Every finding on record at Syringa Chalet Nursing Facility

Based on observation and interview, the facility failed to provide a safe and functional environment. This was true for 1 of 4 resident rooms (room # 411) whose sharps containers were overfilled. This failure had the potential for injury and infections. Findings include:On 1/20/26 at 8:27 AM and on 1/21/26 at 12:55 PM, observed in resident room [ROOM NUMBER], the sharps container filled past the full line and the flip top not freely movable.On 1/21/26 at 1:59 PM, the DON and surveyor observed in resident room [ROOM NUMBER], the sharps container filled past the full line.On 1/21/26 at 2:01 PM, the DON stated the sharps container should have been changed when it was full and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 1 of 4 residents (Resident #26) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time. Findings include:Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (a psychiatric disorder characterized by persistent delusions of persecution, unwarranted suspicion, and hallucinations) and anxiety.Resident #26's medical record documented she had been transferred to the hospital on 7/19/25 and returned to the facility on 8/4/25. The facility bed hold document had not been completed for Resident #26.On 1/22/26 at 4:03 PM, the Administrator stated the bed hold had not been completed at the time of transfer to the hospital and should have been.

Based on policy review, record review and staff interviews, the facility failed to include person-centered care information on the baseline care plan for 1 of 8 residents (Resident #37) reviewed for baseline care plans. This failed practice had the potential for an adverse event if resident's mental health, safeguards, and safety measures were not addressed. Findings include:The facility's Baseline Care Plan policy, dated 7/11/24, documented The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. The baseline care plan will: 1. Be developed within 48 hours of a resident's admission2. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:a. Initial goals based on admission orders.b. Physician orders.c. Dietary orders.d. Therapy services.e. Social Services.f. PASRR recommendations, if applicable.Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, anxiety disorder, and status post right hip revision. Resident #37's PASRR Mental Illness Evaluation dated 1/8/26, documented recommendations for the following social services:- individual psychotherapy - community based rehabilitative services- mental health case management - weekly or quarterly psychiatrist appointments for psychiatric prescription medication management - development of safety plan to address suicidal ideationResident #37's physician order dated 1/12/26, documented she would wear a knee immobilizer while lying in bed or sitting in a chair.Resident #37's baseline care plan, not dated, did not document PASRR recommendations or the physician ordered knee immobilizer. On 1/21/26 at 5:00 PM, the DON confirmed the PASRR recommendations and the order for the knee immobilizer was not on the baseline care plan and should have been.

