Every finding on record at Teton Healthcare of Cascadia

Based on policy review, observation, record review, and interviews, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #49). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:The facility's Self-Administration of Medications policy dated 11/28/17, documented under Procedure 2. the interdisciplinary team determines that it is safe for the resident to self-administer drugs before the resident is allowed to do so, and the decision is periodically reviewed according to the resident's status. Procedure 2b. documented the determination of who will be responsible (resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration. Procedure 4. documented appropriate notation of these determinations is documented in the resident's medical record and care plan.Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (a reversible, acute, or chronic brain dysfunction caused by systemic illness, toxins, or chemical imbalances) and acute respiratory failure with hypoxia (acute hypoxic (or hypoxemic) respiratory failure is a critical condition where the lungs cannot adequately transfer oxygen to the blood).On 3/2/26 at 8:02 AM, observed Resident #49 had OTC Refresh eye drops on her overbed table. Resident #49 stated, she keeps them in the room for when she needs them.Resident #49's medical record documented no patient assessment for self-administration of medications and no documentation in her care plan to allow self-administration of medications.On 3/3/26 at 1:38 PM, the RN Clinical Resource Nurse stated Resident #49 should not have Refresh Eye drops in her room and she had not yet been assessed for self-administration of said medication.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 17 residents (#4 and #5) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Call Light Response Time policy, revision date 10/15/22, documented. Procedure 1. Resident Access a. Call light systems are expected to be available, within reach, at the bedside and in toileting and bathing areas.Resident #4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including unspecified psychosis (symptoms of a significant disconnection from reality, such as hallucinations, delusions, or disorganized behavior) and muscle weakness. On 3/2/26 at 8:07 AM, observed Resident #4 sitting at her side table in the middle of her room eating breakfast and her call light was tied around the nightstand drawer handle behind her next to the bed and not within her reach. Resident was unable to independently reach call light. On 3/2/26 at 8:12 AM, CNA #1 stated Resident #4's call light should be within reach and had not been. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis to one side of the body) and diabetes. On 3/2/26 at 2:55 PM, observed Resident #5 reclining in his bed and his call light was on his bedside table to the left side of his bed, which was not within his reach. Resident #5 stated he could not reach his call light where it had been placed after staff helped him with cares. On 3/2/26 at 3:02 PM, CNA #1 stated Resident #5's call light should have been within reach and had not been. On 3/4/26 at 3:18 PM, the CNO stated resident call lights should be within the resident's reach and had not been.

Based on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (CMS- 10123 form) for 1 of 1 resident (Resident #81) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include: Resident #81 was admitted to the facility on [DATE], with multiple diagnoses including post-surgical repair of fracture left femur and muscle weakness.On 3/4/26 at 1:20 PM, during record review the NOMNC documented .effective date coverage of your current skilled nursing facility services will end on 11/18/25, however; the NOMNC had a signature of resident and resident's representative on 11/17/25.On 3/4/26 at 1:35 PM, review of Social Services Note dated 11/17/25 12:12, documented Social Services spoke with daughter via telephone about the NOMNC issued for last covered day of 11/18/25.On 3/4/26 at 1:40 PM, the CEO stated the NOMNC for Resident #81 should have been signed 48 hours prior to the end of covered skilled nursing services and had not been.

Based on observation and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment. This was true for the facility. This deficient practice created the potential for diminished quality of life and safety risk including potential for infections and cross-contamination. Findings include:On 3/2/26 at 12:22 PM, observed two large dining room ceiling vents with brown hairy-like debris covering 1/3 of the inside of each vent and a small strip of red confetti-like paper in one vent.On 3/2/26 at 12:23 PM, observed brown/black discoloration on the ceiling around the other dining room ceiling vents.On 3/2/26 at 12:34 PM, the CEO stated the vents should have been cleaned and had not been.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 2 residents (Resident #23) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility. Findings include:The facility's Discharge or Transfer policy revised 8/30/25, documented under NOTICE OF TRANSFER OR discharge: 1. The facility must provide the resident, the resident's representative (if any), and the Office of the State Long-Term Care Ombudsman with a written notice at least 30 days before the resident is transferred or discharged , except when .c. The resident's urgent medical needs require an immediate transfer.The facility's Bed-Hold policy revised 9/9/25, documented Facilities are required by Federal regulation to have policies addressing holding a resident's bed during periods of absence such as hospitalization or therapeutic leave. Additionally, facilities provide this written information about these policies to residents prior to and upon transfer for such absences.Resident #23 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes, heart failure, and cirrhosis.On 9/22/25, Resident #23 was transferred to the ER. Resident #23's medical record did not document he received a written Notice of Transfer or Bed Hold policy.On 2/8/26, Resident #23 was transferred to the ER. Resident #23's medical record did not document he received a written Notice of Transfer or Bed Hold policy.On 3/3/26 at 4:00 PM, the RN Clinical Resource Nurse stated they could not locate the Notice of Transfer or the Bed Hold for Resident #23's ER transfers on 9/22/25 or 2/8/26.

Based on record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 2 of 3 Residents (#2 & #73) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care. Findings include:The facility's Baseline Care Plans policy revised date 10/15/22, documented under Procedure 1. A baseline plan of care is developed within 48 hours of admission to address the immediate needs of the residents and will be utilized/updated as needed until a comprehensive care plan can be developed and implemented. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease (the final, irreversible phase of kidney failure where kidneys no longer function sufficiently on their own, requiring dialysis or a transplant for survival) and acute respiratory failure with hypoxia (acute hypoxic (or hypoxemic) respiratory failure is a critical condition where the lungs cannot adequately transfer oxygen to the blood). Resident #2's baseline care plan was initiated on 2/2/26, but not locked or completed until 2/3/26, which exceeds the required 48 hours baseline care plan requirement. On 3/3/26 at 9:28 AM, the RN Clinical Resource Nurse stated a baseline care plan is not completed until locked. On 3/4/26 at 10:54 AM, the CNO stated baseline care plans are not completed until locked. On 3/4/26 at 11:01 AM, the RN Clinical Resource Nurse stated Resident #2's baseline care plan had not been completed within 48 hours and should have been. Resident #73 was admitted to the facility on [DATE], with multiple diagnoses including Necrotizing Fasciitis (a rare, life-threatening bacterial infection that destroys skin, fat, and muscle tissue), and diabetes with diabetic polyneuropathy (a common, progressive nerve disorder caused by high blood sugar damaging peripheral nerves). A closed record review, (meaning the resident has been discharged ) on 3/3/26, indicated Resident #73's baseline care plan was not completed until 12/29/25, 5 days after her admission. On 3/3/26 at 9:20 AM, the RN Clinical Resource Nurse stated the baseline care plan should have been created within 48 hours of admission and had not been.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 1 of 6 residents (Resident #3) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include.Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including acute and chronic respiratory failure and other abnormalities of breathing. On 3/2/26 at 8:07 AM, during interview Resident #3 stated his left arm is swollen and has been for a while. On 3/2/26 at 8:08 AM and 3/5/26 at 9:52 AM, observed Resident #3 sitting in his room not wearing a compression glove to the left hand and Tubi grip sleeve to his left arm from the wrist to the shoulder. On 3/2/26 at 11:03 AM, during record review noted Resident #3 physician order dated 9/16/25 - Compression glove to left hand, Tubi grip sleeve to left arm from wrist to shoulder every day and night shift for edema. On 3/2/26 at 11:06 AM, Resident #3's care plan reviewed with no documentation regarding compression glove to left hand and Tubi grip sleeve to left arm. On 3/5/26 at 10:17 AM, the RN Clinical Resource Nurse stated Resident #3's care plan should have been updated when the resident received physician orders for the compression glove and Tubi grip sleeve and had not been.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 3/3/26 at 1:50 PM, observed the Daily Staffing sheets for February 2025 through July 2025, noting the name of the facility and LPN hours were not listed on any of these sheets.On 3/4/26 at 10:35 AM, the CEO stated the LPN hours, and name of the facility should have been on the daily staffing sheet from February 2025 through July 2025 but were not.

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 2 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 3/3/26 at 8:52 AM, observed during the 400 Hall medication cart audit the narcotic accountability sheet, dated 3/2/26 to 3/3/26, with 1 licensed nurse signature not documented on 3/3/26. On 3/3/26 at 8:53 AM, RN #2 stated two nurses should have signed the narcotic accountability sheet and had not. On 3/4/26 at 8:44 AM, observed during the 100 Hall medication cart audit the narcotic accountability sheets, dated 2/6/26 to 2/12/26, 2/13/26 to 2/20/26, and 3/1/26 to 3/3/26 with 1 licensed nurse signature not documented on 2/11/26, 2/12/26, 2/13/26, 2/19/26, and 3/3/26. On 3/4/26 at 8:48 AM, RN #4 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 3/4/26 at 3:15 PM, the CNO stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart and had not.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure physician orders documented adequate indications, diagnosis, or duration for use when residents were prescribed antibiotics. This was true for 1 of 4 residents (Resident #14), reviewed for antibiotic use. This failed practice had the potential to cause significant harm if the resident was to develop an antimicrobial resistance or toxicity. Findings include:The facility's Physician/Providers Orders Policy, revised 9/12/25, documented under Procedure the following:2. Ensure each medication order includes:Resident nameDrug name and strengthIndication or diagnosisDosage, frequency, route, and durationOther monitoring/parameters required by state or federal regulationThe facility's Unnecessary Medications Policy, revised 9/10/25, documented The facility will ensure that each resident's medication regimen is free from unnecessary medications. This includes medications prescribed in excessive dose, without adequate indications for use, without appropriate monitoring, or in the presence of adverse consequences that indicate the medication should be reduced or discontinued. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis in the lumbar region (a narrowing in the spinal canal in the lower back) and neurogenic bladder (nerve damage that prevents the bladder from properly storing or emptying urine).Resident #14's physician order dated 9/22/25, documented Gentamicin Sulfate Injection Solution (Gentamicin Sulfate). Use 400 mg via irrigation every day and night shift for Inject 60cc solution into bladder via foley. Clamp for 30 minutes then unclamp.Resident #14's physician order for the Gentamicin Sulfate did not document an adequate indication or diagnosis and indicated the duration as indefinite. On 3/3/26 at 1:37 PM, the ACNO stated the order for Gentamicin dated 9/22/25, should have had an indication for use and duration but had not.

