failure to consistently test concentration levels of sanitizing solutions may result in unsanitary surfaces and a sanitizer concentration that is either too weak to sanitize or too strong and failure to ensure cupboards/appliances remained locked may result in chemical contamination or injury and has the potential for spread of foodborne illness to residents, staff, and visitors. Findings include: The Food Code, U.S. Public Health Service, Food and Drug Administration, U.S. Department of Health and Human Services, 2013, page 499, stated, . Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic. Review of the facility policy titled Dietary Procedure for Mixing & Testing Sanitizing Solution for Surface and Table Sanitizing occurred on 03/30/22. This policy, dated September 2021, stated, Dietary staff are responsible for mixing sanitizing solution, testing the sanitizing solution, and recording readings, each time the solution is needed and prior to using the solution. Sanitizer reading should be 50-100 ppm [parts per million]. If the reading is above 100 ppm, you must dilute the solution with water, and retest the solution. Record the reading on the sanitizing record provided in each kitchen. Observation and interviews on the afternoon of 03/29/22 showed the following: * A red bucket filled with approximately three quarts of liquid set inside a kitchen sink in the Western unit. Hand-written instructions on the outside of the bucket stated to mix one chlorine tablet with seven quarts of warm water. A dietary supervisor (#7) identified the liquid contents in the sanitizer bucket as water and chlorine sanitizer. When asked, the supervisor (#7) used a test strip to test the chlorine concentration in the bucket. The test strip showed a concentration of 200 ppm, and the supervisor stated, Oh, that's too strong. The supervisor further stated, Generally it [contents of the bucket] is dumped out [when finished after meals]. Review of the facility's document titled Nutrition and Food Services Sanitizing Record for March 1-29, 2022, lacked evidence of testing/test results on 42 of 87 possible entries. During an interview on 03/30/22 at 11:14 a.m., a dietary aide (#11) stated staff are required to test the chlorine concentration of each sanitizer bucket when filled prior to use at the end of each meal and record the test results. The dietary aide confirmed the March 2022 testing log lacked several required entries. * An unlocked refrigerator and an upper cupboard with a broken safety latch/lock that contained food items. The dietary supervisor (#7) confirmed the refrigerator is to remain locked, agreed the unlocked cupboard had a broken safety latch, and stated the cupboard should be locked so the residents can't get in.

TRANSMISSION BASED PRECAUTIONS 1. Based on observation, facility policy review, and staff interview, the facility failed to follow infection control practices for 2 of 2 sampled residents (Resident #1 and #2) on Transmission-based precautions (TBP). Failure to follow infection control practices related to proper procedure for personal protective equipment (PPE) usage may result in the spread of infection to residents, staff, and/or visitors. Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 03/30/22. This policy, revised 11/01/21, stated, . Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on isolation precautions as recommended by current CDC [Centers for Disease Control] guidelines. Review of the facility policy titled Transmission-Based Precautions occurred on 03/30/22. This policy, revised 03/26/21, stated, . 'Transmission-based precautions' are a group of infection prevention and control practices that are used in addition to standard precautions for residents who may be infected or colonized with infectious agents that require additional control measures to prevent transmission effectively. Type and duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions . Infection/Condition . Coronavirus (COVID-19) . Precaution . Droplet/Contact . Comments . Droplet/Contact with N95 mask, eye protection, gown and gloves . - Observations on 03/29/22 of Resident #2 showed the following: * 10:59 a.m., door closed to room with an isolation cart by the room and a sign on the door that indicated Contact/Droplet isolation precautions. The sign stated, . N95 mask for all staff . use gown, gloves and eye covers . * 11:08 a.m., a staff nurse (#4) donned a gown, N95 mask, gloves and entered the room. The staff nurse (#4) failed to don eye protection. * 11:22 a.m., the staff nurse (#4) exited the room, her N95 face mask remained in place, her gown and gloves had been removed and she performed hand hygiene. When asked if staff were required to wear eye protection in Resident #2's room, the nurse (#4) stated yes. - Observations on 03/29/22 of Resident #1 showed the following: * 2:33 p.m., the door to the room closed with an isolation cart by the room and a sign on the door that indicated Contact/Droplet isolation precautions. The sign stated, . N95 mask for all staff . use gown, gloves, and eye covers . * 2:49 p.m., a certified nursing assistant (CNA) removed her surgical mask, placed it on top of the isolation cart, removed a used N95 face mask from a paper bag, donned the N95 mask, placed her surgical mask in the paper bag. Without performing hand hygiene the CNA donned eye protection and a gown, removed gloves from her uniform pocket and entered the room without donning them. * 3:00 p.m., the CNA (#5) exited the room, removed the eye protection, placed them on the isolation cart, and removed the N95 mask cupping it in her palm. The CNA failed to handle the N95 mask properly or perform hand hygiene prior to reapplying the surgical mask. * Observation on 03/30/22 at 10:35 a.m., showed Resident #1's room door open and the bin for soiled isolation gowns by the open door with the cover open. During an interview on 03/30/22 at 3:20 p.m., an administrative nurse (#3) stated she expected staff to wear eye protection when entering isolation room. She expected staff to utilize appropriate donning/doffing technique for isolation rooms and isolation room doors to remain closed as indicated. ENVIRONMENT 2. Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 2 of 8 sampled residents (Resident #5 and #6) and 4 supplemental residents (Resident #11, #12, #13 and #14). Failure to maintain a clean and sanitary environment has the potential for transmission of communicable diseases and infections to residents, staff and visitors. Findings include: Review of the facility policy titled Routine Cleaning and Disinfection occurred on 03/30/22. This policy, dated January 2021, stated, . It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Consistent surface cleaning and disinfection will be conducted with detailed focus on high touch areas to include, but not limited to . toilet seats . Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned: a. on a regular basis b. When soiling and spills occur . Observations of resident rooms on 03/29/22 showed the following: * 11:03 a.m., Resident #5 and Resident #13's shared room and bathroom showed the bathroom floor contained a sticky substance and smelled of urine. Most of the floor on Resident #5's side of the room contained a sticky substance with visible dried sticky shoe track marks to the bathroom. At 2:41 p.m., the shared bathroom remained sticky and continued to smell of urine. * 11:17 a.m., Resident #6 and Resident #14's shared room showed a commode located at the foot of Resident #6's bed. The commode contained feces, urine, and perineal cleansing wipes. The floor in front of the commode contained an area of wet and dry feces/urine. Visible dried sticky shoe track marks located on most of the floor on Resident #6's side of the room extended to the exit door of the room. * 11:28 a.m., Resident #11 and Resident #12's shared bathroom showed feces smeared on the front of the toilet bowl, the toilet seat, and the flooring surrounding the toilet and loose brown debris scattered on their bathroom floor. At 3:24 p.m., the shared bathroom continued to have scattered areas of dried feces inside the toilet bowel and the toilet seat and scattered loose debris remained on the bathroom floor. Observations of resident rooms on 03/30/22 showed the following: * 10:42 a.m., Resident #5 and Resident #13's shared bathroom contained dried feces in the toilet, the floor contained a sticky substance and smelled of urine. * 10:45 a.m., Resident #6's room, an area of wet and dry feces/urine located on the floor in front of the commode. During an interview on 03/29/22 at 3:07 p.m., a housekeeping staff member (#6) stated each resident's room in the unit, including the bathrooms and toilets, are cleaned daily and would be recleaned if housekeeping is notified of the need prior to the end of their shift. During interviews on 03/30/22 at 7:20 a.m. and at 3:13 p.m., an administrative staff member (#3) and an environmental staff member (#8) stated unit staff are expected to notify housekeeping if a resident's room needs recleaning. The staff members (#3 and #8) also stated, the unit staff have access to the housekeeping area after the housekeeping staff is done for the day, and the unit staff are expected to clean up soil and spills as needed as they occur.

Based on information provided by the complainant, observation, record review, review of facility policy, and staff interviews, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 3 sampled residents (Resident #3) with a history of falls. Failure to respond to call lights in a timely manner may result in incontinenece and falls with/without injury. Findings include: The complainant alleged the facility failed to answer residents' call lights in a timely manner. Review of the facility policy titled Call light: Accessibility and Timely Response occurred on 03/30/22. This policy, dated April 2021, stated, . all staff members who see or hear an activated call light are responsible for responding . Observation on 03/29/22 at 4:07 p.m. showed Resident #3 in a recliner, with a partially raised footrest, and the call light activated. A certified nursing assistant (CNA), (#5) entered the room at 4:24 p.m. (17 minutes later) to assist the resident with toileting cares. Review of Resident #3's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], identified partial/moderate supervision required for transfers . occasional incontinence . fall with injury 12/19/21 . The current care plan identified, . has some urinary incontinence/dribbling, . asks for assistance from time to time . history of falls while transferring to bathroom . at risk for falls . staff to offer assistance with FWW [front wheeled walker] for ambulation . 12/19/21 tripped over her walker while transferring from her bed to recliner . During an interview on 03/29/22 at 4:40 p.m., a staff nurse (#12) stated, We are short staffed today. She explained they did not have the required number of staff members on Unit 2 (Homestead) from 4:00-4:30 p.m. During an interview on 03/30/22 at 8:11 a.m., two administrative staff members (#2 and #3) confirmed Unit 2 (Homestead) did not have the required staff coverage on from 4:00-4:40 p.m. on 03/29/22. The administrative staff member (#3) reported she expects staff to answer call lights within 5 to 10 minutes for safety reasons.

Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to notify the physician and/or resident representative of falls for 1 of 4 sampled residents (Resident #4) reviewed for falls. Failure to promptly notify the physician and/or the resident representative of a fall limits their ability to be fully informed of the resident's status. Findings include: Information received from the complainant indicated the facility staff failed to notify the provider and/or resident's representative of a change in the resident's condition. Review of the facility policy titled Falls occurred on 03/30/22. This policy, revised 11/12/19, stated, . The Physician will be updated regarding the residents fall . The POA [power of attorney (also referred to as resident representative)] will be updated regarding the resident's fall. Review of Resident #4's medical record occurred on all days of survey and identified the resident with severe cognitive impairment and a representative listed. Review of Resident #4's fall records, dated December 2021 through March 2022, identified the facility failed to notify the resident's representative about a fall that occurred on December 15, 2021 and failed to notify the provider and the resident's representative about falls that occurred on December 26 and 27, 2021. During an interview on 03/30/21 at 10:27 a.m., an administrative staff member (#1) confirmed the facility failed to notify Resident #4's representative and/or the provider about several falls that occurred.

Based on observation, review of Safety Data Sheets (SDS), and staff interview, the facility failed to ensure an environment free of accident hazards on 1 of 4 kitchenettes (Western Unit). Failure to ensure filled sanitizer buckets are kept out of a resident's reach, label all chemical containers, and store chemical and cooking items in locked drawers/cupboards placed the residents at risk for injury. Findings include: Review of the SDS for Ecolab 21 Apex (Trademark) Solid Sanitizing (chlorine) Tablet stated, . Harmful if swallowed or in contact with skin. Causes serious eye damage . Review of the SDS for cooking spray (food grade) stated, . Causes mild skin irritation . eye irritation . inhaling the contents can be harmful or fatal. Inhalation may cause narcotic like effects resulting in oxygen deficiency, a risk of unconsciousness as well as central nervous system depression. Symptoms include headache, dizziness, or loss of breath. Observation on 03/29/22 at 2:21 p.m. showed Resident #5 self-propelled his wheelchair into the Western unit kitchenette, and with no staff present, rummaged through items located on a table adjacent to the steam table and attempted to open a locked cupboard. Observation and interviews on the afternoon of 03/29/22 showed the following: * A red bucket filled with approximately three quarts of liquid set inside the kitchen sink in the Western unit kitchenette. Hand-written instructions on the outside of the bucket stated to mix one chlorine tablet with seven quarts of warm water. The dietary supervisor (#7) identified the liquid contents in the sanitizer bucket as water and chlorine sanitizer. The supervisor stated, Generally it [contents of the bucket] is dumped out [when finished after meals]. * An uncovered can of cooking spray in an unlocked cupboard. The dietary supervisor (#7) stated, This [the can of cooking spray] should probably be in a locked cupboard. * A small clear unlabeled bottle containing blue liquid located in an unlocked drawer. The dietary supervisor (#7) identified the blue liquid as possible diluted Dawn dish soap and stated staff should have labeled the spray bottle and placed it in a locked cabinet/drawer.

