Every finding on record at Twin Falls Transitional Care of Cascadia

Based on observation, interview, policy review, and review of the 2022 FDA Food Code, the facility failed to appropriately store, distribute, and label foods. 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 and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The facility's Food and Storage Policy dated 11/21/17, documented under Labeling and Rotation, Opened or repackaged food must be labeled with use-by date.The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.The facility's Meal Service policy dated 9/12/25, documented For in-room delivery: Ensure food is covered during transport and uncovered at bedside.On 7/19/26 at 12:07 PM, during lunch service CNA #6 was observed taking a meal tray with a cup of coffee without a lid or protective covering on it from the hot cart stationed on the 400-hall and delivered it four rooms away from the hot cart.On 7/19/26 at 12:13 PM, during lunch service the SW was observed taking a meal tray with a cup of juice without a lid or protective covering on it from the hot cart stationed on the 400-hall and delivered it 6 rooms away from the hot cart. The SW had also touched Resident #59's brownie after she unwrapped it.On 7/19/26 at 12:15 PM, the SW stated she did not think the juice had to be covered and did not realize she could not touch the resident's food.On 7/20/26 at 4:28 PM, the CM stated the small cups should of had the clear lids on them and the coffee cups should of had the white lids on them when going down the hall.On 7/20/26 at 4:37 PM, CM stated the staff should not have touched Resident #59's food.On 7/19/26 at 9:20 AM, the following was observed during the kitchen tour:In the refrigerator:- plastic container of lime juice with use by date of 7/17/26- thick dust and dirt observed on the cooler fans In the freezer:- opened package of plant-based burgers with received date but no opened date In the pantry:- scalloped potatoes, dry, opened date of 3/11/26, and used by date of 6/11/26- two coffee carafes stored in pantry, both with dark brown and thick white stains and product on the outside of the containers- croutons with open date of 5/13/25, and use by date of 6/13/26- stuffing with open date of 3/25/26, and use by date of 6/25/26 On 7/19/26 at 10:00 AM, the Culinary Manager stated expired foods should be discarded and opened foods should have an opened date and a discard by date and had not.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Inhalant (Nebulizer) Medication Administration policy revision date 9/16/25, documented equipment must be cleaned and maintained according to infection control protocols. The facility's Cleaning and Disinfecting of Reusable Equipment policy dated 9/25/25, documented all reusable non-critical equipment will be cleaned and disinfected between resident use.The facility's Laundry/Linens policy dated 10/8/25, documented personal clothing is laundered separately and returned promptly to the resident. 5. Delivery to resident care areas is conducted in a manner that minimizes cross-contamination. The following was observed for proper cleaning and storage of respiratory equipment: The facility's Oxygen Administration, Safety, Storage & Maintenance policy, revision date 10/10/25, documented Infection Control 3. Store oxygen and respiratory supplies in a plastic bag when not in use. On 7/19/26 at 10:02 AM, observed Resident #67's CPAP mask lying uncovered in her bedside nightstand. On 7/19/26 at 1:52 PM, observed Resident #53's CPAP mask lying uncovered on her bed under her pillow. On 7/19/26 at 9:55 AM, observed Resident #106's nebulizer lying on his bedside table not bagged. His nebulizer machine was observed to be covered with a gray substance. On 7/20/26 at 5:04 PM, the CNO stated resident's respiratory equipment should have been kept clean, and the tubing should have been in a bag. - The following was observed for multiple resident use equipment: On 7/21/26 at 7:57 AM, the vital sign machine on the cross hall observed with a light brown splattering substance to the base. On 7/21/26 at 8:01 AM, RN#1 stated the vital sign machine should have been cleaned after each resident use. - The following was observed for proper handling and transporting of laundry: On 7/21/26 at 11:14 AM, observed provide incontinent care to Resident #20 and placed his wet under pad on the floor. On 7/21/26 at 11:15 AM, observed CNA #5 removed Resident #7's dirty clothes and bed linen and placed them on the floor. On 7/21/26 at 8:10 AM, observed Laundry Aide #1 carrying personal clothes, on hangers from the laundry room to room [ROOM NUMBER], without a protective covering. On 7/21/26 at 8:14 AM, Laundry Aide #1 stated she should have covered the clothes.

Based on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter and administered oral medication to residents in the dining room. This was true for 1 of 1 resident room observed during the survey process and 1 of 1 resident (Resident #16) observed in the dining room. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include: Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by disturbances of thinking, mood, and behavior), anxiety, and paraplegia (paralysis of lower portion of the body). On 7/19/26 at 12:07 PM, observed in the dining room with other residents present, LPN #3 approach Resident #16 with a cup containing oral medications and administered the medications to him while he waited for lunch. On 7/19/26 at 1:17 PM, Resident #16's medical record had not documented his preference to have medications administered in the dining room. On 7/21/26 at 3:35 PM, the CNO stated Resident #16 should not have received medications in the dining room as his medical record had not documented that medications could be administered to him in the dining room. On 7/19/26 at 10:50 AM, observed CNA #1 open and then entered room [ROOM NUMBER] without knocking. On 7/19/26 at 11:20 AM, Resident #60, who resides in room [ROOM NUMBER], stated that sometimes staff don't knock but they just enter her room, and they should knock first. On 7/21/26 at 10:25 AM, the CNO stated staff should be knocking and waiting for a response from residents before entering their room.

Based on observation, staff interview, and policy review it was determined the facility failed to ensure the facility provided call light access within the resident's reach in 2 facility shower stalls. 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 1. Resident Access a. Call light systems are expected to be available, within reach, at the bedside and in toileting and bathing areas.On 7/20/26 at 11:17 AM, observed 100 Hallway shower stall with the call light box mounted on the upper area of the shower stall without a call light string and not within reach of a resident using the shower stall. On 7/20/26 at 11:24 AM, observed 400 Hallway shower stall with the call light box mounted on the upper area of the shower stall without a call light string and not within reach of a resident using the shower stall. On 7/21/26 at 11:57 AM, the CRN stated the showers should have a call light box with strings that are accessible by residents and staff assisting the resident when in the shower stall and did not.

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 whose environment were observed. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified or residents were injured due to unsafe areas in the facility. Findings include: The facility's Homelike Environment policy, revision date 9/17/25, documented under Facility Standards 1.a Maintain a sanitary, orderly, and comfortable interior.The following areas were observed for a clean, homelike environment: On 7/19/26 at 12:25 PM, the vents on the dining room ceiling and the area around the vents were observed with a gray, fuzzy substance. On 7/21/26 at 8:21 AM, observed the vent in the TV room with a gray, fuzzy substance. On 7/21/26 at 8:32 AM, observed the vent in the middle of the 300-hall hallway with a gray, fuzzy substance. On 7/21/26 at 8:57 AM, observed in the medication room cobwebs on the wall above the refrigerators, a gray, fuzzy substance on the vents on the ceiling, and a dry gray substance on the floor. On 7/21/26 at 11:04 AM, the CEO stated the facility did not have a weekly cleaning schedule. The CEO also stated the vents and area around the vents should have been cleaned. Review of the 100-hall and 400-hall Responsibilities form did not include cleaning of the vents on the ceiling. Review of the Environmental Services Checklist: Terminal Cleaning of Patient Rooms form did not document cleaning of the vents. Review of the Housekeeping Checklist: Daily Cleaning of Resident Rooms form did document that the vents were to be dusted. On 7/21/26 at 12:11 PM, the Maintenance Manager stated on Fridays he had an employee that should have cleaned the vents, and he just started working on putting together a cleaning schedule.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1of 21 residents (Resident #52) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Comprehensive Care Plans and Conference policy, revision date 9/3/25, documented the plan will be created, reviewed, and revised by an interdisciplinary team familiar with the resident's status and care needs, with active involvement from the resident and their representative, when applicable. Updates to the care plan will occur as needed based on the resident's response to interventions or change or change in condition when a resident sustains a fall.Resident #52 was admitted to the facility on [DATE], with multiple diagnoses which include sick sinus syndrome (a heart rhythm disorder) and wedge compression fracture of the fourth lumbar vertebra.On 7/19/26 at 4:16 PM, observed Resident #52 lying in his bed with his oxygen on via nasal cannula. Elbow pads observed on both elbows. Resident #52's Physician's order dated 7/6/26, documented oxygen: 2L/min via Nasal Cannula continuous PRN. Observe resident for signs/symptoms of respiratory distress (e.g., tachypnea, dyspnea, accessory muscle use, cyanosis, unexplained anxiety/agitation) PRN. If concerns noted, alert provider and document in medical record. Resident 52's Physician's order dated 7/14/26, documented wound care to elbows: elbow protectors to be worn at all times, check placement Q shift. Review of Resident #52's medical record documented a CSCD- Skin inspection assessment dated [DATE], documented: Bruising to BUE, Scabs to Bilateral elbows. Elbow protectors to be worn at all times and nurses to check placement Q shift. On 7/19/26 at 4:44 PM, a review of Resident #52's care plan did not have his oxygen use or his elbow pads to elbows documented. On 7/20/26 at 5:00 PM, the CRN stated Resident #52's care plan was updated today but the oxygen and elbow pads should have been on his care plan. On 7/20/26 at 5:11 PM, the CNO stated Resident #52's oxygen and elbow pads were not on his care plan until today and should have been care planned when ordered.

Based on policy review, observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 1 resident (Resident #60) whose record was reviewed for respiratory services. This failure created the potential for the resident to experience increased fatigue and low oxygen levels. Findings include:The facility's Oxygen Administration, Safety, Storage and Maintenance policy dated 10/10/25, documented the following:- verify provider order prior to initiating/changes oxygen therapy.- supplemental oxygen use is reflected in the Resident's care plan.- monitor oxygen parameters as needed and/or as ordered.Resident #60 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including stroke and chronic respiratory failure with hypoxia (a long-term, progressive inability of the lungs to oxygenate the blood sufficiently).Resident #60's physician oxygen order dated 3/14/26, documented oxygen 3 L/min via Nasal Cannula continuous. Observe resident for signs/symptoms of respiratory distress (e.g., tachypnea, dyspnea, accessory muscle use, cyanosis, unexplained anxiety/agitation) PRN. If concerns noted, alert provider and document in medical record.Resident #60's care plan documented give oxygen as ordered by the physician.On 7/19/26 at 10:50 AM, observed Resident #60 did not have her oxygen cannula on during Hoyer lift transfer and while ADL cares were performed at the sink. When the surveyor questioned CNA #3 about Resident #60's oxygen CNA #3 applied the oxygen cannula to her.On 7/21/26 at 10:30 AM, the CNO stated the CNAs should have had Resident #60 on her oxygen during the Hoyer lift transfer and during ADLs as prescribed by the physician and had not.

Based on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate and included scheduled and actual hours. 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:State Operations Manual, Appendix PP -.the facility posts the following information on a daily basis: facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census. On 7/20/26 at 1:40 PM, the daily posted staffing sheets were reviewed for the months of January 2026 - July 2026, the following was observed:No actual licensed and unlicensed staff hours documented on the sheets for the 7 months reviewedOn 7/21/26 at 11:55 AM, the CRN stated the facility had not documented the actual licensed and unlicensed staff hours on the daily posted staffing sheets and should have.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately; this was true for 1 of 21 resident's rooms inspected (Resident #101) and 1 of 1 treatment carts audited. This failure created the potential for adverse effects if residents self-administered medications inappropriately or did not take their medications and created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include: The facility's Self-Administration of Medication policy revision date 9/16/25, documented Residents may self-administer medications when it is determined to be safe and appropriate. The facility will assess each request using a team-based approach that includes input from nursing staff, the resident's physician, and other relevant disciplines. The assessment will consider the resident's ability to manage medication independently and safely, including whether bedside storage is appropriate. Resident #101 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection and bacteremia (bacteria in the blood stream). Resident # 101's admission MDS start dated 7/17/26, documented he had a BIMS of 9, meaning he had moderate cognitive impairment. On 7/21/26 at 1:31 PM, observed on Resident #101's bedside table a bottle of Systane (artificial tears) eye drops. On 7/21/26 at 1:37 PM, LPN #2 stated the eye drops should not have been in the room. On 7/21/26 at 2:35 PM, a review of Resident #101's medical record did not document an order for Systane eye drops. On 7/21/26 at 2:38 PM, a review of Resident #101's medical record did not document a self-administration of medication assessment. On 7/19/26 at 9:25 AM, observed an unlocked and unattended treatment cart on the 400 Hall. On 7/19/26 at 10:00 AM, RN # 1 opened the resident's closed room door and came out of a resident's room and stated she forgot to lock the treatment cart door and should have. On 7/21/26 at 10:30 AM, the CNO stated the wound care treatment cart should have been locked when unattended by a licensed nurse and was not.

Based on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 20 Residents (Resident #7) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the resident's wishes were not followed or documented regarding their advance care planning. Findings include: Resident #7 was admitted to the facility on [DATE], with diagnoses including Spotted Fever due to Rickettsia rickettssi (disease caused by the bite of a tick or mite) and diabetes. On 6/10/25 at 10:02 AM, during review of Resident #7's medical record a POST and a Letter of Guardianship was found. No documentation of Advance Directive and no documentation that the facility had offered to assist Resident #7 or resident guardian with formulating an Advance Directive. On 6/10/25 at 11:47 AM, CRN stated Resident #7 has a guardian so Advance Directives were not discussed and no Advance Directive documentation exists.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 2 of 20 residents (#32 and #38) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, major depressive disorder, and anxiety. Resident #32's PASRR level II dated 12/13/24, documented she had a diagnosis of PTSD (serious mental illness), ADD, and situational anxiety/depression. Resident #32's admission MDS assessment, dated 12/23/24, documented under question A1500, she was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Resident #32's admission MDS assessment dated [DATE], and her quarterly MDS assessment dated [DATE], did not document under section I6100 her diagnosis of PTSD. 2. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, fractured right femur, and complication of internal left hip prosthesis. Resident #38's admission MDS assessment dated [DATE], documented under question A1500, he was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/11/25 at 2:30 PM, the CRN with the CCO present, stated Resident #32's MDS, section A1500, should have been marked yes and I6100 should have indicated she had a diagnosis of PTSD. On 6/11/25 at 2:35 PM, the CRN with the CCO present, stated Resident #38's MDS, section A1500, should have been marked yes.

Based on record review, policy review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness, intellectual disability, or a related condition. This was true for 1 of 8 residents (Resident #58) reviewed for PASARR Level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Pre-admission Screening and Resident Review (PASARR) policy dated 11/19/24, documented if a positive Level 1 screen, an in-depth evaluation (PASARR Level II screen) of the individual by the state-designated authority is conducted prior to admission to the facility. The state-designated authority determines whether the individual has a mental disorder (MD) or an intellectual disability (ID) or related condition. The state-designated authority determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs. The facility's Interdisciplinary Team uses the PASARR when conducting their assessments of the resident, developing the care plan, and when transitions of care occur to promote a comprehensive assessment and development of a plan of care for residents with MD or ID. Resident #58 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute and chronic respiratory failure with hypoxia (a situation where the lungs fail to adequately transfer oxygen into the bloodstream, leading to low tissue oxygen levels) and post-traumatic stress disorder (PTSD - a mental health condition that can develop after experiencing or witnessing a traumatic event). Resident #58's medical record documented he was diagnosed with post-traumatic stress disorder with an onset date of 1/30/25. On 6/9/25, Resident #58's medical record documented the following related to PASRR and MDS reviews: - PASRR I dated 1/30/25, documented depressive disorder and Bipolar disorders. - PASRR II dated 1/30/25, documented Resident #58 has the diagnoses of Anxiety, Depression, Bipolar Disorder for which medication is prescribed. Documents did not state concerns related to mental health. No further evaluation for specialized service needed. - MDS dated [DATE], under I6100 PTSD was not marked YES. - PASRR I dated 2/27/25, documented depressive and anxiety disorder, Bipolar disorders, and PTSD. - PASRR II dated 3/4/25, documented Resident #58 has depression, anxiety, bipolar, and PTSD. He is prescribed Lamictal and Latuda to treat mental illness. Sending PASRR forward to MH for further review. - PASRR I dated 4/8/25, documented depressive disorder and Bipolar disorders. - PASRR II dated 4/8/25, documented Resident #58 has the diagnoses of bipolar disorder and depression for which medication are prescribed. No further evaluation needed. - PASRR II dated 4/22/25, documented Resident #58 has the diagnoses of Depression and Anxiety for which medication is prescribed. Documents did not state concerns related to mental health. No further evaluation for specialized service needed. - PASRR I dated 5/1/25, documented depressive disorder, Bipolar disorders, and PTSD. - PASRR II dated 5/2/25, documented Resident #58 readmitted to hospital with plan to return to skilled nursing facility. Documentation shows suicidal ideation; mental health diagnoses bipolar, PTSD, depression, and anxiety; medications prescribed Hydroxyzine, Lamictal, and Latuda. - MDS 5/9/25, I6100 PTSD was marked yes. - PASRR I dated 5/29/25, documented depressive disorder and Bipolar disorders. - PASRR II dated 5/29/25, documented Resident #58 has depression, anxiety, and bipolar; medications to treat mental health Gabepentin, Hydroxyzine, Lamotrigine, and Lurasidone. On 6/10/25 at 9:10 AM, the Social Services Manager stated she had missed the errors on the past PASSR's and had just requested a PASRR I and PASRR II corrections as listed below. - PASRR I dated 6/9/25, documented Resident #58 has depression, anxiety, bipolar, and PTSD. - PASRR II dated 6/10/25, documented facility requested new PASRR review due to incorrect form 87. Resident #58 has diagnoses of depression, anxiety, bipolar, PTSD, and insomnia due to other mental disorder. On 6/10/25 at 10:05 AM, the CNO and CRN stated the facility staff should have caught these PASRR I and II errors and requested corrections but had not.

Based on record review and staff interview, it was determined the facility failed to resubmit the PASRR level II for those residents with a 30 day exemption when their stay exceeded 30 days. This was true for 3 of 20 residents (#12, #38, and #63) reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include. 1. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including depression, anxiety, and congestive heart failure. Resident #12's PASRR level II dated 8/5/24, documented the following: - Meets the criteria for hospital exemption - Has a known or suspected major mental illness - Physician has certified he will need less than 30 calendar days for services. - If the participant stays past 30 days from admission, the facility was to submit the most current MDS, Medical Doctors orders, social notes, and psych. information to BLTC. 2. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, fractured right femur, and complication of internal left hip prosthesis. Resident #38's PASRR level II dated 4/3/25, documented the following: - Meets the criteria for hospital exemption - Has a known or suspected major mental illness - Physician has certified he will need less than 30 calendar days for services. - If the participant stays past 30 days from admission, the facility was to submit the most current MDS, Medical Doctors orders, social notes, and psych. information to BLTC. On 6/10/25 at 12:54 PM, the CRN stated the facility did not submit the most current MDS, Medical Doctors orders, social notes, or psych. information to BLTC for residents #12 and #38 and should have. 3. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including Autonomic Nervous System disorder (conditions that disrupt the body's ability to regulate involuntary functions like heart rate, blood pressure, digestion, and temperature), Parkinson's Disease (a progressive neurodegenerative disorder that affects the brain, specifically the nerve cells that produce dopamine), and borderline personality disorder (characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). On 6/9/25, Resident #63 medical record documented the PASRR level II dated 3/11/25, would need to be resubmitted with current MDS, Medical Doctor orders, social notes and psych. information to BLTC for update if her stay at the facility exceeded 30 days. On 6/10/25 at 9:10 AM, the Social Services Manager stated she had recently found this issue and had resubmitted required documents to BLTC for review. On 6/10/25 at 10:05 AM, the CNO and CRN stated the facility staff should have caught this PASRR level II error back in April 2025 and requested an updated PASRR level II but had not.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician and the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff used opened oxygen supplies after it had fallen on the floor. This was true for 2 of 15 residents (Resident #63 and #41) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue, low oxygen levels and infection. Findings include: 1. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including Autonomic Nervous System disorder (conditions that disrupt the body's ability to regulate involuntary functions like heart rate, blood pressure, digestion, and temperature), Parkinson's Disease (a progressive neurodegenerative disorder that affects the brain, specifically the nerve cells that produce dopamine), and borderline personality disorder (characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). Resident #63's care plan dated 3/31/25, documented oxygen therapy as ordered. Change disposable oxygen tubing, nebulizer supplies, connecting tubing, corrugated tubing, etc weekly. Resident #63's TAR for June 2025, RN #5 documented oxygen tubing and bubbler were changed on 6/5/25. On 6/9/25 at 9:37 AM, observed Resident #63's oxygen concentrator tubing and empty bubbler were dated 5/30/25 as the last changed date. On 6/9/25 at 1:30 PM, with the CEO present, observed Resident #63's empty bubbler and tubing that were dated 5/30/25. On 6/10/25 at 10:46 AM, the CRN stated the night nurse told her she had assigned the task of changing the O2 tubing and humidifiers to the CNAs and then she spot checked a few rooms to make sure it was done but did not check Resident #63's room and should have. 2. Resident #41 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including congestive heart failure (a chronic condition where the heart is unable to pump enough blood to meet the body's needs, leading to fluid buildup in the lungs and other tissues) and chronic respiratory failure with hypoxia (a condition where the lungs are unable to effectively exchange oxygen and carbon dioxide in the blood over a prolonged period, resulting in chronically low blood oxygen levels). On 6/10/25 at 2:27 PM, observed CNA #1 drop Resident #41's oxygen cannula tubing end on the ground when filling his liquid portable unit. On 6/10/25 at 2:31 PM, observed CNA #1 pick-up Resident #41's oxygen cannula tubing from the ground and reconnect it to his liquid portable unit while he was in the resident council meeting. On 6/10/25 at 2:35 PM, CNA #1 stated he should not have dropped Resident #41's oxygen cannula tubing end on the ground and should not have reused that tubing on his oxygen unit. On 6/10/25 at 2:39 PM, the CRN stated CNA #1 should have replaced Resident #41's dropped cannula tubing before reconnecting it to the portable oxygen unit and did 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 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 6/8/25 at 3:42 PM, during 400 Hall medication cart audit, observed the narcotic accountability record, dated 6/4/25 to 6/8/25, with 2 licensed nurse signatures not documented. On 6/8/25 at 3:45 PM, LPN #2 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 6/11/25 at 7:56 AM, during 100 Hall medication cart audit, observed the narcotic accountability record, dated 6/5/25 to 6/11/25, with 1 licensed nurse signature not documented. On 6/11/25 at 8:05 AM, LPN #3 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 6/11/25 at 2:35 PM, CNO stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observation, record review and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 medications (5.71%) which affected 1 of 6 residents (Resident #38) whose medication administrations were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication. Findings include: The following was observed during the medication pass: a. Resident #38's physician order documented Calcium 600mg/Vitamin D 10 mcg oral tablet daily. On 6/11/25 at 8:17 AM, LPN #3 stated Resident #38 had been receiving Calcium 600mg/Vitamin D 10 mcg in chewable form and the facility did not have chewable tablets so she could not administer the medication. On 6/11/25 at 8:50 AM, CNO stated the facility did not have Calcium chewable tablets available to administer to Resident #38. b. Resident #38's physician order documented Lidocaine External patch 4% (Lidocaine) apply to left leg base topically one time a day for pain, on for 12 hours in AM and off at PM. On 6/11/25 at 8:24 AM, LPN #3 removed a previously applied Lidocaine patch from Resident #38's left leg base then applied a Lidocaine External patch 4% (Lidocaine) to his left leg base. On 6/11/25 at 8:37 AM, LPN #3 stated the lidocaine patch should be removed after 12 hours and had not been. On 6/11/25 at 8:38 AM, LPN #3 stated the Lidocaine patch is hard to write on so she did not date, time, initial the patch. On 6/11/25 at 11:20 AM, CNO stated the Lidocaine patch should have been removed in the PM and had not been, and the Lidocaine patch should have been dated, timed, initialed by the LPN and had not been.

Based on observations and staff interviews it was determined the facility failed to ensure medications were properly stored and not expired, and biologicals were labeled when opened. This was true for 1 of 1 medication storage room audited. This failure created the potential for residents to receive expired medications with decreased efficacy and use of expired biologicals. Findings include: 1. On 6/11/25 at 8:52 AM, observed the following in the medication storage room refrigerator: - one bottle of mouthwash opened with an expiration date of 4/17/25 - two bottles of omeprazole suspension with an expiration date of 4/17/25 On 6/11/25 at 8:53 AM, CNO stated the mouthwash and omeperazole suspension was expired and should have been removed from the refrigerator and had not been. 2. The following was observed for biologicals. On 6/11/25 at 8:54 AM, one set of glucose test solutions were not dated when opened. On 6/11/25 at 8:55 AM, CNO stated glucose test solution was not dated when opened and should have been.

Based on observation, Idaho Food Code review, policy review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility's Food and Supply Storage policy dated 11/28/17, documented for food products that are opened and not completely used or prepared at facility and stored, the product should be labeled as to its contents and use-by dates. On 6/8/25 at 9:56 AM, observed in the dry food storage room, opened container of dry scalloped potatoes with a use by date of 6/7/25. On 6/8/25 at 10:00 AM, observed in the walk-in refrigerator, an undated container of tea and a tray of individually poured cups of juice that were not dated and the tray they were on was not dated. On 6/8/25 at 10:04 AM, observed in the walk-in freezer, a bag containing pizzas that had been opened but had not been dated. On 6/8/25 at 10:07 AM, the Culinary Manager stated these food items should have been properly dated and were not.