Based on observations, record review, and staff interviews it was determined the facility failed to ensure medications were not expired and were secure and inaccessible to unauthorized staff and residents. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy and potential for harm to a resident if they obtain medications which were left unattended and unsecured by staff. Findings include: The facility's policy, Medication Storage & Labeling, dated 10/13/25, documented.Procedure 2. Storage Requirements a. General Medications: i. Store in locked compartments (cabinets, carts, medication rooms), ii. Maintain clean, sanitary conditions: prevent contamination.5. Disposal a. Expired or discontinued medications must be removed promptly and disposed of per facility policy and DEA guidelines to prevent diversion. On 3/2/26 at 8:50 AM, observed in the Medication Storage room with LPN #1 present the following:Three bottles of Rena Vite 100 tablets with a manufacturer printed expiration date of 1/2026Two bottles of Melatonin 1mg with a manufacturer printed expiration date of 2/2026One bottle of Multi Vitamin 1000 tablets with a manufacturer printed expiration date of 2/2026One bottle of Pro Stat Liquid Protein 30 ounces with a manufacturer printed expiration date of 2/2026Two bottles of Anti-dandruff shampoo with Selenium Sulfide 1% with a manufacturer printed expiration date of 2/2026 On 3/2/26 at 9:02 AM, the CNO stated the expired medications should have been removed from the Medication Storage room and had not been. 2. On 3/4/26 at 12:12 PM, observed the 100 Hall medication cart unlocked and unattended by staff. On 3/4/26 observed between 12:12 PM and 12:16 PM, three staff members walk by the medication cart without acknowledging the cart was unlocked and unattended. On 3/4/26 at 12:17 PM, observed RN #4 walking down 100 hallway and approached the unlocked and unattended medication cart. On 3/4/26 at 12:18 PM, RN #4 stated the medication cart should not have been left unlocked when leaving the cart unattended. On 3/4/26 at 3:16 PM, the CNO stated the medication cart should not have been left unlocked when the nurse left the cart unattended. 3.The following was observed during the medication cart audits. On 3/4/26 at 12:21 PM, the 100 Hall medication cart was audited with RN #4 present. The following medications were observed loose in the bottom of the medication cart drawer 2 and medication cart drawer 3: - 1 medium blue colored capsule with DCX 30 printed on capsule - 1/2 white colored capsule with D 02 imprinted on capsule - 1 medium white colored round tablet with M imprinted on tablet on one side and C37 imprinted on other side - 1 medium round light brown tablet with 60 imprinted on tablet - 1/2 tablet light blue with 540 imprinted on one side - 1 small white round tablet with TV imprinted on one side and 4 numbers (2204) imprinted on the other side - 1 bottle of Multi Vitamin with manufacturer printed expiration date 2/2026 On 3/4/26 at 12:30 PM, RN #4 stated the pills should not have been loose in the medication cart and the medication cart drawers should have been cleaned to remove any loose pills. On 3/4/26 at 12:33 PM, the CNO stated the pills should not have been loose in the medication cart and should have been destroyed.

Based on the FDA Food Code, policy review, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled, cooking equipment was free of encrustation, and the floors were properly cleaned and sanitized. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination of food and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code 2022, 3-501.17 documented, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . 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.The FDA Food Code 2022, 4-601.11, documented, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.The facility's Food Safety & Storage policy dated 11/28/17, documented the following under Labeling and Rotation:Opened or repackaged food must be labeled with contents and use-by-date.Food removed from original packaging must be labeled with its common name, unless clearly identifiable, and use-by or expiration date.Ready-to-eat food held longer than 24 hours must be labeled with preparation and use-by-dates.On 3/2/26 between 8:00 AM - 8:20 AM, observed the following:- the walk-in refrigerator contained 11 individual salads dated 3/1/26.- the walk-in freezer contained chocolate pieces on a cookie sheet that was not covered, labeled, or dated.- the clean pots and pans storage rack contained muffin pans that were encrusted on the front and back of the pans.- the drain hole under the food prep sink had a split grate covered in black dirt and grime-like substance reaching beyond the opening of the hole onto each side of the tiles surrounding the drain hole.- underneath the counters, handwashing sink, and food prep sink where the floor and wall meet, had a thick layer of dirt, food, and grime.On 3/2/26 8:40 AM, the CFM stated the salads should have been used on 3/1/26 and discarded them.On 3/4/26 at 11:40 AM, the CFM stated the floor underneath the food prep sink was dirty and he had scrubbed it the previous day (3/3/26). The CFM and Dietician confirmed the encrustation on the muffin pans and stated they would replace them.

Based on observation, staff interview, and record review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment during medication administration. This was true for 1 of 4 residents (Resident #60) observed for infection control. These failures put residents at risk for cross contamination and infection. Findings include:The facility's policy, Medication Administration, revision date, 12/18/21, 9/10/25, documented.Procedure 9. a. Remove medication from the storage receptacle (container, bottle, or blister pack) without directly touching the medication.Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that restricts airflow causing breathing difficulty) and diabetes.Resident #60's physician orders documented fifteen morning medications for resident including Colace 100 mg - 1 soft gel capsule by mouth.On 3/4/26 at 8:30 AM, observed RN #3 place all fifteen medications in a medication cup and enter Resident #60's room. Resident #60 stated she did not want the Colace; RN #3 removed the Colace capsule from the medication cup with her ungloved finger and provided the medication cup to Resident #60. On 3/4/26 at 8:37 AM, RN #3 stated she should have used a spoon or donned gloves to remove the Colace from the medication cup and had not. On 3/4/26 at 3:18 PM, the CNO stated RN #3 should not have used her ungloved finger to remove the medication from the medication cup.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility who are transferred with Hoyer lift equipment. This deficient practice created the potential for harm from cross contamination due to equipment not being cleaned between use. Findings include:The facility Work Practices Cleaning policy dated 1/1/18, documented multiple use resident care items are properly cleaned/disinfected between each resident use. Resident care items may include but is not limited to resident lifts.The following areas were observed: - On 8/14/25 at 7:55 AM, observed in room [ROOM NUMBER], a sticky substance on the over the bed table and a dry black substance on commode. - On 8/14/25 at 8:25 AM, observed in room [ROOM NUMBER], next to Resident #89’s bed and by the bathroom door a trash can with soiled briefs in it. On 8/14/25 at 8:30 AM, CNA #4 stated the garbage should be taken out after each time a resident's brief had been changed. - On 8/14/25 at 8:31 AM, observed Resident #1’s wheelchair with a towel on the seat with a dry yellow substance on it and dried crumb like substance under the wheelchair cushion. On 8/14/25 at 8:31 AM, Resident #1 stated her daughter told her that her wheelchair needed to be cleaned because it stunk. On 8/14/25 at 8:33 AM, CNA #4 stated the wheelchairs are to be cleaned two times a week by the night shift. - On 8/14/25 at 8:36 AM, observed in room [ROOM NUMBER]’s bathroom, a dried brown substance on the commode seat and 1 opened bag of briefs on the floor. -On 8/14/25 at 8:47 AM, observed in room [ROOM NUMBER] a trash can with soiled briefs and dirty incontinent wipes. - On 8/14/25 at 9:45 AM, observed in room [ROOM NUMBER], a Hoyer sling lying on the floor, next to recliner and 2 bags of briefs sitting on the floor in the bathroom. On 8/14/25 at 10:00 AM, Housekeeper #1 stated the rooms were to be cleaned daily and this included the over the bed table. On 8/14/25 at 10:31 AM, the DON stated the trash cans with dirty briefs should have been taken out every time the resident’s briefs were changed, the resident’s supplies should not have been stored on the floor, the CNAs should have cleaned the over the bed tables, and the night shift were to clean the wheelchairs at night, but they did not have documentation that the wheelchairs were being cleaned. On 8/14/25 at 1:02 PM, the Administrator with the Maintenance Assistant present, stated the over the bed tables should have been cleaned daily by the housekeepers. On 8/14/25 at 7:05 AM, the blue crossbeam pad on the Hoyer lift on the 100 hall was dirty with whitish and brown marks on it. LPN #1 stated she was not sure how they get dirty because they try not to allow the residents to touch the pad. On 8/14/25 at 7:12 AM, the gray crossbeam pad on the Hoyer lift on the 400 hall was dirty to the point of being black. CNA #1 stated she was not sure how or when the crossbeam pad gets cleaned. On 8/14/25 at 10:50 AM, the DON stated the Hoyer lift cross beam pads should be kept clean or removed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 3 residents (Resident #5) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:The facility Accidents and Supervision to Prevent Accidents policy dated 10/15/22, documented under falls, development of a person-center plan of care by the interdisciplinary team can evaluate potential use of therapy, devices, environmental adjusts, review of medications, and treatment of other impacting factors may reduce the number of outcome severity of falls. If fall occurs, manage the fall, then determine root-cause analysis to assist with updates to the fall prevention plan. When reviewing root-cause, evaluate all the causal factors leading to the resident fall as the(y) may also assist in developing and implementing relevant, consistent, and person-centered interventions to prevent future occurrences.Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including acute osteomyelitis on right ankle and foot (a bone infection, usually occurring within two weeks of the initial infection) and adult failure to thrive.Resident #5's medical record documented he had a fall on 3/14/25, when he leaned forward in his wheelchair to reach his drink and food in the dining room and he slipped out of his wheelchair to the ground. The IDT assessment directed that staff were to ensure Resident #5's drink and food are closer to him in the dining room, so he did not have to lean forward in his wheelchair. Resident #5's care plan fall prevention interventions had not included the IDT assessment recommendationsOn 8/14/25 at 11:10 AM, the DON stated Resident #5's care plan fall interventions had not including the IDT assessment recommendation from the 3/14/25, fall and should have.

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately; this was true for 1 of 18 resident's rooms inspected (Resident #1). This failure created the potential for adverse effects if residents self-administered medications inappropriately or did not take their medications. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and hypertension.On 8/14/25 at 8:44 AM, observed on Resident #1's bedside table a medication cup with a purple substance with multi-colored specks and a spoon in it.On 8/14/25 at 8:48 AM, RN #1 stated Resident #1 did not have an order to self-administer medications, she did not have it documented in her care plan to self-administer medication so she should not have left the medications in her room.On 8/14/25 at 11:38 AM, the DON stated residents should not have medications left in their room.

Based on observation and staff interviews, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment, when staff did not follow proper enhanced barrier precautions protocol. These failures had the potential to impact 1 of 5 residents (Resident #70) observed with EBP signs on their room doors, placing them all at risk for cross-contamination and infection. Findings include:Resident #70 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis (inflammation of the bladder) and dysphagia (difficulty or pain with swallowing). On 8/14/25 at 7:36 AM, observed CNA #2 had not donned a gown or gloves when she assisted Resident #70 with a transfer from her bed into her wheelchair and then into the shower room where she assisted her with a shower. Resident #70 was on EBP with a sign on her door that documented for staff to wear gown and gloves when assisting with transfers and showering. On 8/14/25 at 7:40 AM, CNA #2 stated she thought she only needed to donn gown and gloves when assisting Resident #70 with her catheter.On 8/14/25 at 7:45 AM, CNA #3 stated the EBP sign indicated staff were to wear gloves and gown when assisting residents with bathing/showering, transferring, and catheter care.On 8/14/25 at 11:00 AM, the DON stated staff were to wear gloves and gowns when assisting residents with cares who have EBP signs on their door.