Based on record review, facility policy review, and staff interview, it was determined the facility failed to follow physician orders to administer medications when residents do not have a bowel movement within 72 hours for 1 of 6 Residents (Resident #7) reviewed for bowel and bladder care. This failed practice had the potential for residents to experience discomfort when medications were not administered according to physician's order. Findings include: The facility's SCNF Bowel and Bladder Protocol dated 7/8/20, documented:24-48 hours after last Bowel movement and if change in bowel movement routine, offer prune juice or Milk of Magnesia48-72 hours after last bowel movement, offer Bisacodyl 5mg PO/PR72 hours after last bowel movement, review of resident condition with medical provider/designee unless previous order entered.Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Bipolar schizoaffective disorder (a serious mental illness combining symptoms of schizophrenia [hallucinations, delusions] with mood swings from bipolar disorder [mania and depression]) and constipation.Resident #7's physician orders for bowel care management were documented as: -Milk of Magnesia Suspension - Give 30 ml by mouth, may repeat one time in 24 hrs as needed for constipation. Order date 12/12/22 at 9:03 AM.-Bisacodyl 5mg (Dulcolax) 5 mg EC tablet. One time order entered on 12/14/25 at 12:18 PM, 1/5/26 at 6:34 PM, and 1/12/26 at 8:22 AM. Resident #7 had a documented bowel movement on 12/14/25 and not again until 12/23/25, over 192 hours with no documented bowel movement. No documentation of Resident #7 receiving the physician ordered medications for constipation management between 12/15/25 and 12/23/25.Resident #7 had a documented bowel movement on 12/30/25 and not again until 1/6/26, with only one documented administration of Bisacodyl 5mg EC tablet PO on 1/5/26 at 7:01 PM. No documentation of Resident #7 receiving the physician ordered medications for constipation management between 12/31/25 and 1/4/26.Resident #7 had a documented bowel movement on 1/6/26 and not again until 1/12/26, with only one documented administration of Bisacodyl 5mg EC tablet PO on 1/12/26 at 8:31 AM. No documentation of Resident #7 receiving the physician ordered medications for constipation management between 1/7/26 and 1/11/26. On 1/20/26 at 3:57 PM, the Administrator stated Resident #7 should have received the ordered medications for bowel management and had not.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 7 of 7 Residents (#2, #6, #8, #13, #18, #28, and #30) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:a. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including disorganized schizophrenia (characterized by prominent disorganized thinking, speech, and behavior), and anorexia (a serious eating disorder). Resident #2's physician oxygen order dated 12/3/25, documented oxygen 1-2 LPM by nasal cannula as needed to keep sats greater than 90%. 1/21/26 at 10:47 AM, observed the following low SpO2 documentation in Resident #2's medical record with no medical interventions documented by nursing staff:- 1/14/25 at 14:49 SpO2 90% - 1/7/25 at 14:49 SpO2 90% - 1/3/25 at 09:15 SpO2 90% - 12/27/25 at 11:57 SpO2 90% - 12/25/25 at 15:18 SpO2 90% -12/18/25 at 09:11 SpO2 90% - 12/15/25 at 09:27 SpO2 90% - 12/10/25 at 00:09 SpO2 90% - 12/3/25 at 09:30 SpO2 90% b. Resident #6 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including anxiety disorder and dementia. On 1/20/26 at 10:20 AM, observed Resident #6 lying in her bed with the O2 regulator set at 2 lpm but O2 cannula was lying on the overbed table and not in her nose. Resident #6's physician oxygen order documented oxygen by nasal cannula PRN, titrate 2-5 LPM to keep sats at 90% as resident allows. On 1/21/26 at 9:30 AM, observed the following low SpO2 documentation in Resident #6's medical record with no medical interventions documented by nursing staff.- 1/20/26 at 11:11 SpO2 89%- 12/11/25 at 09:43 SpO2 86% (There was a 2-hour late intervention documented by staff)- 12/4/25 at 14:11 SpO2 87%- 10/17/25 at 09:42 SpO2 83%- 10/8/25 at 08:00 SpO2 89%- 10/7/25 at 10:09 SpO2 88%- 8/27/25 at 14:41 SpO2 86%- 7/2/25 at 15:07 SpO2 85%- 6/30/25 at 08:36 SpO2 86% c. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dementia and upper respiratory infection. Resident #8's physician oxygen order documented titrate oxygen 2-5 LPM by nasal cannula PRN, as resident allows, to keep sats greater than 90%. 1/21/26 at 10:35 AM, observed the following low SpO2 documentation in Resident #8's medical record with no medical interventions documented by nursing staff.- 1/12/26 at 10:14 SpO2 88%- 11/24/25 at 09:31 SpO2 88% d. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including Bipolar schizoaffective disorder (a serious mental illness combining symptoms of schizophrenia [hallucinations, delusions] with mood swings from bipolar disorder [mania and depression]) and hypertension (high blood pressure). Resident #13's physician oxygen order dated 12/5/24, documented oxygen 2-3 LPM by nasal cannula as needed to keep sats greater than 90%. 1/21/26 at 3:47 PM, observed the following low SpO2 documentation in Resident #13's medical record with no medical interventions documented by nursing staff:- 1/11/25 at 08:25 SpO2 90% - 1/8/25 at 10:11 SpO2 90% - 12/29/25 at 09:18 SpO2 90% - 12/27/25 at 11:57 SpO2 90% -12/25/25 at 15:09 SpO2 90% - 12/20/25 at 16:15 SpO2 90% - 12/17/25 at 09:41 SpO2 90% e. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including paranoid schizophrenia (characterized by intense paranoia, delusions (like being spied on or plotted against), and auditory hallucinations (hearing voices) and obesity. Resident #18's physician oxygen order documented oxygen 2-5 LPM by nasal cannula to keep sats greater than 90% as resident tolerates. 1/21/26 at 9:40 AM, observed the following low SpO2 documentation in Resident #18's medical record with no medical interventions documented by nursing staff.- 9/22/25 at 09:34 SpO2 89%- 8/31/25 at 10:06 SpO2 87%- 7/28/25 at 10:13 SpO2 85%- 6/30/25 at 08:36 SpO2 88%- 6/27/25 at 10:19 SpO2 88% f. Resident #28 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including Bipolar schizoaffective disorder (a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions) with those of bipolar disorder (manic highs and depressive lows)) and diabetes. On 1/20/26 at 12:07 PM, observed Resident #28 sitting at the nurse's station without his supplemental oxygen speaking with the Activities Director. Resident #28 stated to the surveyor he only used the oxygen at night. On 1/20/26 at 12:35 PM, observed a portable liquid oxygen unit in Resident #28's room which he stated he only used when he was sitting his chair watching tv in his room. Resident #28's medical record documented O2 ordered 9/2/25 at 2 to 5 LPM to keep SpO2 at 87% to 90% as patient allows. On 1/21/26 at 10:00 AM, observed the following low SpO2 documentation in Resident #28's medical record with no medical interventions documented by nursing staff.- 1/19/26 at 08:22 SpO2 85%- 12/16/25 at 09:41 SpO2 85%- 11/28/25 at 09:50 SpO2 86%- 11/9/25 at 15:46 SpO2 80% g. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty or discomfort in breathing) and dementia. Resident #30's physician oxygen order documented oxygen per nasal cannula 0.5-5 LPM, titrate to keep sats between 88-92% as resident allows. On 1/21/26 at 9:50 AM, observed the following low SpO2 documentation in Resident #30's medical record with no medical interventions documented by nursing staff.- 11/27/25 at 09:48 SpO2 82% (There was a 5 hour late nursing intervention documented.)- 11/13/25 at 15:09 SpO2 87%- 11/08/25 at 16:40 SpO2 84% On 1/21/26 at 12:38 PM, the DON stated the low SpO2 documentation without documented nursing intervention were caused by poor and lacking nursing intervention documentation.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 1/21/26 at 12:46 PM, during the medication cart audit, observed the narcotic accountability sheets, dated 1/1/26 to 1/21/26, with 3 licensed nurse signatures not documented on 1/8/26 and 1/13/26. On 1/21/26 at 12:48 PM, RN #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 1/21/26 at 1:07 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 2 medication carts. This failure created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:The facility's Control and Administration of Medications policy dated 11/13/24, documents All medication areas and cabinets shall be kept locked at all times when the medication nurse is not present. On 1/20/26 at 12:30 PM, the following was observed during resident mealtime: - Sawtooth Hall and Targhee Hall medication carts observed unattended, outside of the dining room - Sawtooth Hall medication cart was observed to have one drawer, with medications, ajar. On 1/20/26 at 12:33 PM, RN #2 approached the Sawtooth Hall medication cart and was asked by the surveyor if the Sawtooth Hall medication cart should be locked. RN #2 stated yes, the cart was locked. Surveyor pointed to the drawer that was ajar. RN #2 was able to pull the drawer out and push it back in and relock the Sawtooth Hall medication cart. RN#2 stated the drawer should have been locked but was not.

Based on observation and interviews, it was determined the facility failed to ensure all call light strings in resident bathroom showers were easily accessible to residents. This issue was observed for 2 of 13 resident rooms (#303 and #307) bathroom shower call lights. This failure had the potential for harm if residents were not able to summon staff for assistance. Findings include:On 1/21/26 at 9:35 AM, observed in rooms [ROOM NUMBERS], the bathroom shower call light string was curled up so it was not accessible for a resident who may have fallen to the floor.On 1/21/26 at 12:50 PM, the Administrator stated the bathroom shower call light strings should not be curled up and should extend to the floor area of the shower but were not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living (ADLs). This was true for 2 of 10 residents (#8 and #18) reviewed for decline in ADLs without services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include: 1. Resident #8 was admitted [DATE], with multiple diagnoses including schizophrenia and diabetes. Resident #8's Quarterly MDS, dated [DATE], section GG, documented no impairment to UE or LE. Resident #8's State optional MDS, dated [DATE], section G documented Independent with bed mobility, transfers, and toileting. Resident #8's Quarterly MDS, dated [DATE], section GG, documented bilateral lower extremities impairment. No impairment to bilateral upper extremities. Resident #8's State optional MDS, dated [DATE], section G, documented limited assistance with bed mobility, limited assistance with transfers, and extensive assistance with toileting. Resident #8's medical record did not document she received restorative nursing services or had declined restorative services. On 12/3/24 at 3:30 PM, the DON stated they did not have a restorative program. On 12/5/24 at 11:43 AM, the DON stated there was no documentation by staff documenting something had been done to prevent decline in Resident #8's ADLs. 2. Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder bipolar type (a rare mental illness that occurs when someone experiences both schizophrenia and bipolar disorder symptoms at the same time) and polyneuropathy (a disease that occurs when many peripheral nerves in the body malfunction at the same time). Resident #18's Quarterly MDS assessments documented her decline in ADLs as follows: On 1/30/24, the MDS documented no impairment for upper or lower extremities and resident was using both walker and wheelchair. On 4/23/24, the MDS documented no impairment for upper extremities, impairment for both sides of lower extremities, and resident only using wheelchair. On 7/16/24, the MDS documented impairment on both upper and lower extremities, resident only using wheelchair. Related to resident mobility, resident lying to sitting on side of bed, helper does more than half the effort, resident sitting on side of bed to lying, helper does more than half the effort. On 10/1/24, the MDS documented related to resident mobility, resident lying to sitting on side of bed, helper does all the effort, resident sitting on side of bed to lying, helper does all the effort. A review of Resident #18's record identified the following orders and treatments related to her ADL decline: On 9/5/24, Resident #18's physician discontinued physical therapy. A physician order, dated 9/10/24, documented restorative nursing for general muscle strengthening, stamina, and active range of motion (AROM), 30 minutes daily, 6 to 7 days a week. Resident #18's care plan, initiated 9/26/24, directed staff to perform restorative nursing for general muscle strengthening, stamina, and AROM. 30 minutes per episode. On 9/14/24, a CNA documented 15 minutes of range of motion (ROM) was performed for Resident #18. On 9/16/24, a CNA documented resident refused treatment that day, stating, she can't do it, now that [Physical Therapist] was gone. On 12/3/24 at 12:12 PM, Resident #18 stated since the Physical Therapist left a few months ago she had not participated in any physical therapy and she felt her abilities and strength had declined. When asked if she wanted restorative nursing services after her physical therapy was discontinued, she stated, yes. On 12/3/24, 4:18 PM documentation was requested related to restorative nursing care being offered or provided to Resident #18, the DON stated there was none other than the CNA documentation on 9/14/24 and 9/16/24 . On 12/4/24 at 2: 32 PM, the DON confirmed Resident #18 had not received restorative services, as ordered, and her decline of strength had been occurring for a period of time. 51121