Based on record review and staff interview, it was determined the facility failed to ensure accurate data was entered into a resident's medical record. This was true for 1 of 20 residents (Resident #51) whose medical records were reviewed. This deficient practice placed residents at risk when inaccurate medical data is entered into their medical records. Findings include: Resident #51 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic congestive heart failure (a long-term condition where the heart's pumping ability is weakened, leading to fluid buildup in the lungs and other parts of the body) and chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems). Resident #51's physicians' order dated 6/2/25, documented BIPAP with home settings with oxygen at 2 liters with humidification. On 6/10/25, observed in Resident #51's medical record the following SpO2 documentation: - 6/3/25 14:13 90.0% Oxygen via Nasal Cannula LPN #1 - 6/2/25 14:01 96.0% Oxygen via Nasal Cannula LPN #1 - 5/22/25 21:58 94.0% Oxygen via Nasal Cannula RN #1 - 5/21/25 7:06 93.0% Oxygen via Nasal Cannula LPN #2 - 5/16/25 10:28 94.0% Oxygen via Nasal Cannula LPN #3 - 5/6/25 9:36 94.0% Oxygen via Nasal Cannula RN #2 - 4/21/25 9:49 93.0% Oxygen via Nasal Cannula RN #2 - 4/20/25 9:02 93.0% Oxygen via Nasal Cannula RN #3 - 4/16/25 9:13 94.0% Oxygen via Nasal Cannula LPN #3 - 4/11/25 8:04 92.0% Oxygen via Nasal Cannula RN #2 - 4/6/25 19:41 92.0% Oxygen via Nasal Cannula RN #4 - 4/5/25 23:40 91.0% Oxygen via Nasal Cannula RN #5 - 4/2/25 21:25 94.0% Oxygen via Nasal Cannula RN #1 - 3/30/25 9:33 96.0% Oxygen via Nasal Cannula LPN #3 - 3/29/25 12:36 94.0% Oxygen via Nasal Cannula RN #6 On 6/10/25 at 9:53 AM, the CNO stated Resident #51's oxygen order was for oxygen used with his BIPAP and not with a nasal cannula and there was no cannula in the resident's room. On 6/10/25 at 10:33 AM, the CRN stated the SpO2 nasal cannula issues were documentation errors and should have been caught and corrected.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure proper procedures for cooling leftovers were followed; maintain proper holding food temperatures; and equipment, floors, and dishware were cleaned and/or maintained. This placed all 52 residents residing in the facility who received meals from the kitchen at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's policy titled, Use of Leftovers, dated 2021, documented leftovers must be cooled to 70 degrees F (Fahrenheit) within 2 hours and then to 41 degrees F within another 4 hours. The facility's policy titled, Food Storage, dated 2021, documented all refrigerator units should be kept clean and in good working condition at all times. Time/temperature control for safety foods must be maintained at or below 41 degrees F unless otherwise specified by law. The facility's policy titled, Food Temperatures, dated 2021, documented temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area. The facility's policy titled, General Sanitation of Kitchen, dated 2021, documented, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During the kitchen tour on 7/2/24 at 9:27 AM with [NAME] #2 and on 7/3/24 at 1:56 PM with the RD the following observations were made: On 7/2/24 at 9:27 AM, the temperature of the walk-in refrigerator measured 48 degrees F. [NAME] #1 was asked if 48 degrees F was correct. [NAME] #1 stated, No, but the gaskets around the door were torn and a work order was placed for repair. The gaskets were observed torn on the lower door. [NAME] #1 demonstrated how the door should be pushed shut since the door did not seal on its own. The floor in the walk-in refrigerator was observed with food, trash debris, rusted areas, and a build-up of dirt-like debris under the shelving. The floor also contained a large yellow spill. On 7/3/24 at 1:56 PM, the RD stated the walk-in refrigerator was deep cleaned but she was not sure how often. The two range ovens contained dried cream-like spillage on the outside doors. Inside the right oven contained a foiled baking sheet with a collection of dried food debris. On 7/3/24 at 2:05 PM, the RD confirmed the soiled condition and stated it should be cleaned. The walls in and around the steam table and coffee station contained dried splatters. On 7/3/24 at 2:06 PM, the RD stated the walls should be cleaned frequently. The floor throughout the kitchen contained scuff marks, worn areas, cracked tiles, and gaps with a dark gummy substance between tiles. An accumulation of dried food debris was observed on the floor between the oven and steamer. On 7/3/24 at 2:07 PM, the RD acknowledged the floor needed cleaning and repair. The RD stated the facility had discussions about it. On 7/3/24 at 2:08 PM, [NAME] #2 was asked if there were leftovers. [NAME] #2 stated, Yes, the breakfast gravy placed in the walk-in refrigerator at 9:00 AM. A half size six-inch-deep stainless-steel pan was observed covered with tin foil containing gravy in the walk-in refrigerator. [NAME] #2 was asked to check the temperature of the gravy. The gravy measured at 65 degrees F. [NAME] #2 was asked how she cooled hot foods down quickly. [NAME] #2 stated she poured the gravy from a larger deep steamtable pan and into the current pan. The RD was present and acknowledged the gravy was still too hot after five hours, stating the staff should be using shallow pans, leave the lid off for a few hours, etc. to get the temperature down quickly. According to calculations using Newton's Law of Cooling, the temperature of the gravy after five hours should be at 43.7 degrees F. On 7/4/24 at 7:33 AM, [NAME] #1 was observed taking the holding temperatures of the cold foods and beverages on the breakfast tray line. The pears were measured at 45 degrees F, cut strawberries measured at 43 degrees F, cottage cheese was measured at 46 degrees F, milk was measured at 43 degrees F, chocolate milk was measured at 44 degrees F, and the health shake was measured at 42 degrees F. [NAME] #1 was asked what the holding temperatures should be for cold foods and [NAME] #1 stated below 50 degrees F. On 7/4/24 at 7:38 AM, eight beverage pitchers on the breakfast cart, trays, plate bases and lids on the tray line were noted to be coated with a white residue. [NAME] #2 stated the white coating was due to hard water, stating she was waiting for the product to arrive as they were out of the product for three to four months. During an interview 7/4/24 at 11:42 AM, the CEO was asked about the kitchen's dishes and pitchers that contained hard water stains. The CEO stated he was aware and was considering a water softener for the facility. During a follow-up interview on 7/5/24 at 12:23 PM, [NAME] #1 was asked if she was aware the cold food and beverage items on the breakfast tray line on 7/4/24, should be held at 41 degrees F but some measured above 41 degrees F. [NAME] #2 stated, No, not until 7/4/24.

Based on policy review, record review, I&A report review, fall investigation summary report review, and resident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 5 residents (#1, #3, #5, and #7) reviewed for quality of care. Specifically: * Resident #5 was harmed when he had an unwitnessed fall resulting in pain and an undetected and untreated pelvic fracture and pelvic dislocation. * Resident #1 and #7 were at risk for worsening conditions or adverse reactions when their medications were administered late. * Resident #1 and #3 were at risk for worsening conditions when they did not receive their medications as ordered. * Resident #1 was at risk of infection or bleeding, when her PICC (percutaneous intravenous central catheter - method to deliver sterile mediations and fluid into a vein) dressing changes, monitoring, and care of the site were not documented as completed. * Resident #3 was at risk for infection when her indwelling catheter (flexible tube inserted into the bladder to drain urine) care was not documented as completed. Findings include: 1. The facility's Fall Response and Management policy, revised 5/17/21, documented residents were assessed for injuries after an unwitnessed fall. It documented residents were assessed for pain, the location and severity of pain was determined, obvious deformities were looked for, and the resident's limb strength and motion were evaluated after a fall. The policy documented the resident was observed for injuries, soreness, and weakness for at least 72- hours after a fall. This policy was not followed. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An I&A report dated 9/17/21 at 7:22 PM, documented Resident #5 fell out of his wheelchair while attaching his prosthetic legs. The report documented he had a second fall 20 minutes later. The report documented Resident #5 fell out of bed after staff put him into his bed after the first fall. His pain was documented as 4 on the 0-10 pain scale (0 being no pain and 10 the highest pain level), and no injuries were documented. A progress note, dated 9/18/21 at 8:49 AM, documented Resident #5 was medicated for chest, upper thigh, and forehead pain. Resident #5's September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's record did not include post-fall assessments from 9/18/21to 9/20/21 as required by the facility post-fall policy to include observing for injuries, soreness and weakness for at least 72 hours after a fall. A nursing progress note dated 9/20/21 at 10:53 AM, documented Resident #5 complained of increased pain in his left hip with all movement. The note documented Resident #5's hips appeared mildly asymmetrical, but it was difficult to tell as resident keeps LLE [left lower extremity] in extended position as he states that it hurts less. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An X-ray report, dated 9/20/21 at 1:00 PM, documented Resident #5's left leg and hip had no fracture or dislocation visualized on the X-ray. The report documented if Resident #5 continued to experience left hip pain, a CT (a diagnostic tool that uses a series of X-rays to make a 3D picture of tissue and bone) could be performed to evaluate for a fracture. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented he would be given Tylenol, 1000 mg, by mouth three times a day for seven days. Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 5's MAR, documented an additional order for PRN Tylenol on 9/21/21. A nursing progress note, dated 9/21/21 at 2:16 PM, documented Resident #5 had not complained of left hip or pelvis pain during that evening. Resident #5's MAR for 9/21/21, documented he rated his pain a 3 out of 10 on the pain scale during the day and a 5 out of 10 on the pain scale during the night. There was no documented pain assessment or post-treatment follow-up after the scheduled Tylenol was given to Resident #5. There was no documentation in Resident #5's record he was given PRN Tylenol for breakthrough pain (pain not controlled by a scheduled pain medication). A nursing progress note, dated 9/22/21 at 8:25 AM, documented Resident #5 was medicated for left hip and leg discomfort. Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in Resident #5's record he was given PRN Tylenol for breakthrough pain. A nursing progress note, dated 9/23/21 at 1:30 AM, documented Resident #5 had no complaints of left hip or leg pain during the evening. Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in Resident #5's record he was given PRN Tylenol for breakthrough pain. On 9/26/21, Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented pain assessment in the progress notes. There was no documentation additional pain medication was given to Resident #5 other than his scheduled Tylenol. On 9/27/21, Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . He was given scheduled Tylenol at 7:00 AM and 2:00 PM. Resident #5's record did not include documentation additional pain medication was given for breakthrough pain. The 2:00 PM dose of Tylenol was the last scheduled dose of pain medication for Resident #5. On 9/29/21, Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's record did not include documentation he was given pain medication, a pain assessment was performed, or that the physician was notified he was having pain after the last dose of his scheduled Tylenol. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #5 continued to report pain to his left hip, shifted his body in his wheelchair to keep weight off his hip, could not tolerate lying flat in bed, and had difficulty raising his leg in front of him. The note documented a CT scan was ordered. On 10/1/21 at 9:02 AM, Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no other documentation pain medication was given to Resident #5 for the month of October. On 10/8/21, Resident #5 had a CT scan which showed a displaced and broken left pubic bone, 21 days after he fell . There was no documentation Resident #5 was assessed for pain on this date, and no documentation on Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A Fall Investigation Summary Report, undated, documented facility leadership became aware of Resident #5's fracture on 10/11/21, more than one month after his fall. An orthopedic physician's office visit note, dated 10/12/21, documented Resident #5 stated he continued to have pain when he attempted to stand or walk. There was no documentation on Resident #5's MAR pain medication was given on this date. On 11/5/21 at 2:22 PM, Resident #5 was interviewed via a Spanish interpreter regarding his hip fracture and care. He stated he had pain daily and reported it to the nurses, but no one paid attention to me. When asked if he requested pain medication, he stated, Yes, but no one gave me anything. On 11/4/21 at 4:29 PM, the CRN stated Resident #5's clinical picture was unclear because his initial X-ray did not show a fracture, but he continued with pain that varied. When asked why the facility did not send him to the ER for an emergency CT when he was having pain, and one leg appeared longer than the other, she stated the clinical picture did not appear emergent, so they did not send him for a CT. When asked why the facility waited 21 days to get a CT, she stated the Radiology report was vague and left too much to interpretation. When asked why Resident #5's pain was not assessed daily, she stated he only had pain on the days documented in the MAR, and he had days without pain. 2. The facility's policy for Medication administration, dated 1/2021, stated the following: * Medication is administered within 60 minutes of the scheduled time, except before or after meal orders, which are administered based on the mealtimes. This policy was not followed. a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse practitioner progress note, dated 7/30/21 at 1:35 PM, documented Resident #1 was to continue IV (intravenous - a way to deliver sterile medication and fluids through a catheter inserted into a vein) [MEDICATION(S)] (antibiotic) until 8/4/21 for [CONDITION(S)] of her right foot. The note also documented Resident #1 was to continue to receive [MEDICATION(S)] (antibiotic) by mouth until 8/19/21 for enterocolitis. Resident #1's MAR for July and August 2021, documented the IV [MEDICATION(S)] was to be given every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM. Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] * 7/4/21: 10:00 PM dose administered on the next day on 7/5/21 at 12:22 AM, 142 minutes after the scheduled time * 7/5/21: 2:00 PM dose administered at 4:34 PM, 124 minutes after the scheduled time * 7/8/21: 10:00 PM dose administered at 11:33 PM, 93 minutes after the scheduled time * 7/9/21: 10:00 PM dose administered at 11:17 PM, 77 minutes after the scheduled time * 7/10/21: 10:00 PM dose administered at 11:26 PM, 86 minutes after the scheduled time * 7/13/21: 10:00 PM dose administered at 11:57 PM, 117 minutes after the scheduled time * 7/19/21: 2:00 PM dose administered at 3:19 PM, 79 minutes after the scheduled time * 7/21/21: 2:00 PM dose administered at 3:45 PM, 105 minutes after the scheduled time * 7/24/21: 10:00 PM dose administered at 11:09 PM, 69 minutes after the scheduled time * 7/28/21: 2:00 PM dose administered at 5:19 PM, 199 minutes after the scheduled time * 8/1/21: 2:00 PM dose administered at 3:28 PM, 88 minutes after the scheduled time * 8/2/21: 2:00 PM dose administered at 3:24 PM, 84 minutes after the scheduled time * 8/4/21: 2:00 PM dose administered at 4:22 PM, 142 minutes after the scheduled time b. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MAR for August and September 2021, documented she was to receive [MEDICATION(S)] (a long-acting insulin that works up to 24 hours to lower blood sugar) at bedtime between 7:00 and 10:00 PM for diabetes. Resident #7 received her [MEDICATION(S)] greater than the 60-minute parameter from the scheduled time directed in the facility's policy, as follows: * 8/9/21 at 11:53 PM, 123 minutes after the scheduled time * 8/13/21 at 11:29 PM, 89 minutes after the scheduled time * 8/15/21 at 11:09 PM, 69 minutes after the scheduled time * 8/19/21 at 11:39 PM, 99 minutes after the scheduled time * 8/27/21 at 11:51 PM, 111 minutes after the scheduled time * 9/1/21 at 11:50 PM, 110 minutes after the scheduled time On 11/4/21 at 12:35 PM, the DON said Resident #7 's insulin schedule was flexible between 7:00 PM to 10:00 PM. He said if it was given past 11:00 PM it was considered given late. On 11/4/21 at 4:30 PM, the CRN said the facility's medication administration time is one hour before and one hour after the scheduled time. She said if a medication was administered after one hour of the scheduled time, it was considered given late. 3. The facility's policy for Medication administration, dated 1/2021, stated if a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. This policy was not followed. a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's MAR for July, August, September, and October 2021, documented she did not receive medications ordered by the physician. Examples include: * [MEDICATION(S)] (nasal spray to relieve allergy symptoms): 1 spray in each nostril one time a day in the morning. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (antihistamine): 1 tablet by mouth at bedtime. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medication for high cholesterol): 1 tablet by mouth at bedtime. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] capsule delated release (anti-reflux medication): 1 tablet by mouth, one time a day in the morning. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] HCL (medication for high blood pressure): 1 tablet by mouth at bedtime. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medication to treat [CONDITION(S)]): 2 tablets by mouth at bedtime. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medication to treat hypothyroid): 1 tablet by mouth in the morning. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's MAR for August, September, and October 2021, documented she did not receive medication ordered by the physician. Examples include: * [MEDICATION(S)] (medication to reduce risk of stroke): 1 tablet by mouth two times a day. On the AM shift and the PM shift. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medication to treat diabetes): 500 mg by mouth two times a day at 8:00 AM and 5:00 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] sorbitex calcium packet (medication to treat higher than normal potassium in the blood): 1 packet by mouth one time a day at 5:00 AM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medication to treat bladder spasms): 1 tablet by mouth three times a day at 9:00 AM, 2:00 PM, and 7:00 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * Tylenol extra strength (medication for pain): 2 tablets by mouth three times a day at 6:00 AM, 2:00 PM, and 10:00 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MAR for August, September, and October 2021, documented she did not receive medication ordered by the physician. Examples include: * [MEDICATION(S)] (medication to reduce risk of stroke): 1 tablet by mouth two times a day on the AM shift and PM shift. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * Calcium Acetate (medicine to control high blood levels of phosphorous in people with kidney disease): 1334 mg by mouth three times a day at 8:00 AM, 12:00 PM, and 5:00 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] calcium (medicine to lower high cholesterol): 1 tablet by mouth, one time a day before sleep. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . * [MEDICATION(S)] (medicine to treat high blood pressure and heart failure): 1 tablet by mouth two times a day on the AM shift and PM shift. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/4/21 at 12:35 PM, the DON said if the documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the nurse was to contact the pharmacy and notify him and the physician when medication was unavailable. The DON said if the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The facility's policy for Vascular Access Devices (types of devices utilized for venous access, including a peripherally inserted central catheter [PICC]) and Infusion Therapy, dated August 2021, documented dressing changes were done at established intervals and if the dressing was compromised or infection suspected. The policy documented charting the dressing changes included site assessment, measurement of the external length of the catheter (the small, flexible tube placed into a vein to administer sterile medications and fluids), dressing used, catheter securement, and the resident's response to the procedure. The facility's policy for Maintaining Patency of Peripheral and Central Vascular Access Devices, dated August 2021, stated the vascular access device was aspirated (a method to check for patency by pulling back on the plunger of a syringe to check for blood in the catheter to ensure it is in a vein and not in the tissues) and flushed (pushing sterile fluid into a catheter with a syringe to ensure there is no resistance). The vascular access devices were flushed after each medication and routinely to ensure patency. The policy stated after each flush is completed, the nurse documented the procedure in the resident's medication record. The facility's policy for Vascular Access Devices and Infusion Therapy, dated August 2021, for catheter removal documented once a vascular access device is removed, the nurse should apply gentle pressure at the insertion site with sterile, dry gauze until the bleeding stops, apply sterile ointment and apply the dressing, and leave in place for a minimum of 48 hours or per physician order. The policy stated the nurse should assess the length and integrity of the PICC and inspect the tip. The policy further stated the nurse should document the procedure. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse practitioner progress note, dated 8/18/21 at 9:20 AM, documented Resident #1's course of IV antibiotic for the [CONDITION(S)] was completed. The nurse practitioner planned to have nursing to discontinue her PICC line that day. A nurse practitioner progress note, dated 8/25/21 at 2:59 PM, documented Resident #1's orthopedic physician (doctor who specializes in bones, joints, ligaments, nerves and tendons) gave approval to remove her PICC line. Resident #1's record did not include documentation of the routine PICC line dressing changes, flushes, PICC site monitoring, PICC line removal date, description of the PICC line measurement, or monitoring of the site after it was removed. On 11/4/21 at 12:22 AM, the DON said on 6/12/21, Resident #1 received one PICC line dressing change on 6/12/21 which was documented in the June 2021 MAR. The DON confirmed there was no other documentation the PICC line dressing changes, flushes, measurements, and monitoring was completed in Resident #1's record. The DON also confirmed the facility should follow the policy's requirement to provide PICC line related care, documentation, and monitoring. 5. The facility's policy for Indwelling Catheters (a flexible tube inserted into the bladder to drain urine), dated 11/28/17, stated an indwelling catheter which is inserted into the bladder and allowed to remain in the bladder is called an indwelling catheter. The policy stated the facility provides care for a resident including insertion and ongoing care that adhere to professional standards of practice and infection prevention procedures, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] This policy was not followed. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan documented Resident #3 had a suprapubic catheter (a hollow flexible tube inserted into the bladder through a cut in the stomach that is used to drain urine from the bladder), related to [CONDITION(S)] bladder (when a person lacks bladder control). Resident #3's physician order, dated 8/18/21, documented to cleanse around the suprapubic catheter insertion site, using normal saline, dry the skin, and apply allevyn (foam dressing) and tape. The note documented to change the dressing once daily and as needed. Resident #3's MARs for her suprapubic catheter care in August, September, and October 2021, were blank on the following dates: 8/18/21, 8/19/21, 8/27/21, 8/30/21, 8/31/21, 9/4/21, 9/7/21, 9/8/21, 9/9/21, 9/14/21, 9/23/21, 9/28/21, 10/4/1, 10/15/21, 10/9/21, 10/11/21, 10/12/21, 10/19/21, and 10/25/21. On 11/4/21 at 12:35 PM, the DON said if the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent and treat pressure ulcers. This was true for 3 of 8 residents (Resident #3, #4, and #7) reviewed for wounds. This deficient practice resulted in harm to Resident #3 when his Stage 4 pressure ulcer worsened after a surgical procedure, and Resident #3, #4 and #7, when they developed avoidable pressure ulcers. Findings include: The National Pressure Injury Advisory Panel website, accessed on 11/9/21, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable (skin that does not turn white when pressed with a finger) [CONDITION(S)] (red discoloration of the skin resulting from injury), which may appear differently in darkly pigmented skin. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable - Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. Deep tissue injury - Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The facility's policy for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * Pressure ulcer and other wound and skin-related interventions were created in collaboration with the interdisciplinary team and implemented to identify, prevent, or reduce the risk of acquiring pressure and or non-pressure related wounds or skin issues. * Residents received routine weekly skin checks to validate that there are no unidentified skin concerns. In addition, new areas of potential concerns would be addressed such as the fit of footwear, health of feet, or need for a protective sleeve. * With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer/pressure injury or non-pressure skin alteration should be documented. * At a minimum, documentation for each wound should include the date observed, location and staging; size, depth, presence, location and extent of any undermining or tunneling (caused by erosion under the wound edges with a small opening leading to a longer or larger area of erosion); exudate (drainage) type (such as purulent [pus] or serous [thin watery], color, odor and approximate amount; pain and frequency; wound bed's color and type of tissue; wound bed's character including evidence of healing [granulation tissue] or necrosis [slough, eschar]; description of wound edges and surrounding tissue [rolled edges, redness, hardness, or maceration [skin broken down by moisture and appears wrinkled]). * Observe wounds for signs and symptoms of infection. This policy was not followed. 1. Resident #3 was readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's annual MDS assessment, dated 9/8/21, documented she had moderate cognitive impairment and required assistance of two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. The assessment documented both her lower legs were impaired and she did not walk and required a wheelchair. Resident #3's care plan for skin integrity, dated 3/20/21, documented she had a Stage 4 pressure injury to her left lower back. The interventions, updated on 8/12/21, included the following: * Administer treatment per physician order. * Monitor and document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * Observe skin during ADL care. Notify licensed nurse of skin integrity impairments. * Offload and relieve pressure every 2 hours during every shift and as needed while in bed or sitting dependent in a wheelchair. Use pillows to help as needed. * Notify provider immediately of new or worsening skin concerns. * Weekly licensed nurse skin assessment to include review and check of footwear. Resident #3's quarterly MDS assessment, dated 3/30/21, documented she had one unstageable pressure ulcer upon re-admission. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was to be changed twice a week and PRN on Monday and Thursday. Resident #3's MAR documented the dressing change was not completed as ordered on 8/2/21/, 85/21, 8/12/21, 8/19/21, 8/30/21, 10/4/21, and 10/11/21. A wound evaluation note, dated 6/8/21, documented Resident #3 had a facility acquired Stage 4 pressure ulcer to her left lower back that was a year old. It was unclear if this was the same pressure ulcer identified in the quarterly MDS on 3/30/21. A provider wound care office visit note, dated 7/1/21, documented Resident #3 had a wound debridement (removal of damaged tissue from a wound) of her lower back Stage 4 pressure ulcer. The note documented the physician who debrided the wound thought the wound would heal without difficulty. The wound measurement was 1 x 1 x 0.3 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The area was to be cleaned and dressed with a wound cleanser. Resident #3's MAR documented the moist to moist dressing change was not started until 7/5/21, three days after it was ordered. The MAR also documented Resident #3's dressing was not changed on 7/11/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented staff were to use pillows to help as needed and to notify the provider immediately of new or worsening skin concerns every shift. Resident #3's TAR documented this task was not completed as ordered on 8/5/21, 8/11/21, 8/18/21, 8/19/21, 8/27/21, 8/30/21, 9/7/21, 9/14/21, 10/5/21, 10/9/21, and 10/25/21. A nurse practitioner note, dated 7/16/21, documented Resident #3 had a Stage 4 pressure injury, moisture associated skin damage to the middle of her spine, and two open wounds to the upper spine. The note did not include a description of the wound such as size, depth, color, odor, wound bed tissue or character, or an assessment of Resident #3's pain. A wound evaluation note, dated 7/20/21, six weeks after the 6/8/21 evaluation, documented Resident #3 had a facility acquired pressure wound to her back that was 10% closed. The note documented Resident #3 was to be on a turning/repositioning program for wound healing. A nurse practitioner note, dated 7/20/21 at 8:28 PM, documented Resident #3's Stage 4 pressure ulcer measured 1.5 x 2 x 0.5 cm, 0.5 x 1 x 0.2 cm larger than the measurement on 7/2/21 after the wound debridement. The note documented the Stage 4 pressure ulcer had a mix of slough and granulation tissue. The note documented Resident #3 stayed in bed all day due to pain and she had a new blood-filled blister to the left mid-back. There were no documented wound evaluations after the wound clinic visit on 7/2/21 until 7/20/21 (3 weeks later) when the wound was evaluated at the facility by the nurse practitioner. A nurse practitioner note, dated 7/28/21, documented Resident #3's Stage 4 pressure injury measured 1.5 x 1.5 x 0.3 cm. The note documented the blister on her back measured 3 x 3 x 0.1 cm. The note further documented Resident #3 had moisture associated skin damage to the middle of her spine and two open wounds on the upper spine. The note did not include measurements of the two open wounds on Resident #3's upper spine, or description of the wounds such as color, odor, wound bed tissue or character, or an assessment of Resident #3's pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented to change the dressing twice a week and as needed, once a day on Tuesday and Friday for pressure injury. Resident #3's MAR documented this skin care treatment was not completed on 8/27/21, 8/31/21, 9/7/21, 9/14/21, 10/5/21, 10/12/21, and 10/19/21. A nurse practitioner note, dated 8/25/21 at 9:37 AM, one month after the last assessment, documented Resident #3's Stage 4 pressure ulcer measurement on 8/24/21 was 0.4 x 1 cm, and the blood-filled blister was resolved. The note documented there was new ulceration above the pressure injury which measured approximately 1 x 1 x 0.1 cm. The note did not include a description of the wound such as color, odor, wound bed tissue or character, or an assessment of Resident #3's pain. After Resident #3's readmission to the facility on [DATE], she developed a blood-filled blister to her mid left mid-back, moisture associated skin damage to the middle of her spine and two new open wounds on her upper spine, and a new ulceration above her Stage 4 pressure ulcer. On 11/4/21 at 12:25 PM, the DON said if the documentation on Resident #3's MAR and TAR were blank, it meant the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/5/21 at 1:20 PM, the CRN said the most recent Stage 4 pressure ulcer wound measurement for Resident #3 was on 8/25/21. She confirmed the facility's policy for pressure ulcer and non-pressure ulcer wound assessment and measurement was weekly or whenever the dressing was changed. She said the wound measurement documented in Resident #3's nurse practitioner note was not weekly or per dressing change, and it did not meet the facility's requirement. 2. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS assessment, dated 10/29/21, documented Resident #7 was cognitively severely impaired, required extensive assistance with two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. The assessment documented she was at risk for pressure ulcers. Resident #7's care plan, revised on 8/13/21, documented she had a wound to her right heel, scarring and redness to her right sacral (tailbone) and gluteal fold area (fold under the buttocks), open areas to the left gluteal fold, a right great toe amputation, and a diabetic ulcer to the right plantar foot (bottom of the foot near the heel) . The care plan documented the following: * Assess, record, and monitor wound healing. * Measure length, width, and depth where possible. * Assess and document the status of wound perimeter, wound bed, and healing progress. * Report improvements and declines to the physician. An MDS assessment, dated 7/29/21, documented Resident #7 had one unstageable pressure ulcer and a diabetic foot ulcer (a skin sore with full thickness skin loss cause by complications of diabetes). Resident #7's Wound Evaluation Reports, dated from 8/3/21 to 11/5/21, included wound assessments, wound images, and monitoring documentation. The evaluations did not include wound measurements. A nurse practitioner progress note, dated 8/24/21, documented Resident #7's diabetic ulcer to her right planter foot, measured 0.5 x 0.5 x 0.2 cm. The note documented Resident #7 had 3 new unstageable pressure ulcers to her bilateral buttocks and coccyx (tailbone) which measured 9 x 8 x 0.1. cm. It was unclear if the measurement was for one pressure ulcer or for all 3 of the new pressure ulcers. A nurse practitioner progress note, dated 10/12/21, documented Resident #7's diabetic ulcer on her right planter foot, measured 0.4 x 0.5 x 0.2 cm. The note did not include measurements for the pressure ulcers on her coccyx. A nurse practitioner progress note, dated 10/26/21, documented Resident #7's diabetic ulcer to the right planter foot measured 0.3 x 0.3 x 0.2 cm. The note did not include measurements for the pressure ulcers on her coccyx. On 11/5/21 at 1:20 PM, the DON said Resident #7's pressure ulcer wound on her right heel was a diabetic foot ulcer and was developed during the facility stay. The DON said Resident #7's bilateral buttocks pressure ulcers started 8/24/21, and the coccyx pressure ulcer started 6/8/21. On 11/5/21 at 1:50 PM, the RCN said the nurse practitioner sometimes documented wound measurements separately in the progress notes. The RCN confirmed Resident #7's wound documentation did not meet the facility's policy requirement to measure wounds weekly or when the wound dressings were changed. 3. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 9/2/21, documented Resident #4 was at risk of developing pressure ulcers. Resident #4's Skin Inspection Evaluation form, dated 10/20/21, documented Resident #4 had no new skin issues observed on his body or torso, and his tailbone had a light pink healing wound on the skin that was covered with a dressing. There was no Skin Inspection Evaluation documentation from 10/24/21 to 11/4/21. On 11/5/21 at 11:47 AM, LPN #1 performed a dressing change to Resident #5's tailbone wound. Resident #5 was standing up at the bedside for the dressing change. While Resident #5 was standing, LPN #1 assessed a golf ball sized, non-blanchable, reddened round area on the skin of Resident #5's right hip. After his right hip was assessed, Resident #5 sat down in his wheelchair with his right hip touching the side of his wheelchair. On 11/5/21 at 11:58 AM, LPN #1 stated if Resident #5 did not have a skin assessment documenting the reddened right hip, she would have to make an incident report because it was an undocumented skin concern. She reviewed the chart and stated the last skin note for Resident #5 was on 10/21/21, and there was no documentation of any reddened areas on his skin.