Based on observation, policy review, record review, staff interview, and review of the facility's investigation report, it was determined the facility failed to ensure proper storage and use of Hoyer lift equipment to prevent resident falls or injury. This was true for 1 of 1 resident (Resident #233) whose record was reviewed for falls. This resulted in harm to Resident #233 when proper use of a Hoyer lift was not provided. Findings include: The facility Space and Equipment policy revision date 12/4/19, documented under Procedure 6. Resident care equipment is stored after use in an area out of egress while maintaining availability. Licensed nursing and plant operations will validate proper storage and availability of resident care equipment when not in use. On 12/17/24 at 10:13 AM, observed a Hoyer lift being stored in room [ROOM NUMBER] which created a potential fall hazard when residents try to leave the room with their walker or wheelchair. On 12/18/24 at 11:40 AM, the CRN stated Hoyer lifts should not have been stored in resident's rooms. Resident #233 was admitted to the facility on [DATE], with multiple diagnoses including necrosis of left femur and dementia. On 6/26/24 the facility incident report documented during a Hoyer lift transfer for Resident #233, the Hoyer lift tipped over, causing a laceration to his head and bruising on his cheek. A nursing note dated 6/26/24, documented CNA #2 was transferring Resident #233 using an improper technique, when the Hoyer lift tipped over, hitting the resident in the head. On 6/26/24 at 7:23 PM, Resident #233 was transferred via ambulance, to a hospital emergency department where he received 3 staples to his scalp to close the laceration. On 12/20/24 at 10:38 AM, the CRN stated all CNAs should have been properly trained and had competencies completed on safe Hoyer lift transfers before use.

Based on observation, review of policy, record review, and interviews, it was determined the facility failed to ensure a) Certified Nursing Assistants (CNAs) were trained and had documented competencies to operate the facility Hoyer lifts and b) Licensed nurses had appropriate competencies and skills sets to provide respiratory related services to residents. This was true for all nursing staff employed by the facility. This had the potential for adverse effects and harm to residents who are transferred with Hoyer lifts or had an order for respiratory therapy. Findings include: The facility Competency Verification of Nursing Staff policy revised on 3/1/24, documented that completed competencies and education plans should be filed in employee's education file to include new hires' competency verification and annual competency review. 1. Resident #233 was admitted to the facility on [DATE], with multiple diagnoses including necrosis of left femur and dementia. On 6/26/24 at 5:30 PM, during a Hoyer lift transfer for Resident #233, the Hoyer lift tipped over, causing a laceration to his head, and bruising on his cheek. Resident #233's nursing note dated 6/26/24 at 7:30 PM, documented CNA #2 was attempting to load Resident #223 from the side of the Hoyer lift using an improper technique for the Hoyer when the Hoyer tipped over hitting the resident in the head. On 12/19/24 at 3:39 PM, the Administrator stated there were no CNA competencies documented for Hoyer lift usage prior to 7/2/24. On 12/20/24 at 11:35 AM, CNA #8, stated she had been at the facility for 5 years and had not been competency tested on the Hoyer lift. On 12/20/24 at 11:37 AM, CNA #9, stated she received training at a different facility but had not been competency tested on the Hoyer lift at this facility prior to 7/2/24. On 12/20/24 at 11:36 AM, CNA #10, stated she had not been competency tested on the Hoyer lift. On 12/20/24 at 11:36 AM, CNA #11, stated she received training on Hoyer lifts in CNA school but had not been competency tested on the Hoyer lift at this facility prior to 7/2/24. On 12/20/24 at 3:45 PM, the CRN stated all CNAs should have had a signed competency to operate the Hoyer lift but did not. 2. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, respiratory failure, and diabetes. Resident #41's physician's order prescribed the use of AVAP (non invasive ventilation mode that automatically adjusts the inspiratory pressure support to deliver a set title volume) at 23 cmH2O inspiratory and 12 cmH2O expiratory for tidal volume of 550 cc with oxygen at 3 liters per minute with humidification. Resident #41's care plan instructed nursing staff to maintain ventilator settings as ordered - Trilogy AVAP at 55% FIO2 with 20 cmH2O. On 12/17/24 at 7:30 AM, Resident #41 stated he was having an issue with the AVAP, not able to get a deep enough breath and the machine seemed to be breathing too fast for him. He also stated, the air was too cold, causing his throat to be sore. On 12/17/24 at 7:34 AM, observed Resident #41's AVAP settings were 25 cmH2O inspiratory and 12 cmH2O expiratory with no set tidal volume, and set respiratory rate of 20 breaths per minute. Also, the humidify heater had not been turned on. There was no set AVAP respiratory rate documented in Resident #41's physician orders or care plan. On 12/17/24 at 7:48 AM, LPN #2, stated she had only been trained to turn the AVAP on and off and help Resident #41 put his full-face PAP mask on. She also stated she did not know how to turn on the humidifier. On 12/19/24 at 11:50 AM, the CRN stated there were no competencies or training documentation for the AVAP machine for the nursing staff. 50983

Based on observation and staff interview, it was determined the facility failed to ensure a) the kitchen equipment and environment was maintained and clean, and b) food was served in a safe and sanitary manner. These deficiencies placed all residents who consumed food prepared by the facility at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section ,d+[DATE].12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. The FDA Food Code Section ,d+[DATE].14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; a) A kitchen inspection was conducted on [DATE] at 10:17 AM, with the Culinary Manager (CM) and Registered Dietician (RD) present. The following was observed: - A temperature log for the dish machine was was missing recorded temperatures for the dish machine on [DATE] and [DATE]. - A sanitizer log was missing recorded santitation readings on [DATE] and [DATE]. On [DATE] at 10:25 AM, the CM stated he did not know why the logs were not filled out. - The ice machine was observed to have a significant amount of calcified water build up on the outside, right front edge and top near the lid. On [DATE] at 10:30 AM, the CM stated the build-up was from the hard water. When asked how often the ice machine is cleaned, the CM did not know, and stated maintenance was who cleans the ice machine. On [DATE] at 12:25 PM, the Administrator stated the water had hardened and calcified on the outside of the ice machine. - The floor between the kitchen and dishwashing area, had a layer of dirt and grime along the threshold. On [DATE] at 10:35 AM, The CM stated the threshold was loose and the dirt could be the glue that was holding the threshold in place. On [DATE] at 12:25 PM, the Administrator stated the floor does need cleaned but they need to find the right chemicals to clean it with. b) On [DATE] at 7:42 AM, observed RNA #1 pour orange juice into 4 cups for residents, however the orange juice was dated to expire [DATE]. On [DATE] at 7:44 AM, RNA #1 stated the kitchen should not have sent out expired orange juice and she should not have poured it into resident cups. On [DATE] at 7:46 AM, observed RNA #1 put her fingers in the resident's cups to pick them up and filled them with juice and then served them to the residents. On [DATE] at 7:52 AM, RNA #1 stated she was trying to pick up 3 cups with one hand and put her fingers in the cups by accident. On [DATE] at 1:05 PM, the CM stated the RNA should not have put her fingers in the resident's drink cups and the outdated orange juice should not have been served. On [DATE] at 8:23 AM, observed the cook cracked raw eggs on a grill with gloved and non-gloved hands, sometimes leaving the serving line to wash his hands and other times he just kept serving foods on to resident plates. On [DATE] at 8:46 AM, the cook stated that he should be washing hands after working with raw food, like eggs, and before touching the ready to eat foods. On [DATE] at 1:25 PM, the CM stated the cook should be washing hands after cracking eggs on to the grill and before returning to the serving line. 51121

Based on observation, resident and staff interview, record review, and policy review, it was determined the facility failed to ensure residents' urinary catheters were secured to the body to avoid tugging and pulling at the insertion site, the physician orders [REDACTED]. This was true for 1 of 2 residents (Resident #5) reviewed who had a urinary catheter. Resident #5 was harmed when he developed a skin tear with full skin thickness loss to the underside of the head of his penis at the urethral opening and experienced ongoing pain related to the indwelling urinary catheter and tear. Findings include: The facility's Skin Integrity policy, updated (MONTH) (YEAR), documented the procedure for skin impairment identified after a resident's admission included notification to the physician and resident representative, implementation of new interventions, weekly evaluation by facility clinicians. The policy also stated significant abrasions and bruises, which included skin tears, were evaluated weekly by licensed nurses and documented in the medical record. The policy was not followed. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. An 8/25/18, quarterly MDS assessment documented Resident #5's cognition was intact; he required extensive assistance with bed mobility, transfers, and toileting; he had functional limitation in range of motion in both upper and both lower extremities; and an indwelling urinary catheter was in use. A nurse's note, dated 6/12/18 at 11:30 PM, documented Resident #5 had a size 16 French Foley catheter placed to check for residual urine (the amount of urine in the bladder after urination). The note documented the catheter was left in place. A physician telephone order, dated 6/13/18, stated Resident #5 was to have a #16 French Foley catheter for a [MEDICAL CONDITION] bladder (lack of bladder control due to spinal cord or nerve problem). The order stated the catheter was to be changed every 6 weeks and as needed if it failed. There were no nurse's notes in Resident #5's record from 8/2/18 to 8/14/18, 12 days. A nurse's note, dated 8/15/18 at 11:30 PM, documented Resident #5 had a 2 cm tear at the meatus (urethral opening) of his penis. The note documented Resident #5 did not complain of pain from the tear. A physician telephone order, dated 8/16/18, included DermaPhor moisture barrier 3 times a day to the tear until it healed. Resident #5's care plan was updated on 8/16/18 to address the tear at the meatus of his penis. Interventions included: moisture barrier cream to meatus 3 times a day and to encourage Resident #5 not to manipulate his urinary catheter or his penis. Nurse's notes, dated 8/18/18 and 8/19/18, documented Resident #5 complained of a burning sensation to his penis. A nurse's note, dated 8/21/18, documented Resident #5 had increased pain and burning to penis with further tearing. The nurse documented Dermaphor was applied and Resident #5 was educated not to tug at the catheter. Resident #5's care plan identified the potential for issue related to the use of a Foley catheter related to [MEDICAL CONDITION] bladder. This was initiated on 8/29/18, 78 days after the insertion of the catheter. Interventions were to check the catheter every shift and as needed; check the tubing for kinks every shift; and monitor for and document pain and discomfort due to the catheter. A nurse's note, dated 9/2/18 at 11:20 PM, stated Resident #5 was pulling at the catheter and had a small amount of bleeding. The nurse stated he needed a catheter securement device. A securement device assists to hold the catheter in place and prevent pulling of the tubing. On 9/5/18, a nurse stated the catheter securement device was placed, 3 days later. There was no documentation a securement device was in place prior to 9/5/18. A nurse's note, dated 9/6/18 at 10:00 PM, documented Resident #5's catheter came out. The balloon which held it in place was intact but deflated. The nurse documented a larger catheter, size 20 was inserted with no trauma and was draining urine. A size 20 catheter is larger than a size 16, which was ordered by the physician on 6/13/18. Nurse's note, dated 9/7/18 and 9/8/18, documented the securement device for the catheter was in place and urine was draining into the bag. A physician telephone order, dated 9/10/18, included a referral to a urologist (a specialist for the [MEDICAL CONDITION] system) ASAP for the torn meatus and erosion related to the Foley catheter. Pain Management flowsheets for (MONTH) (YEAR) and (MONTH) (YEAR) for Resident #5 were blank. On 9/12/18, the following observations and interviews conducted: * 8:50 AM - Resident #5 was in his wheelchair by his bed watching television. He welcomed the surveyor into his room. Resident #5 said he had a urinary catheter because he could not urinate and the tape to secure the catheter kept coming off his leg and had caused a tear on his penis. He said it was painful. * 8:54 AM - CNA #5 and CNA #6 transferred Resident #5 into bed and pulled down his pants to place a bedpan under him. Loose tape was on his urinary catheter and a loose securement device was on the inside of his right thigh, which had a lot of hair. The catheter was not secured and Resident #5 said, See it's coming loose. * 9:30 AM - When Resident #5 finished using the bedpan, LPN #6 removed the bed covers and loosened his incontinence brief. There was an approximately 3 cm wide by 3 cm long open area, or gap, at the urethral meatus at the posterior aspect of the head of the penis. The wound was bright pink without signs or symptoms of inflammation or infection. Resident #5 said the catheter had caused the wound, and his penis was very painful. A securement device was not on either of his legs and there was no tape on the catheter. As LPN #6 began to pull up the bed covers, Resident #5 asked if she was going to secure the catheter. LPN #6 said Oh yeah, and she went to get a securement device. Resident #5 said extra securement devices were in his bedside table drawer. LPN #6 got a securement device out of the drawer and applied it to a hairy area on Resident #5's right inner thigh. The securement device immediately began to loosen. LPN #6 said she would get a different type of device to secure the catheter. * 9:40 AM - LPN #6 and the surveyor exited Resident #5's room and LPN #6 said the resident had a history of [REDACTED]. * 5:15 PM - prior to the evening meal, LPN #1 took Resident #5 to his room and attempted unsuccessfully to visualize the size of his urinary catheter while he sat in his wheelchair. LPN #1 refastened Resident #5's clothing and said she would look again for the catheter size after the evening meal. At that point, Resident #5 said the catheter securement device was not sticking. LPN #1 moved the resident out of his room without checking the securement device. * 5:30 PM - the DNS said skin assessments and monitoring of the urethral meatus wound should be documented on the TAR (treatment administration record). The DNS reviewed Resident #5's (MONTH) and (MONTH) (YEAR) TARs and said she did not see documentation the urethral meatus wound was assessed or monitored. At that time, the weekly skin assessments/evaluations and the Incident/Accident (I&A) report of the wound were requested. * 6:15 PM - LPN #1 said Resident #5 had eaten and he was ready to lay down. The surveyor accompanied LPN #1 to Resident #5's room. LPN #1 visualized his catheter and said it was a size 20, not size 16, as ordered by his physician. On 9/13/18 at 8:30 AM, the DNS provided a Weekly Skin Evaluation record which documented the following: * 8/15/18 - a 2 cm full thickness skin tear to Resident #5's urethral meatus was noted. The wound bed was pink/beefy red, there was minimal serous (clear) drainage, no odor, the surrounding skin color was pink, no pain, and the surrounding tissue/wound edges were normal skin. * 8/18/18 - the wound size was unchanged, the wound bed, surrounding skin color, and surrounding tissue was normal, no drainage or odor, and no pain. * 8/20/18 - the wound size was unchanged, the wound bed was pink, beefy red, the surrounding skin color and tissue/wound edges were normal, no drainage or odor, and no pain. * On 9/2/18, 13 days later - the wound size increased to 2.5 cm, the wound bed was pink, beefy red and the surrounding skin color was pink, the surrounding tissue/wound edges were normal, there was minimal bleeding, no odor or pain. * On 9/12/18, 10 days later - the wound size increased to 3 cm, the wound bed was pink, beefy red and the surrounding skin color was pink, the surrounding tissue/wound edges were normal, there was no drainage or odor and no pain. On 9/14/18 at 10:50 AM, Resident #5 said his catheter securement device won't stay on and It's damn irritating. On 9/14/18 at 11:15 AM, the DNS said she did not find an I&A report regarding the 8/15/18 wound to Resident #5's penis, but an I&A should have been completed. The DNS also said Resident #5's catheter should have been secured better to prevent injury to his penis. Resident #5 was harmed when a tear resulting in full thickness skin loss developed on his penis after the facility failed to secure, or adequately secure, his indwelling urinary catheter for 3 months after the catheter was placed on 6/12/18. In addition, the wound size increased when a larger size catheter than ordered was placed and the facility did not comprehensively assess or monitor the wound at least weekly per the facility's policy.