Based on observation, policy review, resident, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 4 of 36 residents (#1, #18, #21, and #23) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Finding include: The facility's Dignity policy, dated 5/9/24, documented the facility would promote care for residents in a manner and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The following residents were observed in an open area of the facility and had received medication or had their blood sugar checked: 1. On 12/2/24 at 7:44 AM, Resident #1 was observed sitting outside the dining room, waiting for her breakfast. Two other residents were sitting in the hallway and were able to observe RN #1 checking Resident #1's blood sugar. Resident #1's medical record did not document her wish to have her blood sugar checked in common areas. 2. On 12/3/24 at 7:48 AM, Resident #21 was observed sitting in the dining room, drinking a beverage. Another resident was sitting across the table from Resident #21 and observed RN #1 spoon feeding Resident #21 her medications. Resident #21's medical record did not document her wish to receive her medication in the dining room. 3. On 12/3/24 at 8:19 AM, Resident #23 was observed sitting in the common area, waiting for her breakfast. Two other residents were sitting in the common area and observed RN #1 checking Resident #23's blood sugar. Resident 23's medical record did not document her wish to have her blood sugar checked in common areas. 4. On 12/3/24 at 11:51 AM, Resident #18 was observed sitting in the activity room. There were 4 other residents in the activity room who observed RN #2 pulling Resident #18's sleeve up on her right arm and administering her insulin injection. Resident #18's medical record did not document her wish to receive her insulin in common areas. On 12/3/24 at 7:47 AM, RN #1 stated the facility conducts audits asking residents if they wanted their medications and blood sugar testing administered outside their rooms, and the residents had physician orders documenting the residents preferred their medications be given outside their rooms. On 12/4/24 at 11:49 AM, the DON stated there were no audits conducted to ensure residents had agreed to have their medications or blood sugars checked in common areas. She stated the residents should have orders that documented nurses may administer medications in a common area, and it should be on the resident's care plan. On 12/5/24 at 10:59 AM, the DON stated she did not have orders for Residents #1, #18, #21, or #23 to receive medications in common areas.

Based on record review and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 1 of 12 residents (Resident #22) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time. Findings include: Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact with others) and traumatic brain injury (a brain injury caused by an external force, such as a blow or jolt to the head). Resident #22's medical record documented she had been transferred to the hospital on 10/8/24, and returned to the facility on [DATE]. The facility bed hold document had not been completed until 10/15/24, 3 days after Resident #22 returned to the facility. On 12/4/24 at 2:40 PM, the DON stated the bed hold should have been completed at time of transfer to the hospital.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 3 of 12 residents (# 2, #14, and #33) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #2 was admitted to the facility on the 1/18/18, with multiple diagnoses including bipolar and hypertension. Resident #2's Quarterly MDS, dated [DATE], did not document she had a feeding tube (a small, flexible tube that provides a way to deliver nutrition through the stomach). Resident #2's Quarterly MDS, dated [DATE], documented she had a feeding tube. On 12/2/24 at 11:58 AM, RN #1 stated Resident #2 did not have a feeding tube. On 12/3/24 at 10:48 AM, the DON stated the feeding tube documented on Resident # 2's MDS was an error in reporting and should not have been on her MDS. 2. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including psychotic disorder (a severe mental illness that causes a person to lose touch with reality and have abnormal perceptions and thoughts) and bipolar disease (a mental illness that causes extreme shifts in mood, energy, and activity levels). The Quarterly MDS dated [DATE], documented Resident #14 had an enteral feeding tube. On 12/2/24 at 9:00 AM, Resident #14 stated she did not have a feeding tube in place. On 12/4/24 at 2:59 PM, the DON stated Resident #14 has not had a feeding tube in place while at the facility. 3. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including dementia and major depressive disorder. Resident #33's pharmacy Drug Regimen Review report documented she was on Risperidone (an antipsychotic) for psychosis. Resident #33's care plan, dated 1/30/24, documented she used psychotropic medications related to her disease process of dementia with behavioral disturbance and psychosis. Resident #33's Quarterly MDS, dated [DATE], Section I - Active Diagnoses, documented she had major depressive disorder and depression. Psychiatric disorder (including dementia with behavior disturbances) was not documented on Resident #33's Quarterly MDS. Resident #33 did not have a psychosis diagnosis documented on her Quarterly MDS. On 12/5/24 at 11:39 AM, the DON stated the doctor had not updated Resident #33's medication list and therefore the Quarterly MDS was wrong. She further stated Resident #33's Quarterly Assessment should have included her diagnosis of psychosis. 51121

Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current physician orders. This was true for 1 of 12 residents (Resident #10) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services had been provided that were not ordered by the physician. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder depressive type (a mental illness that involves a combination of schizophrenia symptoms and depressive episodes) and rotator cuff tear (a tear in the muscles and tendons that surround the shoulder joint). On 12/3/24, Resident #10's care plan, initiated on 9/10/24, documented Resident #10 was to be given spironolactone (an anti-hypertensive medication) however, this medication was not listed in Resident #10's active or discontinued medication orders. On 12/4/24 at 1:50 PM, the DON stated Resident #10 was not receiving spironolactone and her care plan should have been updated to remove that medication.