THIS IS A REPEAT DEFICIENCY FORM THE STANDARD SURVEY CONDUCTED ON 01/16/20 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 6 of 21 sampled residents (Resident #7, #26, #31, #65, #71, and #78), and 2 supplemental residents (Resident #9 and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION C: COGNITIVE PATTERNS and SECTION D: MOOD The Long-Term Care Facility RAI Manual, revised October 2019, Pages C-1 to C-2 stated, . C0100: Should Brief Interview for Mental Status Be Conducted? . Code 0, no: if the interview should not be conducted because the resident is rarely/never understood, cannot respond verbally, in writing, or using another method . Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood . Pages D-2 to D-3 states, . D0100: Should Resident Mood Interview Be Conducted? . Code 0, no: if the interview should not be conducted because the resident is rarely/never understood or cannot respond verbally . Code 1, yes: if the resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method . Attempt to conduct the interview with ALL residents . - Review of Resident #7's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for sections C0100 and D0100. - Review of Resident #9's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for sections C0100 and D0100. - Review of Resident #26's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for section C0100 and D0100. - Review of Resident #31's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for section C0100 and D0100. - Review of Resident #40's medical record occurred on August 30-31, 2021. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for section C0100 and D0100. - Review of Resident #71's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], identified facility staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for section C0100 and D0100. - Review of Resident #78's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS, dated [DATE], identified faciltiy staff coded both C0100 and D0100 as rarely/never understood. Facility staff failed to attempt interviews for section C0100 and D0100. During an interview on 09/01/21 at 2:21 p.m., an MDS coordinator (#3) confirmed facility staff failed to complete sections C0100 and section D0100 correctly for Residents #7, #9, #26, #31, #40, #65, #71 and #78. SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI Manual, revised October 2019, page J-34, states, . Coding Instructions for J1900C, Major Injury: · Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). · Code 2, two or more: if the resident had two or more major injurious falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Review of Resident #65's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified a fall with major injury. Resident #65's progress notes identified the following: * 06/05/21 at 7:26 p.m.: . resident reported he fell in his room when his sheet got tangled around his legs when he got up yo [sic] walk and he fell on his right side. He got himself up. He is not sure if he hit his head and no noted redness or lumps to his head. Resident able to move all 4 limbs and denies pain. Resident alert and oriented as per norm. * 06/06/21 at 12:30 a.m.: Resident voiced his back is sore from his fall, but resident able to ambulate as per norm. * 6/07/21 at 3:15 p.m.: Resident had a witnessed fall in the dining room during activities. Resident was standing up to sing karaoke and tripped over the stand of the large computer. Resident had no skin issued [sic] noted after the fall and VS [vital signs] were stable. Resident denied having any pain . During an interview on 08/31/21 at 3:47 p.m., an MDS coordinator (#3) confirmed the resident had no major falls during the MDS time frame, and confirmed the quarterly MDS dated [DATE] was inaccurately coded.

Based on record review and review of facility policy, the facility failed to adequately assess the circumstances and causative factors contributing to the recurring falls experienced by 1 of 1 sampled residents (Resident #8) requiring extensive assistance with toileting, and failed to implement/provide appropriate interventions and/or assistance to prevent falls and harm/injury from occurring. Failure to assess and implement interventions for Resident #8 resulted in the resident experiencing avoidable falls and injury while attempting to toilet unassisted. Findings include: Review of the facility policy titled Toileting Protocol occurred on 01/05/17. The policy, dated 09/26/2016, stated, Policy: To help aid residents maintain bowel and bladder continence, highest level of functioning and safety associated with toileting. Data collected from the 72 hour bowel and bladder assessment is used to design an individulized toileting schedule to meet the resident's needs. This schedule is implemented and may be adjusted accordingly to resident's needs and/or changes in status. Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE] identified a hip fracture and one fall with major injury. A quarterly MDS, dated [DATE], identified Resident #8 with severely impaired cognition, required extensive assist of one for toileting, transfers, and ambulation, and had two falls with no injury, one fall with injury, and one fall with major injury. Resident #8's current care plan identified, Problem: Resident has a history of falling r/t (related to) dementia, medication use. Approach start date 09/20/16: . alarms in place that monitors rising. (Resident #8) at times removes alarms per self and staff should attempt to place alarm boxes out of (Resident #8) easy reach. Encourage resident to use call light and wait for staff assistance when needed . Provide resident an environment free of clutter. Assure the floor is free of glare, liquids, foreign objects. Approach start dated 11/28/16: Ensure styrofoam noodle is in place while (Resident #8) is laying in bed. Approach start date 11/21/16: Ensure floor mat is in place while (Resident #8) is lying in bed. Problem: ADL (activities of daily living) . Resident required assistance with ADLs and is frequently incontinent of urine. Approach start date 11/17/16: . restorative therapy program that will ambulate her to and from meals . Approach start date 12/08/16: After initiating the 72 hour bowel and bladder program on 12/01/2016, it has been determined that (Resident #8) will benefit from a toileting schedule approximately every two hours, and as needed. Resident #8's nurses note identified the following: * 08/28/16 at 11:45 p.m.: Res (resident) call light in the BR (bathroom) went off and answered the light, cord was pulled out from the call box, resident observed on the floor lying on her right side, no apparent injury noted, res stated 'I just want to pee and I don't know what happened.' . Tab alarm was in place but resident knows how to took (sic) it out, noted that walker was at the side of the bed. will continue to monitor res, fax sent to MD (medical doctor). A computerized tomography (CT) completed on 09/02/16 identified Acute comminuted fractures through the right superior pubic region. * 09/06/16 at 11:29 a.m.: CT results indicate nondisplaced pelvic fracture . * 10/28/16 at 9:52 a.m.: Called to resident's room by staff. Resident was found lying on the floor on her right side next to her bed. Tab alarm was in place and sounding upon arrival. Resident c/o (complained of) pain to her R (right) lower rib cage. Family notified and would like for resident to be monitored at this time. Have ensured alarms are in place and floor is free from clutter and resident has call light available. * 11/09/16 at 11:34 p.m.: Resident got up to BR and CNA (certified nurse assistant) found resident on the floor in BR. Hematoma forming to lateral left eye. Laceration to lateral area noted. Alarm on bed. No new interventions to prevent further falls were implemented following this incident. * 11/10/16 at 10:14 a.m.: . c/o pain entire left side. Call placed to MD. To send to ER (emergency room ). Family in agreement. * 11/10/16 at 2:39 p.m.: Returned from ER. No new fractures. * 11/20/16 at 9:32 a.m.: At 0830 (8:30 a.m.), alarm sounded . Resident lying next to her bed on her left hip, brief was lying beside her as well as one slipper. staff unable to turn resident onto left side due to pain reported by resident. Also stated pain to left ribs. * 11/20/16 at 10:50 a.m.: Floor pad, chair and bed alarms and tab alarm in place. 15 minute checks in place . * 11/21/16 at 12:46 p.m.: Daughter requesting floor mat at all times when resident is in bed. * 11/22/16 at 2:38 p.m.: Observed lying on left side on fall mattress. Tab alarm was on but did not went (sic) off. * 11/22/16 at 9:20 a.m.: Bed was in lowest position. A silent alarm has been ordered to prevent resident from removing the alarm. * 11/25/16 at 11:55 a.m.: Alarm sounded. On floor mat. Self-transferred from wheelchair and laid down on mattress. Tab alarm attached to resident. * 11/27/16 at 4:27 p.m.: . found resident sitting with her butt on floor mattress and back against the bed . Resident's bed alarm was not connected. * 11/28/16 at 9:21 a.m.: . styrofoam noodle to prevent from falling out . * 11/29/16 at 9:21 a.m.: Resident was seen by staff crawling from her bed to her mattress next to the bed. When asked what she was doing resident said she needed to use the bathroom. Resident was assisted to the BR. Will continue to monitor for continuing occurrences. Resident #8's toileting record identified she was last toileted at 9:14 p.m. on 11/28/16, over 12 hours earlier. * 11/30/16 at 12:04 a.m.: This evening, resident was observed x 2 crawling from her bed to the mattress saying she had to go to the bathroom. Staff assisted resident to the bathroom both times as reported to this nurse by CNA who observed it. * 12/01/16 at 6:26 a.m.: Staff report resident was crawling OOB (out of bed) onto mattress next to bed. Resident states she needed to use the BR. Resident assisted to BR then back to bed. Resident #8's toileting record identified that she was last toileted at 8:13 p.m. on 11/30/16, over 10 hours earlier. * 12/07/16 at 9:38 a.m.: Staff report observing resident crawling OOB onto her floor mat. Resident indicated she needed to use the BR. Staff provided assistance. Toileting record identified no documentation for toileting on 12/06/16, with last toileting documented at 8:22 p.m. on 12/05/16, over 33 hours earlier. * 12/16/16 at 2:18 p.m.: Resident found by CNA crawling on hands and knees onto her bathroom floor. Neither the tab alarm or bed alarm were in place. Resident's alarms were put into place and checked to make sure they were working. * 12/20/16 at 4:30 a.m.: Resident observed sitting on the floor near the BR door, tab alarm, bed and chair alarm went off. Call light was within reach, FWW (front wheeled walker) was near the bed by the floor mattress . stated 'please help me, I need to use the BR.' Assisted resident x 2 . Educated resident to call if needs help to go to BR . * 12/21/16 at 11:17 p.m.: Resident alarm alerted staff resident sitting on edge of bed. Staff assisted resident to BR. Mattress placed next to bed on the floor for resident safety. Alarms in place on bed. The toileting record identified Resident was last toileted at 10:04 a.m. on 12/21/16, over 13 hours earlier. * 12/22/16 at 12:57 a.m.: Resident alarm alerted staff that resident was sitting up. Staff assisted to BR without incident. Mattress replaced on floor beside bed after toileting. * 12/23/16 at 5:16 p.m.: . resident standing trying to climb over foot pedals. Her alarm was wrapped around the back of her chair. Will continue to monitor and test the alarms as well as speak to the CNAs. * 12/31/16 at 4:51 p.m.: Tab alarm sounded . upon entering the room, resident lying on back just outside bathroom door. Tab alarm was lying beside resident on pad. Silent alarm did not sound. Resident stated, 'I wanted to go to the bathroom.' . Post fall huddle performed with CNA staff. No new interventions to prevent further falls were implemented following this incident. Failure to toilet Resident #8 at the assessed frequency approximately every two hours and as needed, and failure to assess the need for new interventions and consistently implement the current interventions resulted in falls/injuries.