Based on record review, family and staff interviews, and policy review, it was determined the facility failed to ensure the facility provided CPR per documented instructions and according to the resident's wishes for 1 of 1 resident (Resident #53) whose death record was reviewed. The facility failed to verify Resident #53's code status and initiate lifesaving interventions consistent with his code status, when staff found him unresponsive. The failure to initiate CPR may have contributed to Resident #53's death and placed the health and safety of the 22 other residents residing in the facility, with a code status of Full Code (resuscitate/initiate CPR), in Immediate Jeopardy. Findings include: The facility's Emergency Medical Response policy and procedure, dated [DATE], instructed staff to identify the patient's code status, evaluate the patient or resident, and initiate appropriate medical intervention. The facility failed to follow its policy. Resident #53 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #53's hospital Admission History and Physical, dated [DATE] at 3:42 AM, documented his code status was Full Code and was electronically signed by a Nurse Practitioner. Resident #53's POST form, located in his facility record, documented Resuscitate (Full Code) with aggressive interventions for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. The aggressive interventions included intubation, mechanical ventilation, and that the receiving hospital may admit him to intensive care. Resident #53 signed the POST form on [DATE], and the physician signed it on [DATE]. Resident #53's (MONTH) 2019 Physician Orders did not include his code status. Resident #53's care plan, dated [DATE], documented his code status as Full Code. A Care Plan Meeting Note, dated [DATE] at 12:22 PM, documented an OT, RN, BOM (Business Office Manager), LSW, Resident #53, and his son and daughter in-law, were in attendance. The summary of the meeting documented, Reviewed progress in therapy and medications. Discussed discharge plan/date. Family desire to honor resident's wishes and make it possible for resident to return home with support from (Name of Hospice). Discharge is scheduled for Tuesday. No concerns at this time and all questions have been answered. Advance directive reviewed (yes/no): No. The note was documented by the LSW. A Nurse's Progress Note, dated [DATE] at 10:34 AM, documented, Resident (#53) passed today approx.(approximately) 0600 (6:00 AM). His body was released to mortuary per family. Resident #53's record did not include documentation the facility assessed him or initiated CPR per his wishes. The Record of Death, dated [DATE] at 6:00 AM, documented Resident #53's principle cause of death was [MEDICAL CONDITION] and was signed by the primary care physician. On [DATE] at 5:00 PM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON stated Resident #53 passed away and the family was okay with his death. The DON stated the nurses should have documented their assessment of Resident #53. The DON reviewed Resident #53's POST form and stated she was not aware his code status was Full Code. The DON stated her expectations, and the facility's protocol, was for the licensed staff to assess the resident, review the code status in the resident's record, and initiate CPR if the resident had a code status of Full Code. The DON stated the facility did not initiate CPR for Resident #53. The DON stated the coroner was notified for all deaths in the facility if the resident was not receiving hospice services. On [DATE] at 5:47 PM, Resident #53's son stated Resident #53 had a living will and his code status was Do Not Resuscitate (DNR). Resident #53's son stated he did not provide the living will to the facility and was unaware Resident #53's POST form documented a code status of Full Code with aggressive interventions. On [DATE] at 6:10 PM, LPN #4, who admitted Resident #53 to the facility on [DATE], stated she received a verbal report on [DATE] at 6:00 AM, from RN #2 that Resident #53 had passed away. LPN #4 stated she was told by RN #2 Resident #53's code status was DNR. LPN #4 stated she notified his son and he stated to her, to let him go. LPN #4 stated she did not assess Resident #53 or look in his record to validate his code status. LPN #4 stated she documented on Resident #53's neurological assessment flow sheet, Passed on [DATE] at 6:30 AM. LPN #4 stated when she reviewed and filled out the POST form with Resident #53, he was adamant on being a Full Code. On [DATE] at 6:29 PM, RN #2 stated on [DATE], she and the LSW attended a care conference with Resident #53 and his family, regarding their wishes for Resident #53 to be discharged home with hospice services on [DATE]. RN #2 stated on [DATE], she provided a verbal report to LPN #4 when CNA #2 stated Resident #53 was gone. RN #2 stated she clarified what gone meant and her and LPN #4 went down to his room to assess him. RN #2 stated Resident #53 was pale, his eyes were halfway closed, and he had his arms by his side. RN #2 stated Resident #53 did not have an apical pulse (heart beat) and was not breathing. RN #2 stated she did not look in his record for his code status and did not initiate CPR. RN #2 stated the last time she assessed Resident #53 was at 2:30 AM on [DATE], when she completed a neurological assessment from a fall he had on [DATE] at 3:00 AM. RN #2 documented on the neurological assessment Resident #53 was alert, pupils were equal and reactive to light, he had equal hand grasps, and was able to move all extremities. RN #2 stated at the time of the neurological assessment the nursing staff were unable to obtain Resident #53's temperature, however, his blood pressure, pulse, and respirations were stable. RN #2 stated the facility's protocol was to notify the coroner for all residents' deaths if they were not on hospice services. RN #2 stated when the assistant coroner came to the facility to assess Resident #53's death and requested his face sheet and POST form. RN #2 stated that was when she realized Resident #53's code status was Full Code and the assistant coroner went to talk with the son, who was in Resident #53's room. RN #2 stated the assistant coroner returned to the nurse's station and returned the POST form to RN #2 and stated to her that she did not need his POST form. RN #2 stated she notified the DON via phone on [DATE], that Resident #53's code status was Full Code per his POST form and the facility did not initiate CPR. RN #2 stated that on [DATE] during the stand-up meeting, the DON instructed the LSW to review all the residents' records to assure their Advance Directive and POST forms matched. RN #2 stated nothing more was discussed or investigated regarding the death of Resident #53. On [DATE] at 6:58 PM, the LSW stated Resident #53 had a care conference on [DATE]. The LSW stated herself, RN #2, Business Office Manager, Resident #53, and his son and daughter in-law were present during the care conference. The LSW stated the care conference was regarding Resident #53 being discharged home with hospice services on [DATE]. The LSW stated she did not review his Advance Directives or his POST form with Resident #53 or the family. On [DATE] at 8:35 AM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON verified she did not know Resident #53 was a Full Code until she reviewed his POST form on [DATE] at 5:00 PM. On [DATE] at 9:29 AM, CNA #2 stated when she found Resident #53 on [DATE] at 6:15 AM, he was pale and there was no movement in his chest. CNA #2 stated she was with another CNA and left the room to notify the nurses. CNA #2 stated she notified RN #2 and the day shift nurse, could not remember who it was, that Resident #53 appeared passed. CNA #2 stated both nurses went to Resident #53's room and she assisted other residents and did not know what the nurses did from there. On [DATE] at 10:20 AM, CNA #3 stated she worked the night shift, on [DATE] at 6:00 PM until [DATE] at 6:30 AM. CNA #3 stated she assisted Resident #53 to the bathroom, on [DATE] at 5:00 AM, and he was alert and awake. CNA #3 stated Resident #53 was on 30 minute checks at the time, following a fall he had on [DATE]. CNA #3 stated what Resident #53 was doing at the time of each 30 minute check was documented. The facility provided a 24 hour, 30-minute check form, dated [DATE], for Resident #53. On [DATE] at 5:00 AM, CNA #3 documented Resident #53 was in bed and awake. The 30-minute check form was blank for the 5:30 AM check. At 6:00 AM and 6:30 AM, the 30-minute check form documented, Bed without initials. At 7:00 AM, the form documented he was in the w/c (wheelchair). Resident #53's record documented he passed on [DATE] at 6:00 AM. Removal of Immediate Jeopardy: On [DATE] at 4:02 PM, the Administrator, DON, Nurse Practice Educator, and Clinical Quality Specialist Nurse were informed verbally and in writing of the immediate jeopardy. On [DATE] at 4:53 PM, the Clinical Quality Specialist Nurse provided a plan to remove the immediate jeopardy. The facility's plan to remove the immediate jeopardy was: * Residents and/or responsible parties were interviewed and each resident's code status was verified. * Physician orders were obtained for residents' code status. * Care plans were updated to reflect the residents' wishes for their code status. * In-service education for all employees to locate a resident's code status in the record under the Advance Directive tab. * In-service education to all licensed staff, which began on [DATE], regarding: a. Documentation of Advance Directives including POST Form. b. Managing Cardiac/Respiratory Arrest Policy and Procedure when discovery of a patient with no pulse, no blood pressure, no respirations staff immediately: determine if Full Code or DNR in the resident's record if a resident's code status is Full Code initiate CPR. c. Advance Directive/POST form quiz to be completed by each licensed staff prior to starting their next scheduled shift. Each in-serviced staff member was given a copy of the policy and procedure and required to sign the in-service was completed. On [DATE] at 6:15 PM, the Clinical Quality Specialist Nurse and the Administrator were informed the plan was acceptable to remove the immediate jeopardy. Implementation of the above corrective actions was verified by the survey team prior to the team leaving the facility on [DATE].

Based on staff interview and record review, it was determined the facility failed to ensure 1 of 1 resident (Resident #53) reviewed for death in the facility was provided CPR per his wishes documented on his POST form. The licensed staff neglected to verify Resident #53's code status when he did not have an apical pulse (heart beat) or respirations and neglected to initiate CPR per his documented wishes. The failure may have contributed to Resident #53's death and placed the other 22 residents residing in the facility with a code status of Full Code (initiate resuscitation) at risk of not receiving CPR per their wishes. Findings include: Resident #53 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #53's hospital Admission History and Physical, dated [DATE] at 3:42 AM, documented he his code status was Full Code and was electronically signed by a Nurse Practitioner. Resident #53's Initial Nursing Assessment, dated [DATE], documented he was alert and oriented to person, place, and time. The assessment also documented Resident #53's judgement and insight was intact. Resident #53's POST form, located in his record, documented Resuscitate (Full Code) with aggressive interventions for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. The aggressive interventions included intubation, mechanical ventilation, and that the receiving hospital may admit him to intensive care. Resident #53 signed the POST form on [DATE], and the physician signed it on [DATE]. Resident #53's (MONTH) 2019 Physician Orders did not include his code status. Resident #53's care plan, dated [DATE], documented his code status was Full Code. A Nurse's Progress Note, dated [DATE] at 10:34 AM, documented, Resident (#53) passed today approx. (approximately) 0600 (6:00 AM). His body was released to mortuary per family. The Record of Death, dated [DATE] at 6:00 AM, documented Resident #53's principle cause of death was [MEDICAL CONDITION] and was signed by the primary care physician. On [DATE] at 5:00 PM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON stated Resident #53 passed away and the family was okay with his death. The DON stated the nurses should have documented their assessment of Resident #53. The DON reviewed Resident #53's POST form and stated she was not aware his code status was Full Code. The DON stated the facility did not initiate CPR for Resident #53. On [DATE] at 6:10 PM, LPN #4, who admitted Resident #53 to the facility on [DATE], stated she received verbal report on [DATE] at 6:00 AM from RN #2 Resident #53 had passed away. LPN #4 stated she was told by RN #2 that Resident #53's code status was DNR. LPN #4 stated she did not assess Resident #53 or look in his record to validate his code status. LPN #4 stated when she reviewed and filled out the POST form with Resident #53 on [DATE], he was adamant on being a Full Code. On [DATE] at 6:29 PM, RN #2 stated, on [DATE], she provided verbal report to LPN #4 when CNA #2 stated Resident #53 was gone. RN #2 stated she clarified what gone meant and her and LPN #4 went to Resident #53's room to assess him. RN #2 stated Resident #53 was pale, his eyes were halfway closed, and he had his arms by his side. RN #2 stated Resident #53 did not have an apical pulse and was not breathing. RN #2 stated she did not look in Resident #53's record for his code status and did not initiate CPR. On [DATE] at 8:35 AM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON verified she did not know Resident #53's code status was Full Code until she reviewed his POST form on [DATE] at 5:00 PM. On [DATE] at 9:29 AM, CNA #2 stated she found Resident #53 in bed on [DATE] at 6:15 AM, he was pale and there was no movement in his chest. CNA #2 stated she left the room to notify the nurses. CNA #2 stated she notified RN #2 and the day shift nurse, could not remember who it was, that Resident #53 appeared passed. CNA #2 stated both nurses went to Resident #53's room, and she assisted other residents. CNA #2 said she did not know what the nurses did from there. The facility licensed staff neglected to initiate CPR when Resident #53's wishes per his POST form and care plan documented Full Code. This failure may have resulted in his death.