Based on staff interview, and record review, it was determined the facility failed to: a) Clarify vague surgical incision care orders and/or follow subsequent incision care orders, consistently monitor surgical incisions, or develop a surgical incision care plan; b) Obtain wound care orders, consistently monitor, or develop a care plan for a laceration with staples; c) Consistently monitor residents' pain and/or the efficacy of prn medications after administration; d) Ensure residents' bowel care needs were met; and e) Ensure an access device for [MEDICAL TREATMENT] was monitored. This was true for 2 of 3 residents (#7 & #14) reviewed for surgical incisions or lacerations; 2 of 15 residents (#13 & #14) reviewed for pain and/or prn medication use; for 1 of 15 residents (#13) reviewed for bowel care, and 1 of 2 residents (#1) reviewed for [MEDICAL TREATMENT]. Resident #14 was harmed when his surgical incision became infected and dehisced (separation of all layers of an incision) requiring emergency room (ER) care and hospitalization for a wound infection and renal (kidney) failure. The residents were also at risk for more than minimal harm when Resident #7's surgical incision and #14's stapled [MEDICAL CONDITION] were not consistently monitored and assessed; Resident #13 and #14's pain was not recognized and/or adequately managed; Resident #13's bowel care needs were not recognized or addressed; and Resident #1's [MEDICAL TREATMENT] access device was not care planned or monitored. Findings include: 1. Resident #14 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. a. Resident #14's admission nursing note, dated 1/19/17 at 9:35 pm, documented, Surgical sites at left side of spine. Resident #14's Transitional Care Unit/Skilled Nursing Facility (TCU/SNF) admission orders [REDACTED]. However, his facility admission orders [REDACTED]. Only change prn (as needed) for drsg failure. On 4/5/17 at 5:45 pm, the Director of Nursing (DON) said a Hospitalist clarified the surgical incision wound care orders when he signed the facility admission orders [REDACTED]. The DON said that some physicians do not want the dressing removed unless the dressing fails. The DON said there were no other orders or documentation of facility attempts or requests for clarification of Resident #14's surgical incision wound care/dressing orders. The DON did not explain how the 1/19/17 TCU/SNF order, to cover the surgical incision with a dressing, was changed to the facility's 1/19/17 admission orders [REDACTED]. Resident #14's care plan identified the potential for alteration in skin integrity on 1/20/17, with a goal to maintain skin integrity. The 1/20/17 Admit Care Plan identified a decline in health status, left rib fractures, and falls as problem areas. However, the care plan did not address the surgical site. Resident #14's January 2017 Treatments record included the order to keep the left [MEDICATION NAME] dressing CDI and only change the dressing prn for dressing failure. All of the spaces to document prn dressing changes were blank from 1/19/17 to 1/31/17. One Nurse's Note, dated 1/21/17 at 10:15 pm, documented the dressing was changed due to failure and leaking. Resident 14's general surgeon documented on 1/25/17, .some delayed healing at the superior part of his incision please replace steri strips as they fall off. Resident #14's January 2017 Medications and Treatments records did not include the order to replace the steri strips as they fell off. Nor was it included on Resident #14's care plan or mentioned in Nurse's Notes for January 2017. There was no documented evidence that facility nurses were aware of the 1/25/17 order to replace the steri strips and no evidence Resident #14's back incision was consistently monitored by facility staff. A 1/30/17 at 10:10 pm Nurse's Note documented, Surgical incision on back has s/s of infection. MD (Medical Doctor) aware, MD gave instructions to set-up appointment with (general surgeon). The next evening, a 1/31/17 at 7:00 pm Nurse's Note documented Resident #14's back incision dehisced (separated) and there was purulent drainage (drainage that green, yellow, brown or white in color and is a thick liquid, almost always a clear sign of infection), in the wound for which the resident was sent to an ER. A 1/31/17 at 11:00 pm Nurse's Note documented Resident #14 was admitted to the hospital for an infection to the wound and [MEDICAL CONDITION]. On 4/7/17 at 10:00 am, the Regional Director of Clinical Operations (RDCO) said there was no documentation that the status of the steri strips was monitored or that steri strips were replaced. Resident #14 was harmed when the facility failed to clarify wound care orders, consistently monitor a surgical incision and to follow subsequent orders forsteri strips to be replaced as they fell off. The resident's surgical incision became infected and dehicsed (opened) requiring transport for emergent care and hospitalization for an infected incision and [MEDICAL CONDITION]. b. A 1/19/17 facility Occurrence Report documented Resident #14 had an unwitnessed fall in the bathroom at 6:00 pm, which resulted in a head injury with a 2 cm laceration with minor bleeding. The report documented Resident #14 was transported by ambulance to a hospital ER at 6:20 pm. A Nurse's Note, dated 1/19/17 at 9:35 pm, documented Resident #14 returned to the facility on [DATE] with 3 staples in place to the [MEDICAL CONDITION]. The [MEDICAL CONDITION] with staples was not mentioned in other Nurse's Notes through 1/31/17, nor was it addressed in Resident #14's care plan or Medications and Treatments records for January 2017. No orders regarding the care/treatment of [REDACTED]. Resident #14's January 2017 Medications and Treatment records did not include monitoring or care/treatment of [REDACTED]. In addition, no new skin impairment was added to Resident #14's Treatments record on 1/26/17. There was no documented evidence the facility monitored the [MEDICAL CONDITION] with staples from 1/20/17 to 1/31/17 (11 days) or provided any type of care or treatment to the wound. c. Resident #14's pain care plan, dated 1/20/17, identified statements of pain and facial grimaces as problem/concern areas with goals for relief from pain within one hour of administration of pain medication(s) and for pain to be controlled at 0-4 on a scale of 1-10. Resident #14's TCU/SNF admission orders [REDACTED]. Resident #14's January 2017 Medications record included orders to monitor pain every shift (days and nights) beginning 1/19/17. The pain monitoring flow sheet for the 1/26/17 day shift was blank, and pain was documented as zero on both shifts thereafter through the day shift on 1/31/17. Occupational Therapy (OT) Treatment Encounter Notes documented, .high level of pain today .progress is limited by pain and confusion on 1/26/17; .pain increased throughout session to high .reduced alertness today on 1/27/17, and .greatly limited by pain . on 1/30/17. Resident #14's prn [MEDICATION NAME] was not monitored for efficacy 4 of 17 times (24%) after it was administered. The space to document the result of the prn pain medication was blank following administration on 1/19/17 at 10:20 pm, 1/21/17 at 4:00 am, 1/24/17 (time illegible), and 1/31/17 at 7:15 am. The efficacy of the prn medication was not documented in Nurse's Notes for those dates and times. On 4/7/17 at 11:00 am, the RDCO said Resident #14's prn [MEDICATION NAME] was not consistently monitored for efficacy. 2. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13 was discharged home on[DATE]. Resident #13's Admit Care Plan documented compression fractures and vertebroplasty as problem areas on 12/15/16, with approaches of medications per orders and monitor pain every shift and medicate prn. A 12/15/16 Pain - IDT (Interdisciplinary Team) Care Plan also documented Statements of pain as a problem with a goal for relief from pain within one hour of administration pain medications. In addition, an Initial Care Plan: At Risk for Constipation, identified on 12/18/16, included an intervention to monitor bowel function daily. Resident #13's TCU/SNF admission orders [REDACTED]. No bowel medications or protocols were included in Resident #13's admission orders [REDACTED] Attached to the facility admission orders [REDACTED]. A single line was drawn through the order. The single line was not dated or initialed. a. Resident #13's prn pain and muscle relaxant medications were not consistently monitored for efficacy as follows: * The facility admission orders [REDACTED]. The efficacy of the medication was not monitored. * The December 2016 Medications record contained documentation that the efficacy of prn [MEDICATION NAME] (muscle relaxant) was not monitored 2 of the 3 times it was administered. * The December 2016 Medications record contained documentation that the efficacy of prn [MEDICATION NAME] was not monitored 2 of the 6 times it was administered. The efficacy of the prn APAP/[MEDICATION NAME], and [MEDICATION NAME] medications was not documented in Resident #13's Nurse's Notes from 12/15/16 through 12/30/16. In addition, Nurse's Notes, dated 12/15/16 to 12/30/16, and the December 2016 MAR, contained documentation that the resident's pain was not assessed for 8 days from 12/15/16 through the day shift on 12/24/16. b. Resident #13's Bowel Monitor Flowsheet was blank from 12/15/16 to 12/23/16, indicating Resident #13 did not have a bowel movement (BM) for 8 days. In addition, Resident #13's undated Bowel Monitor for Continence or Incontinence form was blank 7 of 48 opportunities for documentation (15%) with a minus sign documented to note bowel continence the other times. The minus sign did not indicate whether the resident had a BM or not. Nurse's Notes, for 12/15/16 through 12/30/16, did not document whether Resident #13 had a BM. In addition, no orders for a bowel protocol/medication(s) were located in the resident's clinical record. On 4/7/17 at 12:40 pm, the DON said the efficacy of Resident #13's pain was not monitored every shift and prn pain and muscle relaxant medications were not always monitored for efficacy. The DON said Resident #13's BM flowsheet was blank from 12/15/16 to 12/23/16, and that BMs were not documented elsewhere in the clinical record. At 3:00 pm, the DON said there were no orders for bowel medications or a bowel protocol. 3. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #7's Admitting Nurse's Notes, dated 3/27/17 at 6:00 pm, documented a surgical incision under the left arm with staples described as clean, dry, intact, and open to air. Resident #7's care plan documented pain as a problem related to a fractured clavicle and ribs, and the potential for skin impairment. Resident #7's care plan did not address the surgical incision. Resident #7's Weekly Skin Evaluations, dated 3/27/17 and 4/5/17, documented the surgical wound was pink and measured 0.75 cm in length x 20 cm in width x 0 cm in depth, no discharge, had no odor, and the surrounding skin was described as normal. Resident #7's April 2017 Treatment Administration Record (TAR) directed staff to conduct weekly head-to-toe skin assessment and initiate a wound form for any new impairment. Other than documentation that no new impairment was noted on 4/5/17, Resident #7's clinical record contained no evidence the surgical wound was assessed or monitored for signs and symptoms of infection. On 4/7/17 at 11:21 am, the Regional Director of Clinical Services said facility nurses were responsible for monitoring any surgical wound for signs/symptoms of infection every shift. 4. Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's [MEDICAL TREATMENT] Care Plan, dated 3/29/17, documented the following interventions: * [MEDICAL TREATMENT] Mondays, Wednesdays and Fridays * Facility to provide sack lunch for the resident * Monitor [MEDICAL TREATMENT] catheter on the right chest permacath (external catheter placed into the large central veins of the chest or upper arm as a [MEDICAL TREATMENT]) for signs and symptoms of infection, [MEDICAL CONDITION], ischemia (insufficient blood supply to an organ usually due to obstruction), bleeding, dislodgement, and presence of catheter cap in place every shift, and document any change/abnormality in progress notes and notify physician. * Monitor extremity or area of fistula or graft Resident #1's [MEDICAL TREATMENT] Flow Sheet, from 4/1/17 to 4/6/17, documented the following were being monitored: * [MEDICAL TREATMENT] catheter on right upper chest for signs and symptoms infection, [MEDICAL CONDITION], ischemia, bleeding, dislodgement and presence of catheter cap in place each shift * Palpate fistula or graft for presence or absence of thrill (vibration of blood going through your arm) every shift and document * Auscultate (listening for sounds produced within the body with a stethoscope) fistula or graft for bruit (rushing sound), presence or absence every shift * Monitor extremity (arms or legs) or area of fistula or graft for changes in circulation, movement, and sensation * Document any changes in progress notes and notify MD On 4/5/17 at 9:50 am, two catheter ports were observed on Resident #1's upper chest. The resident said they were used for [MEDICAL TREATMENT]. There was no [MEDICAL TREATMENT] access device, such as a fistula or graft, on either of the resident's arms. On 4/7/17 at 3:30 pm, the Regional Director of Clinical Services, when shown Resident #6's [MEDICAL TREATMENT] Flow Sheet, shook her head and said nurses should have only monitored the permacath for signs and symptoms of infection and/or bleeding, and to ensure the dressing was intact.