Based on information provided to the Division, record review, and staff interview, the facility failed to assess the appropriateness of the continued use of a stand lift (aide) for 1 of 1 sampled resident (Resident #1) who experienced a fall during a transfer. Failure to investigate the first fall, reassess the appropriateness of the stand lift, and implement alternative interventions resulted in Resident #1 being transferred with the stand lift for three additional days and experiencing additional unresponsive episodes during transfers in the stand lift.. Findings include: Information provided to the Division indicated the facility failed to notify family members when Resident #1 "slipped out of a lift." Resident #1's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. The quarterly Minimal Data Set (MDS), dated [DATE], identified severely impaired cognitive skills and extensive assistance of one person required for transfers. The daily living needs sheet, dated 01/24/12, further identified, ". . . Transfers . . . Sit to stand . . . Harness sizes: Medium . . . Number to operate lift: 1-2 . . ." The accident/incident report regarding the certified nursing assistant (CNA)'s back injury, dated 04/11/14, identified, ". . . Time of incident: 12:00 p.m. ? . . . was transfering (sic) (Resident #1) from his reclyiner (sic) to his wheelchair with easy stand (lift) and all of a sudden her (sic) started shaking a little. then he just went limp and let go. so I had to quickly grap (sic) him and get him in his chair (be)cause he was almost out of the sling . . . Describe Type/Extent of Injury: hurt my back . . . Describe in detail the action that will or has been taken to prevent a recurrence: . . . Educated aide to use lowering technique if possible using hip and leg to lower resident to floor and/or use hip and leg to rest resident's weight until help comes." The progress notes, dated 04/11/14, identified: * 12:45 a.m. (sic), "Staff reporting that resident had unresponsive episode while the (sic) were transferring him with stand aide at 11:15. Resident went limp when he was standing. . . ." * 6:48 p.m., "Staff reported that resident had another unresponsive episode while transferring. Symptoms were same as earlier. . . ." During an interview on 06/17/14 at 9:39 a.m., a certified nursing assistant (#5) indicated Resident #1 experienced additional unresponsive episodes while being transferred the weekend of April 11-13, 2014. The progress note, dated 04/14/14, identified: *7:44 a.m., "(As per nursing staff) Resident will be changed to a hoyer lift x 2 assist due to recent unresponsive spells in the stand lift. Will reassess as appropriate." * 2:00 p.m., "Call to (physician) at 8:00 a.m. to report condition of res (resident's) arm and unresponsive episodes. MD (medical doctor) ordered res to go to ER (emergency room ). . . ." * 3:28 p.m., "Res returned from ER . . . Have been using stand aid to transfer res and will now use hoyer r/t res weakness. . . ." The current care plan failed to address Resident #1's transfer needs, including the use of a Hoyer lift with two persons assisting. The facility failed to provide evidence they investigated Resident #1's falls from the stand lift on 04/11/14 at 11:15 a.m. and 6:48 p.m. During an interview the morning of 06/14/14, when asked why Resident #1's falls from the stand lift were not investigated, an administrative staff member (#7) stated, "We didn't consider it a fall, since he was strapped into the lift." This contradicts the CNA's statement "I had to quickly grap (sic) him and get him in his chair (be)cause he was almost out of the sling." This also failed to account for the CNA's back injury secondary to bearing Resident #1's weight. The facility failed to: * Investigate Resident #1's falls from the stand lift on 04/11/14 at 11:15 a.m. and 6:48 p.m. * Care plan Resident #1's transfer needs, ensuring staff are aware he required a Hoyer lift with two persons assisting. * Ensure staff used the appropriate mechanical lift from April 11-14, 2014, thereby reducing the risk of additional falls with/without injury during transfers.

Based on information provided to the Division, observation, record review, resident interview, and staff interview, the facility failed to ensure proper respiratory care for 1 of 1 sampled resident (Resident #2) with orders for continuous oxygen. Failure to administer oxygen as ordered resulted in Resident #2 experiencing significant anxiety/fear after he ran out of oxygen on more than one occasion both in and out of the facility. Findings include: Information provided to the Division indicated the facility failed to ensure the availability of continuous oxygen for Resident #2 within and when outside the facility. Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. The facility also identified Resident #2 as interviewable. The physician's orders [REDACTED].> (greater than) 90%." Observation of the noon meal on 06/16/14, showed Resident #2 eating in his room following tray set-up. He wore a nasal canula and received oxygen via a concentrator. During an interview on 06/16/14 at 4:00 p.m., when asked if staff ensured he received continous oxygen throughout the day, Resident #2 stated he "ran short of oxygen more than once." He expressed being "scared to eat in the dining room" and being "scared to go to church." He further stated, "I want to be near the concentrator." He reported, "Once they (the CNAs) took me down there (chapel on first floor), and I told them I couldn't get my oxygen. They left me down there. They finally brought me back to my room, hooked me up to the concentrator, and left. I checked myself (with an oxygen saturation monitor), they (saturation level) were down to 80 (percent)." When asked if staff ensured he received continous oxygen when outside the facility, Resident #2 stated, "They (CNAs) said the tanks were full. We had to come back in (to the facility) for full tanks. Last week at (Clinic), I ran out of oxygen. We called, and they brought a tank." During an interview on 06/16/14 at 2:55 p.m., when asked if any Public Transit staff member had returned to the facility to obtain oxygen for Resident #2, a supervisory staff member of Public Transit (#1) confirmed transit staff have returned to the facility due to Resident #2's tank running low/out of oxygen. During an interview on 06/16/14 at 3:40 p.m., when asked who is responsible for ensuring oxygen availability, a managerial staff member (#2) stated the "nurses and CNAs make sure the oxygen tanks are full." During an interview on 06/16/14 at 4:20 p.m., when asked who is responsible for ensuring oxygen availability, a second managerial staff member (#3) confirmed "CNAs prep (prepare) the tanks." When asked who is responsible for ensuring oxygen availability outside the facility, the managerial staff member (#3) stated, "Maintenance takes tanks to the hospital and clinic if needed." She further stated, "(Resident #2) was struggling with Helios (portable liquid oxygen tanks). The more oxygen he needed, the worse they worked." During an interview on 06/23/14 at 11:00 a.m., when asked if any Maintenance staff member had transported oxygen tanks to the hospital/clinic for Resident #2, an administrative maintenance staff member (#4) confirmed tanks were taken to both the hospital and clinic for Resident #2. He stated, "Sometimes the CNAs forget to fill them (oxygen tanks) and we have to run one over there." He further stated, "He (Resident #2) panics. He even uses a concentrator in the dining room, (be)cause he's scared he'll run out (of oxygen)." Resident #2's current care plan failed to address his need for continuous oxygen, and his increased anxiety/fear of staff failing to administer the oxygen as prescribed by his physician. The facility failed to: * care plan Resident #2's oxygen usage, ensuring all staff were aware of his need for 4-6 liters of continous oxygen via nasal canula to maintain saturation levels greater than 90%, * ensure the availability of continuous oxygen for Resident #2 within and when outside the facility, * address Resident #2's increased anxiety/fear of not being able to breathe following his previous experiences of his oxygen tanks running low/out of oxygen.

Based on observation, record review, facility policy review, professional reference review, and staff interview, the facility failed to monitor and assess for adequate indications for use of medications for 1 of 6 sampled residents (Resident #2) who received [MEDICAL CONDITION] medications to control behavior and had dosages of the drugs increased without evidence of attempts by the facility to minimize the behavior through effective non-pharmacological interventions. Providing [MEDICAL CONDITION] medications without appropriate monitoring and assessing for adequate indications for their continued use resulted in the resident receiving unnecessary medications and resulted in an avoidable fall and femur fracture on 01/16/14. Findings include: Review of the facility policy titled, "Behavior Assessment and Monitoring" occurred on 01/16/14. This policy, dated April 2007, stated, ". . . Monitoring . . . 4. If psychoactive medications are used to treat behavioral symptoms of dementia, the nursing staff and Attending Physician will periodically reconsider their indication and consider whether they can be tapered or document why tapering cannot or should not be attempted (for example, recurrence of psychotic symptoms after several previous attempts to taper medications). . . ." The "Nursing 2013 Drug Handbook," 33rd edition, Lippincott, Williams & Wilkins, Pennsylvania, page 1421-1422, stated, ". . .[MEDICATION NAME]. . . Indications & Dosages, short-term management of [MEDICAL CONDITION] . . . For elderly . . . 5 mg (milligram) P.O. (oral) immediately before bedtime. Or, 6.25 mg of extended-release form. Maximum daily dose is 10 mg immediate-release and 6.25 mg extended-release. . . Action . . . Onset (is) rapid, peak (of) 30-120 min (minutes) . . . Half-life: 2 1/2 hours. . . Nursing considerations . . . Use drug only for short-term management of [MEDICAL CONDITION], usually 7 to 10 days. . ." Page 843-844, states, ". . . [MEDICATION NAME] . . . Indications & Dosages, anxiety . . . Elderly patients: 1 to 2 mg P.O. daily in divided doses. Maximum, 10 mg daily. . . Adverse Reactions . . . [MEDICAL CONDITION] . . ." Page 1192-1195, states, ". . . [MEDICATION NAME] . . . Indications & Dosages, [MEDICAL CONDITION] . . . Adverse Reactions . . . [MEDICAL CONDITION] . . ." Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as able to make herself understood and usually understands others, moderately impaired cognition, and exhibiting other behavioral symptoms not directed toward others four to six days, but less than daily. This MDS identified Resident #2 as having two or more falls with no injury. A Significant Change MDS, dated [DATE], identified Resident #2 as having one fall with no injury. Resident #2's current care plan stated: * ". . . Problem . . . Resident has [DIAGNOSES REDACTED]. She needs some help with decision making. She has had some periods of yelling out . . . Approach . . . Assist (Resident #2) with decisions as needed. She needs cues and supervision. Her appointed Guardian . . . and her case manager . . . are involved in her care and assist with decisions for her health and well being. Please keep them informed . . . At times, she may not understand or may misinterpret what you are telling her. Please keep your explanations simple and short. Allow her time to understand what you are saying and to respond to you . . . Offer reminders as to meal times, activities, etc as needed and assist her to those things . . . (Resident #2) needs reassurance and frequent encouragement. Please offer both as needed. If she is yelling out, please make sure she is safe and offer reassurance. Inform the charge nurse . . . * Problem . . . Resident has [DIAGNOSES REDACTED]. In the past, she has had periods of being anxious, fearful and verbally abusive at times . . . Approach . . . If (Resident #2) starts getting anxious or fearful, please make sure she is safe, reassure her that everything is okay. Let her charge nurse and/or the social worker know . . . Please respect (Resident #2's) right to have her space, ask her if she needs anything before you leave her room and keep her belongings she uses often close to her and her room clutter free . . . (Resident #2) enjoys visiting about her life. Offer her reassurance as needed. Stop in when you have time and chat with her. She likes to get hugs. She is very religious and gains much strength with her faith . . . When (Resident #2) has verbal behaviors, offer her reassurance that she is safe and if time, sit an (sic) visit with her. Infmr (sic) the charge nurse . . . * Problem . . . Resident has history of falling. She has arthritis, [MEDICAL CONDITION] as well as a [MEDICAL CONDITION] disorder (review of the medical record identified no [MEDICAL CONDITION] in the past year) that puts resident at risk for falls and injury . . . Approach . . . Resident most likely will not remember to use the call light when she wants to get up because she has dementia so if you see her transferring herself please go in and assist her . . ." Review of physician's orders identified the following medications: [REDACTED] *[MEDICATION NAME]([MEDICATION NAME]) 2.5 mg (milligrams) PO (oral) Q (every) HS (hour of sleep) PRN (as needed) started on 08/07/13 for a [DIAGNOSES REDACTED]. Increased to 10 mg at HS on 10/23/13. Current dose 12.5 mg at HS increased on 01/14/14. * [MEDICATION NAME] ([MEDICATION NAME]) 1 mg PO BID (twice a day) increased on 05/30/13 for a [DIAGNOSES REDACTED]. * [MEDICATION NAME] ([MEDICATION NAME]) 1 mg PO BID PRN started on 08/02/13 for a [DIAGNOSES REDACTED]. * [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily started on 06/25/13 for a [DIAGNOSES REDACTED]. Review of the medical record showed a fax to the physician, from a Hospice nurse, dated 05/29/13, stated, "pt (patient) is having increasing agitation and yelling out, St. Luke's staff feels her behaviors are getting out of control. She currently is using [MEDICATION NAME] 1 mg every morning and 0.5 mg at bedtime. Also has PRN order for [MEDICATION NAME] 1 mg every 4 hours as needed. Would you like to change/increase any of these medications?" The physician responded by increasing [MEDICATION NAME] to 1 mg twice daily. The resident improved and was taken off Hospice on 06/14/13. The medical record lacked any further documentation supporting this dose of [MEDICATION NAME]. Review of Resident #2's Progress Notes/Behavior Notes from February 2013 through January 2014 identified the following: * 07/03/13 at 3:00 a.m. - "Resident has been screaming all nocs (night). Res (resident) has call light on q (every) 5 min for minor tasks such as throwing something in trash, moving item to the left. CN (charge nurse) has been in residents room [ROOM NUMBER] times the past 3 hrs (hours), not to mention numerous times CNA (Certified Nursing Assistant) as well. Resident denies pain, discomfort, hunger. Fluids were offered several times et (and) accepted. Res has continous (sic) severe out-bursts of yelling at staff. CN redirected resident numerous times. Res does not voice what she wants or "why" she puts call light on so frequently. (0330 (3:30 a.m.)) Resident received PRN [MEDICATION NAME] 1 mg PO. (0400 (4:00 a.m.)) Resident resting quietly in bed." * 07/19/13 (no time noted) - "Resident yells for help more than 10x (ten times). She said we don't do anything for her and she is the last always." * 07/26/13 (no time noted) - "Constant pressing of light and yelling. Helped resident to the best of my ability but still attended to her 6 times." * 07/27/13(no time noted) - "Resident keep (sic) crying. She said it hurts her something and nobody listen's (sic) to her. She keeps calling help for more than 10x." * 07/28/13 (no time noted) - "Resident said we never do anything for her. She keeps yelling help 10x." * 07/29/13 (no time noted) - "Resident kept yelling for help more than 10x. I ask her what she needs. She said her stomach hurts." * 07/30/13 (no time noted) - "Resident keep (sic) yelling at mid-night she called seven times (7x) in about two hours. She wanted to get up about 1:00 am." (Ambien was initiated on 08/7/13 with no evidence of [MEDICAL CONDITION].) * 08/10/13 (no time noted) - "Resident hollared (sic) and screamed out for most of the PM shift. Very agitated. Could not re-direct. Reported to nurse. Behaviors continued throughout entire shift." * 08/29/13 at 9:50 a.m. - "Fax prepared for MD (medical doctor) reguarding (sic) resident continueing (sic) to be restless at NOC even after non-med (medications) interventions." (Ambien increased on 09/03/13 with no evidence of [MEDICAL CONDITION].) * 09/04/13 at 4:10 a.m. - "Resident to sleep @ (at) approx. (approximately) 2145 (9:45 p.m.) (after) receiving HS meds (medications). She awoke around 1 am et 2:15 am for drink of water et to be repositioned. She awoke @ 0345 (3:45 a.m.) for the day. Has been pleasant et states she slept very well." * 09/06/13 at 6:05 a.m. - "Resident to sleep around 10 pm. Slept well all night, was up x2 (two times) for cares et water. Up @ 5 am for the day. She hollered x1 (one time) in the middle of the night." * 09/09/13 (no time noted) - "Resident was yelling "help me", multiple times throughout the shift. Resident was very agitated & (and) after you helped her & thought she was done screaming she would think of something else & start up again." * 09/26/13 (no time noted) - "Resident has been hollaring (sic) and screaming early in the morning. She was very disturbing to the other residents. Resident pushed & forced herself to go through in between seated residents (in dining room), while CNA help has been offered and asked to wait a second. Resident has yanked the call light cable out of the box the second time, and it had to be repaired the first time (on 9/25/13)." * 10/08/13 (no time noted) - "Resident was yelling at me to hurry up with cares, and when I was feeding other residents in the dining (room), she yelled "help me". I approached her and assured her that I was going to assist. I think a lot of attention seeking could be a factor. She constantly wants everyone to focus on her only and gets angry when you assist others." * 10/08/13 at 3:52 a.m. - ". . . Resident continued on though hollering that she needed help. When approached in her room by the CN, she asked for something to help her sleep and began crying a little. CN tried to redirect res by sitting and talking to res for awhile, by offering some crackers, and by rubbing her back. None of these activities helped to relax her enough to fall back asleep. At 0130 (1:30 a.m.), 1 mg [MEDICATION NAME] was given po. Res. is now asleep and has had no further c/o (complaints of) pain." * 10/11/13 (no time noted) - "Resident didn't sleep all night, she was yelling all night and was spilling water everywhere, she was also hitting the table hard." * 10/17/13 at 6:57 a.m. - "Res (resident) yelled out durning (sic) NOC shift. Started around 9 pm. She was given prn [MEDICATION NAME] which did not settle her. Then she was screaming out very loudly that she was having severe pain. She was given 0.5 ml (milliliter) of [MEDICATION NAME] which did not help either. She was finally gotten up in her w/c (wheelchair) around 0100 (1:00 a.m.) and was content until 4 am where she started yelling out again. She was toileted, repositioned, redirected, given a snack and fluids and no intervention seemed to help." * 10/20/13 at 10:12 p.m. - "post entrey (sic) res was up and wake (sic) all night SAT. (Saturday) 10/19-10/20 she would yell, cry, hit, the table, mak (sic) all kinds of noise, she had no c/o pain, discomfort, stated she could not sleep tried different (sic) ways to help nothing would work, giving a snack, tv, reposioning (sic), finaly (sic) put (in) wheelchair and then she was quiet 0330 (3:30 a.m.)." * 10/20/13 at 2:00 a.m. - "Res yelling has not selpt (sic) even after HS meds (given at . . . 2100) Res very restless" * 10/21/13 at 11:08 a.m. - "Sent fax to (name of provider) re: (regarding) resident not sleeping at night. Requesting a different sleeping med. or increase current." (Ambien increased on 10/23/13 with no evidence of [MEDICAL CONDITION].) * 10/23/13 at 3:30 a.m. - "Res has been calling out all night. Call light log was taken and she used her call light 10 times between 9 pm and 2 am. She has not slept at all and the only intervention that calmed her was getting her dressed and sitting up in her w/c." * 10/24/13 at 4:29 a.m. - "Res did not sleep well this NOC shift. She was yelling out all night and using her call light excessively. When approached resident could not make her needs known. With the new increase in [MEDICATION NAME] did notice res slept very well until about 2400 (12:00 a.m.)." * 10/25/13 at 7:17 a.m. - "Res was unable to sleep for the most part of the NOC shift. She was on her call light several times." * 10/29/13 at 2:43 a.m. - "Res slept very well from 2100 (9:00 p.m.) until about 0200 (2:00 a.m.). She then started using her call light excessively and yelling out. She was not easily redirected with food, water, bathroom, and repositioning. Will continue to monitor sleep." * 10/30/13 at 3:29 a.m. - "Res continued to yell out throughout the night and use her call light excessively. Interventions to redirect failed. These interventions included snacks, fluids, repositioning, toileting, and medication." * 11/12/13 at 3:40 a.m. - "Res yelled out very loudly up until midnight last night. She refused to stop screaming unless we got her in her w/c. Res was offloaded every hour and taken to the bathroom but stayed out of bed all night." * 11/18/13 (no time noted) - "Residen (sic) is crying for help all night long. She wanted her bottom teeth in, then she scream for help again cause she is itching, after few minutes she ring (sic) again and crying she said to raise her head up." * 11/19/13 (no time noted) - "Resident was screaming for help after breakfast, very very loud." * 11/21/13 at 2:05 a.m. - "Resident has been calling out for help all shift. Call light in reach, but has not been using it. Took all scheduled medications. Res has also been tearful at times and not able to explain why. Is able to be redirected but then calls out at times and is not able to voice what she wants. Shall cont (continue) to monitor." * 11/22/13 at 1:57 a.m. - "Resident was calling out and yelling at times, administered PRN [MEDICATION NAME] 1 mg PO at 2324 (11:24 p.m.) and resident was transferred from bed to recliner and has been sleeping comfortably. Shall cont to monitor." * 11/23/13 (no time noted) - "Resident is yelling for help all night long. More than 50x (fifty times). She wants every single thing at one time. She said she has been calling all night long and nobody came she started crying. She said nobody cares about her. She called again more than 5 times she wants to get up at 3:15 AM." * 11/24/13 at 1:59 a.m. - "Res was calling out wanting h2o (water), was itching, needed turned, hungery (sic), needed to urinate, wanted in her recliner then finaly (sic) was wanting to get up in wheel chair has been fighting sleep has not slelp (sic) yet" * 11/26/13 (no time noted) - "Resident has been yelling for help all night long-she wanted to get ready at 12:00 AM then she wanted food then called more that (sic) 15 times and ask for more food, to get up, lotion, and she kept calling for help and she did not sleep." * 11/27/13 (no time noted) - "Resident yelled for help at 12:00 AM and stayed up till 2:00 AM. She wanted to get ready for breakfast. She said I told her its (sic) to early to get up then she went to sleep and again yelled for help after 3 mins (minutes). She wants to be covered." * 11/29/13 at 1:45 a.m. - "res (has) been yelling out this night, c/o itching been scrathing (sic) has marks on upper left arm, applied (sic) [MEDICATION NAME] ([MEDICATION NAME]) cream seemed to help just some. res has had a pass (sic) of ithcing (sic) and scrathing (sic), sending concern to dr." * 12/04/13 at 7:13 a.m. - "Resident was up throughout the night . . . She was assisted to the bathroom, redirected, given food and fluids. She was yelling and banging items against her bedside table, pushing her call light often. She was given [MEDICATION NAME] at approximately 0330 (3:30 a.m.), this did help her calm down. She has been fairly quiet since about 0430 (4:30 a.m.)