Based on observation, record review, and interview, it was determined the facility failed to ensure care plans were followed. This was true for 1 of 12 residents (Resident #9) whose care plans were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder bipolar type (a rare mental illness that occurs when someone experiences both schizophrenia and bipolar disorder symptoms at the same time) and chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). Resident #9's care plan, initiated on 10/17/24, directed CNAs and licensed nursing staff to keep oxygen saturations at 90% and licensed nursing staff are to contact the physician with decreased pulse oximetry. The following oxygen saturation checks below 90% were documented: 10/21/24 at 8:47 AM, SpO2 89%, obtained by CNA #1 10/26/24 at 10:03 AM, SpO2 89%, obtained by CNA #2 10/27/24 at 10:10 AM, SpO2 89%, obtained by CNA #3 10/31/24 at 9:34 AM, SpO2 84%, obtained by CNA #4 11/10/24 at 9:49 AM, SpO2 86%, obtained by CNA #2 11/15/24 at 2:46 PM, SpO2 84%, obtained by CNA #5 11/17/24 at 10:03 AM, SpO2 81%, obtained by CNA #6 11/18/24 at 12:20 AM, SpO2 86%, obtained by CNA #7 11/22/24 at 9:49 AM, SpO2 80%, obtained by CNA #8 Resident #9's medical record did not include documentation licensed nursing staff notified his physician. On 12/4/24 at 2:58 PM, the DON stated the CNAs documented the oxygen saturation information and had not notified the licensed nursing staff of the low oxygen level and should have.

Based on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods and wash hands prior to donning gloves. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: 1. U.S. Food and Drug Administration 2022 Food Code documented: Annex ,d+[DATE].15 documented hands must be washed before donning gloves. On [DATE] at 7:40 AM, observed a senior cook leave the serving line area to thin out puree with her gloves on and returned to the serving line area with gloves on. She then removed gloves but she did not wash hands before redonning gloves. On [DATE] at 8:00 AM, the Dietary Manager stated the senior cook should have washed her hands after doffing gloves and donning new gloves. 2. U.S. Food and Drug Administration 2022 Food Code documented: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On [DATE] at 7:05 AM, observed the following expired foods in the walk-in refrigerator: - cut up lettuce in a plastic bag with use by date of ,d+[DATE], - a container with ranch dressing with expired date of ,d+[DATE], - a container of pineapple juice with use by date of ,d+[DATE]. On [DATE] at 7:08 AM, the Dietary Manager stated these expired food items should have been removed from the walk-in refrigerator. 3. The facility policy Refrigerated Food Storage, dated [DATE], documented under III. Procedure, A,2,b. Nursing staff will discard any food items that are marked with a date five (5) days prior to the current date or longer. On [DATE] at 2:24 PM, observed the following expired food items in the resident refrigerator: - Opened salsa with resident name and opened date of [DATE]. - Opened mayonnaise with resident name and opened date of [DATE], expired date [DATE]. - Opened French Onion Dip with resident name and opened date of [DATE]. - Opened Watermelon Minute Maid with resident name and opened date of [DATE] and expired date of [DATE]. On [DATE] at 3:10 PM, the DON stated those expired food items in the resident refrigerator should have been thrown away.

Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator. U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled. On 12/2/24 at 8:04 AM, observed five uncovered garbage cans in the kitchen and food serving area without closing lids. On 12/4/24 at 9:25 AM, the Dietary Manager stated she was not aware the garbage cans had to have closing lids on them.

Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure residents' were protected from falls by providing them with appropriate beds. This was true for 1 of 2 residents (Resident #78) reviewed for falls. This resulted in harm to Resident #78 when her clothing caught on a bed extender bar and fell , sustaining a left rib fracture. Findings include: The facility's policy for Fall/Accident Prevention, dated 4/11/19, documented the following: * The resident's environment remained as free of accidents/hazards as possible, and each resident received adequate supervision and assistive devices to prevent falls or accidents. * Staff identified environmental factors that may contribute to falling, such as room layout, furniture placement, and lighting. Resident #78 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #78's quarterly MDS assessment, dated 2/26/19, documented she was cognitively intact and independent with activities of daily living. Resident #78 had no history of falls since admission to the facility. A care plan, initiated on 12/10/18, documented Resident #78 was at moderate risk for falls related to her use of psychoactive medications. Interventions included the following: * Encourage her to use her wheeled walker correctly and not to sit on the seat to propel herself and staff not to push her while seated on her wheeled walker. * Encourage her to participate in activities that promote exercise and physical activity for strengthening and improved mobility. * Ensure she wore appropriate footwear when using her wheeled walker. * Ensure her call light was within reach, and encourage her to use it for assistance as needed. A Progress Note, dated 3/5/19 at 6:00 PM, documented Resident #78 reported she was not sleeping at night and the nursing unit she was in was much louder. The note stated the PA-C discussed with Resident #78 that moving to a different room may help with her sleep because the new room was located on a quieter floor with a slower pace and due to issues she was having with other residents on her unit the move may also be a better fit. A Progress Note, dated 3/12/19 at 1:48 PM, documented the DNS and the LCSW spoke to Resident #78 about transferring her to another room which was quieter and had a bathroom. Resident #78 became very upset and screamed and threw things in her room. A Progress Note Addendum, dated 3/14/19, documented that on 3/13/19 Resident #78 stated she would like to see the room with the bathroom that facility staff suggested she move to and staff took her to view the room. Resident #78 moved to the room with the bathroom and a Progress Note, dated 3/22/19, documented Resident #78 had made some progress since changing rooms as there was decreased stimulation. A Fall Scene Investigation Report, dated 3/24/19 at 7:00 AM, documented at 5:40 AM Resident #78 was heard cussing under her breathe in her room. The staff then heard a thud coming from Resident #78's room and they heard Resident #78 asking for help. When staff entered Resident #78's room, she was observed lying on the floor on her left side facing her closet with her feet towards her bed and her head towards the door. Resident #78 stated she was trying to get up to scratch her back when her pant leg got stuck on the extender bar of her bed frame and she fell on to her left knee and then to her left side. Resident #78's pants were noted to be loose around both legs and the waist. The report also documented Resident #78 complained of pain in her ribs on the left side. The report documented the extender bars were removed from Resident #78's bed immediately after the fall. Alert Charting Notes for Resident #78 documented she complained of pain after the fall on 3/24/19, as follows: - An Alert Charting Note, dated 3/24/19 at 1:21 PM, documented Resident #78 was crying, yelling, hitting walls and cursing throughout the shift. Resident #78 complained of soreness and stated her knees were hurting, and she refused to get out of bed. The note documented Resident #78 received pain medication as ordered. - An Alert Charting Note, dated 3/25/19 at 1:55 PM, documented Resident #78 complained of pain to her knee and she was given pain medication as requested and ordered. - An Alert Charting Note, dated 3/26/19 at 1:34 PM, documented Resident #78 refused to eat breakfast but ate lunch in the day room. Resident #78 complained about stiffness but seemed to be in good spirits most of the shift. - An Alert Charting Note, dated 3/26/19 at 4:07 PM, documented Resident #78 was medicated twice for pain. The note did not state where the pain was located. - An Alert Charting Note, dated 3/27/19 at 9:43 PM, documented Resident #78 was medicated twice for pain. The note did not state where the pain was located. A subsequent chest x-ray report, dated 3/28/19, documented Resident #78 had an x-ray due to pain in her left rib area. The chest x-ray result documented Resident #78 had a left fifth rib fracture near the costochondral junction (joint between the ribs and cartilage located in the front of the rib cage). On 8/21/19 at 2:01 PM, the DNS said Resident #78 complained of inability to go to sleep due to noise in her room. Resident #78 was provided with an ear plug, as well as head phones but she said it did not help her and she continued to complain of the noise in her room. The DNS said Resident #78 was advised to transfer to another room, which was quieter. The DNS said Resident #78 was transferred to another room previously occupied by a resident who needed a bigger mattress, and an extender bar was placed on the bed to accommodate the bigger mattress. This bed was then used by Resident #78. When asked if Resident #78 needed the bigger mattress and the extender bar, the DNS said No. The DNS said the extender bars were missed during a room assessment when the room was prepared for Resident #78. On 8/23/19 at 11:01 AM, RN #1 showed the surveyor a bed with an extender bar attached. RN #1 said she was on duty the morning Resident #78 fell . RN #1 said the mattress was on top of the extender bar and it was not visible when the mattress was on it. RN #1 said when staff heard a thud and heard Resident #78 ask for help, they went to her room and saw her on the floor. RN #1 said she saw Resident #78's mattress pushed slightly to the left exposing the extender bar. RN #1 said that was the time she found out there was an extender bar attached to Resident #78's bed. RN #1 said the bed extender bars were removed immediately after Resident #78's fall.