Based on observation, staff and interested party interview, and record review, it was determined the facility failed to thoroughly assess and monitor existing pressure ulcers (PU)s in a timely manner, clarify vague orders, and/or follow PU treatment orders, and prevent the development of avoidable PUs. This was true for 2 of 5 sample residents (#2 & #3) reviewed for PUs. Resident #2 was harmed when one of two existing deep tissue injury (DTI) PUs deteriorated and required surgical debridement and Resident #3 was at risk for more than minimal harm when an avoidable Stage II PU developed. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including falls, altered mental status, rhabdomyolysis with a right thorax DTI and a right greater trochanter (hip) DTI. Resident #2's 9/30/16 admission Minimum Data Set (MDS) assessment documented short and long-term memory impairment, moderately impaired cognition, and 2 unstageable PUs with eschar. The resident's 10/24/16 significant change MDS assessment documented the same as well as a surgical incision; and, the 3/13/17 quarterly MDS assessment documented healed PUs and 1 Stage IV PU with granulation tissue in the wound bed. Resident #2's 9/26/16 Alteration in Skin Integrity initial care plan documented DTIs at the right shoulder and right hip. Approaches included treatment per orders and weekly skin evaluations. On 11/22/16, hematoma surg(ical) site self inflicted scratch, was added to the care plan. Resident #2's Transitional Care Unit/Skilled Nursing Facility (TCU/SNF) admission orders [REDACTED]. Resident #2's facility admission orders [REDACTED]. In addition, there was no documentation in the resident's clinical record of attempts to contact the physician or Wound Clinic for clarification of the vague wound care order. Resident #2's Nursing Admission Evaluation, dated 9/23/16 at 3:34 pm, documented a back view of a body diagram with a vertical line below the right shoulder to the waist and a vertical line below the right gluteal fold to mid thigh. Wound care was written by each of these vertical lines. On 9/26/16, three days after admission, a Physician Assistant's (PA's) order for the right shoulder and right hip PUs documented staff were use normal saline, pat the PU dry, apply [MEDICATION NAME], non-stick dressing, and cover the PUs with exudry and tape every 3 days, and prn (as needed) for dressing failure. A Nurse's Note, dated 9/26/17 at 5:00 pm, documented measurements for the right shoulder and right hip PUs but did not include any other characteristics for either of the PUs, such as Stage, drainage, odor or condition of the periwound skin. An Admission Body Assessment, dated 9/27/16, 4 days after Resident #2's admission, documented circled areas below the right posterior shoulder and at the right hip. Stage II with a single line drawn through it was written next to both of the circled areas. Deep tissue and hematoma was also written by the shoulder area and Deep Tissue was also written by the hip area. On 4/7/17 at 10:00 am, the Director of Nursing (DON) said an Licensed Practical Nurse (LPN) admitted the resident on 9/23/16 and the facility did not allow LPNs to stage PUs. The DON said the admission order for PU wound care was clarified on 9/26/16, and an RN reassessed Resident #2's PUs on 9/27/16. Resident #2's September 2016 Treatments record documented the right shoulder and right hip PU wound care/dressing changes were completed on 9/26/16 and 9/28/16. On 9/28/16, a referral to a wound care clinic was ordered. On 10/4/16, Resident #2's PUs were assessed and treated at a wound clinic. The wound clinic changed the right hip wound care/dressing orders to daily, and prn for dressing failure, with an enzymatic [MEDICATION NAME] agent. The wound clinic also changed the right shoulder wound care/dressing orders to every other day, and prn dressing failure, using a barrier ointment and foam dressing. The wound clinic documented Resident #2 was to return to the wound clinic in one week. Resident #2's October Treatments record documented the 10/4/16 order for the right hip PU was implemented daily 10/6/16 through 10/8/16 and the right hip PU wound care with normal saline, pat dry, [MEDICATION NAME], non-stick dressing, exudry and tape was completed on 10/3/16, 10/6/16, 10/9/16, 10/12/16 at wound care, on 10/15/16, and then see new. The October Treatments record documented the 10/4/16 order for the right shoulder PU was implemented 10/7/16, 10/11/16, 10/13/16, 10/15/16 and 10/17/17. It also documented the right shoulder PU was cleaned with normal saline, lotion was applied to the surrounding skin, and the PU covered with a foam dressing on 10/14/16 and 10/16/16. an order for [REDACTED]. A 10/9/17 at 11:00 pm Nurse's Note, documented Resident #2's right hip peri-wound is bright red and inflamed and he presented with a slight fever. The Nurse's Note documented that Tylenol reduced the fever and inflammation. A 10/12/16 at 4:30 pm Nurse's Note, documented the wound clinic talked to Resident #2's family about [MEDICATION NAME] (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) his the right hip PU and they were told it may go to the bone. A 10/14/16 at 2:20 pm Nurse's Note, documented Resident #2 was seen by the physician and surgery to debride his right hip PU was scheduled for 10/17/16. A 10/15/16 at 8:45 pm Nurse's Note, documented black eschar in the middle of the right hip PU wound bed with red inflamed peeling skin around it. It also documented Resident #2 did pull dressing off and was picking at the wound. A 10/17/16 untimed Nurse's Note documented, surgical debridement of right (R) trochanter wound and the facility was notified Resident #2 would stay at the hospital overnight for observation. On 4/6/17 at 10:30 am, Resident #2's Interested Party said that PU wound care wasn't getting done and frequently the dressings were not in place when Resident #2 arrived at the wound clinic. The Interested Party said the lack of wound care may have contributed to delay in healing of the right hip PU. The Interested Party said the wound clinic did all the PU wound care/dressing changes now. On 4/6/17 at 10:55 am, Resident #2's right hip PU dressing was observed to be clean, dry, and intact when Certified Nursing Assistant (CNA) #4 provided an incontinence brief check and there were no signs or symptoms of skin breakdown on Resident #2's right posterior shoulder/torso. Resident #2 was harmed when 1 of 2 DTI PUs deteriorated and required surgical debridement. The facility failed to clarify vague wound care orders on admission, did not thoroughly assess the right hip and right shoulder PUs until 4 days after admission, then performed 2 different orders for wound care and dressing changes for the right hip PU and two different orders for wound care and dressing changes to the right shoulder PU. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Facility staff completed a Braden Scale assessment (for predicting pressure ulcer risk), dated 5/6/16, and Resident #3 was determined to be at high risk for developing a pressure ulcer. Braden Scale assessments completed on 9/21/16, 2/24/17, 4/6/17, each determined he was at high risk of developing pressure ulcers. Resident #3's skin care plan related to immobility and incontinence, initiated on 5/6/16, directed staff to provide him treatment as ordered, complete weekly skin assessments, reposition him every 2 hours, make a referral to the Registered Dietician (RD), administer [MEDICATION NAME] as ordered, monitor his nutrition and hydration status, provide him supplements as ordered, provide a pressure reduction mattress on his bed and a pressure reduction pad in the chair, and float his heels. The goal date was last reviewed and revised on 9/21/16. Resident #3's Admission Minimum Data (MDS) assessment, dated 5/17/16, documented he was severely cognitively impaired, exhibited no behaviors that interfered with staff providing cares, and was dependent on at least 2 staff for bed mobility, transfers, dressing, and toileting. The assessment documented Resident #3 had a Stage II pressure ulcer with an onset date of 5/9/16, 4 days after admission to the facility. Resident #3's physician orders, dated 5/16/16, documented, Pressure sore to bottom: Cleanse with normal saline, cover with [MEDICATION NAME], change every 3 days, and as needed for dressing failure. The treatment was discontinued on 5/27/16 with the notation, Area resolved. A Nurse's Note, dated 5/27/16 at 1:40 am, documented the pressure ulcer was resolved. Resident #3's physician orders, dated 9/8/16, documented, Wound to coccyx: Clean with normal saline, Cover with [MEDICATION NAME], Change every 3 days and as needed. On 9/9/16, the RD documented Resident #3 had a new Stage II pressure ulcer to the left of the coccyx and that treatment was in place. A Nurse's Note, dated 9/11/16, documented Resident #3's buttocks had been offloaded with pillows. A Nutrition, Hydration, Skin Committee (NHSC) Note, dated 9/22/16, documented Resident #3's coccyx wound had healed. A physician order, dated 12/17/16, directed staff to apply a [MEDICATION NAME] ultra-thin dressing to a blanchable red area of Resident #3's right buttock. Dressing changes were to take place every 3 days starting 12/28/16. A late entry Nurse's Note, dated 12/20/16 for 12/19/16, documented a purple area on Resident #3's buttock appeared to be healing with no open area noted. A Nurse's Note, dated 12/20/16 at 2:15 pm, documented increased skin breakdown. A Nurse's Note, dated 1/7/17, documented Resident #3 had no signs or symptoms of skin breakdown. On 4/6/17 at 10:25 am, LN #1 stated staff turned Resident #3 side-to-side, floated his heels, and used pillows to relieve pressure when the head of the bed was elevated. On 4/6/17 at 2:30 pm, LN #1 provided wound care to the sacral pressure ulcer. Upon completion, staff returned Resident #3 to a semi-sitting position and pushed a pillow under each hip/buttock. LN #1 stated the pillows were used to relieve pressure.