." * 01/09/14 at 1:43 a.m. - "Res has hollered out all evening/noc. Restless, unable to redirect, getting in/out of bed, yelling. Admin (administered) PRN [MEDICATION NAME] per orders. Will cont to monitor. * 01/10/14 at 2:04 p.m. - "Noted increased use of PRN [MEDICATION NAME] between 2300 (11:00 p.m.) and 0100 (1:00 a.m.) nightly due to hollering out with increased anxiety and difficulty sleeping. Fax out to MD (provider) to update and advise of any medication changes." * 01/13/14 at 11:38 p.m. - "resident appeared to be restless and anxious, noted to be hollering for help and using call light every so often with no apparent reason. Unable to be redirected with all cares rendered. Medicated as per ordered. Will continue to monitor throughout the shift." * 01/14/14 at 2:23 p.m. - "Order given to [MEDICATION NAME] 12.5 mg (more than the maximum daily dose of 10 mg) every HS . . ." (Ambien increased on 01/14/14 with no evidence of [MEDICAL CONDITION].) * 01/15/14 at 3:53 p.m. - "NOC CNA reported that res barely slept all night. No adverse effects [MEDICATION NAME] noted." Observations during the week of survey identified Resident #2 was lethargic as evidenced by her eyes closed and head down. Review of physician progress notes [REDACTED]. * 06/11/13 - ". . . Patient appears stable. We will continue current medications . . ." * 10/13/13 - ". . . She also does have some dementia . . . Dementia appears stable . . ." * 12/03/13 - ". . . pt. and staff have no medical concerns, seems happy . . . Assessment Plan, Dementia . . . W/o (without) Behav (behavioral) Disturb (disturbances) . . . reviewed meds, vital signs stable . . ." The physician progress notes [REDACTED]. Review of Resident #2's medical record identified the following falls: * 06/16/13 at 3:45 p.m. - "Resident was sitting on her room floor attempted to transfer herself. No injuries, responsible party was notified via message on answering machine. Primary physician (name of physician) notified via fax. VS (vital signs) BP 140/70 (blood pressure) P 72 (pulse) R 20 (respirations) temp 97.2 (temperature) sats 92% (oxygen saturations) with oxygen on at 2 liters." ([MEDICATION NAME] increased to 1 mg BID on 05/30/13.) * 06/26/13 at 2:15 a.m. - "Res crawled out of her bed and sat on the fall mat by the bed. Res denies hitting head c/o slight pain on buttocks. Tiny scratch on the Rt. (right) shin. Bandaid (sic) applied. No other complaints. Res. helped up with Hoyer and 2 assist. Vitals T-97.5 (temperature), P-71, R-20, B.P. 118/62, O2 (oxygen) Sats 98% in (sic) 3L/NC (liters per nasal cannula). Will monitor." *10/23/13 at 12:31 a.m. - "I was walking down the hall at 2415 (12:15 a.m.) to answer res call light and observed her slide herself from her bed to the floor mat next to the bed. She had been yelling out all night and very aggitated (sic). She was previously given [MEDICATION NAME] which did not seem to be effective at this time. Res has no c/o (complaints of) pain, ROM (range of motion) and neuro (neurological checks) WNL (within normal limits). Vital signs include BP 133/68, P 95, R 24, T 98.3, O2 98. Will continue to monitor." * 11/01/13 at 6:03 a.m. - "Res was observed sitting on the floor mat beside her bed. Res denies pain at the time of fall. No injuries observed. ROM + (and) Neurocheck WNL. Will cont. to monitor" (Ambien increased to 10 mg at HS on 10/23/13.) * 01/16/14 at 2:33 a.m. - "Resident was not able to sleep whole night, keeps putting light on. Needs were provided by the CNA. Staff responded to call light in resident's room and observed observed (sic) resident sitting facing towards the door in front of recliner. Floor was dry and clean, free of clutter, call light was activated. Res screaming of pain, vital signs and neuro's initiated, ROM to all extremities with c/o pain to Left knee. 2 person assist with hoyer lift to recliner. Resident stated 'I was trying to standup and i fell on the floor, my knee hurts so bad' Alert to person, confused to time and place. Resident denies hitting her head and fall on her knees. (Name of provider) notified and received telephone order to send resident to ER (emergency room ) for further evaluation of Left knee. (name of case worker) notified, CN (charge nurse) called the ER Nurse and sent resident to hospital via ambulance." (Ambien increased to 12.5 mg at HS on 01/14/14.) * 01/16/14 at 7:56 a.m. - "Spoke with ER nurse at (name of hospital). (Resident #2) has a [DIAGNOSES REDACTED]. LM (left message) with case worker to return call so update can be made." Resident #2 started [MEDICATION NAME] mg PRN on 08/07/13. The physician increased the dose to 12.5 mg at HS on 1/14/14 with lack of supporting documentation for the increased dose. Resident #2 was admitted to the facility in December 2010 on [MEDICATION NAME] 1 mg in the morning and 0.5 mg at HS. The physician increased the dose on 05/29/13 to 1 mg BID without supporting documentation for the increased dose. Failure to thoroughly assess Resident #2's behaviors and sleeping patterns; develop individualized non-pharmacological interventions specific to the resident's [MEDICAL CONDITION], behaviors, and anxiety; and lack of supporting documentation for the indications of use for the [MEDICATION NAME],[MEDICATION NAME] resulted in the use of unnecessary medications; increased somnolence during the day; avoidable falls; and a femur fracture on 01/16/14.

Based on record review, resident interview, and staff interview, the facility failed to ensure a safe environment for 1 of 1 sampled resident (Resident #2) who experienced a fracture during wheelchair transport. Failure to ensure the resident's foot remained on the wheelchair foot pedal resulted in a fracture of Resident #2's right distal femur. Findings include: During the initial facility tour, on 12/17/12 at 9:00 a.m., a supervisory nursing staff member (#2) reported Resident #2 experienced a fracture of the right leg "three-four months ago" when his right foot "fell off" a wheelchair foot pedal. The staff member reported he continued to be non-weight bearing on the right leg. Review of Resident #2's medical record occurred on December 17-20, 2012. The facility admitted the resident in August 2010. Current [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact and walking did not occur. The facility identified the resident as interviewable. Resident #2's quarterly and significant change MDSs, dated 05/25/12 and 03/11/12, respectively, identified the resident demonstrated functional limitation in range of motion of both lower extremities. The resident's CNA care plan, dated 05/29/12, stated "Mobility . . . Self . . . electric wheelchair . . ." and "Transfers . . . May use stand lift for all transfers. If I am having difficulty may use hoyer lift. . . ." The CNA care plan and the nursing care plan prior to and after the fracture did not identify Resident #2's loss of function in his lower extremities or interventions and safety measures during transfers and transportation. Resident #2's Nurse's Notes stated: *05/29/12, 2:00 p.m. - "Res. (Resident's) Rt. (right) foot fell off of foot pedal of w/c (wheelchair) during transfer to appt (appointment). C/o (Complains of) (R) (right) knee pain c/o (sic). (Nurse practitioner (NP)) aware et (and) states to monitor (R) knee. Res. requests to be transferred to bed per hoyer lift (full body lift) et done so per his request. Has bruise to (Rt) knee. No new swelling as noted by (name) supervisor. Today's faxes observed et filed as noted to monitor by (NP)." . . . 7:00 p.m. - "Res. c/o left toe pain & (and) Rt. knee pain. Scheduled pain meds. (medications) given. Toe bandaid in place." 10:00 p.m. - "Res. c/o Rt. knee pain & requesting pain medication. PRN (as needed) p.o. (by mouth) pain med given. . . ." *05/30/12, 5:30 p.m. - "Res. c/o Rt. knee pain & scheduled pain meds. given. Res. refused to use stand lift this a.m. (morning) & staff used hoyer lift transfer due to knee pain." 11:45 a.m. - "Res. request x-ray of (R) knee due to pain from incident yesterday. Order received per telephone to send to (clinic) for x-ray and (physician) will see on rounds tonight. . . . Knee has reddened area (with) sl. (slight) warmth to area. Remains swollen et painful (with) movement. Receiving pain meds PRN. . . ." 3:15 p.m. - "Res. to be direct admit to hospital per (physician) due to fx (fracture) (R) knee. . . ." Resident #2's physician ordered pain medications on 05/29/12 included Tylenol with Codeine (opioid pain reliever) 300/30 milligrams (mg), one tablet every four hours as necessary for pain relief, Tramadol (opioid pain reliever) 50 mg, one tablet every eight hours, and Fentanyl patch (opioid pain reliever) 12 micrograms per hour, every 72 hours. Resident #2's medical record included an acute care facility history and physical, dated 05/30/12, which stated ". . . He has been confined to a wheelchair for years because of lower extremity [DIAGNOSES REDACTED] of unknown etiology. . . ." The medical record also included a physician progress notes [REDACTED]. . . He will also need to see an orthopedic surgeon about a possible replacement of the right total knee prosthesis based on an orthopedic's (sic) surgeon review of the x-rays after he had the fracture. . . ." Resident #2's medical record also included an x-ray report of the right knee, dated 05/30/12, which stated ". . . Mildly displaced fracture of the distal right femur immediately cephalad (above) to the femoral component of the TKA (total knee arthroplasty (replacement)). Angular deformity with the apex directed anteriorly (forward). . . ." At the surveyor's request to review the facility's incident report for Resident #2's fracture on 05/29/12, a supervisory nursing staff member (#9), provided a "summary" of the incident. This "summary," dated 06/05/12, stated ". . . One of the CNA's (certified nursing assistants) started to take the resident down to the front office where the bus comes to pick up clients, when she was going down the hall the resident's right foot slid off of the right foot pedal on the wheelchair. Since the resident is a paraplegic and cannot physically move his lower extremities he was unable to lift his foot back up on the foot pedal. His right foot then was twisted while it went under the wheelchair. At that time the CNA asked if the resident was all right, he replied 'I think so.' Still in the hall to the office, the CNA stopped by the therapy room and applied a band to help (sic) the legs from falling off the pedals while transferring. She did notice that the wheelchair pedals did not match and the right foot rest on the pedal was loose but still functioning. . . ." The remainder of the "summary" confirms the nurse's notes on May 29-30, 2012. During interview, on 12/18/12 at 1:25 p.m., Resident #2 reported his right foot fell off the right foot pedal of the wheelchair and his right foot "dragged" under the wheelchair as the facility staff member continued to push the wheelchair. Observation throughout the survey identified Resident #2 in a wheelchair with his legs elevated, wearing a right leg immobilizer. Observation of the resident in bed showed a lack of active function in the resident's lower extremities. Resident #2 did request pain medications after observed transfers and positioning of the right leg. Resident #2 has a history of limited lower extremity function. The resident's care plans lacked interventions regarding preventive or protective measures for facility staff regarding his lower extremities during transfers or transportation. The facility staff used a standard wheelchair with a loose foot pedal for transportation on 05/29/12. The CNA applied a band to the wheelchair foot pedal to hold Resident #2's leg in place after the incident. The incident "summary" provided by the facility lacked information regarding corrective action, including staff education, wheelchair maintenance checks, or reviews of other residents for potential similar situations. Failure to ensure the environment remained free of safety hazards for Resident #2, including interventions for his limited lower extremity function and the loose wheelchair pedal, resulted in the resident's right leg fracture. Information provided by the facility failed to identify additional investigation, preventive or staff education measures regarding similar situations.