Based on contract review, policy review, observation, and staff interview, it was determined the facility failed to ensure infection control surveillance of the contracted laundry services which processed residents' personal laundry. This deficient practice hand the potential to impact 27 of 27 residents (#1 - #22, #24 - #27, and #79) residing in the facility, all of whom relied on the facility for laundering of personal clothing. The facility also failed to ensure appropriate hand hygiene was completed during dressing changes. This was true for 1 of 12 residents (Resident #19) reviewed for infection control. These deficient practices placed residents at risk of infection. Findings include: The contract between the facility, and the contracted company providing personal laundry and mending services documented the service requirement as: The Contractor shall comply with all applicable rules, regulations and policies as outlined by the Department of Health and Welfare (Department), the State of Idaho, and local, state and national standards, including The Joint Commission, relating to patient care and hospital operations. The facility and a hospital on the same property, were owned by the same organization. The contract did not include a description of the specific cleaning process or products being used. The facility did not provide documentation regarding how the facility monitored the contractor's process to ensure it met the required standards. On 8/22/19 at 9:42 AM, the Administrator said all laundry was contracted to outside contractors. On 8/22/19 at 9:47 AM, the Infection Preventionist (IP) said the laundry services were contracted offsite, one contractor for linens and another for personal clothing. The IP said she visited and reviewed the contractor's facility and protocols. The IP provided processing and wash formula information from the contractor for linens. The IP did not provide processing and wash formulas from the contractor providing personal clothing laundry services. The facility did not provide documentation that it monitored the contractor's laundry processing of residents' clothing, or the specific guidelines used by the contractor for residents' clothing. On 8/23/19 at 1:16 PM, the DNS and the Environmental Services Director (ESD), provided the facility's contract with the personal laundry service contractor. The DNS and ESD said when they asked the contractor for the processing and wash formula information used by the personal laundry service contractor, the contractor replied it was not in their contract to provide it. 2. The facility's policy for Hand Hygiene, dated 11/4/09, documented hand hygiene was required before applying and after removing gloves, after handling an invasive device, and after contact with body fluids, mucous membranes, non-intact skin, or wound dressings. Resident #19 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #19's care plan directed nurses to provide care to his suprapubic catheter (a urinary catheter that drains the bladder through an incision in the abdomen) twice daily and as needed with water and 4 by 4's (gauze squares), pat dry, change the drain sponge and secure with tape. The intervention was initiated on 10/25/18 and revised on 11/14/18. Resident #19's quarterly MDS assessment, dated 4/30/19, documented he was cognitively intact and required an indwelling catheter. Resident #19's physician orders [REDACTED]. On 8/21/19 at 4:44 PM, LPN #1 said Resident #19's suprapubic catheter dressing change was just changed from twice a day to once a day. On 8/22/19 at 9:43 AM, LPN #2 was observed performing the dressing change to Resident #19's suprapubic catheter as follows: After washing her hands and applying gloves, LPN #2 removed the existing dressing. She then cleansed around the catheter insertion site and cleansed several inches of the catheter tubing from the abdomen outwards, then removed her gloves and did not perform hand hygiene. LPN #2 applied new gloves, retrieved a pen from a pocket in her top, opened a new dressing and wrote the date on it, and applied the new dressing around Resident #19's suprapubic catheter. LPN #2 then removed the used trash bag from the trash can and placed a new trash bag into the trash can. LPN #2 removed the glove from her left hand, did not perform hand hygiene, and exited the room carrying a used trash bag in her gloved right hand and a gray basin containing tape and dressing supplies in her ungloved left hand. LPN #2 walked down the hall carrying the items as previously described and entered the dirty utility room. LPN #2 said she washed her hands before removing Resident #19's old dressing, and then changed her gloves. LPN #2 said she did not wash her hands after removing her gloves and she probably should have. On 8/22/19 at 10:25 AM, the DNS said hand hygiene should be performed between residents, between glove changes, and if you felt your hands were dirty. The DNS said LPN #2 should have performed hand hygiene after removing her gloves during Resident #19's dressing change. On 8/22/19 at 10:51 AM, the Infection Preventionist said hand hygiene should be performed before and after contact with a resident, when going in and coming out of a resident's room, and if touching soiled items. The Infection Preventionist said hand hygiene should also be performed when going from something dirty to clean, and between glove changes.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' urinary drainage bags were kept in a privacy bag. This was true for 1 of 2 residents (Resident #25) reviewed for urinary catheters, and created the potential for harm should residents experience embarrassment related to their exposed urinary drainage bag. Findings include: The facility's policy for urinary catheters, dated 7/1/12, directed staff to maintain resident's privacy and dignity. Resident #25 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #25's quarterly MDS assessment, dated 7/9/19, documented he was cognitively intact and required an indwelling catheter. On 8/19/19 at 3:36 PM, Resident #25 was sitting in a recliner in his room. A urinary drainage bag was observed in a pink basin on the floor. The urinary drainage bag was not in a privacy bag, and the contents of the urinary drainage bag were readily visible to anyone who passed by the doorway or entered the room. A privacy bag was hanging from the seated walker adjacent to Resident #25's recliner. Resident #25 said he had a catheter in place because he could not urinate, and staff placed the urinary drainage bag in the privacy bag only when he walked down to the dining room. On 8/20/19 at 8:51 AM, Resident #25 was sitting in his recliner in his room. A trash can was next to the recliner and the urinary drainage bag was hanging off the trash can. The urinary drainage bag was not in a privacy bag. On 8/21/19 at 10:13 AM, Resident #25 was sitting in his recliner in his room. The urinary drainage bag was in a pink basin on the floor. The urinary drainage bag was not in privacy bag and was visible from the doorway. CNA #1 said that was the way the drainage bag was typically stored. CNA #1 said there was a privacy bag on Resident #25's walker, and staff placed the urinary drainage bag in the privacy bag just when he was up and walking around. On 8/21/19 at 10:20 AM, RN #1 said Resident #25's urinary drainage bag was to be in a privacy bag.