Based on observation, staff interview, record review, and Fall Event Investigation Reports, it was determined the facility failed to ensure supervision and toileting was provided as care planned. This was true for 2 of 4 sample residents (#2 & #6) reviewed for falls. Resident #2 was harmed when an incision and debridement (I&D) was needed to reduce swelling and potential tissue damage from a hematoma above the right eye caused by falls. Resident #6 was at risk for more than minimal harm when the facility failed to consistently implement care planned supervision to prevent falls. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including falls, altered mental status, rhabdomyolysis (rapid destruction of muscle tissue) and 2 deep tissue injuries (DTIs). Resident #2's admission Minimum Data Set (MDS) assessment, dated 9/30/16, documented short and long-term memory impairment, moderately impaired cognition, total assistance with bed mobility, extensive assistance with transfers, dressing and toileting, a history of falls and 2 falls without injury. His most recent quarterly MDS assessment, dated 3/13/17, documented severely impaired cognition, extensive assistance with bed mobility, transfers, dressing and toileting, 2 falls without injury and 1 fall with a non-major injury. A Fall Risk Care Plan, dated 9/27/16, identified Resident #2's history of falls and high risk for falls as problem areas. Approaches included neurological checks at time of fall(s). Care plan revisions included every 2 hour toileting, 10/3/16; the resident was to be in the common area when in his wheelchair or in bed when in his room, 10/10/16; Not left unattended in room, 11/12/16; Supervised while (up) in chair, 12/27/16; and water mug within reach, 12/28/16. Resident #2's Anticoagulation Therapy Care Plan, dated 9/27/16, identified the potential for injury, bleeding, and bruising. Approaches included Lovenox (blood-thinning medication) per physician orders [REDACTED]. His 9/23/16 admission orders [REDACTED] Resident #2's Fall Event Investigation Reports included: * 10/3/16 at 10:00 pm - unwitnessed fall from bed, found on floor between the bed and the wall, time last toileted was blank; root cause Resident needed to use the restroom, initial interventions included, Check resident every 2 hours and assist with urinal. The Interdisciplinary (IDT) Conclusion included Toileting to be offered Q (every) 2 (hours). * 11/12/16 at 3:00 pm - unwitnessed fall from wheelchair while alone and unattended in his room, 5 cm by 4 cm hematoma to the right forehead, sent to emergency room (ER), returned to the facility. The initial intervention was, Resident will not be left in his room in chair. * 11/17/16 at 12:20 am - unwitnessed fall from bed, last toileted at 9:50 pm, sustained large swollen area and a laceration in the swollen area above the (R) eye, sent to ER; * 12/27/16 at 9:15 pm - unwitnessed fall and the Licensed Nurse (LN) and Certified Nursing Assistant (CNA) assigned to the hall were both in other resident's (sic) rooms during the time of fall. He .went looking for some water. Resident is unaware of own limitations and attempted to ambulate without supervision .Water mug to be place (sic) close to patient when he is by nurse cart or by nurse station .; * 1/4/17 at 1:30 pm - unwitnessed fall, left forehead hematoma without laceration, small gap with very little blood out of area and .to lunch .brought back and left next to nurse med cart .Nurse gone to assist in another room .heard patient calling for help from his rest room .first aid provided .transported to ER for further evaluation . Resident #2's Nursing Notes documented: * 11/17/16 at 12:50 am - .very swollen area just above his right eye .laceration to that area which was bleeding .EMT dispatch was called .left facility via ambulance at 0045 (12:45 am). * 11/17/16 at 4:20 am - .returned .Steri strips in place to wound above right (R) eye. * 11/17/16 at 7:10 pm - neuro checks done this shift and (R) frontal lob (sic) swollen and dark purple (R) eye swollen shut. * 11/22/16 at 11:00 am - .to day surgery for [REDACTED]. An 11/23/16 physician progress notes [REDACTED]. History Of Present Illness: .multiple falls in our facility .latest one being approximately a week ago .did sustain multiple hematomas and significant bruising to the orbital regions .right one was more severe than his left .seen at Wound Care .yesterday. It was felt at that time that .right side superior orbital region needed to be debrided in order to avoid necrotic (dead) tissue. This was done last night . Resident #2 was observed in his wheelchair near the nurses' station, in the common area, or the activity room with staff present on 4/4/17 at 8:30 am, 8:35 am, and 1:30 pm; on 4/5/17 at 9:30 am, 9:35 am, 10:25 am, 11:30 am, 12:40 pm, 3:00 pm, 5:35 pm, 6:00 pm, 6:30 pm, 7:30 pm, 7:50 pm and 8:00 pm; and on 4/6/17 at 9:45 am. He was observed in bed on 4/4/17 at 10:00 am and 11:15 am. He was observed in his wheelchair in his room with CNA #4 present on 4/6/17 at 10:50 am. There were no signs or symptoms (s/s) of skin breakdown on the resident's forehead during these observations. On 4/7/17 at 11:00 am, the DON said Resident #2's condition had improved and he was more mobile since admission. She said the staff tried to keep an eye on him when he was in his wheelchair. Resident #2 was harmed when a hematoma to his right forehead, sustained on 11/12/16, when the facility failed to provide supervision while the resident was in his wheelchair alone in his room and when the hematoma was reinjured and lacerated 5 days later, on 11/17/16, when the facility failed to toilet him for 2 and a half hours and required an incision and debridement to reduce swelling and potential tissue damage. 2. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's Significant Change Minimum Data Set (MDS) assessment, dated 2/15/17, documented he had severely impaired cognition, a suprapubic catheter, was frequently incontinent of bowel, and required extensive assistance of 2 staff for bed mobility, transfers and toileting. Resident #6's current Fall Care Plan documented he experienced intermittent confusion and 1-2 falls in the month prior to admission. Interventions included: *Complete Resident Fall Risk Assessment form every quarter and review as needed *Resident assistive device(s) to be within easy reach *Well lit, clutter free environment *Encourage resident to wear non-slip safety shoes *Keep resident clean and dry *Toileting every two hours, after meals, and before preparing for bed *Non-slip mats at bedside *Refer to therapy *Encourage resident to reposition frequently *Padded side rails x 2 *Diversional activities - 2/2/17 *During moments of distress and agitation, transport resident to nurse's station or by nurse's cart - 3/14/17 On 4/4/17 at 9:00 am, Resident #6 was observed sitting in his Tilt N Space wheelchair in the TV room, with the foot rest in the elevated position, and trying to bend to reach his legs. At times he was observed reaching for his catheter bag which was inside the privacy bag. Resident #6's representative was with him at that time and said Resident #6 had experienced five falls since his admission to the facility. An Accident and Incident (I&A) Report documented Resident #6 experienced falls on: * 2/16/17 at 1:00 am - Resident #6 was found lying on the floor of his bedroom. He had been restless throughout the night prior to being found on the floor despite receiving PRN Ativan. Recommended intervention was to offer snacks to him at night if he was awake. *2/25/17 at 11:05 pm - Resident #6 was found lying on the floor of his bedroom next to his bed. The report documented he was toileted and placed in bed approximately 30 minutes prior to the fall. Recommended interventions were to consult with the physician to review and possibly change the resident's medications. *3/14/17 at 11:30 pm - Resident #6 was found on the floor of his bedroom. The I&A report documented, Resident was assisted to bed at 11:00 pm. Resident became very anxious and was witnessed standing next to his bed immediately after being repositioned. Resident assisted back to bed, attends were changed .Five minutes later resident was found sitting on his bottom on the floor . Recommended intervention was to assist the resident to the nurse's station or by the nurse's cart when he was agitated. *3/18/17 at 11:55 pm - Resident #6 was found on the floor of his bedroom. Recommended intervention following this fall was to review his chart for metabolic diagnosis; A1C and Blood Glucose (BG) checks for 14 days were requested. *3/22/17 at 6:00 pm - Resident #6 was assisted to floor after losing balance during a state of combativeness. He was sent to the hospital to have his suprapubic catheter replaced as it was pulled during this period of agitation. The report also documented Resident #6 was in staff line-of-sight to help minimize the risk of fall. Recommended intervention following this fall were to increase his Seroquel to three times a day (TID), and continue to seek placement for him in a facility that specialized in TBI/behaviors. *3/27/17 at 6:00 pm - Resident #6 was found on the floor of his bedroom. An I&A documented he likely attempted to self-transfer out of bed after family left without notifying staff that they were leaving. Recommendation after this fall were to remind family to notify nurse when they were done visiting with the resident and continue to pursue placement options at facilities that specialized in TBI and behaviors. On 4/4/17 at 3:00 pm, Resident #6 was observed sitting by the nurse's station in his Tilt N Space wheelchair. He was sitting forward and pushing himself up as if attempting to rise. The ED approached Resident #6 and wheeled him to the Activity Room. On 4/4/17 at 3:10 pm, Resident #6 was observed being wheeled from the Activity Room. The Activity Director said Resident #6 was getting agitated and she would bring him outside. Resident #6 was observed in the dining room on 4/5/17 at following times: *5:30 pm - Resident #6 was observed in the dining room, sitting at a table by himself. The DON, Resident Care Manager (RCM) #2, Staff Development Coordinator (SDC), and two Certified Nursing Assistants (CNAs) were observed in the dining room distributing drinks to residents. Resident #6 was observed drinking a glass of milk, and on his table were two empty glasses. When he finished drinking his milk, Resident #6 moved his chair back from the table and tried to push himself up to stand. He was able to turn his chair around when a a female resident on the other table yelled at him. RCM #2 walk hurriedly to Resident #6, who at this time had his left leg over the arm rest. RCM #2 spoke to Resident #6 and positioned him back at the table. The RCM left Resident #6 alone at the table and continued to help other residents. *5:40 pm - Resident #6 was observed eating a hamburger. *5:45 pm - Resident #6 dropped his left leg off the foot rest and removed the left foot pedal of the wheelchair. He then tried to push his chair away from the table, but RCM #2 approached and put his foot pedal back onto his wheelchair. *5:52 pm - Resident #6 was observed sitting sideways on his wheelchair with his legs hanging over the left arm rest. Resident #6 was able to turn his chair around and attempted to stand up. The DON approached, but was unable to calm him. The DON called RCM #2 over and the two talked with Resident #6. *5:59 pm - CNA #2 wheeled Resident #6 out of the dining room. *Between 6:01 pm and 7:02 pm, Resident #6 was observed being wheeled in the wheelchair back and forth in the 300 Hall and 400 Hall. At times, Resident #6 and CNA #2 were observed at the Internet Cafe, where Resident #6 appeared calm. Physician Assistant's progress notes documented: *3/15/17 - Increased agitation. We did change his Ativan dose to 0.5 mg qid prn .I do not see an improvement in his agitation however we may need to look elsewhere to another facility to offer more higher staff to patient ratio . *3/27/17 - We are also looking to transition patient to another facility which will allow for higher staffing and increased one to one treatments to discourage falls as well as any behaviors associated with his traumatic brain injury . On 4/6/17 at 12:15 pm, the Physician Assistant (PA) was asked if one-to-one supervision was considered for Resident #6. The PA said the facility's fall risk protocol was in place for Resident #6 and she had seen him by the nurse's station or by the nurse's med cart, where he received increased supervision. She said Resident #6 had increased agitation and was reportedly hitting some staff so his medications were adjusted. On 4/6/17 at 12:35 pm, the DON, said frequent checks for all of residents was every two hours and that would increase to every hour or more as needed. She said Resident #6 had increased agitation and became combative recently so staff was still attempting to assess the cause for this increased agitation and behaviors such as kicking and hitting staff. The DON then provided documentation where Resident #6 was provided with a sitter on 3/5/17. When asked if the resident was provided consistently with a one-to-one supervision, the DON said Resident #6 was placed by the nurse's station or med cart for close supervision. Resident #6 experienced 6 falls while at the facility, 5 of which were unwitnessed and occurred while he was in his bedroom. Four of the unwitnessed falls occurred between the times of 11:00 pm and 1:00 am, and the I&A reports consistently documented Resident #6 had periods of agitation, difficulty following direction, and required frequent redirection and reassurance. Resident #6's 2/16/17 and 3/14/17 I&A reports documented he was restless during the shift prior to those falls. Although Resident #6's care plan was updated to bring him to the nurse's station or by the nurse's cart during moments of agitation, Resident #6 fell while in line-of-sight of staff. The facility failed to consistently provide supervision to Resident #6 and left him in his room unattended.