1. Based on record review, and review of facility policy and procedure, the facility failed to ensure 1 of 1 closed record resident (Resident #16) who experienced persistent chest pain received the appropriate care and services necessary to treat his medical condition. Failure to provide the necessary care and services delayed medical treatment and resulted in the resident being transferred to the hospital and being diagnosed with [REDACTED]. Findings include: Review of the facility policy titled, "Change in a Resident's Condition or Status" occurred on 01/11/12. The policy, dated 04/07/09, stated, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition. . ." The medical record of Resident #16, reviewed January 10-11, 2012, showed the facility admitted the resident on 10/25/11 from an acute care hospital stay with [MEDICAL CONDITION], shortness of breath, and swelling of his ankles. The resident's admission [DIAGNOSES REDACTED]. The record indicated Resident #16 as his own responsible party, and a code level 2 (treating reversible conditions without chest compressions). Resident #16's discharge instructions from the acute care hospital, dated 10/25/11, stated "Pertains to patients with shortness of breath, [MEDICAL CONDITION], or heart failure . . . When to call your Doctor: . . . Increased shortness of breath. Having to prop yourself up in bed with pillows to breathe. . . New or increased swelling in ankles, lower legs or belly . . . Chest pain." Resident #16 physician's orders on admit included: "[MEDICATION NAME] 0.4 milligrams sublingual (under the tongue) as needed up to 3 doses 5 minutes apart, if after 3 doses still has pain call the MD (medical doctor) - notify the MD of nitro ([MEDICATION NAME]) use" "Oxygen at 1 liter nasal canula to keep saturation > (greater than) 88% (percent) but < (less than) 96%" Resident #16's nurses notes stated the following: *10/25/11 at 5:30 p.m., "Resident admitted to St. Lukes Home today at 1210 (12:10 p.m.). Arrived via ambulatory status. . . Code Status explained (with) family and res. (resident) and Code Level II was decided upon. . . BP (blood pressure) 90/50 sitting, 79/42 standing. . . O2 (oxygen) sats (saturation) 98% on RA (room air). . .+1 [MEDICAL CONDITION] (swelling) to bilat (bilateral) feet and ankles. . . No c/o (complaints) of pain at this time, although res. confirms that he sometimes has 'chest pain' that he takes nitro for. No c/o (complaints) SOB (shortness of breath) at this time . . . Res pleasant, cooperative and highly coherent." *10/25/11 at 10:00 p.m., ". . . blood pressure 108/62, oxygen 95%. . . Res c/o SOB place O2 @ (at) 2L (liter), HOB (head of bed) elevated. c/o pain through chest muscles D/T (due to) (low) BP (blood pressure) no [MEDICATION NAME] given will monitor for (changes)." The facility failed to notify the physician promptly of the change in the resident's medical condition, and failed to follow the physician's orders for the administration of [MEDICATION NAME] and oxygen at 1 liter not 2 liters. *10/25/11 at 10:30 p.m., "Res still c/o being uncomfortable with SOB faxed MD for PRN (as needed) [MEDICATION NAME] order ro (related to) anxiety with SOB will monitor for (changes)." *10/25/11 at 10:31 p.m., "Contacted on-call M.D. Telephone order: [MEDICATION NAME] 0.5 mg (milligrams) po (by mouth) now for SOB may repeat q6h (every 6 hours) x (times) 2 if no relief. [MEDICATION NAME] administered res states 'That's not gonna help' Told res. we could repeat dose in 6 hours if he had no relief. Res then asked if he could have an Alka-[MEDICATION NAME] and a Tylenol PM. Told res he may have [MEDICATION NAME]. Res states, 'If I drink that I will puke.' Then told res there was no order for him for Alka-[MEDICATION NAME] or Tylenol PM. Res stated 'Well then I don't want anything.' Will monitor for (changes) in SOB." The facility contacted the physician for an antianxiety medication, but failed to inform the physician of the resident's complaints of chest pain, SOB, and the need to administer oxygen to the resident. *10/25/11 at 11:30 p.m., "Res req (requested) APAP ([MEDICATION NAME]) for pain. 325 mg po 2 tabs given. Will monitor for (changes)." The MAR (medication administration record) stated, "Reason Given: res req c/o chest pain." The facility failed to follow the physician's orders and administer [MEDICATION NAME] for his continued complaints of chest pain. *10/25/11 at 11:45 p.m., "BP 100/60. Res still c/o chest pain. Res states 'I should probably just go back to the hospital' Asked res why he wanted to go to the hospital Res states 'I have this chest pain and no one can figure out how to stop it.' [MEDICATION NAME] 0.4 mg sl given." The facility failed to reassess the resident's chest pain in 5 minutes after the [MEDICATION NAME] was administered as ordered by the physician, and failed to contact the physician with the resident's complaint of chest pain. *10/25/11 at 11:55 p.m., "Asked res if he was hurting anywhere. Res states, 'No, I'm not hurting anywhere, I think that tylenol really helped.' Asked res if he was experiencing chest pain. States 'NO I just got to sleep. How long will this medicine last?' Told res medicine should relieve pain for the duration of the night. Res states 'Don't bet on it. I took [MEDICATION NAME] and it only lasted 3 hours.' Res seemed comfortable and relaxed (without) c/o chest pain. Will monitor for (changes)." *10/26/11 at 12:01 a.m., "Res sleeping in bed (without) evidence of respiratory distress." There was no evidence of further monitoring of Resident #16's condition, until the following nurses note on: *10/26/11 at 9:30 a.m., ". . . 2+ [MEDICAL CONDITION] to feet/ankles, c/o pain to [MEDICAL CONDITION] (upper middle part of the abdomen) area states gets this often esp (especially) if eating then going to bed. . ." The facility failed to notify the physician of the increase in [MEDICAL CONDITION] as ordered in the discharge instructions from the acute care hospital, and failed to assess and treat the [MEDICAL CONDITION] pain. *10/26/11 at 12:15 p.m., "fax per Dr to clarify admit orders and for [MEDICATION NAME] BID (two times daily) and prn for anxiety." There was no evidence of further monitoring of Resident #16's condition, until the following nurses note, more than 13 hours later, on: *10/27/11 at 2:00 a.m., "Resident c/o indigestion 10 ml [MEDICATION NAME] given." *10/27/11 at 2:45 a.m., "Resident c/o being shaky 0.5 mg [MEDICATION NAME] given po. Resident stated that he needed to go back to hospital. I asked why he thought he needed to go back to hospital, Res stated 'Because no one knows what is wrong with me' I ask (sic) resident to see if the [MEDICATION NAME] would help. To give the medications time. Resident stated that he would see if the medication would help him sleep. If so then he would not have to go back to hospital. . .Res talked about how he didn't want to be alone. . ." *10/27/11 at 3:30 a.m., "Resident c/o chest pain 0.4 mg [MEDICATION NAME] ([MEDICATION NAME]) given sl - will continue to monitor. . . B/P 100/60, O2 sats 97%. . ." The facility failed to reassess the resident's chest pain in 5 minutes after the [MEDICATION NAME] was administered as ordered by the physician. *10/27/11 at 3:45 a.m., "Nurse placed nasal canula O2 @ 2L. Res sitting in recliner. Res stated chest pain relieved, but wants to remain in recliner." The facility failed to follow the physician order for [REDACTED]. *10/27/11 at 5:15 a.m., "Resident awake, O2 @ 2L. Resident had very little sleep. Resting in recliner @ this time call light in place." *10/27/11 at 7:50 a.m., "BP 88/56. . . Called to residents room. Resident lying on floor in front of bathroom door. Resident had walker laying upturned by side, only one shoe on, No apparent injury. . . Resident responded to touch and verbal stimuli. Neuro's (neurological) WNL (within normal limits) and moved all extremities. Hoyer used to place resident in bed. Neuros initiated. Fax prepared MD, family notified." The fax, dated 10/27/11,stated "Resident observed lying on floor in front of bathroom door. No apparent injury, No bumps or bruises to head. Resident responded to touch and verbal stimuli. Neuros WNL and moves all extremities. Will continue to monitor. Thanks." The facility failed to inform the physician of the resident's persistent complaints of chest pain, the administration of [MEDICATION NAME], and the need for oxygen to be administered. *10/27/11 at 9:30 a.m., "BP 77/53. . . Resident c/o chest pain and SOB, denies radiating pain. Resident is lethargic and weak. O2 per NC at 1L. Pain is helped when resident sits at 90 degree. Will continue to monitor." The facility failed to administer [MEDICATION NAME] as ordered by the physician, notify the physician of the resident's complaints of reoccurring chest pain, decrease in blood pressure, and the change in the resident's medical condition. *10/27/11 at 10:30 a.m., "Assessed res (with) CN (charge nurse). He appears to have (increased) [MEDICAL CONDITIONS] s/s (signs and symptoms). 2+ [MEDICAL CONDITION] to feet. Hands are cool and nail beds are clubbed & blue. Unable to obtain O2 saturation at this time. Call placed to MD with new orders received. Called daughter (name) as well and updated to (sic) fall earlier & current status. She agrees to res being sent to hospital. . ." *10/27/11 at 10:45 "Ambulance here and transferred res to ER (emergency room ). . ." *10/27/11 at 2:45 p.m., "Res. admitted to ER (with) dx (diagnosis) of acute mi ([MEDICAL CONDITION] infarction)." *10/29/11 at 8:30 a.m., "ICU (intensive care unit) nurse from acute care hospital (name) called reported resident passed away." The facility failed to provide adequate monitoring, intervention, and timely notification of the physician (per the physician's orders) which resulted in admittance to the ER (emergency room ) with a [DIAGNOSES REDACTED]. 2. Based on observation, policy and procedure review, record review, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 2 sampled residents (Resident #9) with avoidable pain. Failure to address Resident #9's pain, evidenced during cares, resulted in the resident experiencing increased pain. Failure to try alternative treatment measures for pain or develop a comprehensive care plans related to pain management resulted in Resident #9 experiencing pain and may have resulted in the resident receiving unnecessary psychoactive medications for agitation. Findings include: Review of a facility policy titled "Pain Assessment and Management" occurred on 01/11/12. This policy, dated 02/01/11, stated, " . . . purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions . . . that address the underlying causes of pain. . . . pain management is a multidisciplinary care process that includes the following: a. Assessing potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management . . . conduct a pain assessment . . . whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain . . ." Review of Resident #9's medical record occurred on all days of survey. Current [DIAGNOSES REDACTED]. Scheduled medications and their indications of use included the following: 250 milligrams (mg) [MEDICATION NAME] twice a day (BID) for dementia with behaviors, 650 mg Tylenol once a day for headache or knee pain, 0.5 mg [MEDICATION NAME] three times a day (TID) for dementia with behaviors, and a [MEDICATION NAME] for hip, leg, and back pain (started 01/10/12). Resident #9's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] * 12/07/11 at 2:00 p.m. * 12/11/11 at 5:00 a.m. * 12/16/11 at 4:00 a.m. * 12/27/11 at 11:45 a.m. * 01/06/12 at 4:30 a.m. Review of physician orders and medication administration records (MARs) showed the physician increased the dose of [MEDICATION NAME] from 250 mg (milligrams) daily to twice a day (BID) on 12/09/11. The record showed 0.5 mg [MEDICATION NAME] BID initiated on 12/09/11 and increased on 12/14/11 to three times a day (TID) related to increasing behaviors. Review of Resident #9's current quarterly Minimum Data Set (MDS), dated [DATE] (after the pelvic fracture), identified the resident with severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6, received scheduled pain medication, as needed pain medication, and non-medication interventions for pain. The resident's behavioral symptoms during the assessment period included physical and verbal behaviors 4 to 6 days a week. A MDS narrative note, dated 12/19/11, stated, ". . . with behaviors escalating her primary physician was notified . . . re-ordered the [MEDICATION NAME] . . . (arrow up) the [MEDICATION NAME] . . . 