Based on record review and family and staff interview, it was determined the facility failed to initiate or conduct a thorough investigation of potential neglect for 1 of 1 resident (Resident #53) reviewed for death in the facility. When facility staff found Resident #53 unresponsive, CPR was not initiated, as directed in his POST form which documented his code status was Resuscitation/Full Code with aggressive interventions. The failure placed the other 52 residents at risk of not having their code status wishes honored if they were unable to communicate them. Findings include: Resident #53 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #53's hospital Admission History and Physical, dated [DATE] at 3:42 AM, documented he his code status was Full Code and was electronically signed by a Nurse Practitioner. Resident #53's Initial Nursing Assessment, dated [DATE], documented he was alert and oriented to person, place, and time. The assessment also documented Resident #53's judgement and insight were intact. Resident #53's POST form, located in his facility record, documented Resuscitate (Full Code) with aggressive interventions for cardiopulmonary resuscitation in the event he did not have a pulse and/or was not breathing. The aggressive interventions included intubation, mechanical ventilation, and that the receiving hospital may admit him to intensive care. Resident #53 signed the POST form on [DATE], and the physician signed it on [DATE]. Resident #53's (MONTH) 2019 Physician Orders did not include his code status. Resident #53's care plan, dated [DATE], documented his code status as Full Code. A Nurse's Progress Note, dated [DATE] at 10:34 AM, documented, Resident (#53) passed today approx. (approximately) 0600 (6:00 AM). His body was released to mortuary per family. The Record of Death, dated [DATE] at 6:00 AM, documented Resident #53's principle cause of death was [MEDICAL CONDITION] and was signed by the primary care physician. On [DATE] at 5:00 PM, the Clinical Quality Specialist Nurse and DON were present during the interview. The DON stated Resident #53 passed away and the family was okay with his death. The DON stated the nurses should have documented their assessment of Resident #53 when he was found unresponsive. The DON reviewed Resident #53's POST form and stated she was not aware his code status was Full Code. The DON stated the facility did not initiate CPR for Resident #53. The DON stated the coroner was notified for all deaths in the facility if the resident was not receiving hospice services. The DON stated the coroner did an investigation of Resident #53's cause of death and determined it was [MEDICAL CONDITION] not from the fall that happened on [DATE]. The DON said she was not aware she needed to do an investigation when the coroner did one. The Clinical Quality Specialist Nurse stated the facility should have initiated and completed an investigation into why CPR was not initiated for Resident #53 when his POST form documented his code status as Full Code. On [DATE] at 5:47 PM, Resident #53's son stated Resident #53 had a living will and he was a DNR (Do Not Resuscitate). The son stated he did not provide the living will to the facility and was unaware Resident #53's POST form documented his code status as Full Code with aggressive interventions. On [DATE] at 6:10 PM, LPN #4, who admitted Resident #53 to the facility on [DATE], stated she received a verbal report on [DATE] at 6:00 AM, from RN #2 that Resident #53 had passed away. LPN #4 stated she was told by RN #2 Resident #53's code status was DNR. LPN #4 stated she notified his son and he stated to her, to let him go. LPN #4 stated she did not assess Resident #53 or look in his record to validate his code status. LPN #4 stated she documented on Resident #53's neurological assessment flow sheet, Passed on [DATE] at 6:30 AM. LPN #4 stated when she reviewed and filled out the POST form with Resident #53, he was adamant on being a Full Code. On [DATE] at 6:29 PM, RN #2 stated on [DATE], she provided verbal report to LPN #4 when CNA #2 stated Resident #53 was gone. RN #2 stated she clarified what gone meant and her and LPN #4 went down to his room to assess him. RN #2 stated Resident #53 was pale, his eyes were halfway closed, and he had his arms by his side. RN #2 stated Resident #53 did not have an apical pulse and was not breathing. RN #2 stated she did not look in his chart for his code status and did not initiate CPR. RN #2 stated the last time she assessed Resident #53 was at 2:30 AM on [DATE] when she completed a neurological assessment from a fall he had on [DATE] at 3:00 AM. RN #2 documented on the neurological assessment Resident #53 was alert, pupils were equal and reactive to light, had equal hand grasps and was able to move all extremities. RN #2 stated the nursing staff were unable to obtain Resident #53's temperature. He was cool and clammy with a stable blood pressure, pulse, and respirations. RN #2 stated the facility's protocol was to notify the coroner for all residents' deaths if they were not on hospice services. RN #2 stated when the assistant coroner came to the facility to assess Resident #53's death, she requested his face sheet and POST form. RN #2 stated that was when she realized he was a Full Code and the assistant coroner went to talk with the son, who was in Resident #53's room. RN #2 stated the assistant coroner returned to the nurse's station and returned the POST form to RN #2 and stated to her that she did not need his POST form. RN #2 stated she notified via phone the DON on [DATE], regarding Resident #53 code status being Full Code per his POST form and the facility did not initiate CPR. RN #2 stated on [DATE], during the stand-up meeting, the DON instructed the LSW to review all the residents' charts to assure their Advance Directive and POST form matched. RN #2 stated nothing more was discussed or investigated regarding the death of Resident #53 or why CPR was not initiated.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 4 residents (#7 and #33) reviewed for pressure ulcers. Resident #33 was harmed when he developed an unstageable pressure ulcer to his left heel, sacrum, and a Stage II pressure ulcer to his left inner knee. Resident #7 was harmed when she developed a Stage II pressure ulcer to her right buttock. Findings include: The facility's Skin Integrity Management policy, revised 11/28/16, documented, The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. The policy also included the following: * Identify patient's skin integrity status and need for prevention interventions or treatment modalities through review of all appropriate assessment information. * Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. * Review co-morbid conditions that may affect healing. * Notify Dietitian and/or rehabilitation services as indicated. * Notify physician to obtain orders. * Notify patient, family, health care decision maker of plan of care. * Review care plan weekly and revise as indicated. * Document daily monitoring of ulcer site, with or without dressing. This policy was not followed. 1. Resident #33 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #33's at risk for skin breakdown care plan, dated 9/17/14, included interventions for a Low Air Loss mattress with bolsters, pressure redistribution surfaces to chair, turn and re-position every 2 hours and as needed, float heels while in bed with pillows, observe skin conditions with ADL care, observe skin for signs/symptoms of skin breakdown, and weekly skin checks by the licensed nurse. A facility Guideline for the Low Air Loss mattress, undated, documented, Warning! Do not use as an intervention for heel ulcers. At risk and actual heel wounds should be off the bed surface (off-loaded using a pillow or heel-lift type of device). Resident #33's actual skin breakdown care plan, dated 11/13/18, included interventions for Sage boots (heel protectors) to be worn to bilateral lower extremities (BLE) while in bed. A Significant Change Braden Scale (a tool used to assess a resident's risk for developing pressure ulcers) assessment, dated 1/20/19, documented Resident #33 was at moderate risk for developing a pressure ulcer. Resident #33's annual MDS assessment, dated 2/19/19, documented he was severely cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS documented Resident #33 was at risk for pressure ulcers and had one unstageable pressure with slough (non-viable tissue due to reduced blood supply) and/or eschar (black, necrotic, dead tissue). According to the Johns Hopkins Medicine website, accessed on 4/17/19, an unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown in color) and/or eschar (tan, brown or black) in the wound bed. a. An SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated 11/13/18, documented Resident #33 had an abrasion to his right ankle. Sage boots were initiated to BLE while he was in bed. An SBAR Communication Form, dated 11/21/18, documented Resident #33 had a persistent red area with measurements of 6.0 cm x 5.0 cm to his right heel. The form stated within the reddened area was an intact blister. The measurements of the blister were documented as 3.0 cm x 2.0 cm. The form documented licensed staff were to apply skin prep (a liquid which forms a protective film or barrier) to the wound and cover with a foam dressing. An Incident and Accident Report, dated 11/21/18 at 7:00 AM, documented a new in-house acquired pressure ulcer to Resident #33's right heel. A witness statement by a CNA documented she noticed a pressure ulcer to Resident #33's heel and notified the nurse. The statement did not identify which heel had the pressure ulcer. Resident #33's Weekly Skin Checks, dated 11/16/18 through 12/14/18, did not include documentation of the pressure ulcer to Resident #33's right heel which was identified on 11/21/18. Subsequent skin checks were as follows: - A Weekly Skin Check, dated 12/21/18, documented Resident #33 had a pressure ulcer to his right heel and left lower extremity (LLE). There was no documentation of measurements and/or a description of the appearances of the pressure ulcer to the right heel or the LLE. - The Weekly Skin Checks, dated 12/29/18 and 1/5/19, documented Resident #33 had a pressure ulcer to his right heel with no measurements or description of the appearance of the pressure ulcer. There was no documentation about the LLE pressure ulcer. - The Weekly Skin Checks, dated 1/13/19 and 1/19/19, documented Resident #33 had a pressure ulcer to his left heel, which was not previously identified in documentation, and the dressing was dry and intact. The skin checks did not include appearance or measurements of the pressure ulcer. There was no documentation of the right heel and the LLE pressure ulcers. The TAR's for Resident #33 for (MONTH) (YEAR) to (MONTH) 2019 documented the following: - Resident #33's (MONTH) (YEAR) TAR, dated 11/20/18, documented licensed staff applied skin prep and a foam dressing to his right heel pressure ulcer every 3 days. The licensed staff were to ensure Sage boots were on Resident #33's BLE when he was in bed twice a day. - Resident #33's (MONTH) (YEAR) TAR documented licensed staff were to ensure Sage boots were on Resident #33's BLE when he was in bed twice a day. The (MONTH) (YEAR) TAR did not include documentation on 12/7/18, 12/11/18, 12/15/18, and 12/16/18 the Sage boots were on Resident #33 as directed. - Resident #33's (MONTH) (YEAR) TAR documented licensed staff were to float heels with pillows while in bed every night shift. The (MONTH) (YEAR) TAR did not include documentation Resident #33's heels were floated as directed on 12/7/18, 12/15/18, and 12/16/18. - Resident #33's (MONTH) 2019 TAR included orders for licensed staff to apply Sage boots to BLE while in bed every night shift. The (MONTH) 2019 TAR documented licensed staff were to float heels with pillows when in bed every night shift. The (MONTH) 2019 TAR did not include documentation on 1/3/19, 1/8/19-1/11/19, 1/14/19-1/16/19, and 1/17/19, these were completed . - Resident #33's (MONTH) 2019 TAR documented licensed staff were to apply skin prep and foam dressing to Resident #33's pressure ulcer to the left heel every 3 days. There was no documentation on 1/10/19, 1/13/19, 1/16/19, 1/19/19, 1/22/19, 1/25/19, 1/28/19, and 1/31/19, this was completed. - Resident #33's (MONTH) 2019 TAR included a physician's orders [REDACTED]. A physician's orders [REDACTED]. - Resident #33's (MONTH) 2019 TAR, dated 2/1/19 to 2/21/19, documented licensed staff were to leave the dressing to the left foot clean, dry, and intact. On 2/21/19, the TAR documented licensed staff were to change the dressing to his left heel twice a day using a wet to dry gauze and secure with Kerlix (cotton wrap). The (MONTH) 2019 TAR did not include documentation the treatment was completed on 2/23/19, 2/24/19, and 2/28/19. A physician's orders [REDACTED].#33 was referred to podiatry for care of the unstageable pressure ulcer to his left heel. The podiatry notes were as follows: - An initial assessment Podiatrist Progress Note, dated 1/9/19, documented Resident #33 had a Stage III pressure ulcer to his left heel. According to the Johns Hopkins Medicine website, accessed 4/17/19, a Stage III pressure ulcer is full thickness skin loss and slough may be present but does not obscure the depth of tissue loss and the ulcer may have undermining/tunneling. The measurements of the ulcer were 5.0 cm x 5.0 cm x 0.3 cm. The podiatrist documented the ulcer had a foul smell, slough, and drainage. The progress note documented Resident #33 was very contracted in his lower extremities and the facility recently applied heel boots for protection. The left heel pressure ulcer was debrided (removal of the dead tissue) to ensure adequate healing, reduce risk of infection, and improve overall health of the pressure ulcer. - A Podiatrist Progress Note, dated 1/16/19, documented Resident #33 had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the left heel pressure ulcer and oral antibiotics were started. The left heel pressure ulcer measurements were 5.0 cm x 5.0 cm x 0.3 cm. The progress note documented the pressure ulcer had a foul smell, slough, and drainage with mushy eschar on part of the wound. - A Podiatrist Progress Note, dated 1/25/19, documented Resident #33 was going to continue with oral antibiotics for the infection to his left foot ulcer. The left heel wound measurements were 4.9 x 5.0 x 0.3 cm. The wound characteristics documented foul smell had improved some, slough, and drainage. - A Podiatrist Progress Note, dated 2/6/19, documented the left heel pressure ulcer measurement was 4.9 cm x 4.9 cm x 0.3 cm with the entire wound being covered with a dry eschar present, continued mushiness on the distal wound. A new superficial blister with intact skin underneath was present. The progress note documented the foul smell and the infection were improving and will continue with the antibiotics for another 14 days. - A Podiatrist Progress Note, dated 2/21/19, documented Resident #33 was supposed to have x-rays on 2/13/19 to his left heel. The Podiatrist stated the x-rays were not completed as ordered. The Podiatrist ordered the x-rays again to rule out a bone infection. The progress note documented the Podiatrist spoke to Resident #33's primary care physician to start IV antibiotics. Resident #33's record did not include IV antibiotics were initiated. - A Podiatrist Progress Note, dated 3/5/19, documented the left heel pressure ulcer had worsened. The measurements were 4.9 cm x 6.4 cm x 0.5 cm with improved odor. The wound base was covered with wet eschar and continued mushiness that was worsening and some purulent (fluid containing pus) drainage. - A Podiatrist Progress Note, dated 3/12/19, documented the left heel pressure ulcer was worse at every visit. The measurements were 5.5 cm x 7.3 cm x 1.5 cm. The podiatrist documented the foul odor was much worse on this visit with significant discolored drainage which was purulent in nature. The mushiness was worsening and the wound was deepening. The podiatrist documented he was going to notify Resident #33's primary care physician for a plan. The progress note documented the wound was worsening rapidly and he feared Resident #33 may [MEDICAL CONDITION] (bacterial infection in the bloodstream). The podiatrist referred Resident #33 to a vascular surgeon or orthopedic for possible [MEDICAL CONDITION] (BKA). - A Podiatrist Progress Note, dated 3/19/19, documented the left heel continued to worsen at every visit. The wound measurements are 5.8 cm x 7.8 cm x 1.7 cm, most of the wound was covered with a wet eschar. The progress note documented the podiatrist was still trying to reach Resident #33's primary care physician to refer him for a bone scan and a vascular surgeon or orthopedic surgeon for consult. On 3/25/19 at 3:30 PM, RN #1 and CNA #4 were observed wearing gowns and gloves, while RN #1 was providing wound care to Resident #33's left heel. RN #1 stated he [MEDICAL CONDITION] in his left heel. RN #1 stated Resident #33 had the pressure ulcer for quite a while. RN #1 was observed removing the dressing to Resident #33's left heel. RN #1 was attempting to remove the dressing to his left heel wound without success, then after several unsuccessful attempts, while Resident #33 was hollering out in pain and flinching his left leg in pain, she used wound cleanser to moisten the dried dressing, and then it removed easily from his wound. RN #1 applied two sprays of wound cleanser to the 4 x 4 clean gauze, applied it to his left heel, then applied dry 4 x 4 gauze over the moist gauze, then wrapped his left foot with Kerlix for security. RN #1 stated the dressing was not to be too moist for the wet to moist dressing. On 3/26/19 at 3:20 PM, the Wound Nurse/RN #2 was observed providing wound care to Resident #33's left heel. RN #2 removed the Kerlix dressing, then moistened the dirty 4 x 4 gauze from the wound bed to remove without Resident #33 experiencing pain. RN #2 removed her gloves, washed her hands, and applied a new pair of gloves. RN #2 described Resident #33's left heel wound as pale granulation, slough with moist eschar, and moderate serosanguineous drainage. The measurements were 6.0 x 8.5 x 1.0 cm. RN #2 stated Resident #33's left heel was debrided by a podiatrist back in (MONTH) and continued with the same wet to dry dressing change and the wound became worse. On 3/27/19 at 1:20 PM, RN #2 stated Resident #33 developed a blister to his left heel, on 11/21/18, and the nurses were documenting that it was his right heel when it should have been his left heel. RN #2 stated the Sage boots were initiated on 11/13/18 when Resident #33 developed an abrasion to his right ankle. RN #2 stated the blanks in the TARs meant the treatment was not completed. RN #2 stated she was the Wound Care Nurse up to (MONTH) (YEAR) and then was the ADON (Assistant Director of Nursing) and the facility identified in (MONTH) 2019 residents' were developing facility acquired pressure ulcers and was switched back to the Wound Care Nurse in (MONTH) 2019. RN #2 stated the floor nurses were responsible for the wound care and the weekly skin checks. RN #2 stated she did the weekly skin assessments and measurements. RN #2 stated Resident #33's unstageable pressure ulcer to his left heel was facility acquired and should have been prevented. b. A Weekly Skin Check, dated 1/13/19 and 1/19/19, documented Resident #33 had a moisture associated skin damage to his sacrum. There were no measurements documented or a description of the appearance of the skin damage to Resident #33's sacrum. A Weekly Skin Check, dated 2/3/19, documented Resident #33 had moisture associated skin damage with blanchable redness to his sacrum. There were no measurements documented. A Weekly Skin Check, dated 2/22/19, documented Resident #33 had an open area to his sacrum. There were no measurements documented or a description of the appearance of the open area. A Weekly Skin Check, dated 3/1/19, documented Resident #33 had a pressure ulcer to his sacrum. There were no measurements documented or description of the appearance of the pressure ulcer. A Weekly Skin Check, dated 3/8/19, documented Resident #33 had an open area to his sacral area. There were no measurements documented or description of the appearance of the open area. A Skin Integrity Report for Resident #33 was initiated on 1/28/19 to his sacrum. The report documented the appearance was 100% [MEDICATION NAME] (ex. stg 2), measured 2.0 cm x 3.0 cm, and with minimal serous drainage. A physician's orders [REDACTED]. On 3/26/19 at 3:33 PM, RN #2 was observed providing wound care to Resident #33's sacrum. RN #2 stated the wound bed measured 4.0 x 2.5 cm and was covered with slough. RN #2 stated the sacrum wound was unstageable due to the slough in the wound and worsened in size and description. c. An SBAR, dated 3/18/19, documented redness to Resident #33's left inner knee with measurements of 0.5 cm x 0.5 cm. On 3/25/19 at 3:40 PM, RN #1 stated Resident #33 developed a pressure ulcer to his left inner knee caused by putting pressure on his right inner knee. CNA #4 was observed applying a pillow between Resident #33's knees. CNA #4 stated after Resident #33 developed the pressure ulcer he had been applying a pillow between his knees. A physician's orders [REDACTED]. A Nurse's Progress Note, dated 3/26/19 at 6:53 PM, documented Resident #33 had a 3.0 cm x 2.0 cm open area with black coloring to 75% of the wound bed/edges. Resident #33's care plan did not include licensed staff were to place a pillow between his knees. On 3/27/19 at 1:42 PM, RN #2 stated Resident #33 developed the unstageable pressure ulcer to his left knee was caused by the Sage boots being poofy, which positioned his knees together and that added more pressure. On 3/28/19 at 10:06 AM, the DON stated Resident #33's care plan did not include nursing staff were to place a pillow between his knees to prevent further breakdown. 2. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #7's admission MDS assessment, dated 10/22/18, documented she was cognitively intact and at risk for pressure ulcers. Resident #7's care plan, dated 10/15/18, documented she was at risk for skin breakdown. Interventions in the care plan directed staff to assist with repositioning every two hours, observe skin condition with ADL care daily and report abnormalities, provide redistribution surfaces to chair and bed as per protocol, provide peri care/incontinence care as needed, float her heels while in bed with pillows, and complete weekly skin assessments by licensed nurse. ADL flowsheets for (MONTH) 2019 documented Resident #7 was to be turned and repositioned every two hours as specified in her plan of care. There was no documentation Resident #7 was turned and repositioned for all shifts on 2/1/19, and for the day shift on 2/12/19. On 2/9/19, 2/18/19, and 2/27/19, for the day shift staff documented it was not applicable. On 2/13/19 and 2/14/19, for the evening shift staff documented it was not applicable. Resident #7's record included documentation of weekly skin checks. The weekly skin checks dated 2/1/19, 2/4/19, 2/11/19, 2/18/19, and 2/25/19, documented Resident #7 had no skin issues. The skin check, dated 3/4/19, documented there were no skin issues for Resident #7. On 3/6/19, two days later, the skin check documented she had a Stage II pressure ulcer on her coccyx (tailbone). According to the Johns Hopkins Medicine website, accessed 4/17/19, a Stage II pressure ulcer is partial thickness loss of skin which presents as a shallow open area with a red/pink wound bed, and may also present as an intact or open/ruptured fluid filled blister. An Incident and Accident Report, dated 3/6/19 at 10:00 AM, documented Resident #7 had developed a new in-house acquired Stage II pressure ulcer to the coccyx. A physician assessment, dated 3/6/19, documented Resident #7 developed a pressure injury to the right buttock as a result of immobility and reduced nutrition. Resident #7's TAR for (MONTH) 2019 included a physician order, dated 3/6/19, for Z-guard (a skin protectant paste) to coccyx each day and night, and to discontinue when resolved. The Z-guard was not applied during the day shift on 3/9/19, 3/11/19, 3/19/19, 3/24/19, and 3/25/19. The Z-guard was not applied during the night shift on 3/12/19 and 3/18/19. An SBAR Communication Form, dated 3/6/19, documented Resident #7 had a 0.3cm x 0.3 cm open area which was non-blanchable and surrounded by blanching redness 7.5 cm x 4 cm x 0.2 cm entire area. The SBAR documented there was no drainage, the wound was intact, and no odor. The SBAR documented licensed staff were to apply a Z-guard twice daily and as needed until the wound resolved, and to notify the physician if it worsened. A skin integrity report, dated 3/6/19, documented Resident #7 had a Stage II pressure ulcer to her coccyx, which measured 0.3 cm x 0.3 cm and surrounded by non-blanching redness, 7.5 cm x 4 cm x 0.2 cm. On 3/25/19 at 2:52 PM, Resident #7 was observed sitting in her bed and she stated everything was fine and she was happy with her care. She stated she was well taken care of and had no concerns or issues with the care provided by the facility. Resident #7 stated the facility was taking care of her pressure ulcer. On 3/25/18 at 3:30 PM, RN #2, who was the wound nurse, stated she completed weekly skin checks, changed dressings and provided wound care on her assessments, which included wound measurements. RN #2 stated the nurses provided daily wound care. On 3/28/19 at 9:15 AM, RN #2 reviewed Resident #7's record and stated she completed a skin check assessment on Resident #7 on 3/4/19, and found no skin issues. RN#2 stated the hospice CNA found the pressure ulcer on her coccyx and reported it to her and the hospice nurse. RN #2 stated she assessed the wound and the hospice nurse assessed the wound. RN #2 stated she thought the pressure ulcer developed due to Resident #7 declining in health, not expressing her needs to staff, staff not recognizing the change in condition she had experienced during this time, and due to Resident #7 indicating her care was great. RN #2 stated Resident #7 did not request additional care and did not like to ask for help. On 3/28/19 at 11:20 AM, RN #2 stated the care plan did not get updated with the interventions for wound care for the pressure ulcer identified on 3/6/19. RN #2 stated the nurses should have been updating the care plans. RN #2 stated the facility was going to provide Resident #7 a pressure hybrid bed, and the bed was not ordered, care planned or put in place. RN #2 stated the facility had the bed in-house and did not know why the bed placement was not initiated. RN #2 stated she had additional wound care notes separate from the TAR. RN #2 stated she kept separate notes to make sure the TAR was readily available to staff. The additional notes were not provided for review. RN #2 stated Resident #7's pressure ulcer had improved.

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents' pain levels were assessed and treated prior to wound care. This was true for 1 of 3 residents (Resident #33) reviewed for pain management. Resident #33 was harmed when he experienced increased pain during a dressing change and the facility did not identify and treat it. Findings include: The facility's Pain Management policy, dated 3/1/18, documented nursing staff to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. An individualized care plan will be developed and address and treat underlying causes of pain and using specific strategies for preventing or minimizing different levels or sources of pain or pain related symptoms. Resident #33 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #33's skin breakdown care plan, dated 10/29/18, documented licensed staff were to monitor for verbal and nonverbal signs of pain related to wound or wound treatment and medicate him as ordered. A physician's orders [REDACTED].#33 received a [MEDICATION NAME] 12 mcg/hr apply 1 patch every 3 days; Tylenol 325 mg two tablets every 4 hours as needed for mild pain; and [MEDICATION NAME] 5/325 mg 1 or 2 tablets every 6 hours as needed for moderate or severe pain. On 3/25/18 at 3:30 PM, RN #1 was observed providing wound care to Resident #33's open area to his left heel. Resident #33 hollered out in pain and was flinching his left leg in pain during the removal of the dressing. RN #1 was attempting to remove the dried dressing by tugging on the dressing while it was stuck to the open wound. RN #1 stated to Resident #33 she would provide a pain pill after the wound care was completed. RN #1 stated she administered pain medication prior to the wound care. RN #1 continued to remove the dried dressing without success, while Resident #33 was hollering and flinching his left leg in pain and she did not stop the procedure to relieve the pain. Resident #33's (MONTH) (YEAR) MAR, documented Resident #33 received a [MEDICATION NAME] of 12 mcg/hr on 3/23/19 and it was due to be changed on 3/26/19. Resident #33's MAR indicated [REDACTED]. Resident #33's Narcotic Count Sheet for [MEDICATION NAME] 5/325 mg did not include documentation Resident #33 received [MEDICATION NAME] as needed pain medication on 3/25/19. On 3/26/19 at 3:20 PM, RN #2 stated Resident #33 should receive pain medication 30 to 45 minutes prior to the dressing change. On 3/28/19 at 9:09 AM, the DON stated there was no documentation in Resident #33's record that he received as need pain medication on 3/25/19. The DON stated RN #1 should have administered pain medication prior to the dressing change and should have stopped when he was hollering out in pain. Resident #33 was harmed when the facility failed to administer pain medication prior to a dressing change or stop the dressing change when he hollered out in pain.

Based on observation, record review, staff interviews, and policy review, it was determined the facility failed to ensure residents admitted to the facility did not develop multiple pressure ulcers, or that pressure ulcers that did develop did not worsen under the facility's care. This was true for 2 of 4 (#2 and #10) residents reviewed for pressure ulcers and resulted in harm to Resident #10, who developed multiple pressure ulcers to the right heel, buttocks, and coccyx. Findings include: 1. Resident # 10 was readmitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and history of urinary tract infections. Resident #10 did not have a [DIAGNOSES REDACTED]. Resident #10's 8/19/16 readmission MDS assessment documented the presence of 1 Stage I pressure ulcer. a. Resident #10 developed multiple wounds during his stay at the facility: Resident #10's initial Skin Integrity Report, dated 8/12/16, documented the presence of a MASD (moisture associated skin damage) wound to his right buttocks with flaking blanchable skin measuring 2 cm (centimeter) by 0.8 cm and less than 0.1 cm deep. On 8/10/17 at 4:30 pm, the SDC (Staff Development Coordinator) stated the wound was MASD due to fecal incontinence, refusals to reposition, and refusal of cares. A Nurse's Note, dated 10/13/16 at 11:00 pm, documented the presence of a MASD to the buttocks and a Stage I pressure ulcer to the right heel. Resident #10's clinical record did not include a Skin Integrity Report for the pressure ulcer to the right heel until 10/31/16. A Nurse's Note, dated 10/20/16 at 11:00 pm, documented the presence of a MASD to the middle of the buttock and right buttock. The clinical record did not document the wound sizes or an assessment of the wounds until 10/22/16. Resident #10's initial Skin Integrity Report, dated 10/22/16, documented the presence of a new wound to the right buttocks with [MEDICATION NAME] tissue measuring 8 cm by 5.6 cm and 0 cm deep. Resident #10's initial Skin Integrity Report, dated 10/22/16, documented the presence of a new open area to his coccyx with [MEDICATION NAME] tissue which was intact and deep purple measuring 3.3 cm by 3 cm and no depth documented. A Nurse's Note, dated 10/24/16 at 2:52 pm, documented the nurse assessed Resident #10's buttock and coccyx region and observed a 10 cm x 7 cm reddened open area to the coccyx and right buttock. The Note documented a low Air Loss (LAL) Mattress was initiated, incontinence was reevaluated, repositioning every two hours was continued, and a Turn and Position (TAP) device were initiated. The LAL mattress was initiated after the facility had identified multiple pressure ulcers. Resident #10's Skin Integrity Report, dated 10/28/16, documented the presence of an unstageable PU wound to the left buttock and coccyx. Resident #10's initial Skin Integrity Report, dated 10/31/16, 18 days after the right heel injury was discovered, documented the presence of a SDTI (Suspected Deep Tissue Injury) pressure ulcer to the right heel measuring 4.2 cm x 2.4 cm with an unknown depth. Resident #10's Skin Integrity Report, dated 12/16/16, documented the right heel wound as healed. Resident #10's Skin Integrity Report, dated 1/5/17, documented the presence of the right heel SDTI pressure ulcer again. The report documented the wound was intact and deep purple and measured 3.8 cm x 2.6 cm and less than 0.1 cm deep. The Skin Integrity Records identified the same wounds on multiple sheets and it was unclear to as to what was measured, assessed, and treated. b. An At Risk for Skin Breakdown Care Plan, dated 10/17/15, documented Resident #10 was a risk of skin breakdown related to impaired sensation, a history of pressure ulcers, limited mobility, incontinence and moisture excessive perspiration. Interventions included floating Resident #10's heels while in bed, staff were to monitor his skin for breakdown, and pressure redistribution surfaces were to be applied to his bed and wheelchair. The at risk care plan revised interventions on 2/23/16 to include staff was to ensure the right heel was elevated at all times, Resident #10 could reposition himself, and Resident #10 was to have sage boots on his feet while in a wheelchair. A Skin Breakdown Care Plan, dated 10/17/15, documented Resident #10 had a wound to his right heel. The right heel Skin Breakdown Care Plan documented the wound as resolved on 2/23/16. A Skin Breakdown Care Plan, dated 9/20/16, documented Resident #10 had an abrasion on his medial back. Interventions included weekly skin and wound assessments with measurements and description of the wound. Resident #10's clinical records did not include documentation of the abrasion to his medial back as identified on the care plan. After the discovery of the heel, coccyx, right and left buttock pressure ulcers, the Skin Breakdown Care Plan of his medial back was revised on 10/28/16 to include interventions of a low air loss mattress to protect his skin, staff were directed to turn and reposition the resident at least every two hours and as needed (PRN), and staff were to monitor Resident #10 for placement and use of Prevalon positioning system every shift and PRN. The revisions to the care plan did not include the unstageable pressure ulcers to his coccyx, right and left buttocks and reopening of his right heel. The facility did not provide evidence the care plan was updated to include these wounds. c. Resident #10's February 2017 Physician order [REDACTED].>* Staff was to apply skin prep each shift and every night shift PRN for the SDTI to the right heel, ordered 10/31/16. * Staff were to cleanse the unstageable right buttock and coccyx wounds with normal saline, pad dry and cover with Duoderm/[MEDICATION NAME] every night shift every two days and PRN, ordered 1/6/17. * Skin Checks were to be completed on Monday and Friday nights and staff were to document whether there was no skin injury/wound; a new skin injury/wound; and/or a previously noted skin injury/wound, ordered 1/4/17. * Staff were to apply Z-guard to Resident #10's buttocks each day shift, ordered 1/4/17. Resident #10's February 2017 MAR and TAR documented weekly skin assessments were to be completed twice a week. The February 2017 MAR and TAR did not include documentation of a weekly skin assessment on 2/23/17 and 2/27/17. Resident #10's February 2017 MAR and TAR documented staff was to apply skin prep every shift to the right heel. The February 2017 MAR and TAR did not include documentation this was completed 2/13/17, 2/14/17, 2/15/17, 2/17/17, 2/26/17, 2/27/17, and 2/28/17. Resident #10's February 2017 MAR and TAR documented staff were to cleanse the unstageable right buttock and coccyx wounds with normal saline, pad dry and cover with Duoderm/[MEDICATION NAME] each night shift every two days. Resident #10's February 2017 MAR and TAR did not include documentation this was completed on 2/15/17. Resident #10's 2/17/17 Physician order [REDACTED]. Resident #10's February 2017 MAR and TAR did not include documentation this was completed on 2/17/17 and 2/23/17. Resident #10's 2/24/17 Physician order [REDACTED]. Resident #10's February 2017 MAR and TAR did not include documentation this was completed on 2/24/17. Resident #10 went 8 days without a dressing change. Resident #10's February 2017 MAR and TAR documented staff was to apply Z-guard to the buttocks each day shift. Resident #10's February 2017 MAR and TAR did not include documentation this was completed 2/13/17, 2/14/17, 2/15/17, 2/26/17, 2/27/17, and 2/28/17. Similar findings related to MARs and TARs were found for October 2016 through January 2017, as well as for 3/1/17 through 3/6/17. On 8/10/17 at 4:30 pm, the SDC stated Resident #10 was resistive to cares, floating of the heels, and repositioning. She could not find consistent documentation of the refusals. The SDC also stated she was unable to locate documentation of wound measurements. On 8/11/17 at 9:20 am, the SDC stated she could not find evidence that treatments had been completed other than those documented as completed on Resident #10's MAR and TAR. On 8/11/17 at 1:37 pm, the SDC stated the facility could not locate an I&A after the discovery of the medial abrasion to the back was identified. She stated she did not know why an I&A was not completed, but one should have been completed. The facility was inconsistent with identification and measurements of wounds in the Nurses Notes and on the Skin Integrity Records related to whether there were 1 or 4 wounds present on Resident #10's coccyx and buttock region. The facility failed to update and maintain the plan of care related to pressure related wounds. The facility failed to ensure the care and treatment of [REDACTED]. The facility did not ensure that wound identification was consistent, or that assessments, interventions, treatments, and care plan updates of multiple recurrent pressure ulcer wounds was performed and documented. 2. Resident #2 was admitted to the facility on [DATE] following surgical replacement of the right hip, and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 12/27/16 annual MDS assessment, 5/1/17 significant change MDS assessment, and 6/27/17 quarterly MDS assessment each documented Resident #2 was at risk to develop pressure ulcers, but had no healed or unhealed pressure ulcers. Resident #2's care plan, initiated 1/7/16, documented the skin was to be monitored for signs and symptoms of breakdown and a pressure reducing surface was to be applied to the bed. Additional care plan interventions, initiated on 5/2/17, directed staff to assist the resident turn every 2 hours as tolerated, evaluate for any localized skin issues, observe the skin daily with ADL care, report abnormalities, and float the heels while in bed as tolerated. On 7/12/17, the care plan directed staff to float (Resident #2's) heels while in bed. The clinical record documented Resident #2 sustained fractures to the right tibia and fibula from a fall at the facility on 4/19/17. The resident was subsequently hosptalized on [DATE] for pain and fracture management, and a long leg cast was applied on 5/2/17. Resident #2's physician orders, dated 6/1/17 and the July 2017 TAR documented a non-removable cast was in place to the resident's right lower leg. An Orthopedic Office Visit Progress Note, dated 7/11//17, documented the cast was removed from Resident #2's right leg without complications, and recorded non-[MEDICAL CONDITION] in the right lower leg. Progress Notes (PNs) documented the following: * 7/11/2017 at 1:53 pm - The resident's cast was removed and noted physician orders [REDACTED]. No documented abnormalities or concerns regarding the skin after the long leg cast was removed from the right lower leg. * 7/12/2017 at 9:49 am - .without cast on leg. * 7/12/2017 at 1:14 pm - A change in condition was noted related to a skin wound in the morning. The physician was notified at 11:30 am and family was notified at 1:00 pm. * 7/12/17 at 1:41 pm - A Braden Scale documented the resident was at moderate risk for the development of pressure ulcers. * 7/12/17 at 5:36 pm - This am (morning) RN (Registered Nurse) assessed RLE (right lower extremity) skin . area of 4 cm X 3.5 cm X UN (unstageable), stable dry black eschar (dead tissue) to R (right) heel. Reviewed wound and risk factors with MD (physician) and is agreeable . wound is unavoidable due to occurring under a hard cast . and not able to be assessed until cast removal. A Skin Integrity Report, dated 7/12/17, recorded a 4 cm by 3.5 cm unstageable pressure ulcer to the right heel. The resident was observed multiple times daily during the survey with Sage boots in place to both feet and lower legs. On 8/8/17 at 5:35 pm, the right heel pressure ulcer, covered by black eschar, was observed as RN #3 measured it at 2.4 by 2.9 cm. On 8/10/17 at 5:10 pm, LPN (Licensed Practical Nurse) #7 said skin should be assessed with [REDACTED]. On 8/11/17 at 9:10 am, the DON (Director of Nursing) said residents' skin should be assessed as soon as possible after a cast was removed, but we have 24 hours. When asked to provide a policy/procedure regarding skin assessment after cast removal, the DON provided a copy of the Skin Integrity Report that documented, .to accurately stage (determine the size and nature of the ulcer) within 24 hours of admission and/or after discovery of a new in-house acquired pressure ulcer. On 8/11//17 at 10:45 am, the DON provided two hand-written statements, both dated 8/10/17. One statement, written by LPN #4, documented he did not remember what time the resident returned to the facility on [DATE], but he assessed the resident's skin and identified a (sic) area on (right) her heel appears black and was dry. He further stated the DON was notified and that he was informed the wound would be assessed for staging. The DON's 8/10/17 statement documented she was notified of a black spot on Resident #2's right heel, and she advised LPN #4 that the area would be assessed by herself or another RN first thing in the morning. The facility failed to promptly assess a black area on Resident #2's right heel after removal of a long leg cast that had been in place for more than two months. The resident returned to the facility after cast removal in the early afternoon on 7/11/17, and the heel pressure ulcer was not assessed until the next day.