Based on record review and staff interview, it was determined the facility failed to obtain informed consent for 1 of 5 residents (Resident #8) reviewed for [MEDICAL CONDITION] medication. This deficient practice placed residents at risk of receiving [MEDICAL CONDITION] medications without knowledge of the risks and benefits associated with each medication, alternative treatment options, and the right to refuse the medication. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED].>[MEDICAL CONDITION] disorder (a chronic mental health condition characterized by hallucinations, delusions, mania, and depression), dementia, and medication induced dyskinesia (involuntary muscle movements). Resident #8's (MONTH) 2019 physician's orders [REDACTED]. Resident #8's physician's progress notes documented he received [MEDICATION NAME] from 9/17/12 to 11/17/16. A physician's orders [REDACTED]. Resident #8's record did not include a consent for the [MEDICATION NAME] when it was reordered. On 8/20/19 at 2:03 PM, the Administrator said Resident #8 had a daughter who made decisions for him. On 8/23/19 at 12:30 PM, the DNS said the facility did not need a consent for the [MEDICATION NAME] because it was classified as an [MEDICAL CONDITION] medication, not a [MEDICAL CONDITION] medication. On 8/23/19 at 2:07 PM, the Physician said the facility did not need a consent for the [MEDICATION NAME] because it was not classified as a [MEDICAL CONDITION] medication. Resident #8 and/or his representative was not provided the opportunity to consider all options before making the decision to add [MEDICATION NAME] to Resident #8's medication regimen.

Based on staff interview and record review it was determined that Resident #6 was harmed when the facility failed to prevent Stage 2 pressure sores from reoccurring. This was true for 1 of 9 (# 6) sampled residents. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent annual MDS, dated [DATE], documented the resident: * had short and long term memory issues, * required total assistance with transfers, dressing, eating, and personal hygiene. * incontinent of bowel and bladder, and * had a Stage 2 pressure sore that started on 12/20/12. The resident's comprehensive care plan, dated 1/17/13, documented a problem of; "Potential for pressure development and/or skin breakdown." The interventions were: "1. Assess skin during cares and showers, report any concerns to the charge nurse, 2. [MEDICATION NAME] ointment as ordered at bedside for skin protection and redness. 3. Apply Vaseline to both feet after shower and every morning. Physicians order 8/30/2012. 4. Weekly skin assessment, trim fingernails with each skin assessment. 5. Position resident high in bed so feet will not touch the footboard. 6. When transferring resident please make sure footboard of chair is pushed in and placed back out for his feet to rest on after resident is seated in his chair. 7. Bariatric Rotating Air mattress. Check proper functioning QS (every shift). 8. Cover all toes on left foot with soft boot during transfers and when in wheelchair. 9. Q2 hour turn schedule. (Started) 12/20/12. 10. ROM exercises per PT (Physical Therapy) recommendations (started) 5/2/2012. 11. Comfort company black foam pressure pad to geri chair. Cover chair with full sheepskin." According to Progress Notes (PN) and other documentation, the resident had pressure ulcers that were first noticed around 10/15/12 and 12/20/12 both Stage II and resolved quickly. The documentation was: - PN 10/17/12 at 12:27 p.m. "Assessment of reported skin breakdown dated 10/15/12. Resident gluteal cleft on the right buttock, 3 small pimple like areas. Area is blanchable, no [DIAGNOSES REDACTED] noted, no open areas, no drainage. Applied [MEDICATION NAME]. Will continue to monitor ...." - PN 10/17/12 at 2:05 p.m. (Addendum to the above note) "Assisted staff with continence care x 2. [MEDICATION NAME] applied after each attend change this shift. Resident lying down with support on the left side to encourage pressure relief. Gluteal cleft on right buttocks clean, with barrier applied. No drainage noted or observed...." - "physician progress notes [REDACTED]. October 24, 2012 at 12:03 p.m. reason for visit "Stage II pressure ulcer." The note documented: "There is no break down in the gluteal cleft... Skin is intact....Plan: Stage II pressure ulcer resolved." A second pressure ulcer appeared to the same area and it was documented as follows: - On 12/20/12 at 1:00 p.m. a "Nursing Wound Care Note" documented: Pt (patient) seen in his room for wound care to right buttock adjacent to the cleft 1/2 way down.... [DIAGNOSES REDACTED]: none, [MEDICAL CONDITION]: none, Drainage: none, Odor: none, Granulation : none, wound bed: pink and Size/depth: 0.7 cm x 0.6 cm. Dressing: [MEDICATION NAME] spot ..." - 12/21/12 at 9:40 p.m. a PN documented, "A PRN (as needed) new [MEDICATION NAME] spot applied to right buttock. 0.5 cm X 0.5 cm open area noted. Site appears bright red and superficial. No drainage, active bleeding or odor noted..." - "Physicians Progress Note - Medical Clinic" documented: December 24, 2012 at 2:38 p.m. reason for visit "wound care and 60 day review." The physician documented, " ....It should be noted that he has a gluteal cleft pressure sore that is being monitored...."Skin: In gluteal cleft there is approximately 0.5 mm annular area where the top layer of skin is removed. There is pink healing skin under this. There is no redness, drainage or odor. Surrounding the area is more intact pink skin where it has healed." The physician documented that it was a "Stage 2 Pressure Ulcer." - 12/30/12 at 9:39 p.m. a PN documented, "A new [MEDICATION NAME] spot applied to right buttock. 0.5 cm X 0.5 cm pink area noted skin intact...." - On 12/31/12 at 12:18 p.m. the "Nursing Wound Care Note" documented the area was "closed." The resident's spouse was interviewed on 1/30/13 at 1:30 p.m. and indicated that the resident had sores on the buttock at another facility he was at and also had one upon admission to the facility. The DON was interviewed and indicated that the resident had a pressure sore upon admission to the facility. No further information was obtained. The resident had a reoccurring area on the gluteal cleft that reopened. The facility failed to ensure interventions were in place to prevent the redevelopment of Stage II pressure ulcers. The Administrator and DON were informed on 1/31/13 at 5:00 p.m. No further information was provided.