12/14 behaviors continued et (and) her Dr (doctor) (arrow up) the [MEDICATION NAME] . . . takes Tylenol 650 mg . . . took prn (as needed) Tylenol (two times) . . . Little to no chg (change) (with) cares or behaviors in last 3 mo (months). . ." Resident #9's care plan, updated 12/27/11, identified " . . . Problem . . . I have had falls in the past. I have lower back pain . . . I fell [DATE] and fractured my pelvis . . . Approaches . . . See my daily living needs plan . . . Problem . . . I tend to have lower back discomfort and knee pain . . . I have some pain upon movement because of my fractured pelvis . . . Approaches . . . If I am having pain offer me help to reposition, offer me a massage, see my medication sheets, treatment record and physician's orders. Move me slowly for repositioning and transfers. . . ." Resident #9's Daily Living Needs, updated 01/04/12, stated, " . . .Transfers: . . . Comments: Move me slowly for transfers and repositioning - I have a fractured pelvis . . . Other notes: Report any pain or changes in my behavior to my charge nurse . . . " Observations of Resident #9 included the following: * 01/08/12 at 4:05 p.m.: two unidentified visitors in the Resident's room. One stated Resident #9 "isn't usually like this." When asked what she meant the visitor stated Resident #9 laid sleeping through their visit and not conversing with them. * 01/09/12 at 9:20 a.m., A CNA (#19) provided morning cares with an administrative nurse member (#13) in the room. Resident #9 cried out "Hey!" when the CNA lifted her left leg to remove a pillow. When the CNA (#19) removed the resident's brief and performed perineal cares, Resident #9 cried out and tried to reach out and stop the CNA's hand. When the CNA (#19) placed a new brief, the Resident stated a profanity and grasped the CNA's arm and shirt. Resident #9 cried out "Ah!"as the CNA (#19) placed a pillow between her knees. When the administrative staff nurse (#13) asked the resident if she had pain, the resident replied "Shut up!" * 01/09/12 at 9:40 a.m.: a CNA (#19) entered Resident #9's room with a breakfast tray. As the CNA raised the head of bed (HOB) Resident #9 cried out, "Get out of here" and "Owe, Owe, Owe!" Resident #9 again cried out as the CNA (#19) repositioned her. Resident #9 slapped and grabbed the CNA's (#19) hands as the CNA attempted to give the resident a drink. At 10:05 a.m. a license practical nurse (#21) entered and offered a pain pill which the resident refused. * 01/09/12 at 1:40 p.m., two CNAs (#19 and #20), with an administrative nurse member (#13) present in the room, transported Resident #9 back to bed using a full body lift. The resident screamed "No!" during the transfer and stated, "Yes" when asked if her back hurt. The two CNAs (#19 and #20) rolled Resident #9 to her left side and placed a pillow under her right side. Resident #9 stated, "Owe, Owe, Owe!" during movement. A licensed practical nurse (#21) entered room and offered a pain medication, but the resident didn't open her eyes or mouth. * 01/09/12 at 2:55 p.m., Resident #9 laid in bed on her right side while an administrative nurse completed a pain evaluation. The Resident responded "yes" to having pain in her back, hip, legs and "yes" when asked if it hurt to move. The resident responded "yes" when asked if she would like something else for pain. Resident #9's nurse's notes stated the following: * 01/04/12 at 7:15 p.m., ". . . found resident sitting on floor by bed. Resident denies hitting head . . ." * 01/05/12, "(late entry for 5:15 p.m.) . . . Resident observed on floor beside w/c (wheelchair). . .Resident denies pain . . ." * 01/06/12 12:15 a.m. "Res (resident) uncooperative early pm (with) assessment but once in bed did cooperate. When in w/c sat leaning over, would not sit straight up. Some c/o (complaints of) back pain when transferred to bed . . . Inconsistent (with) c/o back pain . . ." and at 12:30 a.m., "Res uncooperative (with) taking fluids. Denies pain." * 01/06/12 at 4:30 a.m., ". . . Res uncooperative and gets angry when asked about pain." * 01/06/12 at 3:30 p.m., ". . . Resident very uncooperative during assessment. Continued to yell at CN (charge nurse) and resist assessment. Resident denies pain. . . .Refused to move lower legs for CN to assess strength. . . . refused to let CN perform ROM (range of motion) to legs but attempted to stand out of w/c (wheel chair) this afternoon. . ." * 01/09/12 at 3:45 p.m., "While observing peri-cares at 1400 (2:00 p.m.), noted res. to be in what seems a great deal of pain (with) any movement. She yells out "ouch," hollering at staff and guarding (with) any movement. When pain assessment conducted, res. answered "yes" when asked if her legs, arms, back, and hips hurt. She also answered "yes" when asked if movement makes it worse. MD (medical doctor) faxed to ask for pain medication other than her current daily and PRN (as needed) Tylenol. . . ." * 01/10/12 at 9:00 a.m., Resident #9 complaining of pain with movement and nurse practitioner wrote orders to transfer to clinic today. * 01/10/12 at 2:10 p.m., Resident #9 returned from an appointment with new orders for a [MEDICATION NAME] and follow up bone scan scheduled on 01/12/12. During an interview on 01/11/12 at 9:30 a.m., a CNA (#19) identified Resident #9 showed signs of pain on 01/09/11. The CNA failed to notify the charge nurse or offer alternative forms of pain relief, except repositioning. A pain evaluation for Resident #9, completed on 01/09/12 at 3:15 p.m., stated, " . . . Res. has shown increasing behaviors and yelling out, especially (with) movement which has increased following discharge from hospital . . ." This evaluation identified Resident #9 as having groaning, whimpering, grimacing, clenching of the jaw, resisting care, irritability, and guarding limb or other body part. The MAR indicated . . .refused to open mouth to take po (by mouth) meds" and the medical record lacked evidence that the facility administered pain medication for 23 hours from the time the resident responded yes to having pain during her pain assessment until 01/10/12 at 2:10 p.m. when her physician ordered a [MEDICATION NAME]. During an interview on 01/09/12 at 2:50 p.m. an administrative nurse (#13) stated she noticed today that Resident #9 had behaviors related to pain. This staff member reported Resident #9 had an increase behaviors when she was readmitted in December with her pelvic fracture and at that time her [MEDICAL CONDITION] medications were adjusted. During an interview on 01/10/12 at 1:10 p.m., the administrative nurse (#13) agreed that Resident #9's current pain may be related with the falls on 01/04/12 and 01/05/12.

Based on observation, record review, facility policy review, professional reference review, and staff interview, the facility failed to provide necessary care and services regarding feeding assistance for 1 of 1 sampled Resident (Resident #2) observed to be fed in bed by a staff member, and for 1 closed record (Resident #15) regarding the provision of appropriate diet consistencies. Failure to provide appropriate feeding assistance may result in choking and/or aspiration. Failure to ensure the proper diet texture resulted in Resident #15 experiencing hypoxemia, tachypnea, labored breathing, coughing, and subsequently resulted in an admission to the hospital. Findings include: The Source for Dysphagia: Third Edition by Nancy B. Swigert copyright 2007 LinguiSystems, Inc., page 125 and educational handouts, identified the following: * "Compensatory Treatment Techniques: . . . 1. Appropriate Seating During the oral intake of medicines, food and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair. . . ." * "Teaching Sheet for PO Feeding . . . 3. Signs and symptoms of aspiration: . . . Throat clearing . . ." * ". . . Why is it important for patients to sit at 90 degrees when eating? . . . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue. . . ." Review of the facility policy titled "Dining Assistance" occurred on 01/27/11. This policy, reviewed/revised 05/10/10, stated, "Purpose To assist the resident with dining as is necessary in order to meet his/her nutritional needs. . . . Procedure . . . 4. If dining in the room, raise the head of the bed as indicated. Need to have head of bed elevated . . . be sitting up to make swallowing easier and reduce the risk of aspiration and choking. . . ." - Review of Resident #15's medical record occurred on 01/27/11. [DIAGNOSES REDACTED]. Record review identified Resident #15 went to the hospital on [DATE] with a [DIAGNOSES REDACTED].#15 required a pureed diet with honey-thick liquids. Nurses notes revealed the following: *01/19/11 @ 12:50 p.m.: "Res. (resident) returned from hospital . . . diag (diagnosis) of pneumonia . . . Res. diet texture has (changed) to pureed diet (and) liq. (liquids) are now honey thickened due to trouble (with) swallowing . . ." *01/21/11 @ 12:45 p.m.: "Resident coughing. Increased respirations 30. Use of stomach muscles. Oxygen increased to 3L(liters)/NC (nasal cannula). (Oxygen) at 80%. BP (blood pressure) 99/51. P (Pulse) 69. T (temperature) (97.6). . . ." *01/21/11 @ 1:05 p.m.: "Res. suctioned by Unit Coordinator. Ambulance and ER (emergency room ) notified. . . ." *01/21/11 @ 3:38 p.m.: "ER called. Stated resident going to be admitted with pneumonia and [MEDICAL CONDITION]. . . ." An incident investigation form completed on 01/21/11 by the facility indicated Resident #15 received a lunch tray with mechanically soft foods and thin liquids from the dietary department on 01/21/11. The resident ate a few bites of food and drank two sips of tomato juice. Upon realizing the resident received the wrong tray, facility staff gave Resident #15 a new tray with pureed foods and honey thickened liquids. The resident consumed a few bites of food and his liquids from the new tray. The resident then started coughing, and was subsequently transported to the hospital. During an interview on 01/27/11 at 10:50 a.m., an administrative dietary staff member (#16) stated dietary staff placed menu selection slips labeled with Resident #15's name in the activity room (where Resident #15 ate his meals) prior to his admission to the hospital. When Resident #15 returned from the hospital, an unidentified CNA completed one of these slips for Resident #15 (which still identified the resident required a mechanical soft diet with thin liquids), and the kitchen also received a change of diet order to a pureed diet. Kitchen staff prepared a second tray. Dietary staff delivered both trays in a cart to the dining room. The staff member stated it was dietary staffs' responsibility to ensure dietary staff did not prepare two trays. During an interview on the morning of 01/27/11, a social services staff member (#26) stated a CNA, not realizing Resident #15 had a new diet order, gave Resident #15 the tray with the mechanically soft food and thin liquids. The staff member (#26) stated, "That should not have happened." Resident #15 returned to the facility with a new diet order on 01/19/11. However, on 01/21/11 (three days later), facility staff failed to ensure Resident #15 received the appropriate diet and fluid consistency which then resulted in an admission to the hospital. - Observation on 01/26/11 at 8:45 a.m., showed a CNA (#7) feeding Resident #2 as he laid in bed on his right side. The staff had previously raised his bed to an approximate 40 degree angle. The resident lifted his head off the pillow, accepted a sip of his liquid or bite of food, and laid his head back down on the pillow before chewing and/or swallowing. Resident #2 cleared his throat twice during the observation. Resident #2's medical record, reviewed January 25-27, 2011, identified current [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified problems with long term memory and moderately impaired decision making skills. His quarterly MDS, dated [DATE], identified extensive assistance from one person for eating, mechanically altered diet, and therapeutic diet. The Dietary Quarterly Assessment, dated 12/16/10, identified the following: * "Mechanically Altered Diet: mech. (mechanical) soft . . ." * "Eating Ability: supervision to total assist . . ." * "Meal Intake: (less than) 75% @ (at) meals/range 15-70%. . ." The Physician Orders, dated 01/12/11, identified the following: * "Regular diet, mechanical soft with whole meats cut into dime size pieces." * "Food @ (at) bedside . . ." The current care plan entitled My Daily Living Needs, dated 12/17/10, identified the following: * "Elevate: Head of Bed; 90 degrees when eating . . ." * "Eating: Assist . . ." During an interview on 01/27/11 at 11:00 a.m., a management nursing staff member (#15) agreed residents should not be offered liquids and/or food while they are in a reclined position.