Based on observation, staff interview, and review of clinical records and incident/accident (I&A) reports, it was determined the facility failed to ensure residents were adequately supervised and assisted as care planned. This was true for 2 of 6 (#2 and #9) residents reviewed for falls. Resident #2 was harmed when she sustained two fractures to her right lower leg as one staff, rather than two, assisted her with a transfer. Two days after the injury, the resident experienced significant pain and required hospitalization . Resident #9 sustained a skin tear related to a fall on facility grounds. The facility failed to care plan for falls and supervision which placed the resident at risk for harm. Findings include: 1. Resident #2 was admitted to the facility on [DATE] following right hip replacement, and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 12/27/16 annual Minimum Data Set (MDS) assessment and 3/27/17 quarterly MDS assessment both documented moderately impaired cognition, extensive assistance required from two or more staff for transfers, occasional pain, and no falls. The resident's 5/1/17 significant change MDS assessment differed from the previous two assessments in the following areas: severely impaired cognition, frequent pain, and one fall. The Activities of Daily Living (ADL) care plan, dated 1/7/16, recorded 2 person Hoyer lift for all transfers. An SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 4/19/17, documented, CNA (Certified Nursing Assistant) was transferring resident, alone, back to bed and resident's knee and foot gave way, resident was lowered to the ground, then assisted back to bed. The SBAR documented the only change was new pain in the right hip and thigh. The pain was rated as 7 (on a scale of 1-10 with 10 being the most severe). Movement aggravated the pain, and lying still and pain medication alleviated the pain. A 5/2/17 Event Summary Report documented the resident was lowered to the floor on 4/19/17 at 3:30 pm. The report also documented a CNA transferred the resident using a one person assist and asked the resident to put her arms around her neck. During the transfer the CNA stated that she had to lower the resident to the floor because the resident's legs buckled. The CNA reported that she assisted the resident to the floor softly and she did not think that the resident was injured. Upon interview, this CNA confirmed that she did not use a gait belt for this transfer, and she did not consult the Kardex (guidance to CNAs) for the transfer status. The CNA summoned another CNA to assist with placing the resident in bed. Progress Notes (PN) dated 1/19/17 through 8/8/17 documented: * 4/19/17 at 6:40 pm - The resident fell in the afternoon. * 4/20/17 at 2:32 pm - The resident reported she had a seizure, was unable to say how long it lasted, and nursing assessment documented no significant changes. Progress Notes after the fall documented the resident had no significant pain and no significant changes. *4/21/17 at 12:00 am - Physician Assessment: Right leg pain, worsening pain after a fall . structural abnormality to the right leg . will xray the lumbar spine, pelvis and entire leg. Given the pain with simply touching her leg, I recommended we do the xrays in house. The physician also ordered Valium as a muscle relaxer at that time. * 4/21/17 at 6:15 pm - Light purplish blue discoloration to (right) shin approx(imately) 15 X 7 cm (15 by 7 centimeters). Xray results showed acute fracture of the tibia and fibula, however the physician ordered further evaluation at the hospital due to difficulty reading the in-house xray report. * 4/21/17 at 7:57 pm - Planned transfer out of the facility. *4/21/17 at 8:13 pm - Notified by physician the resident would be a direct admit to the hospital surgical floor. A hospital admission assessment, dated 4/21/17 at 9:08 pm, documented an orthopedic surgeon was consulted and the resident was allowed no oral intake except for anti-seizure medication with a sip of water in anticipation of surgery. A hinged brace was applied to the right lower extremity. A 4/21/17 hospital x-ray report confirmed fractures of the tibia and fibula without significant displacement. Orthopedic and Internal Medicine Notes documented Resident #2 was equipped with a hinged long leg splint and placed on non-weightbearing status on the right lower extremity. The Notes documented, Try for reasonable pain control for the resident who was just moaning and in obvious pain . The 4/25/17 Event Investigation Interview Record documented the CNA transferred Resident #2 to her bed and the resident's legs started to give out. The resident's legs were positioned between the CNA's legs, and the CNA sort of walked her backward to sitting then onto her back in laying position. The resident was then lifted by her arms and pants into bed, which had been lowered. The 4/25/17 Investigation Interview Record also documented the CNA was not aware the resident required two-staff for transfers. On 8/10/17 at 5:20 pm, LPN (Licensed Practical Nurse) #7 said the information regarding how to transfer the resident was accessible to each CNA on a tablet device, and training was provided to the CNA during orientation regarding how to access this information. Resident #2 fell on [DATE] when she was transferred by one CNA. Two days after the fall, the physician identified worsening pain in the right leg. The resident was transferred to a hospital and was diagnosed with [REDACTED]. She required inpatient hospitalization for pain control and was placed on NPO status (nothing by mouth) in anticipation of surgical intervention. On day two of the hospitalization , the physicians determined that non-operative care was the best option and a splint was applied to stabilize the right leg. 2. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's Quarterly MDS assessment, dated 7/21/17, documented she was cognitively intact, required extensive assistance of 2 or more staff members for transfers and had no falls. Resident #9's clinical record did not contain a Fall Care Plan prior to 8/9/17. On 8/9/17 at 3:30 pm, the DON stated Resident #9 did not currently have a care plan in place for falls. Resident #9's Fall Care Plan, dated 8/9/17, documented she was to alert staff when going outside to pick fruit and she was to use a Reacher assistive device when outside picking fruit. Resident #9's Situation, Background, Assessment, Recommendation (SBAR) Communication form, dated 7/19/17, documented she experienced a fall on 7/18/17. The SBAR did not identify how Resident #9 fell . On 8/9/17 at 3:30 pm, the Director of Nursing (DON) stated the facility had not completed an investigation into Resident #9's 7/18/17 fall. She stated the nurse who was on duty the day of the fall did not report the fall. The DON stated Resident #9 was found outside by a visitor and the nurse left a note in the chart without notification to other staff, the physician, or the resident's family. The DON stated she learned Resident #9 fell the next day during a skin assessment in which a 2.8 centimeter (cm) by 2.1 cm skin tear was discovered on Resident #9's left hand. The DON stated she asked the resident how the injury occurred and Resident #9 stated it was from a fall the previous day. The DON stated Resident #9 had been trying to pick a plum and fell out of her chair. The DON stated the fall was unwitnessed. On 8/10/17 at 8:40 am, LPN #1 stated Resident #9 was now asked to inform staff when she wanted to go outside and pick fruit and staff were to ensure she had a Reacher assistive device when picking fruit. LPN #1 said she informed staff of the goals and new interventions. On 8/7/17 at 3:35 pm, Resident #9 was observed notifying a staff member she wanted to go outside to pick fruit. Resident #9 left through the front door, propelled her wheelchair to a walnut tree, reached up with her hand, and picked a walnut. On 8/7/17 at 3:43 pm, Resident #9 propelled her wheelchair across the grass near a gazebo with a walnut in hand towards other fruit trees on the side of the building. The resident did not have any tools or the Reacher assistive device, nor was Resident #9 accompanied by staff while she was outside. On 8/10/17 at 8:40 am, LPN #1, when informed of the observation, stated she did not realize Resident #9 was without the Reacher assistive device. On 8/11/17 at 12:20 pm, Resident #9 stated the facility had given her a Reacher to pick fruit that week.

Based on observation, staff and resident interview, and record review it was determined the facility failed to ensure a resident's physician was notified of a resident's changing medical condition, and failed to monitor pain levels as prescribed by the physician. This was true for 2 of 13 (#s 6 and 7) sampled residents. Resident #6 was harmed when her physician was not notified of a change in her health status for 6 days after symptoms began, and she had to be admitted to the hospital for stabilization. Resident #7 had the potential for harm when pain levels were not monitored as the physician had prescribed. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #6's MAR indicated [REDACTED]. The medication was documented as refused on 7/13/14. On 7/13/16, Resident #6 was discharged to the acute care hospital. Her H&P from that date documented new [DIAGNOSES REDACTED]. The resident remained in the acute care hospital until 7/16/14, when she was readmitted to the facility. Resident #6's physician's orders [REDACTED]. The resident's MAR indicated [REDACTED]. On 7/16/14 Resident #6's MAR indicated [REDACTED]. Of the 35 opportunities to document this value, only 4 measurement opportunities were documented. Thirty of the remaining spaces documented either "X 1," "X 2," or, "X 3", indicating the resident had voided an unmeasured amount either once, twice, or three times for that shift. On 7/17/14, Resident #6's care plan documented: *"Altered Respiratory Status: shortness of breath/difficulty breathing related to: [MEDICAL CONDITION]." Interventions included, "Monitor labs as orders (sic) and notify MD of changes as needed," and, "Observe for alterations in respiratory status including shortness of breath, pain/discomfort with breathing, abnormal lung sounds and report abnormalities to MD;" and *"Risk for fluid output exceeding intake characterized by fluid volume deficit..." Interventions included, "Observe intake and output (every) shift." Resident #6's 7/23/14 Admission MDS documented the resident had not experienced shortness of breath, but did require oxygen therapy. On 7/23/14 at 8:20 AM, a SBAR (Situation, Background, Assessment, and Request) form in Resident #6's record documented, "Situation...2 (plus) [MEDICAL CONDITION] (bilateral) legs (and) puffiness under eyes. This started on 7/22/14...stayed the same...treatment for [REDACTED]...7/16/14 - 124 (pounds). 7/21/14 - 127.5 (pounds) oximetry % (percent) 96 on O2 (oxygen) 2 Lpm (liters per minute)...lung CTA (clear to auscultation)...Recent Lab Results none...full code...the resident appears to have more [MEDICAL CONDITION] Diuretic orders. Reported to this nurse during shift change that the resident is having 2 (plus) [MEDICAL CONDITION] to (bilateral lower extremities) even with TED hose on. Resident (complains of) puffiness under eyes as well..." The form documented the above information was reported to the resident's physician at 7:40 AM on 7/23/14. However, there was no documentation of the physician's response to the information, and no new medication or treatment orders were noted. Resident #6's Nurse's Progress Notes (PNs) documented the facility continued to monitor [MEDICAL CONDITION] to her lower extremities on 7/23/14 and 7/24/14. Between 7/24/14 and 7/27/14, there was only one entry in the resident's PNs, on 7/25/14 at 8:00 AM. The entry documented, "(Speech Therapy) clarification received for 7/18 and 7/22." There was no further documentation the facility had attempted to follow up with the physician regarding the concern with the resident's [MEDICAL CONDITION], or of any of the other concerns documented in the 7/23/14 SBAR. There was no documentation of the status of the resident's [MEDICAL CONDITION] or breathing on 7/25/14 or 7/26/14. On 7/27/14 at 6:00 PM, a PN for Resident #6 documented, "90 % at 2 (liters per nasal cannula)...lungs diminished in bases..." There was still no documentation of physician awareness or follow-up from the 7/23/14 SBAR. On 7/28/14 at 6:45 PM, a PN documented the resident continued to use oxygen at 2 liters per minute, with a saturation of 90%. On 7/28/14 at 10:15 PM, an SBAR in the resident's record documented, "Situation...SOB (shortness of breath) severe...severe anxiety (due to) SOB...wheezing throughout lungs (with) severe SOB...(Physician) notified of SOB unrelieved...transfer to ER..." On 7/29/14 at 3:30 AM, Resident # 6's PNs documented, "...she is being admitted for [MEDICAL CONDITION] exacerbation..." On 7/29/14 at 1:00 AM, a laboratory report obtained at the acute care hospital documented several abnormal values. Of note, the resident's BNP value was 2097 pg/ml, with a normal range of 0-100 pg/ml. On 7/29/14, chest x-ray results from the acute care hospital documented, "[MEDICAL CONDITION] or fluid overload," and, "Bilateral pleural effusions." On 7/30/14 an acute care hospital Inpatient Progress Note documented, "...Note that we had 3 liters (of fluid) out yesterday...she is continuing to get IV [MEDICATION NAME] and we will maintain that at this time..." The resident returned to the facility on [DATE]. Her H&P for that date documented new [DIAGNOSES REDACTED]. On 9/23/14 at 9:30 AM, during a Resident Interview, the resident described the event as a "setback" and stated, "I had [MEDICAL CONDITION] real bad and they couldn't get the [MEDICATION NAME] the doctor ordered for about a week. It got so bad. My legs were all swollen, and it got into my lungs. I was so scared. (The LN) had to call emergency services and the ambulance took me to the hospital. They gave me [MEDICATION NAME] by IV there and I filled five bedpans almost immediately. It was embarrassing, but at that point I didn't care." On 9/24/14 at 10:05 AM, the DNS and MCO were asked about the events leading up to Resident #6's hospitalization . The MCO identified the SBAR form as a communication tool used for a facility nurse to formulate their thoughts on a resident's condition before calling the physician. The facility's expectation was the form should be used for nurse-to-physician communication, and a physician's response should be documented in the resident's record, either on the form, in a PN, or in terms of a new physician's orders [REDACTED]. The DNS was unable to explain how the resident's urinary output could be determined from the documentation on the resident's TAR. When asked to review the labs drawn when the resident arrived at the hospital the DNS stated, "Her BNP was elevated. She was in [MEDICAL CONDITION]." The DNS stated he would look for additional documentation to show the physician was notified when the resident's symptoms first appeared. On 9/25/14 at 10:20 AM, the DNS and MCO stated they had found no further documentation. Resident #6 was harmed when she began to experience signs and symptoms indicating fluid overload, but the facility did not provide documentation that the physician was actually notified until 5 days later. By that time, the resident had become so ill she was frightened, required emergent transport to the hospital, had to receive IV medications, was personally embarrassed, and was admitted to the hospital for stabilization. On 9/25/14 at 10:00 AM, the Administrator, DNS, and MCO were notified of these findings. The facility offered no further information. 2. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Care Plan dated 7/3/14 documented an intervention, "Administer pain medication as per MD orders and note effectiveness..." The resident's September 2014 MAR indicated [REDACTED]. 0-10 scale. Start date 9/8/14." The MAR indicated [REDACTED]. On 9/23/14 at 4:30 PM, the DON was interviewed about pain monitors. When asked why the pain wasn't monitored as ordered, he stated, "The pain documentation (we use) is generic, every shift, not the best." On 9/25/14 at 3:45 PM, the Administrator and DON were informed of the issue. No further information was provided.

Based on observation, staff and resident interview, and record review, it was determined the facility failed to ensure: *Adequate assistance and supervision to prevent falls; *Handrails were readily accessible to residents; and *Seatbelts and side rails were assessed for safety for individual residents. This was true for 4 of 13 sample residents (#s 1, 3, 6 and 16), and any resident wishing to access the handrails near the nurse's station. The deficient practice had the potential to cause harm if residents experienced falls or were using devices not assessed as safe for their individual needs. Resident #6 was harmed when she fell and sustained a left hip fracture in the facility and required surgical intervention. Findings included: 1. Resident #6 was admitted to the facility from the acute care hospital on [DATE], following a fall at home with rib fractures and a history of alcohol abuse, CAD and CHF. Resident #6's MAR documented the resident received Lasix 40 mg at 6:00 AM daily, between 7/7/14 and 7/12/14. The medication was documented as refused on 7/13/14. The record between 7/7/14 and 7/13/14 documented a Fall Risk Evaluation with a score of 21. The form had no specific date of completion, but documented the resident was at high risk for falls. On 7/12/14 at 4:35 PM, Resident #6's Nurse's Progress Notes (PNs) documented, "...Visitor stated she gave resident a bottle of wine, approx(imately) 6 (ounces). Res(ident) drank this bottle of wine. Res(ident) appears to be having (signs and symptoms) of withdrawal. Res(ident) is shaking and mumbling..." On 7/13/14 at 7:00 AM, Resident #6's PNs documented, "Resident (with) increased tremors and mumbling which was reported by evening shift...Resident able to state year, month, and her name...Resident to (acute care hospital) per ambulance..." On 7/13/16, Resident #6 was discharged to the acute care hospital. Her H&P from that date documented new [DIAGNOSES REDACTED]. The resident remained in the acute care hospital until 7/16/14, when she was readmitted to the facility. Resident #6's physician's orders [REDACTED]. The orders did document the resident could have 5 ounces of wine with dinner and at bedtime (6:00 PM and 9:00 PM). On 7/17/14, Resident #6's care plan documented: *"Self Care Deficit anxiety, depression, physical limitations, weakness." Interventions included one person assistance with ADLs, transfers, bed mobility; and to adjust the level of care according to her individual needs. *"Risk for falls related to: unsteady gait, pain, history of multiple falls, generalized weakness, decreased safety awareness, anxiety." Interventions directed staff to reinforce the need to call for assistance, and to encourage the resident to communicate needs and ask for assistance. *The care plan did not document the use of diuretic medication, nor did it include a toileting care plan to maintain continence. *The care plan did not document the use of wine for the resident, her history of obtaining additional wine beyond what was ordered, that she had recently required medical detoxification from alcohol use, nor any additional monitoring to be performed after she had consumed alcohol. On 7/23/14 Resident #6's Admission MDS coded the resident was cognitively intact. However, the instructions further documented, "The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment..." The 7/23/14 MDS further coded: *Limited assistance of one for bed mobility, transfers, dressing, toilet use, and personal hygiene; *Extensive assistance of one for ambulation; *Continent of bowel and bladder; *Balance unsteady, only able to stabilize with staff assistance when moving from a seated position to standing, walking, turning, moving on and off the toilet, and surface-to-surface transfers; and *History of falls before admission. On 7/23/14, Resident #6's CAAs documented:*ADLs - "(Resident #6) has been in the hospital to detox from her (alcohol) abuse. She does require up to extensive assistance with...ambulation...up to limited assistance with...transfers...toileting, personal hygiene..." *Urinary Incontinence - Pertinent medications were documented as anticholinergics, antidepressants and sedatives. Diuretics, which can cause urge incontinence, were not marked as a factor at that time. *Falls - "(Resident #6) has had previous falls from her (alcohol) abuse...she is at further risk for falls due to her daily use of antidepressants...she also takes an antianxiety medication..." Interventions included placing the resident in a room close to the nurse's station, reinforcing the need to call for assistance, and encouraging the resident to communicate needs and ask for assistance. Beginning 7/23/14, Resident #6's PNs began to note changes in her edema levels, oxygen saturations, weight, and lung sounds. Please see F 309 for details of these changes. On 7/25/14, Resident # 6's care plan was updated to include focus areas of her desire to return to her home in the community, and for feelings of sadness. No further care plan updates were noted until 8/11/14. On 7/29/14, Resident #6 was again discharged from the facility to the acute care hospital. Her H&P for that date documented new [DIAGNOSES REDACTED]. On 8/2/14, the resident was readmitted to the facility. Her admission physician's orders [REDACTED]. (NOTE: The resident had received 40 mg of Lasix at 6:00 AM only, no evening dose, between 7/7/14 and 7/12/14. She had not been on diuretic medication in the facility since that time.) No care plan updates were noted related to her new diagnoses, how her recent illnesses may increase her risk for assistance with ADLs or falls, nor how the use of diuretic medication may increase her frequency for toileting assistance. On 8/2/14 at 10:00 PM, Resident #6's PNs documented, "Resident...readmitted to this facility following a hospitalization to receive care for various (diagnoses)...continent of (bowel and bladder), but prefers to wear Poise pads for protection...She is (alert and oriented to person, place, and situation with) mild forgetfulness noted (at) times..." No care plan updates were noted regarding the resident's forgetfulness, nor that the resident was now using an incontinence product. On 8/2/14, Resident #6's MAR documented she received both scheduled doses of Lasix, as well as both allotted glasses of wine. On 8/3/14 at 5:30 PM, a facility Accident and Incident report (I/A) for Resident #6 documented, "Resident was ambulating to the bathroom with walker, went to go open the door to the bathroom, and let go of the walker. The resident then lost her balance and fell on her left side... BIMS was 13 upon return BIMS was 15. Resident was aware she that she should not have been ambulating without assistance." Probable root cause was documented as, "Poor safety awareness, COPD, lost balance before LN could get to her." New interventions included, "Increased supervision, encouraged to use call light, ask for assistance..." An attached statement from the CNA documented, "...When she fell I was helping getting someone up for dinner. I was on the floor by myself when she fell ..." The I/A report included a Fall Risk Evaluation dated 8/3/13, with a score of 23. A hand-written addendum to the form documented, "23 was post-fall. Res(ident) was 14 prior to fall." The form documented scores 12 or greater indicated high fall risk. The I/A included a signed statement from Resident #6, dated 8/3/14 at an unknown time, which documented, "I fell while getting to the bathroom with no help. My fault. Not use call light." The I/A did not address what the facility was doing to address the forgetfulness noted in the 8/2/14 PN, or her poor safety awareness. The I/A also did not address when the resident was last assisted to the toilet. The I/A did not document if the resident had received her Lasix and/or wine before or after the fall. Additionally, the I/A did not address the CNA statement that s/he was the only CNA working on the hall at that time. On 8/3/14 at 10:22 PM, an x-ray report for Resident #6 documented a left femoral neck fracture. The resident was sent to the acute care hospital and admitted for surgical repair of the injury. On 9/23/14 at 9:30 AM, the surveyor observed Resident #6 alone in her room, sitting in her wheelchair at the foot of her bed. The call light was not on. The resident grabbed the foot board of the bed, used it to pull herself to a standing position, shuffled approximately 4 steps to the window, adjusted the blinds, then returned to and sat in her wheelchair. When interviewed, the resident recalled her fall, stating, "I thought I could get from point A to point B, but I didn't make it." The resident said she was aware she should have someone help her whenever she needed to get up, and stated, "I would never make that mistake again. If I need to get up, I ask for help." Only when prompted did the resident recall she had just stood from her wheelchair unassisted to adjust the blinds. On 9/23/14 at 1:10 PM, the MCO and HIM (Health Information Manager) were asked to provide a copy of the care plan in place at the time the resident fell on [DATE]. The MCO stated since the resident had previously been in the facility, was known to the staff, and had been in the facility for "less than 24 hours" when she fell , the facility had been using the care plan in place at the time the resident discharged to the acute care hospital on [DATE]. On 9/23/14 at 4:15 PM, Resident #6 was asked about her written statement regarding the fall. The resident did not recall writing the statement, nor when it was written, but stated, "That's my signature. I must have written it." The resident then looked away from the surveyor and repeated twice, in a quiet voice, "It's my fault. It's my fault." On 9/24/14 at 11:15 AM, the DNS and MCO were interviewed regarding the resident's fall. The DNS stated the facility had determined the root cause of the resident's fall to be that the resident was taking herself to the bathroom without asking for assistance. The DNS stated, "She was alert and oriented. She chose to get up without help. She had a BIMS of 13 when she first came, and it was a 15 when she came back on the 2nd." The DNS stated the facility had not assessed the resident's cognition directly, but had received word from the hospital of her BIMS score. The DNS could not provide documentation from the hospital regarding the score. The DNS stated the resident's fall risk had been assessed as a "14" prior to her fall, which was "barely" at high risk for falls. The DNS stated it would not be unusual to have only 1 CNA working the floor at that time of day, due to the need to provide breaks. The DNS stated, "They have to take their breaks between 2:00 and 5:00 in the afternoon." The DNS stated he would need to investigate further to determine what other fall interventions were in place, whether or not the resident had wine before she fell , when she was last given Lasix, when she was last taken to the toilet, and whether availability of staff at that time had been a factor in the resident's "choice" to go to the bathroom without assistance. On 9/25/14 at 10:20 AM, the DNS and MCO approached stated they did not find any additional documentation regarding the events leading up to the resident's fall. They stated in general, during her previous admissions to the facility the resident had appeared to be alert and oriented, and asked for assistance appropriately. The DNS stated when readmitted for the third time on 8/2/14, the facility's documentation indicated the resident had no changes in cognition, therefore the facility felt it could utilize the same care plan in place previously. The DNS stated the facility had addressed the resident's decreased safety awareness identified as a risk factor on the 7/17/14 care plan by moving the resident to a room closer to the nurse's station, although he was uncertain when this move had taken place. Otherwise, the DNS stated the facility felt the facility's plan had been successful, as the resident had not fallen. The DNS stated the facility was focused on increasing resident independence, and for this resident in particular, this meant treating her "like everyone else" in light of her alcohol abuse history. The DNS stated the resident would not necessarily have a care plan to address her toileting needs "unless she had demonstrated non-compliance or had a change in risk factors other than medication." The DNS stated the facility did not consider the use of a diuretic medication as a risk factor for this resident as she had taken it in the past. (NOTE: The resident had not been on that medication (Lasix) since at least 7/16/14. Since that time, she had developed an exacerbation of COPD, which required hospitalization and IV diuretics to treat. The resident's dose of Lasix on 8/2/14 was twice what she had previously received, and was administered at 10:00 AM, rather than 6:00 AM, as well as 6:00 PM.) The DNS was unable to provide information as to when the resident had last been toileted before her fall, and whether she had received her evening dosage of Lasix and/or a glass of wine before the fall. The DNS and MCO stated they did not feel the facility should have implemented additional supervision for the resident when she returned to the facility because she had usually asked for help before, and had not shown evidence of cognitive deficits. Resident #6 was harmed when the facility failed to identify risks and provide necessary assistance and supervision to avoid falls with injury. On 9/26/14 at 10:00 AM, the Administrator, DNS, and CMO were informed of these findings. The facility offered no further information. 2. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities at F 323 documented, "In 1995, the FDA issued a Safety Alert...Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc. that may cause them to move about the bed or try to exit from the bed. The timeliness of toileting, appropriateness of positioning, and other care-related activities can contribute to the risk of entrapment." a. On 8/8/14, Resident #6's record documented a Restrictive Device Consent for one-quarter side rails on both sides of her bed. On 9/23/14 at 8:05 AM, the resident was observed in her bed, with the quarter side rails both up. The side rails were observed again in the upraised position on 9/23/14 at 9:30 AM and 4:15 PM. b. Resident # 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 9/24/14 at 2:30 PM, Resident # 1 was observed lying in his bed, with two half side rails in the upraised position. The resident stated he used the siderails to move in bed, since he had "no legs." On 9/25/14, the DNS and RDCO were asked to provide documentation the above devices were assessed as safe for the residents to use; this documentation was not provided. **Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan for Risk of Falls dated, 5/7/14 documented interventions that included low bed, resident to wear nonslip footwear, reinforce the need to call for assistance. The resident's Fall Risk Evaluation dated 5/8/14 assessed the resident to be at "high" risk for falls with a score of 13. A second evaluation without a date assessed the resident at "High" risk with a score of 18. The resident's I & A (Incident and Accident) form dated 5/8/14 documented the resident had a fall while the therapist assisted the resident back to bed. The therapist had turned away from the resident and she slid from her w/c (wheel chair). The probable root cause was the resident had poor safety awareness and a recent decline in her condition. New interventions to be put in place were strict observation when up in the w/c and for the resident to remain in the line of sight of the staff. The resident's Therapy Communication to Nursing dated 5/9/14 documented, "Patient found in room attempting to self (transfer) to get to the bathroom this AM & was discovered 1/2 on bed 1/2 off bed by CNA." The problem identified was, "Patient at risk for falls (secondary) to self- (transferring) to get into the bathroom." The recommendations were, "Alarm on bed," and precautions were, "urination urgency." The resident's Care plan for Risk for falls was updated on 5/15/14 to include, nursing to ensure that the resident is not to be left alone when assisting with toileting needs, related to history of self transfers, decreased safety awareness. NOTE: The new intervention was not documented on the care plan til 6 days after the the resident was found 1/2 out of bed due to the need to urinate. On 9/24/14 the DON provided 1/2 hour checks sheets that were implemented on the resident on 5/9/14 and continued on 5/10/14. On 5/11/14 from 6:00 AM until 10:00 PM, the resident was checked every hour and from 10:00 PM until 5:00 AM, the resident was checked every half hour. The fourth check sheet provided without a date, did not document the resident was checked from 6:00 AM until 2:00 PM. From 2:00 PM until 3:00 AM, the resident was checked hourly. NOTE: The checks were not documented on the resident's care plan for falls. On 9//23/14 at 3:35 PM, the DON was asked when nursing received the Therapy Communication to Nursing form dated 5/9/14, would there have been changes in the resident care, and he stated, "It depends." He was asked if he was notified when this form was provided to nurse staff. The DON stated, "Probably not," it would go to the Nurse Manager or Unit Coordinator. He stated he would look into it. On 9/24/14 at 9:25 AM, the DON stated he had asked the nurses about the Communication form and they did not remember anything about it. He was asked if the form had been filed in the chart and staff not notified, he stated, "I am not going to tell you that I am not going to go to the Occupational Therapy Supervisor and talk about it. I am going to tell you she did not fall again." On 9/24/14 at 12:30 PM, the Administrator, DON and MCO were notified of the findings. No additional information was provided. 2. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A Device Evaluation dated 7/22/13 and Quarterly evaluation dated 7/10/14 failed to have a completed assessment to ensure the seatbelt did not pose a safety risk for the resident. On 9/24/14 at 2:21 PM, the DON was interviewed related to Resident #3's Device Evaluation not having an assessment of safety. He stated, " It's not there." 3. On 9/23/14 from 1:45 PM to 3:35 PM, the 400 hall medication carts were observed to be blocking the handrails on both sides of Room 401's door. On 9/24/14 from 10:15 AM to 11:15 the 400 hall medication carts were observed blocking the handrails between Room 401 and the 400 hall medication room. From 3:00 PM to 3:30 PM the medication carts were observed parked outside Room 403, blocking the handrails, on both sides of the door. On 9/25/14 at 1:35 PM, the DON was asked about the medications carts blocking the handrails. He stated, "the staff have direction to keep the carts off the most used areas. The residents usually cut across. The staff is directed to have no carts in the short hall and none in the Day Room, ever. We can re-look at it, is there an issue with that?" On 9/25/14 at 3:45 PM, the Administrator and DON were informed of the findings. The facility offered no further information.