Based on facility records, [MEDICAL TREATMENT] records, EMS (Emergency Medical Services) records, and facility staff, [MEDICAL TREATMENT] center staff, EMS staff, and family interviews, it was determined the facility placed residents in Immediate Jeopardy when it failed to have systems and procedures in place to identify when 1 of 4 sampled residents (#2) experienced a critical hypoglycemic event. This Immediate Jeopardy event, which could have resulted in death, occurred on [DATE], when facility staff transported and delivered Resident #2 in an unresponsive state to a nearby [MEDICAL TREATMENT] center, where he required emergency treatment by EMS staff for a critically low blood glucose (BG) level. The facility at the time of survey had 13 residents with diabetes mellitus, four of whom were routinely transported by facility van to [MEDICAL TREATMENT] appointments. Additionally, 2 of 4 sampled residents (#'s 1 and 3) did not receive blood glucose monitoring as ordered by their physicians. This failed practice placed both Residents #1 and #3 at risk for critical hypo- or hyper-glycemic events. Findings include: On [DATE] at 12:40 PM, the Administrator and DON were notified the facility had an Immediate Jeopardy situation for the lack of monitoring- and interventions for blood glucose levels which placed the 3 sampled [MEDICAL TREATMENT] residents, as well as all diabetic residents in the building, including those also receiving [MEDICAL TREATMENT], in danger that could lead to serious injury or death. The facility provided an acceptable abatement plan on [DATE] at 6:45 PM, which included no admissions of residents with diabetes mellitus until an acceptable follow up survey was completed, revision of the facility's diabetic policy, updated records to reflect the policy changes, monitored care of [MEDICAL TREATMENT] residents, and diabetic/[MEDICAL TREATMENT] education to all of the facility nursing staff. On-site verifiction of the plan's implementation was completed on [DATE] at 7:30 PM and the Immediate Jeopardy was abated. 1. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], documented the resident received [MEDICAL TREATMENT]. Admission physician orders, dated [DATE], documented: *Glimepiride 2 mg (milligrams) po (by mouth) daily, Dx (diagnosis) Diabetes Mellitus, Type II *Pioglitazone 15 mg (one) po daily, Dx: Diabetes Mellitus, Type II *Oxygen: ,[DATE] lpm (liters per minute) sats(uration) (greater than) 90% PRN (as needed), An additional physician order, dated [DATE], documented: *Blood sugar checks (every) AM. The resident's care plan for Diabetes Mellitus, dated [DATE], documented: *Observe for s/s (signs and symptoms) of [DIAGNOSES REDACTED] which included a change in level of consciousness, *Observe for [MEDICAL CONDITION] with s/s which included change in level of consciousness, lethargy, confusion and weakness. *Medication as ordered, *Lab as ordered and report abnormal values promptly, and, *Diet as ordered. An Activities of Daily Living (ADL) flow sheet for the month of [DATE], documented that on day shift from ,[DATE] through ,[DATE], the resident required extensive assistance of 2 persons for transfers. On ,[DATE], however, the resident needed to be transferred by a Hoyer lift with 2 person assist. On ,[DATE] and ,[DATE] the resident was an extensive assist with one person. The [DATE] Treatment Administration Record (TAR) documented the resident did not eat breakfast or dinner on ,[DATE] or breakfast on ,[DATE]. There was no documentation that the resident received an evening snack on [DATE] or an early breakfast on [DATE]. NOTE: The resident had one meal documented as consumed in 24 hours, which was lunch on [DATE]. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The facility routinely ulitized a [MEDICAL TREATMENT] Transfer Communication form to provide the [MEDICAL TREATMENT] center with the resident's medication changes, current lab values and any changes in medical or mental status. The [MEDICAL TREATMENT] center returned the form to the facility when the resident returned to the facility with a report of labs completed at the center, medications provided, follow-up care and recommendations. The resident's [MEDICAL TREATMENT] Transfer Communication form file did not document that he attended his [MEDICAL TREATMENT] appointment on [DATE], where he arrived at the [MEDICAL TREATMENT] center unresponsive and required emergent treatment by EMS for a BG of 30 taken immediately upon EMS arrival at the [MEDICAL TREATMENT] center. A detached single page License Nurse Progress Note (LNPN) entry outside the flow of the [DATE] - [DATE] LNPN documentation, but dated [DATE], was provided to surveyors on [DATE]. That LNPN documented: *"0730 (7:30 AM) (LN #3) went to pt (patient) room to give meds and to get pt. ready for [MEDICAL TREATMENT]....pt assessment done pt somnotent (sic - somnolent) eyes reactive no signs of stroke v/s (vital signs) were normal....I was concerned about his condition and that I did not want to give him his medication for fear of aspiration. I went and read through the chart and looked at H & P (History and Physical) and labs I could not find any reason for pt to be like this she (wife) didn't want a glucose due to the bus is here to get him the bus took him to [MEDICAL TREATMENT]." LN #3 stated the v/s were normal; however, the record did not document v/s were taken on [DATE]. The LN documented concern about the resident's condition but did not provide any detail regarding that "condition." A [MEDICAL TREATMENT] center incident report, dated [DATE] and completed by the LN who cared for the resident at the [MEDICAL TREATMENT] center, documented: "Non responsive on arrival for Tx (treatment). Wife stated pt was 'not normal' at facility before being transported to (name of [MEDICAL TREATMENT] center.)..." "Pt arrived for Tx (treatment) in W/C (wheelchair) slumped over & nonresponsive (with) blank stare. Informed wife we needed to send pt to ER & called 911.... O2 (oxygen) from care center was empty." An Ambulance Service Patient Care Report documented the call from the [MEDICAL TREATMENT] center was received and emergency responders dispatched at 8:43 AM. The ambulance arrived at the [MEDICAL TREATMENT] center at 8:48 AM, and documented: *08:50 AM: The primary impression was "[DIAGNOSES REDACTED]." The assessment documented the resident's skin was cool and diaphoretic; LOC was unresponsive; there was no right or left arm movement; no right or left leg movement; stroke scale was not applicable; blood pressure ,[DATE]; pulse 86; oxygen saturation 92%; BG 30; and the resident's Glasgow Coma Scale (GCS) was 6 out of 15 points. The EMS narrative report documented: Report taken from the wife on scene was the resident had "been unresponsive since wife first saw him this morning" in the facility; "pt was placed in a whelchair by staff at (name of care center) and sent via facility van to his [MEDICAL TREATMENT] appointment." EMS treatment included: an IV (Intravenous catheter) was placed and the resident was administered 500 ml (milliliters) of D5 ([MEDICATION NAME] water). The "pt condition improved until pt returns to baseline of AOx4 (alert and oriented x 4)."... BG went up to 150. The resident's GCS was 15. A [MEDICAL TREATMENT] Progress Note, dated [DATE] at 2:22 PM, and completed by the [MEDICAL TREATMENT] centers Supervisor, documented, "Contacted nursing home about if they checked his blood glucose this am. I talked with (LN# 3) and he stated he assessed him and his lungs were clear and O2% ok but they did not have him listed as a diabetic. I asked him if he gets any diabetic meds. I requested a current med list. He was listed as DMII (Diabetes Mellitus Type II) as a secondary dx (diagnosis) on his med sheet. ( Physician) notified. (Physician) dc (discontinued) one of his diabetic meds." The detached single page LNPN, dated [DATE], documented 3:00 PM: "Pt returned and looked much better. He had some glucose from ( EMS). The ([MEDICAL TREATMENT] center) called and said his blood glucose was 39 and asked if I had (checked) it....Talked with ( resident's MD) as far as can determine the pt never has been Hypoglycemic..." On [DATE] at 9:30 AM, the Supervisor at the [MEDICAL TREATMENT] center was asked about the resident's condition on [DATE]. The Supervisor stated the patient had come into the center slumped over and unresponsive; the staff thought he had a stroke and called 911. The resident's wife was present and stated that staff at the facility told her the staff at the [MEDICAL TREATMENT] center would "take care of it." The patient's oxygen tank was empty. The Supervisor stated she called LN# 3 and he told her the patient was assessed, but did not have a BG on [DATE]. On [DATE] at 10:15 AM, the EMS Division Chief stated the patient was totally unconscious and unresponsive when EMS personnel arrived at the [MEDICAL TREATMENT] center. On [DATE] at 12:30 PM, the resident's wife stated she came in at 7:00 AM and her husband was not ready to go to [MEDICAL TREATMENT]. "He was out of it. I was scared to death; he was there but not responding." When asked what the LN did when she expressed her concern, the wife stated, "I said I don't know what to do, he is not right, but he is supposed to go over and have [MEDICAL TREATMENT]. I was panicked... I had no idea what could have been wrong." When asked whether the resident had spoken to her during the facility van ride to the [MEDICAL TREATMENT] center on [DATE], the resident's wife stated, "He would acknowledge that I was there, but did not talk." The resident's wife stated she did not think the facility van driver realized the situation. When asked whether facility staff had to transfer the resident with a Hoyer lift that morning, she stated, "Yes, that morning they did use the Hoyer lift." Prior to that morning, the resident was transferred with 2 staff. When asked if he remembered the incident, the resident stated, "No." On [DATE] at 3:20 PM, the van driver stated she was CPR (cardiopulmonary resuscitation) certified, had been an RN (Registered Nurse) in Mexico years before, a Medical Technician, a CNA (Certified Nurse Aide), and was instructed in safety and seat belt training for the van. When