Based on observation, incident/accident report review, Material Safety Data Sheet (MSDS) review, record review, and staff interviews, it was determined the facility failed to ensure residents were provided with adequate assistive devices to prevent falls for 1 of 9 sample residents (#2) reviewed. Resident #2 was harmed when he sustained a fractured hip as the result of a fall sustained during assistance from the restroom without the use of a gait belt. Additionally, the facility failed to ensure toxic chemicals were maintained under locked conditions. This failure had the potential to cause harm any resident dining in the second floor dayroom, including 9 of 9 sample residents (#1 - #9). This resulted in the potential for cognitively impaired residents to obtain and ingest a toxic substance. Findings include: 1. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Progress Note (PN - the facility's incident/accident documentation), dated 9/7/12, stated Resident #2 was walking back from his bathroom stating "I'm going to fall, my hips broken and i'm (sic) going to fall." Resident #2 then began to sit backwards. The staff with Resident #2 grabbed the back of his pants and lowered Resident #2 to a sitting position on the floor. A PN, dated 9/8/12, stated a staff was assisting Resident #2 from the bathroom to his bed. Resident #2 was using a walker. Resident #2 began to sit before he was close enough to his bed. The staff with him stood behind Resident #2 and assisted "resident to sitting position on the floor." The documentation did not describe how Resident #2 was assisted to the floor. Both PNs included a "Reviewers Comments" section, both dated 9/14/12, which stated nursing staff had been instructed to use a gait belt for all transfers with Resident #2. However, Resident #2's Care Plan did not include the use of a gait belt for transfers. A PN, dated 10/19/12, stated staff were assisting Resident #2 from the bathroom to his wheel chair. Resident #2 was using a walker. Resident #2 stated he was going to "go down." The staff present prompted him to his wheelchair, but Resident #2 let go of the walker and fell to the ground landing on his left hip. NOTE: The PN did not include documentation related to the use of a gait belt by staff. A Follow Up Note included in the PN stated Resident #2 was transported by ambulance to a local hospital. The "Reviewers Comments" section, dated 10/23/12, stated "Resident was admitted to acute care hospital for surgical repair of (left) hip fracture." The review also stated "orders were written for staff members to use a gait belt with all transfers and when assisting with ambulation." There was no indication the corrective action needed to prevent falls (the use of a gait belt), identified on 9/14/12, had been implemented. The PN did not include information indicating whether or not staff had been using a gait belt at the time of Resident #2's 10/19/12 fall that resulted in a hip fracture. An interview was conducted with the Administrator on 1/31/13 from 11:45 - 11:55 a.m. The Administrator stated follow up on corrective action was to be completed by the treatment team. The Administrator stated a Root Cause Analysis of Resident #2's 10/19/12 fall was completed and found that a gait belt was not used at the time, and the use of the gait belt had not been included in Resident #2's Care Plan. During an interview on 1/31/12 from 11:58 a.m. - 12:45 p.m., the DON confirmed the use of a gait belt had not been included in Resident #2's Care Plan prior to his 10/19/12 fall. According to the Progress Notes, Resident #2 fell on [DATE] and 9/8/12 when being assisted from the bathroom. Corrective action identified to prevent falls, dated 9/14/12, stated nursing staff were to use a gait belt for all transfers and ambulation with Resident #2. The use of a gait belt was not included in Resident #2's Care Plan. This resulted in harm to Resident #2 when he fell on [DATE] and fractured his left hip, which required surgical repair. The facility failed to ensure corrective action sufficient to protect Resident #2 from falls was implemented and followed. 2. Observations were completed at the facility from 1/28/13 - 1/31/13. During meals on the second floor, a closet containing a spray bottle of Clockwork sanitizer was noted to be unlocked and not monitored, as follows: - 1/29/13 from 7:35 - 8:00 a.m. - 1/29/13 from 12:15 - 12:55 p.m. - 1/30/13 at 11:38 a.m. - 1/31/13 at 8:00 a.m. The Material Safety Data Sheet (MSDS) for Clockwork stated "Based on acute toxicity testing, this product is harmful if swallowed." Failure to lock and/or monitor the closet in which the Clockwork sanitizer spray was stored provided opportunity for any resident near the second floor dayroom to access and ingest the chemical. During an interview on 1/31/13 from 11:58 a.m. - 12:45 p.m., the Administrator and Director of Nursing Services both stated the closet was to remain locked at all times and the chemical should not have been left accessible to residents. The facility failed to ensure toxic chemicals were maintained under locked conditions.