Based on observation, staff interview and record review, it was determined that Resident #3 and #5 were harmed when they developed multiple pressure sores in the facility. Specifically: - Resident #3 had two stage II pressure sores on the buttocks. - Resident #5 had two unstagable open pressure sores on both hips and a healed pressure area on the right ischial area. Resident #4 also had the potential to be harmed when she acquired a pressure sore on the left foot toes. This was true for 3 of 13 (#s 3, 4, and 5) sampled residents. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 7/26/11 documented the resident: * Was cognitively intact with a BIMS of 15. * Had moderate to bordering on moderately severe depression. * Did not have behavior symptoms. * Required extensive assistance for bed mobility, dressing, and personal hygiene. * Had pain intensity of 8 on a scale of 0 to 10. * Had a stage III pressure sore. The most recent quarterly MDS assessment, dated 1/14/12 documented the resident: * Was cognitively intact with a BIMS of 15. * Had minimal depression but did indicate he would be "better off dead." * Did not have behavior problems. * Had pain intensity of 6 on a scale of 0 to 10. * Had two unstageable and one stage IV pressure sores. None of the resident assessments documented that the resident was rejecting care. (E0800 = behavior not exhibited) Resident #5 was admitted from a specialty hospital. The 7/21/11 Nursing assessment documented the resident had a stage III pressure sore over the sacrum area with a wound vac in place at the time of admission. During interview with the DON on 4/10/12 at 10:00 a.m. and review of the physician's admission note, dated 8/3/11 at 11:45 a.m., it was determined that the resident was medically unstable and severely compromised when he was admitted . The facility obtained laboratory tests on 8/2/11. The results were severely low laboratory values of [MEDICATION NAME] (alb) 2.4 (normal range: 3.5 - 4.8 g/dl (grams/deciliter)), Hemoglobin (H) 5.5.(normal range: 13.5 - 18.0 g/dl), and Hematocrit (H) 16.9 (normal range: 41 - 50 %). The facility's initial care plan, dated 7/21/11, documented: * Resident has impaired skin integrity r/t (related to) pressure ulcer secondary to: immobility, friction, pressure area to sacrum, pressure areas to both left and right hips. (initiated: 7/27/2011, revised: 10/7/11) The interventions were (NOTE: All interventions were initiated 7/27/11, unless otherwise indicated): "* Encourage resident to float heels when in bed. * Heel protectors in place when in bed. * Check for incontinence and provide peri-care as needed ac and pc meals, qhs & on rounds during the night. (Before and after meals and at bedtime) * Cleanse perineal area well with each incontinence episode. * Ensure special mattress is in place (Joern's air mattress). * Keep skin clean and dry. * Turn and position with skin care (every) 2 hours and prn. * Evaluate for pain (0 - 10). Medicate per orders if pain present. * Document on flow sheet: If skin is intact; mark "Y". If skin is reddened or has open areas; mark "N". Report any new openings to Licensed Nurse. * Monitor healing process and notify MD and responsible party if no improvement. Change treatment as indicated. * Record percentage of meal consumed. * Weekly skin assessments and measure pressure ulcers. * Minnesota solution gauze to pack pressure area, covered with gauze....(Initiated: 8/2/11) * [MEDICATION NAME] dressing to both hips r/t redness and open areas....(Initiated: 10/7/11) Further review of the care plan revealed there was no care plan developed that would address the resident's refusals for care and the risk he was putting himself in by being non-compliant with medical needs. The resident was admitted on [DATE] with a stage III pressure sore on the sacrum/coccyx. The resident acquired three additional pressure sores at the facility. The left hip ulcer was first identified on 9/29/11, the right hip ulcer was identified on 9/29/11 and the right ischial ulcer was identified on 11/7/11. The resident was at severe risk for skin breakdown from the date of admission, and despite the risk the facility was able to prevent the resident from pressure sores developing for 2 months and 8 days. The medical record documentation revealed the resident was both cooperative and uncooperative with treatment and changes. The pressure sore documentation from facility staff and providers are listed chronologically. The quotations are from "Interdisciplinary Progress Notes" unless otherwise noted. 7/21/11 (Pressure Ulcer Documentation Form) Site: Sacral area, Stage: 3, Length: 3 cm, Width 2 cm, Depth: 1.1, Tunneling: yes (two documented). 7/22/11 at 2:00 p.m. "...Reposition (every) 2 (hours)....Res(ident requires ext(ensive) assist (every) 2 (hours) for positioning in bed...." 7/23/11 9:05 a.m. "....Resident is an extensive assist (with) repositioning..." 7/24/11 at 2:30 p.m. "...Assists (with) turning, up for lunch...Propels self in w/c (wheelchair), w/c bound for mobility." 7/27/11 at 12:00 a.m. "...Turned side to side (every) 2 hours, but resident often repositions self back onto his back/buttocks/spine. Res(ident) educated (and) encouraged to stay of (sic) wound but is not always compliant despite these efforts...." 7/31/11 at 12:00 a.m. "...Also noted to be non-compliant (with) turning schedule...." 8/3/11 at 11:45 a.m. (physician progress notes [REDACTED]. Found to have severe [MEDICAL CONDITION] for unknown reasons, but (patient) declines any (treatment) and is aware of consequences... Labs 8/2 [MEDICATION NAME] 2.4, H/H 5.5/17% ((decrease) from 24% early in July)...." (Note: the physician did not address the pressure sore.) 8/7/11 1:50 p.m. "....Dressing changed on coccyx area no [MEDICAL CONDITION] or redness around wound." 8/11/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: unstageable, Length: 5.5 cm, Width 3.5 cm, Depth: 2, Tunneling: yes 3.5 cm, Exudate: small sero-sanguinous, Wound Bed: 90% slough 10 granulation. 8/17/11 at 12:50 p.m. (physician progress notes [REDACTED]. constant pain... Plan 1)Sacral Decubitus - wound (culture) sent..." 8/20/11 1:45 p.m. "...Dressing change done to coccyx area with Minnesota Solution, refuses to get (out of bed), turned (every) 2 (hours), makes needs known." 8/21/11 at 12:30 a.m. "....Call placed to Dr. (name) (with) results of wound culture and orders received for [MEDICATION NAME] 300 mg ... and Bactrim DS 1 orally... Resident educated on the results and new orders and is accepting of treatment for [REDACTED]. 8/21/11 at 9:30 a.m. "....Wound had yellowish (pus like) drainage...." 8/22/11 at 11:30 p.m. "....Turned and positioned (every) 2 (hours...." 8/27/11 at 3:00 a.m. "Dressing changed per orders, noted a large amount of yellowish tan colored slough attached to wound bed, very stringy...." 8/28/11 at 2:50 p.m. "...Dressing to coccyx changed per orders. Area surrounding open area very red, excoriated. Resident turned (every) 2 hours and (as needed). Heel protectors in place..." 9/4/11 at 3:30 a.m. "....Dressing changed continues to have a large amount of slough in the wound bed (with) surrounding area red..." 9/7/11 (physician progress notes [REDACTED]. Has extensive undermining (shallow). Patient is extremely emaciated. Peri wound is rashy... Has been to (hospital name) rehab, had known stage III sacral pressure ulcer. Had issues (with) tobacco use, blood glucose issues, [MEDICAL CONDITION] and depression, osteo[DIAGNOSES REDACTED]... On regular high protein diet, still has severe protein calorie malnourishment... See skin sheet for measurements, debrided loose soft eschar from wound (with) patient's permission..." 9/8/11 at 5:10 p.m. "...Changed position (every 2 (hours) and (as needed) (related to) skin breakdown..." 9/9/11 at 5:00 p.m. "...Addressed resident to change dressing to bottom. Resident refused at this time, stated he didn't want to be bothered right now. Nursing returned around 1:15 p.m. and re-offered dressing change, resident appears to be sad and was not cooperative. Reinforced skin issues/risks. Did allow staff to change position (every) 2 (hours) and PRN...." 9/19/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 6.5 cm, Width 3 cm, Depth: 2.5 cm , Tunneling: yes 4 to 4.5 cm, Exudate: sero-sanguineous, Wound Bed: 80% granulation 20% slough. 9/28/11 at 1:15 p.m. (physician progress notes [REDACTED]." The physician did not document anything else about the wound. The physician further documented that the resident refused the psychiatric evaluation but it was completed on 10/13/11. 9/29/11 at 4:30 a.m. (Change of Condition Documentation form), " Res(ident) (alert/oriented times 3), air mattress promoting skin integrity, non-compliant, refusing to reposition (every) 2 (hours). Res(ident) states, 'leave me alone I will call with my call light when needing help.' Res(ident) refused (urinalysis) x 2 per MD order. Res(ident) (with) 1 cm x 1 cm blanchable reddened area via L(eft) hip.... Res (with) impaired skin integrity (secondary to) non-compliance...." 9/30/11 10:10 p.m. "Resident pleasant and cooperative (with) cares this evening...." (Note: There were three areas of pressure sores.) 10/3/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 5.5 cm, Width 3.5 cm, Depth: 2, Tunneling: yes 4-4.5 cm, Exudate: small sero-sanguineous, Wound Bed: 80% granulation 20% slough. 10/3/11 (Pressure Ulcer Documentation Form) Site: left hip, Stage: II, Length: 2 cm, Width 1.5 cm, Depth:1, Tunneling: no, Exudate: none, Wound Bed: 100% granulation. 10/3/11 (Pressure Ulcer Documentation Form) Site: right hip, Stage: I, Length: 1 cm, Width 1 cm, Depth: 0, Tunneling: no, Exudate: just reddened. 10/6/11 at 3:35 p.m. "IDT Note: Resident pressure areas right hip 1 x 1 cm red area, left hip 1.5 x 1 x .1 cm new area, sacrum 5.5. x 3.5 x 2 cm, has some improvement, resident educated on need to turn at least (every) 2 hours but stated he did not care at this time, will encourage him to turn...." 10/13/11 (physician progress notes [REDACTED]. 10/19/11 at 7:35 a.m. "...Turned and repositioned (every) 2 (hours) and (as needed) for comfort, no acute distress noted, will observe..." 10/26/11 2:00 p.m. (physician progress notes [REDACTED]. Staff reports 2 weeks of [DIAGNOSES REDACTED] around sacral decubitus. Patient has no specific concerns, reports good pain control.... Skin - ring of [DIAGNOSES REDACTED] around sacral decubitus (plus) satellite [MEDICAL CONDITION] plan... 2. Sacral decubitus ulcer - continue treatment, appreciate wound care consult... 4.(situational depression) - patient has more animated affect today... patient declined psychiatric evaluation..." (Note: The physician did not address the left and right sores that had started or the resident psychiatric evaluation completed 10/13/11.) 11/7/11 at 7:00 p.m. "I noted a dressing to right ischial when changing dressing to back. Upon removal an area that measures 3 cm x 3.5 cm (with) darker red area to center measuring 1 cm x 0.6 cm, probable pressure area...." (Note: There were four areas of pressure sores.) 11/7/11 (Pressure Ulcer Documentation Form) Site: right ischial, Stage: unstageable, Length: 3 cm, Width 3.5 cm, Depth: Surface, Tunneling: no, Exudate: none, Wound Bed: 75% granulation 25% eschar. 11/7/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 6.5 cm, Width 2.4 cm, Depth: 2, Tunneling: yes 4-4.5 cm, Exudate: small sero-sanguineous, Wound Bed: 90% granulation 10% slough. 11/7/11 (Pressure Ulcer Documentation Form) Site: left hip, Stage: II, Length: 1.5 cm, Width 1.5 cm, Depth:1, Tunneling: no, Exudate: scant, Wound Bed: 100% granulation. 11/7/11 (Pressure Ulcer Documentation Form) Site: right hip, Stage: I, Length: .5 cm, Width 1 cm, Depth: 0, Tunneling: no, Exudate: none. 11/8/11 at 11:00 a.m. (physician progress notes [REDACTED]." 11/22/11 at 2:30 p.m. "Requested 2 plates for lunch, pleasant demenor (sic)...." 11/23/11 at 1:10 p.m. "IDT Note: Resident's wounds pressure area to right ischial 1 x 1 cm improved now presents as a stage I, sacrum 6 x 2.5 x 2 area clean, left hip 2.7 x 3 cm dark unstageable, right hip .5 x 1 cm reddened..." 11/23/11 (Pressure Ulcer Documentation Form) Site: right ischial, Stage: 1, Length: 1 cm, Width 1 cm, Depth: 0, Tunneling: no, Exudate: none, Wound Bed: 100% granulation. 11/23/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 5.8 cm, Width 2.2 cm, Depth: 2.1, Tunneling: yes, Exudate: small sero-sanguineous, Wound Bed: 95% granulation 5% slough. 11/23/11 (Pressure Ulcer Documentation Form) Site: left hip, Stage: unstagable, Length: 2.7 cm, Width 2.4 cm, Depth: ?, Tunneling: no, Exudate: none, Wound Bed: 100% eschar. 11/23/11(Pressure Ulcer Documentation Form) Site: right hip, Stage: I, Length: 1 cm, Width 1 cm, Depth: 0, Tunneling: no, Exudate: none. 12/2/11 at 2:30 p.m. "Met with IDT to discuss (plan of care).... (name) now has an indwelling catheter which is cared for per facility protocol. He is a paraplegic with multiple stageable areas. He does not leave his room and social services and activities are aware and provide cares as resident will allow. He has had no recent falls. He receives routine pain medication as well as (as needed) for breakthrough pain." 12/7/11 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 5.6 cm, Width 2.5 cm, Depth: 1.8, Tunneling: yes, Exudate: small sero-sanguineous, Wound Bed: 95% granulation 5% slough. 12/7/11 (Pressure Ulcer Documentation Form) Site: left hip, Stage: unstagable, Length: 3 cm, Width 3.3 cm, Depth: ?, Tunneling: no, Exudate: scant - serous, Wound Bed: 100% slough. 12/7/11 (Pressure Ulcer Documentation Form) Site: right hip, Stage: unstageable, Length: 3 cm, Width 3 cm, Depth: unable to measure, Tunneling: no, Exudate: scant serous, Wound Bed: 100% slough. 12/7/11 (Pressure Ulcer Documentation Form) Site: right ischial, closed 12/8/11 at 1:20 p.m. "IDT Note: Resident continues with community acquired pressure ulcer to sacrum measuring 5.6 x 2.5 x 1.8 cm. Improvement noted by very slow healing process. Also has pressure ulcer to left hip unstageable with slough measuring 3 x 3.3 cm. Right hip 3 x 3 cm unstageable. Right ischial is healed at this time...." The resident's pressure sores continued to improve. The resident had been turning and positioning and remained on an air bed. The pressure sores were observed on 4/11/12 at 11:00 a.m. to be: 4/11/12 (Pressure Ulcer Documentation Form) Site: sacral area, Stage: IV, Length: 2.5 cm, Width .9 cm, Depth: 1.3, Tunneling: yes 1.5 cm, Exudate: scant sero-sanguineous, Wound Bed: 100% granulation. 4/11/12 (Pressure Ulcer Documentation Form) Site: left hip, Stage: unstagable, Length: 3.8 cm, Width 4 cm, Depth: .7, Tunneling: no, Exudate: small-serous, Wound Bed: 40% granulation 60% slough. 4/11/12 (Pressure Ulcer Documentation Form) Site: right hip, Stage: unstageable, Length: 4.5 cm, Width 4.5 cm, Depth: .1, Tunneling: yes, Exudate: scant-serous, Wound bed: 20% granulation 80% slough. The DON and nursing consultant were interviewed on 4/10/12 at 10:00 a.m. and 4/11/12 at 3:00 p.m. They provided multiple pieces of documentation which are included in the write up. In addition, their consensus was that the skin breakdown was unavoidable because the resident's laboratory values were poor and the resident refused treatment. The resident was harmed when the facility failed to: -Prevent additional skin breakdown when the resident was medically unstable for more than two months, -Develop treatment plans for the resident's refusals of care, -Get appropriate mental health services involved with the resident's care. 2. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent Admission MDS assessment, dated 1/25/12, documented the following: * Moderately impaired cognitive skills for daily decision making * Independent with bed mobility, transfers, locomotion within the facility, dressing, personal hygiene, and toileting * Height of 5-feet, 8-inches, weight of 181-pounds * No pressure ulcers Resident #3's Skin Integrity Care Plan, dated 1/28/12, documented the following: * "Focus: Resident has impaired skin integrity r/t (related to) pressure ulcer secondary to: chronic progressive disease, non-compliance with therapeutic regime." * "Goals: Resident will have a reduction in size/stage of pressure ulcer; show no signs of infection; (and) comply with therapeutic regime." * "Interventions: Explain the risks and benefits of not following MD orders, and non compliance with treatment/interventions to reduce the risk of pressure ulcers; follow facility protocol/regime for treating breaks in skin integrity/pressure ulcers; weekly wound measurements, until resolved." NOTE: The resident had a number of additional interventions, as well, and was care planned for, and observed to have, a pressure reducing pad to his electronic wheelchair and pressure reducing mattress to his bed. A Physician's Progress Note, dated 2/17/12, documented, "Chief Complaint: New pressure ulcers on his buttocks ... the nursing staff has noted ulcers on his buttocks and would like to have those evaluated today. Bilateral ischial decubitis ulcers. These have a very foul odor, suggestive of a pseudomonas (bacterial infection). I did contact his plastic surgeon ... and informed him of the need to have these surgically debrided and evaluated within the next few days. He (Resident #3) was advised that he needs to be off of these ulcers in an effort to preserve what tissue can be saved. The pathology of the pressure ulcer was described to him in an effort to have him be compliant with offloading the areas." NOTE: Resident #3 was hospitalized for [REDACTED]. The resident was re-admitted to the facility on [DATE]. A Norton Plus Pressure Ulcer Scale Assessment, dated 3/20/12, documented a score of "12" for Resident #3. A score of "10 or less" designated a "high risk" for pressure ulcers. Resident #3's most recent Significant Change MDS assessment, dated 3/25/12, documented the following: * Intact cognitive skills for daily decision making * Extensive assistance of at least two staff members required for transfers and toileting * Extensive assistance of one staff member required for bed mobility * Limited assistance of one staff member required for dressing * Height of 5-feet, 8-inches, weight of 163-pounds * Two Stage II pressure ulcers not present during prior assessment The resident's Pressure Ulcer CAA, dated 3/25/12, documented, "Res(ident) requires assist with bed mobility, has had weight loss, has pressure ulcers ... also has DX [MEDICAL CONDITION] ([DIAGNOSES REDACTED]. Res(ident) has hx (history) of stasis ulcers with surgical intervention. He is also a smoker. Interventions are in place and being utilized." NOTE: An undated Behavioral Drug Monitor Flow Record documented the frequency of staff interventions for the following: "Specific Behaviors: Refusing dressing changes, refusing to lay down to get pressure off of buttocks, (and) provide (Resident #11) with information about pot(ential) adverse outcome if cares refused." Further review of the care plan revealed there was no care plan developed that would address the resident's non-compliant response to attempted nursing interventions such as positioning and wheelchair off loading. Recapitulated physician's orders [REDACTED]. Apply sureprep to periwound area then cover with a [MEDICATION NAME] dressing. Check (each) day shift and change (every) 5 days and prn (as needed)." Start date: 3/20/12. Pressure Ulcer Documentation Forms for February and March 2012 documented the progression of ulcers to the "left buttocks" and "right ischial." At it's worst, the left buttock wound was documented on 2/22/12 as measuring 2.4 centimeters (cm) by 1.1cm by "STDI" (unknown abbreviation), and the right ischial wound, at its worst, was documented as measuring 3.8cm by 1.5cm - no depth documented. Interdisciplinary Progress Notes (IDT Notes) for Resident #3 documented the following: * 2/6/12 - "He (Resident #3) has 3 pressure areas to buttock. Calazine (illegible). States they are very sore." * 2/11/12 (3:37 a.m.) - "Res(ident) c/o (complains of) bottom hurting when showering. Also two satelitle (sic) lessions (sic) on (right) buttock (illegible). Also on (right) buttock an unstageable pressure ulcer 3.8 X 1.5cm, yellowish slough in wound bed (and) red around edges. On left buttock was a 1cm circle, epthelial (sic) indurated, erythmic (sic) (and) tender area. Wounds were covered with a hydrogel to be changed (every) three day (sic). Dr. notified. Res(ident) has been educated on the need to get off of bottom (and) therapy asked to evaluate for repositioning ideas. Suggest he lay on side or stomach, continue to monitor." * 2/11/12 (6:30 a.m.) - " ... ref(used) for nurse to look at groin or feet, or buttocks." * 2/12/12 - "Res(ident) refused for nurse to look at bottom ulcers ..." * 2/15/12 (3:20 p.m.) - "N.O. (New order) received to start OT (occupational therapy) to eval(uate) (and) Tx (treat) for w/c (wheelchair) positioning d/t (due to) sores on buttocks. Res(ident) continues non-compliance (with) ... repositioning off of buttocks for pressure relief." * 2/16/12 - "Upon examination, noted SDTI on (left) buttocks. Also unstageable area to (right) ischial area. MD updated and new orders for dressings. New cushion put in w/c on 2/10/12. Areas have both improved in last 4-5 days. Resident has dx (diagnosis) of [MEDICAL CONDITION]." On 4/10/12, at 3:20 p.m., the facility's wound care nurse (LPN/WCC #5) was interviewed while performing a dressing change to the resident's two buttocks wounds and confirmed that Resident #3 had the two buttocks ulcers prior to his hospitalization in March 2012 and that the two ulcers developed while the resident was under the facility's care. On 4/11/12, at 4:00 p.m., the facility's Administrator and Regional Director of Clinical Operations (RDCO) were interviewed. The Administrator stated Resident #3's two Stage II buttocks ulcers were first discovered by an unnamed nurse on 2/6/12. However, that nurse, the Administrator stated, did not report the wounds to the DON until 2/10/12 and a treatment plan was then put into place. NOTE: The Administrator stated an in-house investigation was performed following the 2/10/12 report to the DON and the unnamed nurse who discovered the wounds on 2/6/12 was terminated from the facility for "neglect." The facility failed to prevent the development of multiple avoidable pressure ulcers to Resident #3's buttocks by not adequately addressing the resident's non-compliant behaviors or treating two Stage II pressure ulcers to the resident's buttocks for four days following their discovery. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], documented severe cognitive impairment (BIMS 4), extensive assistance for transfers and bed mobility, frequently incontinent of bladder, and at risk for pressure sores. No pressure sores were documented. The admission Nursing Assessment completed 11/18/11 documented the resident was at high risk for pressure sores related to a Norton Scale score of 9 (score 10 or less = high risk). Other than the resident's surgical wound to repair her ankle, the resident did not have any open areas or skin conditions. The following was documented in nurse progress notes: 3/13/12 (10:55 am)- "Skin check- no redness under breasts, armpits, abdominal folds, inner buttocks, or behind ears. Peri area clear of rash or visible skin breakdown. No c/o (complaints of) skin irritation or breakdown...." 3/15/12 (4:05 pm)- "Noted during CMS (circulation, motion, sensation) checks to LLE (left lower extremity) several scratches to top left foot, scabbed areas to (left great toe) and 2nd toe, leg protectors with no reinforced toe and no soak. Family notified. MD faxed with request for Bactrim ointment orders, soak applied and brace reapplied." 3/19/12, (2:40 pm)- "...LLE walking foot in place (and) CMS, no s/s (signs/symptoms of) infection to scabbed areas L great toe and 2nd toe, soaks in place under brace...." 3/23/12, (6:30 pm)- "Areas continue to R(ight) great and 2nd toe, no s/s infection, denies tenderness, boot to LLE, no c/o (complaints) voiced...." NOTE: The documentation should have referred to the left toes. 3/25/12, (11:00 am)- "N.O. (New order) Backtracin (sic) ointment to L 2nd and great toe scabbed areas and cover with borderguaze daily until resolved." 3/27/12, (4:40 pm)- "Called MD requesting to DC (discontinue) walking boot, (secondary) to very heavy and bulky for res(ident) to maneuver during therapies, etc. Could we have an order for [REDACTED]." 3/29/12, (7:20 pm)- "...Scabbed areas to L great toe and 2nd toe now resolved, treatment orders dc'd...." The resident's treatment records for March 2012 documented an order dated 3/25/12 for, "Apply [MEDICATION NAME] daily to left 2nd toe and great toe scabbed areas and cover with borderguaze until resolved. Day shift everyday." Documentation indicated the treatment was done 3/25-3/28 and was discontinued on 3/29. NOTE: The topical medication to treat the scabbed areas was requested by fax on 3/15/12 per the above nurse progress note. However, the order was not received until 3/25/12, 10 days later. There was no documentation that the facility attempted to call the physician's office to determine the status of the request. The Unit Manager LN#3 was interviewed on 4/10/12 at 1:45 pm. She was asked about the scabbed areas to Resident #4's toes. She said it was just a couple of scratches and was healed in 2-3 days. The surveyor requested any skin sheets available for detailed descriptions of the scabbed areas to the toes. On 4/11/12 at 8:30 am, the DON stated she had some documentation requests copied, but had been unable to locate any skin sheets for Resident #4. The facility failed to comprehensively assess and monitor the scabbed areas to the Resident #4's left toes. There were no staging, size or other descriptions documented. There was no indication that the facility had determined why the scabbed areas to the toes had developed. It was possible they were caused by the walking boot the resident wore related to her ankle fracture, however, no documentation determined this to be the cause.