Based on observation, record review, review of standards of practice, and staff interview, the facility failed to provide necessary treatment and services to aid in the prevention and promote the healing of pressure ulcers for 2 of 4 sampled residents (Resident #1 and #4) identified with a pressure ulcer and 1 of 14 sampled residents (Resident #5) at risk for pressure ulcers. Failure to consistently implement interventions to prevent and promote healing of pressure ulcers resulted in the deterioration of an existing facility acquired pressure ulcer (Resident #1 and #4), and placed Resident #5 at risk for developing a pressure ulcer. Findings include: The Centers for Medicare and Medicaid Services (CMS) have outlined the standards of practice regarding pressure sores. Some residents have many risk factors for developing pressure ulcers, such as diabetic [MEDICAL CONDITION], frailty, cognitive impairment, and under nutrition. The facility should have a system/procedure to ensure: assessments are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, and addressed. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. The facility failed to ensure Resident #4 received repositioning/pressure redistribution, incontinence care management, and/or adequate nutritional interventions for the treatment of [REDACTED]. - Review of Resident #4's medical record occurred on all days of survey. The facility admitted the resident in June 2009. [DIAGNOSES REDACTED]. The record also identified unstaged pressure ulcers to Resident #4's right heel (onset date 02/09/10) and left heel (onset date 01/13/11). Resident #4's current Minimum Data Set (MDS), dated [DATE], identified one stage III pressure ulcer, extensive assistance from two people with bed mobility, and always incontinent of bowel. Resident #4's care plan, updated 11/28/10, identified the following: ". . . Problem . . . I have very poor circulation to my feet and legs. My skin is very fragile and I have open sores. I have diarrhea often and that is very irritating to my skin. . . . Goal . . . I do not want my sores to get any worse and I do not want any new sores through my next review date. . . ." The "Daily Living Needs" (a part of the care plan) for Resident #4 included a toileting plan of checking and changing her incontinence brief every two hours, as well as a schedule to reposition every two hours and as needed. During the initial tour of the facility on the morning of 01/25/11, facility staff indicated they initially identified the pressure area to Resident #4's coccyx in February 2010. Review of Resident #4's "Pressure Ulcer Record" revealed facility staff measured the coccyx ulcer weekly. The measurements included, in part: * 10/20/10: Stage III, 1.4 x 0.2 cm (centimeters) in size (length x width), 0.2 cm in depth * 11/3/10: Stage III, 1.5 x 0.4 cm in size, 0.2 cm in depth, with the comment: "slightly larger, has had (increased) episodes of loose stools" * 11/30/10: Stage III, 1.4 x 0.7 cm in size, 0.2 cm in depth, with the comment: "larger, more loose stools throughout the day" * 12/08/10: Stage III, 2 x 1.6 cm in size, 1 cm in depth, with the comment: "larger - tunnel noted to (upper) border" * 12/20/10: Stage IV, 1.2 x 1.6 cm in size, 1 cm in depth * 12/28/10: Stage IV, 1.2 x 1.3 cm in size, 1.2 cm in depth, purulent/bloody exudate, with the comment: "signs of infection, CN (charge nurse) notified to update physician." * 01/03/11: Stage IV, 1.5 x 1.5 cm in size, 2 cm in depth, 3.7 cm undermining, purulent/bloody exudate, with the comment: "coccyx has gotten worse, undermining starting." * 01/11/11: Stage IV, 1.7 x 2 cm in size, 1.5 cm in depth, 2.2 cm undermining, with the comment: "has gotten bigger around but decreased in depth. Still yellow drainage." * 01/17/11: Stage IV, 1.5 x 2 cm in size, 1.5 cm in depth, 2.7 cm undermining, with the comment: "coccyx seems to stay the same in size. But undermining has gotten worse." * 01/25/11: Stage IV, 2.7 x 2 cm in size, 2 cm in depth, 3.7 cm undermining Observations of Resident #4 from 1:20 p.m. to 4:45 p.m. on 01/25/11 showed the resident asleep/in bed on her left side in the same position throughout the afternoon. CNA charting indicated staff positioned Resident #4 on her left side at 1:00 p.m. At 4:45 p.m. (nearly four hours later), two CNAs (#8 and #9) entered the room to check the resident's brief and transfer her to the wheelchair. Observation on 01/26/11 at 6:46 a.m. and 7:46 a.m. showed Resident #4 asleep in bed on her left side. CNA charting indicated staff positioned Resident #4 on her left side at 3:00 a.m. At 7:46 a.m. (nearly five hours later), two CNAs (#10 and #11) entered Resident #4's room and transferred her to a wheelchair using a full body mechanical lift. The CNAs failed to check Resident #4's brief. An interview with a CNA (#11) at this time indicated the CNA had last checked and changed Resident #4's brief around 5:30 a.m. At 9:24 a.m. (nearly four hours later), two CNAs (#10 and #14) checked Resident #4's brief after transferring her into bed. Observations of Resident #4 on 01/26/11 from 1:15 p.m. to 4:29 p.m. showed Resident #4 asleep/in bed on her back in the same position throughout the afternoon. CNA charting indicated staff positioned Resident #4 on her back at 12:30 p.m. At 4:29 p.m. (four hours later), two CNAs (#8 and #12) entered Resident #4's room to check her brief and transfer her to a wheelchair. Review of Resident #4's Positioning Records (completed by CNAs) from October 2010 through January 26, 2011 occurred on 01/27/11. The CNA documentation showed facility staff failed to consistently reposition Resident #4 every two hours as identified in her care plan. According to documentation, Resident #4 lay on her back (placing direct pressure on her coccyx) in excess of 2 hours on 45 different occasions. A quarterly dietary assessment, dated 11/28/10, revealed Resident #4 currently received 4 ounces of "Kemp's" (a nutritional supplement) three times a day, and 1 ounce of ProSource (a liquid protein supplement) three times a day. During an interview on 01/26/11 at 10:35 a.m., a supervisory dietary staff member (#16) stated the dietary staff add ProSource to Resident #4's chocolate milk at each meal except breakfast when they add it to her cereal. The staff member stated this is done before Resident #4's tray leaves the kitchen. The following observations of meals occurred during the survey: *On 01/25/11 at 11:42 a.m., an unidentified certified nursing assistant (CNA) delivered a lunch tray to Resident #4. The CNA opened a carton of chocolate milk and poured it in a glass. Observation showed no ProSource added to the milk or to the meal. *On 01/26/11 at 11:35 a.m., a CNA (#28) delivered a lunch tray to Resident #4. The CNA opened a carton of chocolate milk and poured it in a glass. The CNA stated that sometimes the kitchen opens the carton but today she opened it. Observation showed no ProSource added to the milk or to the meal. *On 01/26/11 at 8:35 a.m., an unidentified CNA recorded meal intakes for Resident #4 upon completion of breakfast. CNA charting indicated Resident #4 consumed 100% of her protein, 100% of her starch, 100% of her bread, 25% of her juice, 25% of her milk, and 100% of her supplement. However, observation of Resident #4's meal tray showed Resident #4 consumed 50% of her protein, 100% of her bread, 25% of her juice, and none of her starch, milk, or supplement. A CNA (#5) confirmed the other CNA incorrectly charted the meal intakes. The CNA (#5) then re-recorded Resident #4's intakes in the meal intake record. Failure to accurately record resident intakes may result in the dietary department receiving an erroneous depiction of meal intakes, and may therefore delay initiation of additional dietary interventions or modification of existing dietary interventions. During an interview on the morning of 01/27/11, a supervisory dietary staff member (#16) confirmed Resident #4 is supposed to receive ProSource at each meal and stated she needed to re-educate dietary staff regarding its use. - Resident #1's medical record, reviewed on all days of the survey, identified [DIAGNOSES REDACTED]. Review of Resident #1's care plan and nurses notes indicated a reddened area on right ankle on 08/21/10, resolved 08/27/10. Review of a quarterly MDS, dated [DATE], indicated a stage I pressure ulcer on the resident's right outer ankle. Review of a quarterly MDS narrative, dated 09/03/10, stated, ". . . Skin is intact however has a reddened area on her rt (right) outer ankle (stage I). She now wears blue pressure relieving boots when in bed." Resident #1's most current MDS, dated [DATE], identified the resident required extensive assistance of one person for bed mobility, transfer, toilet use, and personal hygiene. The resident's cognitive assessment, BIMS (Brief Interview for Mental Status) indicated severely impaired. The resident's urinary continence indicated frequently incontinent. The MDS indicated the resident at risk for pressure ulcers. Review of the resident's current "My Daily Living Needs" lacked a positioning schedule. Pressure relieving devices listed included "blue boots when in bed" and PRM (pressure relieving mattress). Review of a faxed communication, dated 12/26/10, to Resident #1's physician stated, "scab noted to rt (right) outer ankle we will cont (continue) to monitor until resolved already has pressure relief mattress & (and) blue boots for pressure in place." The fax from the physician, dated 12/28/10, stated, "noted." Review of Resident #1's "Pressure Ulcer Record" listed date of onset: 12/24/10 and site/location: right ankle. The record continued: * 12/28/10 right ankle stage I size 0.5 cm (centimeters) x 0.5 cm scab to right ankle denies pain. * 01/03/11 right ankle stage I size 0.5 cm x 0.5 cm scab to right ankle no change * 01/14/11 right ankle stage I size 0.5 cm x 0.5 cm no change * 01/17/11 right ankle stage I size 0.5 cm x 0.5 cm no change * 01/25/11 right ankle stage I size 0.5 cm x .05 cm no change During an interview, on 01/26/11 at 8:40 a.m., a management nursing staff member (#19) stated Resident #1's pressure ulcer as a "stage II." This conflicts with the documentation on 01/25/11 at a stage I pressure ulcer. An observation on 01/25/11 at 11:30 a.m., showed a nursing staff member (#27) assessing Resident #1's pressure ulcer on her right outer ankle and showed a scab on the area. An observation on 01/26/11 at 6:55 a.m., showed Resident #1 lying in her bed on her right side without the protective blue boots on her feet. An observation showed the protective blue boots in the resident's closet. An observation on 01/27/11 at 6:40 a.m., upon awaking, showed Resident #1 lying in bed on her right side without protective blue boots on her feet. A CNA (#24) reported the resident should be wearing the blue boots and located the boots in the resident's closet. The CNA (#24) removed the elastic topped slipper socks revealing a indentation above her ankles and placed the blue boots on the residents feet. During an interview on 01/27/11 at 9:30 a.m., a management nursing staff member (#15) stated the pressure ulcer on Resident #1's right ankle is a stage II, but made no comment regarding the failure of nursing staff to place the protective blue boots on the resident's feet while in bed. Failure of facility staff to provide the appropriate/ordered pressure relief to Resident #1's feet placed the resident at risk for further skin breakdown and does not promote timely healing of the existing pressure ulcer on the resident's right ankle. - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified Resident #5 required extensive assistance from two people with bed mobility and was always incontinent of bowel and bladder. Resident #5's "Daily Living Needs" indicated a toileting plan of checking and changing the resident's brief before and after meals and on all night rounds, as well as a schedule to reposition every two hours. The care plan also stated, ". . . I do not have a call light, I am unable to use one due to my condition. Please check on me every 2 hours to ensure my needs are being met. . . ." Observations of Resident #5 on 01/25/11 from 1:00 p.m. to 4:00 p.m. showed the resident sleeping in bed on her left side in the same position throughout the afternoon. CNA charting indicated staff positioned Resident #5 on her left side around 12:00 noon. At 4 p.m. (four hours later), two CNAs (#12 and #13) entered Resident #5's room to reposition her, but failed to check the Resident's brief. Observation showed a reddened area to Resident #5's right hip, and a lightly padded, self adhesive dressing to her left hip. A CNA (#12) stated the dressing was "for her protection" because "her skin is so thin." She also stated they reposition her every two hours and would check on her again around 6:00 p.m. Observations of Resident #5 on 01/26/11 at 6:48 a.m. and 7:36 a.m. showed the resident lying on her back in bed. CNA documentation indicated staff positioned Resident #5 on her back at 3:00 a.m. At 8:38 a.m. (over five hours later), observation showed the resident lying on her right side, and the room smelled of bowel movement (BM). In an interview at 8:43 a.m., a CNA (#14) stated she turned the resident "just a few minutes ago," and that she did not check Resident #5's brief. She also stated, "That (the brief change) was done before I got here. When nights got her up." An interview with a night shift CNA (#11) occurred on 01/26/11 at 7:50 a.m. The CNA stated she changed Resident #5's brief between 5:30 a.m. and 6:00 a.m. Observations on 01/26/11 at 9:14 a.m., 10:22 a.m., and 11:28 a.m. showed Resident #5 in the same position on her right side. Although a CNA (#10) entered Resident #5's room at 10:29 a.m. to offer her a snack, the CNA failed to check the resident's brief or reposition her. At 11:44 a.m., two CNAs (#10 and #14) entered Resident #5's room and changed her brief, six hours after the previous brief change. Observation showed the brief was saturated with urine and soiled with a moderate amount of stool. Observation also showed a reddened area to Resident #5's right hip, and a lightly padded, self adhesive dressing to her left hip. An interview with a supervisory nursing staff member (#1) occurred on 01/27/11 at 1:15 p.m. She confirmed Resident #4 and #5 should be checked and changed every two hours, as well as repositioned every two hours.