asked what she would do if a resident became unconscious, she stated she would return to the facility or go to the ER. She was asked what she remembered about the resident on the morning of [DATE]. The van driver stated she had retrieved the resident's [MEDICAL TREATMENT] book and entered the resident's room to find him "not his normal self," and his wife was in a hurry. The van driver said, "He moved but he didn't talk to me. He tried to open his eyes and nodded...The wife was putting on his coat and he was not helping to put it on. He didn't look good to me." The van driver stated she told LN# 3 to come in to see the resident and when he came into the room he stated he was concerned about the resident. The van driver stated the resident's wife instructed LN# 3 not to give her husband the medications and then she drove the resident to the [MEDICAL TREATMENT] center; she stated during the drive to the [MEDICAL TREATMENT] center the resident was "lethargic, eyes were closed and hands were hanging down." The van driver was asked the resident's condition when she brought him back to the facility and she stated, he was "like his old self, perky and talking." NOTE: The communication form from the facility to the [MEDICAL TREATMENT] center for [DATE] could not be located by surveyors or produced by the facility during the complaint investigation survey. On [DATE] at 4:35 PM the CNA who cared for the resident on [DATE], day shift, stated the resident was not himself, and she did not think he would have been able to eat his breakfast if it was offered. The CNA stated normally the resident would have been up and ready to go to his [MEDICAL TREATMENT] appointment and that morning, she was "concerned" about the resident. The CNA said she told LN #3 about her concerns and he checked the resident. The facility's Blood Glucose Monitoring policy, updated [DATE], directed staff to notify the physician for BG levels either below 70 mg/dl or above 400 mg/dl when signs and symptoms of hypo- or [MEDICAL CONDITION] were present, and provided direction for how to manage insulin when a resident's BG was outside of the set parameters of ,[DATE]. The policy did not provide guidance on oral diabetic medication management, either for normal or abnormal BG measurements. On [DATE] at 5:35 PM, the resident's physician, who was also the Medical Director of the facility, was asked whether he endorsed the facility's diabetic policy, which did not address oral diabetic medications. The physician stated that he agreed with the policy and noted, "You aren't going to see [DIAGNOSES REDACTED] in resident's with oral medications," for Type II diabetes. NOTE: According to the American Diabetes Association, (http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/employment-discrimination/safety-issues.html) " ... severely low blood glucose ([DIAGNOSES REDACTED]), occur only in people receiving certain treatments such as insulin or certain oral medications ..." When asked what he would expect if a resident exhibited s/s of [DIAGNOSES REDACTED] (low blood sugar), he stated he would expect the LN to call him and get a BG. When asked what he would expect if the BG was high, he stated they (facility nursing staff) graduated from nursing school, he trusted the nursing staff's judgment and he would expect them to get a BG. The physician was asked if he was notified when the resident had the significantly low BG of 30 (the reading obtained by EMS). He stated he could not specifically remember the incident, or whether he was told about it. The physician stated he was not in the facility at that time and, therefore, he would not have documented it. He stated he would expect nursing to document they had notified him. On [DATE] at 6:10 PM, the DON stated LN# 3 caring for Resident #2 told her the resident did not want to eat breakfast, he was lethargic, had a [MEDICAL TREATMENT] appointment and that staff were concerned about him. When the DON was asked whether the facility investigated what happened when the resident was transported and delivered by the facility to the [MEDICAL TREATMENT] center unresponsive and with a BG of 30, or whether LN #3 was aware of s/s of [DIAGNOSES REDACTED], she stated, "No." The DON agreed that on [DATE] the LNPN did not document any concerns about the resident that LN #3 may have had. The DON could not determine when the illegible BG had been taken or documented, nor what the actual recorded reading had been. (NOTE: LN #3 caring for Resident #2 that day stated he did not measure the resident's BG prior to the [DATE] transfer to the [MEDICAL TREATMENT] center.). Furthermore, the resident had eaten 1 meal in 24 hours and was documented to have received his morning medications, despite exhibiting s/s of [DIAGNOSES REDACTED]. The facility's policy did not address the monitoring of blood glucose levels or oral diabetic medication management. The facility had not generated a [MEDICAL TREATMENT] communication form for [DATE], and there was no documentation the physician or [MEDICAL TREATMENT] center had been notified of the resident's change of condition on the morning it occurred. The Administrator was asked when he became aware of the incident on [DATE] and he stated "probably" the next day ([DATE]) in the facility's stand up meeting. The Administrator was asked if an I&A form (Incident and Accident) should have been completed for ,[DATE] and he stated it didn't follow the parameters of a "typical" I&A. When was asked if he thought a medical event that required emergent care by the EMS should have prompted an investigation, the Administrator did not answer. On [DATE] at 12:00 noon, the resident's physician was asked if he considered a BG of 30 as a critical value, to which he stated, "Yes, absolutely, yes that's low and definitely needs to be evaluated. That definitely should be caught (as a concern)." When asked if he would have expected an investigation to be completed on ,[DATE] concerning the event, the physician stated, "Certainly, that just makes sense." The physician was asked if a BG of 30 could cause death, and he stated, "Certainly, that can be concerning for possible death." 2. Resident # 3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's physician admission orders [REDACTED] *Autolet BS (blood sugar) (before) meals & bedtime. *Insulin [MEDICATION NAME] (Humalog) subcut(aneous) per sliding scale: ,[DATE]: 0 units, ,[DATE]: 2 units, ,[DATE]: 3 units, ,[DATE]: 4 units, 401+: 5 units. Resident #3's [MEDICAL TREATMENT] Care Plan documented the resident was scheduled to receive [MEDICAL TREATMENT] every Monday, Wednesday, and Friday at 12:15 p.m. The resident's MAR for [DATE] did not contain consistent documentation as per physician orders [REDACTED]. Humalog 100 unit/ ml (milliliter) per sliding scale: Blood Glucose and dose of insulin administered was blank at 7:30 AM on [DATE]; 11:30 AM on ,[DATE], ,[DATE], and ,[DATE]; and at 5:00 PM on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. On [DATE] at 5:20 PM, the DON was asked to explain the blank spaces on the resident's MAR for glucose monitoring in the diabetic resident and she stated the OOF means the resident was out of the facility and the missing documentation is where the nurse did not document it. The DON was asked if the resident's blood glucose had been measured and she stated, "I can't say that it wasn't done, it wasn't documented." On [DATE] at 12:40 PM, the Administrator and DON were notified of the findings. No additional information was provided. 3. Resident #1 was admitted to the facility on [DATE] at 1:30 PM with multiple [DIAGNOSES REDACTED]. Resident #1's Admission Physician order [REDACTED]." The [DATE] Physician order [REDACTED]. BG (blood glucose) TID (three times daily) at 8:30 AM, 1:30 PM and 6:30 PM" with a start date of [DATE]. A fax dated [DATE] documented, "RD recommends D/C (discontinue) of carb count (admit order: carb dosing TCU (Transitional Care Unit)) Resident BG, WNL (within normal limits). Resident on vegetarian diet and doesn't follow vegetarian diet orders from RD. Res(ident) makes dietary choices as food arrives in room." The physician wrote, "Agree" on the faxed order sheet and signed it on [DATE]. A nurse documented as performed on [DATE] at 2:10 AM. The following Progress Notes documented: *"[DATE] at 1:45 AM, "D/C carb count;" *[DATE] at 4:45 PM, "Blood glucose 129, carb count insulin orders were discontinued but BG's are WNL;" and, *[DATE] (not timed), "Cont(inue) to monitor Resident B/G." On [DATE] a physician order [REDACTED]. *"1) D/C carb count; *2) D/C sliding scale insulin; and, *3) D/C [MEDICATION NAME]." An order to discontinue Blood Glucose levels TID was not written by the physician. Review of the resident's MAR for [DATE], documented the resident did not have blood glucose levels for the following dates and times: *8:30 AM, [DATE] through [DATE]; *1:30 PM, ,[DATE],15,17, and 19 through [DATE]; and *6:30 PM, ,[DATE], 19 through [DATE]. On [DATE] at 10:50 AM, the DON was interviewed in the presence of the Administrator, both of whom were made aware of the inconsistent charting of blood glucose levels. When asked if the facility had an order to discontinue checking BG levels TID, the DON stated, "Since the carb count was DC'd on [DATE], it was assumed the BG levels no longer needed to be taken." NOTE: The actual order to "DC the carb count," was dated [DATE]. When told the facility needed an order to discontinue checking BG's TID before discontinuing the order, the DON stated, "Okay, I understand that." When asked if there was any documentation BG levels were discontinued, the DON stated, "Nope." The facility's staff failed to follow the diabetic management policy to notify the physician of critically low levels or when residents were exhibiting signs and syptoms of [DIAGNOSES REDACTED]. The facility's policy and procedure was silent as to care and services for residents with diabetes managed by oral agents. In addition, the facility failed to ensure physician orders [REDACTED]. The cumulative effect of these systematic failures placed individuals with diabetes at risk of experiencing serious and immediate harm and/or death resulting from severe hypo- or hyperglycemic events.