Based on observation, staff and resident interview, and medical record review it was determined that: - Resident #5 was harmed by the facility when they failed to obtain care and treatment for [REDACTED]. In addition, the resident refused baths/showers on occasion and refused to wear clothing which had the potential to result in further isolation and decreased social contact. - The facility failed to develop appropriate care plan and or treatment interventions to address Resident #11's refusal of care related to assessments, the provision of therapies, and the administration of medication. In addition, there were no interventions for the behaviors that were described as either "verbally abusive" or "intimidating" to other residents in the facility and/or staff. This had the potential to result in quality of life and psychosocial decline for Resident #11 and placed other residents at risk for abuse. This was true for 2 of 13 (#s 5 and 11) sampled residents. Findings include: 1. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 7/26/11 documented the resident: *Was cognitively intact with a BIMS of 15 *Had moderate to moderately severe depression (D0300 = 14), *Did not have behavior problems, *Required extensive assistance for bed mobility, dressing, and personal hygiene. The quarterly MDS assessment, dated 10/19/11 documented the resident: *Had moderate depression (D0300 = 12), *Did not have behavior problems. The most recent quarterly MDS assessment, dated 1/14/12, documented the resident: *Was cognitively intact with a BIMS of 15, *Had minimal depression but did indicate he would be "better off dead," *Did not have behavior problems. None of the resident assessments documented that the resident was rejecting care. (E0800 = behavior not exhibited) The resident's initial care plan, dated 7/28/11 documented problems of: "Feelings of sadness, emptiness, anxiety, depression characterized by: ineffective coping, low self esteem, withdrawal from socialization, loss of independence, related to dependence, recent loss (initiated 7/28/11)" and "Negative feelings regarding self related to anger, ineffective coping related to: persistent sadness, grieving, mobility deficit (evidenced by) statements that he has let his family down, missing being home (initiated: 7/28/11)" These problems were no longer on the resident's active care plan. The interventions for the initial care plan were: (NOTE: All interventions were initiated on 7/28/11 unless otherwise noted.) "* Convey acceptance of resident and provide repeated honest appraisals of resident's strengths to resident. * Discuss feelings about placement with residents.(sic) * Discuss feelings of anger and options of appropriate channeling of these feelings with resident. * Encourage loved ones to keep in contact/visit. * Reassessment of need for Psychoactive drug every quarter by (nursing) and pharmacy. To be discussed at the Quarterly [MEDICAL CONDITION] Medication Committee Meeting. * Encourage resident to take active social role within facility. * Medications as ordered by MD, observe for and report any s/s(signs/symptoms) of adverse effects. * Assist resident through various phases of grief process. * Discuss beliefs, values, cultural traditions significant to resident and provide opportunity for resident to follow those important to resident when possible. " The active care plan in the resident's medical record had only one problem identified that would closely resemble a psychosocial problem with interventions. This was: "Resident needs recreational activities for some socialization. (Initiated: 10/19/11)." The interventions were: "* Invite to activities daily. * Encourage participation in beauty/barber shop etc. * Place activity calendar in room. * Involve in meaningful activities of interest: such as TV and socializing. * Offer praise and positive comments when attending activities. * Room visits and activities if resident stays in room: monitor activity needs, provide social opportunities. * Assure activity supplies are in room. Upon request. * Respect resident right to refuse. * Resident likes watching Movie, on his DVD player." NOTE: All interventions were initiated: 10/19/11. There was no documentation in the social service notes or nursing notes related to any of the 7/28/11 interventions being used with the resident. The resident's care plan was changed after 10/19/11, and the initial problems were not included in the care plan. These problems were: *"Feelings of sadness, emptiness, anxiety, depression characterized by: ineffective coping, low self esteem, withdrawal from socialization, loss of independence, related to dependence, recent loss." and *"Negative feelings regarding self related to anger, ineffective coping related to: persistent sadness, grieving, mobility deficit (evidenced by) statements that he has let his family down, missing being home." In addition, the resident was refusing cares and the facility failed to: 1) identify the behavior, 2) identify reinforcers for compliance, and 3) develop a treatment plan. The following notes were extracted from the medical record to show the issues that the resident presented to staff that the facility failed to address and/or develop a treatment plan for: SELF ISOLATION and ANGER: Initially the resident was up in his wheelchair and attended facility functions out of his room. (NOTE: There were multiple notes about turning the resident prior to 7/26/11 but none specific to refusals for getting out of bed.) The Nurse's Notes show a progression toward isolation starting with: * 7/26/11 at 2:45 p.m. "...refused to be gotten out of bed throughout the A.M. shift." (NOTE: This appeared to be the start of the resident self isolating himself in his room; was up in wheelchair prior to this.) * 7/29/11 at 3:00 p.m. "Resident wanted to stay in bed this shift...." * 8/20/11 at 1:45 p.m. "Refuses to get OOB (out of bed)..." * 8/23/11 at 2:00 p.m. "Res(ident) in bed all shift..." * 9/26/11 at 9:45 p.m. "Resident became angry as I was coming onto shift. He stated he had asked for a pain pill (and) his request was not passed to the nurse. Res stated he had waited 45 minutes before calling again. Resident later was medicated for pain (and) fell asleep during the time trays were passed and picked up. When he awoke he asked where his food was. I asked the aide picking up trays. The aide stated resident was asleep so tray was sent back when they were picking up. Resident came back to say, 'So, this is the punishment I get for yelling at the aides today?' I told him of course not. He then said, 'well, how would you explain it then.'...." PRESSURE SORE: Resident #5 was admitted with a stage III pressure sore. The resident would refuse to stay positioned on his side and roll back onto his back, and also would refuse to let staff change the dressing. (NOTE: See additional information at F314 related to pressure sores). Nurse's Notes revealed the following: 7/27/11 at 12:00 a.m. "...Turned side to side (every) 2 hours, but resident often reposition self back onto his back/buttocks/spine. Res(ident) educated (and) encouraged to stay of (sic) wound but is not always compliant despite these efforts...." 7/31/11 at 12:00 a.m. "...Also noted to be non-compliant (with) turning schedule...." 9/9/11 at 5:00 p.m. "...Addressed resident to change dressing to bottom. Resident refused at this time, stated he didn't want to be bothered right now. Nursing returned around 1:15 p.m. and re-offered dressing change, resident appears to be sad and was not cooperative. Reinforced skin issues/risks. Did allow staff to change position (every) 2 (hours) and PRN...." 9/29/11 at 4:30 a.m. "Res(ident) (alert/oriented times 3), air mattress promoting skin integrity, non-compliant, refusing to reposition (every) 2 (hours). Res(ident) states, 'leave me alone I will call with my call light when needing help.' Res(ident) refused (urinalysis) x 2 per MD order. Res(ident) (with) 1 centimeter x 1 centimeter blanchable reddened area via L(eft) hip.... Res (with) impaired skin integrity (secondary to) non-compliance...." REFUSAL/NON-COMPLIANT OF CARES: Nurse's Notes documented several refusals for care in addition to those related to the pressure sores. For example: * 8/2/11 at 3:00 a.m. "Frequently non-compliant with hand washing before and after self cathing, antibiotic therapy continues for a UTI..." * 8/2/11 at 5:20 p.m. "Spoke (with) resident about orders to send to ER(emergency room ) Res(ident) adamant that he does not wish further aggressive treatment. Does not want transfusion or hospitalization , does not desire wound vac treatment or blood glucose checks. Res wishes to be treated (with) comfort measures only. Res states he knows that he may die if critical labs are not addressed...." * 8/8/11 at 3:00 p.m. "Resident refused to get out of bed for daily weights...." (NOTE: IDT notes document refusal for weights on 8/11/11, 8/25/11, 9/8/11, and 9/15/11) The physician wrote an order for [REDACTED]. The physician wrote an order for [REDACTED]. The resident refused to finish the evaluation, but the practitioner was able to get enough information to do an effective evaluation and give a [DIAGNOSES REDACTED]. Axis I: "Depression - severe situational/adjustment. Axis IV: "Psychosocial stressors severe secondary to [MEDICAL CONDITION], separation from family, inability to be employed and engage in social activities." Axis V: "GAF(Global assessment of Functioning).... Currently 10 - 15." (NOTE: GAF score of 10 = In persistent danger of severely hurting self or others.) The NP gave a recommendation and also documented "I will be glad to F/U (followup) as needed." The Social Service representative on 10/19/11 sent a FAX to the physician that documented: "(Resident #5) refused psych eval, just as we suspected. We would like to see if you'd consider adding med(ication) in addition to the [MEDICATION NAME]. Please advise." The resident was seen by an LMSW on 3/8/12 (NOTE: 7+ months after admission and almost 5 months after he was seen by the NP). The social worker documented: "....Then asked resident if he was doing ok here and how he was doing emotionally - thoughts of just wanting to die d/t (due to) his health conditions. He is bed ridden at this time. He use (sic) to have a full active life, and now lays in a bed all the time. This resident is very angry d/t circumstances (health) instantly attacks verbally to staff (and) this SW. Spoke to CNA's on the floor (and) RSD (Resident Services Director), Administrator who state this is how he is. Resident then told SW how he thought SW should do job - don't just sit in an office (and) play, get to know residents before you talk to them. SW then again apologized. This resident reported no plan or attempt to commit suicide (and) then told SW he's sick of 'you guys' asking and not respecting him..." The RSD was interviewed on 4/10/12 at 9:25 a.m. The RSD was asked two questions, then excused herself from the room. These were: * "If a resident has social issues, how are you dealing with them and developing a care plan to address the needs he has." The RSD response was a tearful, "I don't know what to tell you." * "Don't you have someone to help you with complex social issues?" The response was a tearful, "No I don't!" The resident was interviewed on 4/9/12 at 1:30 p.m. After the surveyor established a rapport with the resident, he was very responsive to the questions asked, and did not voice any negativity toward the facility. He felt the staff treated him well. (NOTE: Psychosocial issues are not part of the interview questions, so the subject did not come up.) The resident was harmed when the facility failed to obtain care and treatment for [REDACTED]. The facility: * Failed to get mental health involved with treatment and care in a timely manner, * Failed to develop a care plan/treatment plan to address a variety of mental health issues including refusal of care that resulted in a decline in physical functioning, and * Failed to assist the resident to deal with his losses. The Administrator and DON were informed on 4/11/12 at 4: 30 p.m. Further information was provided and is incorporated in the report. 2. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 3/28/12, documented the following: * Intact cognitive skills for daily decision making * Easily annoyed * Verbally threatened, screamed, and/or cursed at others * Rejected evaluations and/or cares Resident #11's Cognitive Loss/Dementia CAA, signed by the RSD and dated 7/20/11, documented, "(The resident) can be irritable and intolerant of staff requesting he go take his shower on designated shower days and he can have verbal outbursts to get his point across. He will get angry ..." The resident's Behavior CAA, signed by the RSD and dated 7/20/11, documented, "(Resident #11) has refused some baths during assessment period and he has had a couple of verbal outbursts to staff during assessment frame. Will proceed to address in care planning." The resident's ADL Functional/Rehabilitation Potential CAA, dated 7/25/11, documented the resident had "daily behavioral symptoms/decline in behavior." A Quarterly Nursing Assessment, undated, documented Resident #11 was "agitated at times, verbally abusive at times" and displayed "anger at times." A Quarterly Nursing Assessment, dated 12/28/11, documented the resident was "agitated (at) times, verbally abusive (at times)" and displayed "anger (at) times." Resident #11's Care Plan, dated 1/10/12, included identified problems, goals, and interventions for leisure activities, nutritional status, self-administration of medications, ADLs, respiratory care, falls prevention, pain, skin care, mood impairment, and smoking. A section of the Care Plan, not specifically addressed to "behaviors," documented the following: * "Focus: History of dissatisfaction with facility, resistance at times to complying with the smoking policy, refusal to take baths, maintain appropriate grooming." Start date: 5/3/11. * "Goals: (Resident #11) can live in this facility and follow rules." * "Interventions: Report any non compliance with smoking policy to Administrator and Social Services. Make sure (Resident #11) has a copy of the smoking policy. Encourage (Resident #11) to go to Resident Counsil (sic) meetings. Meeting with the Ombudsman, Administration, RSC (Resident Services Coordinator), and (Resident #11) as indeicated (sic). Let Administration and RSC know if (Resident #11) is refusing his baths." Recapitulated physician's orders [REDACTED]." That order was initiated on 5/20/11. An undated Re-admit Social Services Assessment documented, "(Resident #11) can be hostile (and) angry (and) non accepting at (sic) rules and information communicated to him. He sometimes gets mad (and) will insist that is able to 'walk out of here (and) get a job (and) go to work,' etc. It has been ongoing - difficulty accepting rules." Resident #11's Interdisciplinary Progress Notes (IDT Notes) documented the following: * 4/13/11 - "Interviewed (Resident #11) (and) DNS (Director of Nursing Services) to follow up on reports from staff members that he was very hostile (and) verbally abusive to confused resident who bumped into his chair at breakfast today. (Resident #11) denied using foul language or loud vocals, but acknowledged he was upset (with) res(ident) bumping into him (and) told him to go back where he belongs. Staff statements do state he was using foul language (and) was very intimidating to other res(ident). (Resident #11) essentially would not listen to anything said." * 5/10/11 - "(Resident #11) returned from the hospital stay was treated for [REDACTED]. He returned from the hospital (with) an order for [REDACTED]. * 5/18/11 - (Resident #11) ref(used) to answer MDS interview questions, but that is not unusual. I asked staff about mood, we all agree that he is not as happy as when he returned - multiple mood indicators." * 5/19/11 - "Dx (Diagnosis) of anti social behaviors (with) aggression." * 10/6/11 - "Attempted to interview (Resident #11) for MDS. He ref(used) to answer any questions, citing it was stupid (and) he didn't have to. He generally dislikes a lot of the staff, he doesn't care for our schedules, etc. He often states he's leaving but when I approach to set up a plan he pretty much ignores me. He is aware of res(ident) rights, states he does agree 'you have too many rules.'" * 10/11/11 - "(RSD and one other staff member) visited (with the resident) about the reported incident in dining room this (morning), he denied there was (sic) any problems. After visiting (with) him a bit though he did acknowledge he told another res(ident) she should go back to Mexico where she belongs. Denied using foul language in this conversation. He can be loud in vocals when upset and he was upset ..." * 12/28/11 - "Tends to focus on what he wants to hear if theres (sic) conversation he's not wanting to listen too (sic). He often refuses medications, showers, etc. Also smokes is safe in smoking, sometimes requires review of appropriate/designated smoking area (likes to smoke out front)." * 1/9/12 - "Resident provided urine specimen by urinating in clean urinal. This was for an ordered UA (urinalysis) (with) micro [MEDICATION NAME]. When lab came to draw blood for ordered labs, resident refused, and told the phlebotomist that he has given enough blood to figure out what is wrong with him. Resident was educated that some meds he takes neccesitates (sic) lab work to ensure his safety. He still refused." * 1/11/12 - "Res(ident) c/o (complained of) headache tylenol 650 (milligrams - mg) given ... Res c/o of headache not being completely gone, asked for more tylenol. Education provided about how often tylenol can be taken. Res(ident) cursed and yelled. 'I'll get this taken care off (sic)' and stormed off." * 1/12/12 - "Skin assessment attempted - res(ident) states he does not want anyone to see him naked. Asked if he would allow this nurse to view his legs/feet/arms (and) he consented to allow nurse to view areas that could be viewed (without) removing his clothing. Does have thick toenails but states he 'cuts them himself' ... declines podiatry consult." * 1/16/12 - "Res(ident) refused skin check but visible skin is intact ..." * 1/18/12 - "Spoke (with physician's name) re(garding) res(ident's) refusal of meds ... Administrator ... call (sic) him (with) fac(ility) policy re: refusal of care (and) non-compliance." * 1/23/12 - "Res(ident) refused skin check saying 'skin was still same color' ..." * 1/27/12 - "Resident refused meds in early am (morning), offered later; but refused them again." * 1/30/12 - "Res(ident) refused weekly skin check." * 1/31/12 - "Res(ident) had non-productive cough x3 (three times) last night, was offered cough syrup and he refused ..."* 2/6/12 "Resident refused weekly skin (check) ..." * 2/8/12 - "Res(ident) was heard yelling (at) a tablemate after breakfast. Resident was redirected (without) incident." * 2/20/12 - "Res(ident) refused evening medications and skin assessment." * 2/27/12 - "Res(ident) refused skin check, stated his feet was (sic) good (and) had no problem with his ass." * 3/5/12 - "Res(ident) refused skin (check) ..." * 3/12/12 - "Res(ident) refused evening medications and skin check." * 3/26/12 - "Res(ident) refused scheduled medications and weekly skin assessment." * 3/30/12 - "Res(ident) mad (at) nurse at (9:30 p.m.) for not getting medicine (Tyl(enol)) for HA (headache). Nurse apologized (and) asked if I could get the Tyl. Res(ident) stated, 'Forget it, I was the worst RN he had, and he would contact Id(aho) Board of Nursing (every) day until I lost my license.' Res(ident) then went to supervisor and yelled at supervisor. Supervisor gave Tyl. to res(ident). Res(ident) left and went to bed." * 4/2/12 - "Res(ident) refused shower (and) skin assessment." * 4/5/12 - "Resident asked if lab had drawn (complete blood count and complete metabolic panel). Res(ident) stated, 'I refused to let them draw my blood! It's just a racket anyway so they can bill Medicaid!'" * 4/9/12 - "Res(ident) shower day, taken but refused skin checks. Res(ident) took medications and came to me (two hours) later and said he wasn't taking his medication anymore, stating 'they make him sick.'" No c/o n/v (complaints of nausea and/or vomiting), but wanted some '[MEDICATION NAME] to calm him a bit.'" Resident #11's MARs for January and February 2012 documented the following: * January 2012: - Refused [MEDICATION NAME] (ordered for hypertension) each day of the month - Refused [MEDICATION NAME] (ordered for anxiety) 14 days of the month - Refused [MEDICATION NAME] (ordered for [MEDICAL CONDITION]) 27 days of the month - Refused [MEDICATION NAME] (ordered for [MEDICAL CONDITION]) 59 of 62 opportunities to receive - Refused [MEDICATION NAME] (ordered for [MEDICAL CONDITION]) 43 of 62 opportunities to receive * February 2012 - Refused Aspirin (ordered for hypertension) 23 days of the month - Refused [MEDICATION NAME] 28 days of the month - Refused [MEDICATION NAME] 15 days of the month - Refused [MEDICATION NAME] 27 days of the month - Refused [MEDICATION NAME] 61 of 62 opportunities to receive - Refused [MEDICATION NAME] 49 of 62 opportunities to receive - Refused weekly fingernail/toenail trimming 4 of 4 opportunities to receive - Refused weekly skin checks 3 of 4 opportunities to receive On 4/11/12, at 3:45 p.m., the RSD was interviewed. When asked whether Resident #11 received any counseling related to his refusals of assessments, cares, and medications, as well as in relation to the "verbal abuse" and "intimidation" exhibited toward both staff and other residents, the RSD stated, "I asked him, he doesn't want it." When asked whether the facility was meeting the resident's needs, the RSD stated, "This probably isn't the right place for him." The facility failed to appropriately assess and develop a comprehensive Behavior Care Plan to address Resident #11's repeated refusals of assessments, medications, and treatments, or the verbally abusive and intimidating behavior of the resident. This failed practice placed both the resident and other residents at risk for harm.