Based on observation, staff interviews and record review, it was determined the facility failed to ensure a resident at risk for pressure ulcers did not develop multiple avoidable ulcers for 1 of 1 sample resident, (#6) reviewed for pressure ulcers. Resident #6 was harmed when interventions were not put in place to prevent two Stage II pressure ulcers and an unstaged pressure ulcer on Resident #6's ear. In addition, Resident #6 's medical record did not reflect that assessments and interventions were timely and appropriate. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's admission MDS, dated [DATE], documented the resident was not at at risk for pressure ulcers, and no pressure ulcers were present at the time of assessment. The admission assessment documented no treatments were in place for the prevention of pressure ulcers. The quarterly MDS's for 7/1/11 and 9/30/11, documented the resident was at risk for pressure ulcers but there were no current pressure ulcers or healed pressure ulcers. Both quarterly assessments included interventions of a pressure reducing device for the resident's bed, turning and repositioning, nonsurgical dressing (other than to feet) and nutrition or hydration interventions to manage skin problems. Resident #6's wound care progress notes documented: a. 2/7/11 - Resident #6 was seen for wound care for wound on right shoulder over a bony prominence. There was was no [MEDICAL CONDITION], drainage, granulation and the wound bed was dry. The wound was documented as a Stage II and the size was 1 cm by 1 cm with depth to the dermis. A scanned image was attached to the progress note. A Braden Scale Assessment for predicting pressure sore risk was attached and had a score of 17 or low risk. 2/10/11 - The right shoulder wound was documented as [DIAGNOSES REDACTED] "increased amount" around the wound. There was no [MEDICAL CONDITION], drainage, granulation and the wound bed was dry. The wound was documented as a Stage II, the size was 1 cm by 1 cm with depth to the dermis. 2/14/11 - The right shoulder wound was documented as [DIAGNOSES REDACTED] "decreased amount" around the wound. There was no [MEDICAL CONDITION], odor, granulation and the wound bed was documented as healing. Slight drainage was noted. The wound was documented as a Stage II, the size was 1 cm by 1 cm with depth to the dermis. 2/18/11 - The right shoulder wound [DIAGNOSES REDACTED] was documented as none. "decreased amount" around the wound. There was no [MEDICAL CONDITION], drainage, odor, granulation and the wound bed was documented as closed and resolved. The wound was documented as a Stage II. b. Extremely small opening noted to lower fold of right ear lobe. [DIAGNOSES REDACTED] was mild and drainage was scant and clear. There was no [MEDICAL CONDITION] or odor. The wound was not staged. The size and depth was superficial. The assessment stated the wound was caused by the resident lying on his right side in bed. 2/22/11 - The right shoulder wound was documented as no [DIAGNOSES REDACTED], [MEDICAL CONDITION], drainage, odor, or granulation. The wound bed was documented as closed and resolved. The wound was documented as a Stage II with depth to the dermis. Extremely small opening noted to lower fold of right ear lobe. [DIAGNOSES REDACTED] was mild and drainage was scant and clear. There was no [MEDICAL CONDITION] or odor. The wound was not staged. The size and depth was superficial. The assessment stated the wound was caused by the resident lying on his right side in bed. NOTE: There is no other documentation regarding the wound to the ear. c. 5/23/11 - The resident was seen for two wounds. One was near his right nipple which appeared to be non-pressure related. The other wound was on the lateral side of the left scapula (a bony prominence). The documentation included mild [DIAGNOSES REDACTED] to the wound on the back. There was no other documentation regarding the wound on the left scapula. 5/25/11 - The left shoulder had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation. The wound bed was documented as, "Beefy red." Drainage was documented as scant serous. The wound was not staged and the size was 2.5 cm length by 2 cm width. The depth of the wound was not documented. 6/1/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 2 cm length by 2 cm width. The depth and stage were not documented. 6/7/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 2 cm length by 2 cm width. The depth and stage were not documented. 6/17/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 2 cm length by 2 cm width. The depth and stage were not documented. 6/28/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as a blister. Drainage was documented as scant serous and the size of the wound was 2 cm length by 2 cm width. The depth and stage were not documented. 7/1/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as beefy red. Drainage was documented as scant serous and the wound size was 1 cm length by 2.5 cm width. The depth and stage were not documented. 7/5/11 - The left shoulder wound had no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, or granulation. The wound bed was documented as beefy red. Drainage was documented as scant serous and the wound size was 1.5 cm length by 2.5 cm width. The depth and stage were not documented. 7/12/11 - The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 1 cm length by 2.5 cm width. The depth and stage were not documented. 7/15/11 - The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 0.5 cm length by 1.0 cm width. The depth and stage were not documented. 7/19/11 - The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as beefy red. Drainage was documented as scant serous and the size was 0.5 cm length by .75 cm width. The depth and stage were not documented. 7/22/11 - The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as, "Healed all but one small spot." Drainage was documented as scant serous and the size was 0.5 cm length by .75 cm width. The depth and stage were not documented. 7/26/11 - The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as all but one spot healed. Drainage was documented as scant serous and the size was 1 cm length by 2.5 cm width. The depth and stage were not documented. An addendum to the notes documented the resident wound be sent out to wound care due to, "...The fact it is not healing." 7/29/11 -The resident was seen for wound care on the left shoulder. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION], odor, granulation and the wound bed was documented as all but one spot healed. Drainage was documented as scant serous and the size was 1 cm length by 2.5 cm width. The depth and stage were not documented. An addendum to the notes documented the resident wound be sent out to wound care due to, "...The fact it is not healing." Treatment updates from the consulting wound care facility documented: 8/8/11 - A pressure ulcer on the left shoulder that was 1.4 cm by 0.8 cm by 0.1 cm with a moderate amount of serous exudate drainage. The documentation did not identify the stage. 8/15/11 - The wound to the left shoulder was closing. The antibiotic [MEDICATION NAME] was started. 8/22/11 - The pressure ulcer on the left shoulder measured 3.4 cm by 4.0 cm by 0.1 cm. The notes documented the wound had increased in size from it original measurement of 1.8 cm by 1.0 cm by 0.1 cm. The notes documented a minimum amount of serous drainage and the ulcer bed had exposed subcutaneous tissue. The "Impression" section documented there was evidence of a nearly resolved deep tissue injury and the ulcer was essentially resolved, however, there was a thin blister that ruptured. 8/29/11 - The pressure ulcer was 2.0 cm by 1.0 cm by 0.1 cm with minimum amount of serous exudate drainage and exposed subcutaneous tissue. The documentation did not identify the stage. 9/6/11 - Documented the wound was improved and the lesion is healed. 9/19/11 - Documented the wound was healed and the resident was discharged from the wound care facility. Facility progress notes: 9/29/11 -Wound care to wound on left scapula area. There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION],odor or granulation. The wound was documented as a Stage II, Stage III (the physician wrote an addendum and stated it was a Stage II). Drainage was documented as moderate serous and the wound bed was beefy red. The size was documented as 2.5 cm by 3 cm. The depth was not documented 10/3/11 - There was no [DIAGNOSES REDACTED], [MEDICAL CONDITION],odor or granulation. The wound was documented as a Stage II, Stage III (the physician wrote an addendum and stated it was a Stage II). Drainage was documented as moderate serous and the wound bed was beefy red. The size was documented as 2.5 cm by 3 cm. The depth was not documented. During observations from 10/4/11 through 10/6/11 Resident #6 was observed laying on his bed. Resident #6 did get up to go to meals but at all other times was observed laying in his bed. On 10/4/11 at 1:00 p.m. CNA #1 stated Resident #6 seldom got out of bed as he preferred to sleep in his room. Resident #6's Care Plan, printed 4/12/11, documented in the problem section there was a potential for pressure ulcers related to the resident spending most of the time in bed. Interventions were: to complete Braden skin assessments with each staffing (dated 3/12/11), weekly skin checks, monitor skin during cares, physician order [REDACTED]. Resident #6's Care Plan, printed 7/5/11 included the same interventions except the body pillow had been eliminated and handwritten was the use of a pillow to offload his left shoulder when the resident was supine (dated 7/26/11) and to the clinic for wound care (7/26/11). On 10/7/11 at 9:00 a.m. the DON was interviewed regarding Resident #6's Care Plan for pressure ulcers. The DON stated the facility encouraged Resident #6 to change sides he is laying on. When asked if Resident #6 was encouraged to get out of bed he stated the resident would refuse to get out of bed. The DON stated the resident refused the body pillow and would throw it out of the bed. When the DON was told that documentation was missing regarding the characteristics of the wounds the DON stated he would check for further documentation. The surveyor pointed out the pressure ulcer was documented as healed by the wound clinic on 9/19/11, but facility notes documented it was back on 9/29/11. The DON stated he was not able to provide any information regarding the reason the ulcer had returned. When the DON was asked when Resident #6 began using the alternating mattress he stated he would get back to me. During a phone call on 10/12/11 the DON stated the initial air mattress was not an alternating mattress, the alternating mattress was not put into place until the end of September 2011 after the left pressure ulcer reopened. The DON also stated there were no further revisions to the care plan for pressure ulcers. Resident #6 experienced harm when multiple pressure ulcers of at least stage II developed. Resident #6's Care Plan was not revised after the initial pressure ulcer on his right shoulder and he developed a second ulcer on his left shoulder. The ulcer on his left shoulder healed but reopened. Additionally the Resident #6 developed an open area on his ear that was determined to be from laying on his right side. The facility did not provide an alternating air mattress until the ulcer on the left shoulder reopened.