Based on observation, resident and staff interview and record review, it was determined the facility failed to ensure residents' safety from falls for 4 of 13 sample residents (#4, #6, #7 and #9). *Resident #4 was harmed when a fall resulted in head injury requiring sutures. Interventions to prevent further falls were not implemented. *Resident #6 was harmed when staff error caused a fall from a shower chair which resulted in a concussion, muscle sprain and pain. *Resident #7 sustained 2 falls related to lack of care planned footwear and self transfer to the toilet after the call light was not answered timely at night. *Resident #9 fell hours after admission. Assessment and interventions had not been put in place. Findings include: 1. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 3/13/12, documented transfer and ambulation did not occur during the evaluation period, the resident required the extensive assistance of 2 staff for bathing, and experienced frequent pain of "7" on a scale of 1-10, 10 being the highest level. Resident #6's 3/30/11 Falls Care Plan identified a problem of risk for falls related to unstable health condition, pain, generalized weakness. The goals were documented as "No significant injury related to a fall, decreased number of falls by next review." Interventions were described, in part, as use of a hoyer lift for transfers and 2/05/12 staff education and therapy to screen resident for wheelchair positioning. Incident/Accident reports were reviewed and revealed the resident had requested to be readjusted in her wheelchair on 2/5/12 at 11:15 a.m. The report described a CNA held the resident under her arms while another CNA held her legs to readjust her position. The Hoyer pad slid on the wheelchair cushion and the resident was lowered to the floor with her head resting on the wheelchair cushion. No injury was noted as a result of the incident. An inservice record was attached to the report which included the instruction to staff not to physically lift residents requiring Hoyer transfers to adjust position. Staff were instructed to take the resident back to their room, use the Hoyer to transfer them to bed, adjust the pad and return them to the chair via Hoyer lift. According to an investigation report for possible neglect, dated 2/23/12, Resident #6 experienced a fall on 2/23/12 at 8:30 a.m. The report documented the resident fell backwards in a shower chair during transfer with a Hoyer lift. The incident was described as 1 CNA operating the Hoyer lift while the other CNA "slightly tilted back" the shower chair as the resident was lowered into the chair. As the Hoyer lift was released and moved back away from the shower chair, the CNA holding the chair in a "tilted" position lowered it forward to the floor. The chair reportedly flipped backwards at that point, and when the CNA grabbed the bar on the back of the chair to stop the descent, the bar broke. This caused the resident to fall backwards hitting the floor, still seated in the chair. The resident complained of pain to the neck and lower back and was transported to the emergency room for evaluation and treatment. The emergency room report, dated 2/23/12, documented the resident did not lose consciousness as a result of the fall, but did complain of severe pain in the head and neck. The resident received Fentanyl (narcotic analgesic) en route to the hospital. The report documented the treatment with both morphine (narcotic analgesic) and Dilaudid (narcotic analgesic) for pain during the emergency room visit, with a decrease of pain down from a level of 10 to 4. An additional unidentified prescription was reportedly ordered for use after discharge. The report listed [DIAGNOSES REDACTED]. Physician Orders, recapitulated, for 3/12 documented the resident had orders for pain control, dated 2/27/12, for Hydrocodone-Acetaminophen 5-325 mg (narcotic analgesic) 1 -2 tablets as needed every 6 hours. This was in addition to the 5/23/11 order for Duragesic-25 (Fentanyl) patch every 3 days for pain. The resident was interviewed on 4/10/12 at 1:45 p.m. about the fall on 2/23/12. She stated she was in a lot of pain in her neck/head/back after the fall, and it had decreased only slowly over time. The DON and Clinical RN Consultant were interviewed about the incident on 4/12/12. They reiterated facts about the incident in the investigation, and stated 1 of the 2 CNAs involved had been terminated as a result of the investigation. No further information was provided during the interview. Resident #6 was harmed as a result of staff error in transfer technique, and suffered a concussion, muscle sprain and severe pain. This incident occurred 18 days after a previous controlled fall from the wheelchair related to improper technique by staff and staff inservice training on Hoyer lift transfers. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], documented severe cognitive impairment (BIMS 4), extensive assistance for transfers and bed mobility, frequently incontinent of bladder and history of falls. A CAA was triggered for falls and documented, "...had a recent fall with a fracture to her left ankle which makes her have problems with her balance. She has difficulties moving on and off the toilet, surface to surface transfers and moving from seated to standing position which makes her at risk for falls. She is at risk for further falls due to her daily use of anti-anxiety medication and antidepressants. Fall preventions have been put into place and are being utilized." The facility "Resident Fall Evaluation" form did not result in a determination of risk for the resident related to falls. However, the documentation on 11/18/11 indicated the resident had a fall in the last 30 days and had changes in ability for transfers and mobility. The same form documented on 2/10/12 the resident had a fall in the facility. The resident's care plan related to fall risk was initiated 11/19/11 and last revised on 3/1/12. Interventions included: *Non slip footwear *Personal items within reach *Reinforce call light use for assistance *Place call light in reach *Clutter free environment *Pressure alarms to bed and w/c (wheel chair), check placement and function each shift NOTE: The resident was cognitively impaired and had a history of [REDACTED]. Interventions to use the call light or call for assistance were not realistic for the resident due to her dementia. Nurse progress notes were documented as follows: *2/10/12 (1:40 pm)- "Res(ident) had fall at (11:15 am). Alarm sounded and found res on floor next to restroom. Noticed immediately res was bleeding from laceration to head. Pressure applied and bleeding stopped. Small skin tear to (right) wrist, approximated. Family and MD (Medical Doctor) notified. Sent to ER (emergency room ) for eval(uation). A plan to use toileting schedule since res was unassisted in restroom at time of incident." *2/10/12 (6:20 pm)- "Res returned from ER (with) orders to monitor for infection, removed (sic) sutures in 5-7 days and (follow up with) MD if problems arise." (Confirmed by documentation on "emergency room Instruction" form dated 2/10/12). The facility "Event Report," dated 2/10/12, documented, "Alarm was sounding. Door to room closed. Upon opening door, found res lying on the floor. Res was on her right side next to the restroom. Her w/c was in the restroom..." The recommendation to prevent further falls section documented, "Toileting schedule (sic), continue with alarms and therapy for strengthening." The Root Cause Conclusion section documented, "res forgot to seek help prior to transfer/ambulation, dt (due to) her dementia and poor safety awareness." An attached form indicated the IDT (interdisciplinary team) reviewed the event on 2/11/12. Immediate interventions in place to prevent further injuries/falls included a toileting plan and bowel and bladder pattern assessment. Hand written entries were added to the care plan and were dated 2/10/12 as follows: *Toilet between 10:30 - 11:00 am as requested and before meals. *Bowel (and) bladder assessment. These two interventions were carried over to the current care plan revised on 3/1/12. The current care plan did not have any interventions for increased supervision. The Unit Manager LN#3 was interviewed on 4/10/12 at 1:45 pm. She was asked why the care plan listed specific times to toilet the resident between 10:30 and 11:00 am. She stated this was the time she had her fall so it was care planned to toilet her at that time. (Please refer to F315 for additional findings related to incontinence and toileting program for this resident). The facility did not supervise Resident #4 who was a known fall risk, had severe dementia and poor safety awareness. The resident fell and was harmed when she received a head injury that required sutures in a hospital emergency room . Measures to prevent future falls were not established. In addition, the resident did have pain and was medicated for pain related to her head injury as documented on the facility "Pain Evaluation" completed 2/10/12. 3. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], documented severe cognitive impairment (BIMS 3), extensive assistance for transfers and bed mobility, frequently incontinent of bladder and history of falls. A CAA was triggered for falls and documented, "...had a fall at home with a fracture to her left wrist and she has fallen in the facility. She does have poor safety awareness and has difficulties with moving from a seated to a standing position, ambulation, moving on and off the toilet and surface to surface transfers. Multiple fall preventions have been put into place and are being utilized." The facility "Resident Fall Evaluation" form did not result in a determination of risk for the resident related to falls. However, the documentation on 2/15/12 indicated the resident had a fall in the last 30 days and had changes in ability for transfers and mobility. The same form documented on 2/15/12 and on 2/17/12 the resident had a fall in the facility. The resident's care plan related to fall risk was initiated 2/15/12. Interventions included: *Assist resident getting out of bed with 1 person assistance using roll walker with platform. *Non slip footwear. *Have commonly used articles within reach. *Reinforce call light use for assistance. *Place call light in reach. *Clutter free environment Hand written revisions were added to the care plan. *2/15/12- "Pressure alarms to bed and w/c to cue resident to wait for assist." *2/17/12- "Anti-roll back bar to w/c." *3/18/12- "Self releasing seat belt (with) alarm, placed on w/c. Family and MD notified." Direction included to check placement and function of belt every shift and to release the resident every 2 hours and as needed. Nurse progress notes were documented as follows: *2/15/12 (8:00 pm)- "CNA ambulating past residents (sic) room and found her sitting on her rear-end next to the bathroom door, situated on her right buttock. When questioned resident states she wanted to go to the bathroom. Resident had been toileted approx(imately) 20 minutes prior to the event upon leaving the dining room. Resident noted to be incontinent of loose stool & urine. Denies hitting head or other injury, states she 'slid down the door because I couldn't get it open.' Resident assessed and no injury noted...Notified family and consent obtained for pressure alarms..." *2/17/12 (10:15 pm)- "Res alert with confusion. See change of condition form for details about fall at (2:30 pm) this shift...Alarms working properly. Continues to self transfer despite queing (sic) & education." NOTE: Expecting the resident to retain education concerning alerting staff or using call lights was not realistic given her cognitive status. The facility Event Report, dated 2/15/12, documented the resident fell at 8:00 pm. As the nurse note indicated, the resident fell and self reported she was attempting to go the bathroom. No injuries were noted. The conclusion of root cause was, "Cognitive issues related to dementia. Has poor safety awareness and limited insight into her limitations." On 2/15/12 an addition to the care plan included pressure alarms to bed and wheel chair and cue the resident to wait for assistance. An Event Report, dated 2/17/12 (2:30 pm), documented the following: "A PT (Physical Therapist) observed the fall and stated that resident's alarm was sounding and PT began to go into the room. When entering, she observed patient holding the w/c in front of her and then lost balance and fell to the floor on right side. PT stated she did hit her head. I checked her left arm and no injury or complaints of pain...Education implemented to resident about the risks of transferring/ambulating without proper assistance. Resident asked what she was trying to do and she stated 'walking.' ...Interventions included adding anti-rollbacks to the w/c. This was care planned on 2/17/12. On 3/18/12 a facility "Device Evaluation" form was completed for the use of a seat belt with alarm. The medical necessity was, "To create patient safety & prevent falls in future." The documentation indicated the resident could release the safety belt on command. This intervention was implemented a month after the resident's last fall on 2/17/12. There were no additional nurse notes of event reports to indicate the resident had fallen again. The unit manager LN#4 was interviewed on 4/10/12 at 1:45 pm. She was asked why the seat belt had been placed. She said for her safety and she has had no falls since it was implemented. The facility failed to supervise Resident #9 so she would not fall. She came to the facility as a known fall risk and fell approximately 4 hours after she was admitted . She fell again in 2 days. The facility did not determine what additional supervision was needed and relied on educating the cognitively impaired resident on safety and adding alarms to her. The burden to be safe was placed on the resident who lacked insight and judgement regarding her safety. 4. Resident # 7 was admitted to the facility 1/25/12 with [DIAGNOSES REDACTED]. The most recent admission MDS assessment dated [DATE], documented the resident: *Was severely cognitively impaired with a BIMS of 6, *Was moderately depressed, *Required extensive assist for bed mobility, transfers, dressing and personal hygiene, *had a history of [REDACTED]. *Was receiving antipsychotic, antidepressants, and hypnotics medication. The resident's most recent care plan, dated 1/25/12, documented a problem of: "Risk for fall related to: unsteady gait, pain." "Fall with (no) injury" was added on 2/9/12, "Fall with abrasion" was added on 2/14/12 and "Fall (assisted to floor) no injury" was added on 3/18/12. The interventions that were on the care plan were: "* Offer toileting every 2 hours (initiated: 2/14/12), * Side rails up X 2 while in bed as an enabler (initiated: 1/25/12), * Encourage resident to use handrails or assistive devices properly (initiated: 1/25/12), * Resident to to wear non slip footwear (initiated: 1/25/12), * Call MD to address psychotropic meds (2/9/12), * Cont(inue) with therapy for strengthening and endurance (2/9/12), * Place walker within easy reach (2/14/12), * Do not use resident pink slippers, family will take home and replace them (with) safe slippers (3/18/12)." During an interview with the resident on 4/10/12 at 2:00 p.m. the resident gave a general statement that in the past she had put her call light on and no one responded for a long time. As a result of the wait the resident said that she had an incontinence episode. When the aide came in to answer the call light she further stated that she was "scolded" by that staff member. The resident further stated she would get up on her own even though she was supposed to wait for help. The facility's incident and accident reports were reviewed. The resident had two falls related to toileting and improper footwear that were documented as: a. On 2/9/12 at 12:10 a.m. "Res(ident) went to the bathroom and fell in the doorway." The facility documented a probable root cause of: "(No) footwear at the time of the fall. Res(ident) is here for therapy (related to) weakness. She is also on 2 psychotropic med(ications) (with) PRN Ambien. b. On 2/14/12 at 3:45 a.m. "Res(ident) fell trying to toileting (sic) herself. The facility documented a probable root cause of: "The need to toilet, improper footwear." The resident sustained [REDACTED]. The facility failed to provide sufficient supervision to ensure that Resident #7 got to the bathroom before having an incontinence episode and ensure that she had proper footwear on when she self initiated toileting. The Administrator and DON were interviewed about the falls on 4/10/12 at 4:15 p.m. An investigation was started related to the residents allegation of staff scolding her. No other information was provided.

Based on record review and staff interview, it was determined the facility failed to prevent residents from severe, but avoidable, weight loss. This was true for 1 of 5 residents (#2) sampled for nutritional status. Resident #2 was harmed when he experienced a "severe" weight loss of 13-pounds in three months time. This weight loss amounted to an 8.7-percent reduction of the resident's total body mass in three months. Resident #2 also experienced a "significant" 9.45-percent loss of his overall body mass over a six-month period between 10/3/11 and 4/2/12. Findings include: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/13/12, documented the following: * Severely impaired cognitive skills for daily decision making * Set-up assistance only required for independent eating * Height of 5-feet, 8-inches, weight of 136-pounds * Weight loss of 5-percent or greater within the previous month Resident #2's Nutritional Status CAA, dated 6/2/11, documented, "This CAA triggers d/t (due to) use of mechanically altered diet d/t coughing and mild dysphagia r/t (related to) [MEDICAL CONDITION]. Functional problems that affect ability to eat: swallowing problem; functional limitation in range of motion, inability to perform ADLs without significant physical assistance." Recapitulated physician's orders [REDACTED]. * Regular texture diet. Start date: 7/26/11. * "Clarification of therapy order received 7/27/11. ST (Speech Therapy) clarification order. PT (Patient) to be seen 5 X Wk X 30 days (five times weekly for 30 days) to address safe swallow strategy use and tolerance of diet." Start date: 9/15/11. * "Snacks at (10:00 a.m. and 3:00 p.m.) twice a day everyday." Start date: 1/27/12. The resident's Nutritional Status Care Plan, dated 2/8/12, documented the following: * "Focus: Potential alteration nutrition status AEB (as evidenced by) dx (diagnosis) of dementia, dysphagia, s/p (status [REDACTED]. * "Goals: Will not have significant change in weight of 5% in 30 days or 10% in 180 days." Date initiated: 8/2/11. Target date: 4/13/12. * "Interventions: Visit routinely for food preferences (Start date: 2/8/12); add fortified foods (Start date: 2/8/12); provide diet per MD order (Start date: 8/2/11); provide snacks as desired (start date: 8/2/11); monitor weights routinely (Start date: 8/2/11); monitor labs as available (Start date: 8/2/11)." A Weights and Vitals Summary for 5/31/11 through 4/2/12 documented Resident #2's weight as 149.0-pounds on 10/10/11 and as 136.0-pounds on 1/9/12. This 13-pound difference represented an 8.7-percent loss of total body mass in three months. NOTE: Federal guidance at 483.25(i)(2) specifies that a weight loss in excess of 7.5-percent is "severe." According to Understanding Normal and Clinical Nutrition, 6th ed., by Whitney, Cataldo, and Rolfes, "Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1.5 to 2 pounds per week or weight loss of more than 1 percent of body weight per week ..." A Medical Nutrition Therapy Assessment, dated 6/2/11, documented the resident had full dentures, had no known food allergies [REDACTED]. The form also documented the resident's weight as 150-pounds, DBW (desired body weight) of 150-to-170 pounds, and that the resident had a "swallowing assessment" that documented, "ST states he has mild dysphagia." The form also documented, "Resident is at nutrition risk d/[MEDICAL CONDITION] has resulted in mild dysphagia and need for mechanically altered diet. He can feed himself in main DR (dining room) and meal intakes are adequate for needs. He does have some coughing (with) his meals. BMI (Body Mass Index) is in normal range." NOTE: A Food Preferences Interview form, dated 7/28/11, included a handwritten note that read, "Likes most all things/whatever we bring him is fine." A Medical Nutrition Therapy Assessment, dated 8/2/11, documented the resident received "regular" textured meals, was independent with eating, dined in his own room, pocketed food, and had a desired body weight of 154- to 174-pounds. The form also documented, "Resident at nutrition risk r/t dementia, dysphagia, s/p [MEDICAL CONDITION], and HTN. PO (Oral) intakes averaging 100% for most meals. Weight is 155 (pounds) at time of admit. Dines in own room per resident preference. BMI in ideal range ... No adaptive equipment, but does pocket his food at times. ST following." A Medical Nutrition Therapy Assessment, dated 11/30/11, documented the resident was receiving snacks twice daily, was independent with eating, dined either in the main dining room or his own room, exhibited "no problems" with swallowing, had "dysphagia - oral pharyngeal phase," weighed 142-pounds, and received "regular" textured meals. The form also documented, "Resident remains at high nutrition risk r/t dx HTN, hx (history of) [MEDICAL CONDITION], dysphagia, and dementia. Meal intakes average 75% for all meals. Labs done and all within normal range. Dines independently in main dining room for most meals." A Medical Nutrition Therapy Assessment, dated 1/25/12, documented the resident weighed 134-pounds, dined in the main dining room or his own room, was independent with eating, had "dysphagia - tolerating current texture," and meal intakes had declined to 75-percent for breakfast, 50-percent for lunch, and 25-percent for dinner. The form also documented, "Recent weight loss of 4% (in) 30 days. Gained 2 lbs (pounds) back this week. Receives snacks BID (twice daily), including HS (bedtime) snack. Skin is intact. Hx (of) swallowing difficulty - tolerates regular texture at this time. BMI is at lower end of ideal range." The facility was requested to provide meal consumption records for Resident #2 for October 2011 through January 2012. The facility provided those records for October and December 2011, as well as January and February 2012. The record for November 2011 was not given to surveyors by the facility. Those records documented the following: * October 2011 - No data documented for breakfast on 10/19, 10/24-28, and 10/31 - No documentation of alternate breakfast offered when consumption was 50-percent or less on 10/3, 10/5-8, 10/12, 10/17, and 10/20 - No data documented for lunch on 10/10, 10/20, 10/30-31 - No documentation of alternate lunch offered when consumption was 50-percent or less on 10/5, 10/7, 10/9, 10/11-12, 10/17, 10/19, 10/22, and 10/24-27 - No data documented for dinner on 10/4, 10/17, and 10/22-23 - No documentation of alternate dinner offered when consumption was 50-percent or less on 10/9, 10/12, 10/15, 10/25-26, and 10/29-31 - No data documented for snacks * December 2011 - No data documented for breakfast on 12/14, 12/19-20, 12/22-23, and 12/30 - No documentation of alternate breakfast offered when consumption was 50-percent or less on 12/2, 12/4, 12/8, 12/10-11, 12/15-16, 12/18, 12/21, and 12/29 - No data documented for lunch on 12/17, 12/19-20, and 12/30 - No documentation of alternate lunch offered when consumption was 50-percent or less on 12/2-5, 12/7, 12/10-15, 12/18, 12/23, 12/25-26, and 12/31 - No data documented for dinner on 12/3, and 12/16-18 - No documentation of alternate dinner offered when consumption was 50-percent or less on 12/2, 12/4-13, 12/15, 12/19-22, 12/24-28, and 12/30-31 - No data documented for snacks * January 2012 - No data documented for breakfast on 1/2, 1/6, 1/8-9, 1/13, 1/17, 1/20, 1/22, 1/25, and 1/30-31 - No documentation of alternate breakfast offered when consumption was 50-percent or less on 1/1, 1/3-4, 1/7, 1/10, 1/12, 1/14, 1/16, 1/18, 1/26, and 1/28-29 - No data documented for lunch on 1/8, 1/13, and 1/31 - No documentation of alternate lunch offered when consumption was 50-percent or less on 1/1-2, 1/4-7, 1/9, 1/12, 1/14-17, 1/19-26, 1/28, and 1/30 - No data documented for dinner on 1/8 and 1/26 - No documentation of alternate dinner offered when consumption was 50-percent or less on 1/3-7, 1/9-14, 1/16-25, 1/27, and 1/29-31 - No data documented for snacks Resident #2's Interdisciplinary Progress Notes (IDT Notes) for August 2011 through January 2012 documented the following: * 8/4/11 - "Resident with an admit weight 155 (pounds) but questionable error. Current weight 144. Current PO (oral) intake averaging 75/75/100 (percent for breakfast, lunch, and dinner) for most meals. Eats meals in his room, per resident request. Current diet is House, regular. Will add snacks BID (twice daily) to help stabilize weight. Continue weekly weights. Add: refusing some meals sporatically (sic)." * 10/20/11 - "Resident refused weights this week. Recent weight 149 week of 10/13. Weights stable (for) 90 days. Meal intakes average 75/80/75 of house, regular diet. Receives snacks BID and 4 oz (ounces) milk TID (three times daily) with meals. Continue to attempt routine weights and monitor PO intake." * 10/27/11 - "Resident lost 5 lbs (pounds) (in) 2 weeks to a current weight of 144. MD and family notified. Meal intakes average 75/60/60 of house, regular diet. Receives snacks BID and dines in main dining room for most meals. Will increase snacks to increase caloric intake. Continue routine weights." * 11/10/11 - "Resident gained 3 lbs (in) 1 week to a current weight of 146. Meal intakes average 80/75/50. Receives house, reg(ular) diet and snacks BID. MD and family notified. Weight gain desirable. Continue routine weights." * 1/5/12 - "Resident's weight this week is 138. Gradual weight loss trend past 6 months. (Down) 10%, (Down) 10 lbs (in) 3 months. Weight is stable past month. Receives house, regular diet with snacks BID. Meal intakes average 30/50/50%. Will observe if anti-depressants are helpful with improving appetite. Will add resident to receive hydration cart for extra fluids. Continue to monitor PO intake and routine weights." * 1/19/12 - "Resident lost 4 lbs (in) 1 week to a current weight of 132. MD and family notified of weight loss. Meal intakes average 50/40/50 of house, regular diet. Receives snacks BID. Meals in the main dining room. Visit routinely for food preferences. Continue to monitor PO intake and routine weights." On 4/11/12, at 2:30 p.m., the facility's DON and Registered Dietitian Clinical Consultant (RDCC) were interviewed. When asked what interventions were put into place during the three-month period in which Resident #3 experienced an 8.7-percent loss of his total body mass, the DON stated the resident's snacks had been increased from twice daily to three times daily in October, a "hydration cart" had been added to his dietary routine in November, the resident's anti-depressant had been changed in December, and the resident was moved to the assisted dining room and provided with fortified meals in February. IDT Notes documented a discussion of increasing the frequency of snacks, but repeatedly documented the resident was receiving snacks just twice daily rather than three times daily; the facility did not document snack consumption at any point during the time Resident #2 experienced a severe loss of weight and total body mass; documentation of overall meal consumption during the time the resident experienced the severe weight loss was inconsistent and did not include any documentation regarding the provision of alternate meals; a hydration cart would have minimal impact on the resident's weight loss; Resident #2 continued to lose weight from December 2011 to January 2012 despite the change in his anti-depressant medication; and the relocation of the resident to the assisted dining room, as well as the addition of fortified foods, occurred in February, after the resident had already experienced the "severe" loss of total body mass. The facility failed to adequately intervene and prevent Resident #2 from experiencing an avoidable and severe weight loss.

Intakes: ID 849 Intakes: ID 849 Based on a complaint from the community, medical record review and staff interview, it was determined the facility failed to notify a resident's physician when the resident developed symptoms of a cough, elevated temperature, rapid respirations, and low oxygen level (SaO2) within the previous 20 days of treatment for [REDACTED]. The resident was diagnosed with [REDACTED]. The lack of physician notification was true for 1 of 4 sampled residents (#1) reviewed for respiratory infections and condition changes. Findings include: A complaint from the community documented that an identified resident (Resident #1)developed a cough in [DATE]. The resident later developed bilateral crackling in her lungs. The resident received breathing treatments and cough syrup at the time, but her lungs were not checked by the nurses and the resident's primary care physician was not notified of the condition change. Resident #1 was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment coded: * Short term and long term memory problems with moderately impaired daily decision making skills. * Usually understood others - may miss some part/intent of message. * Dependent on extensive assistance of at least one person for bed mobility, transfers, dressing, toileting, and personal hygiene. * Required no special treatments such as oxygen therapy or monitoring of an acute medical condition. The nursing note sections (NNs) of the Interdisciplinary (IDT) Progress Notes, dated [DATE] through [DATE], documented the resident was diagnosed and treated for [REDACTED]. [DATE] - "Resident with increased confusion (and) behaviors." Note: The resident's primary care physician's office was notified and the facility was instructed to do a urinalysis. The urninalysis was negative for infection. [DATE] - "Received... order from (physician) (for) [MEDICATION NAME] 100 mg (by mouth) BID (twice per day) times 10 days (for) URI (Upper Respiratory Infection). [MEDICATION NAME] SVN (single volume nebulizer) every 4 - 6 hours PRN wheezing." [DATE] - ,[DATE] - documented the resident received the [MEDICATION NAME] as ordered without adverse reactions. The nursing notes (NNs) documented respiratory and lung assessments on a daily basis. [DATE] - " [MEDICATION NAME] completed... has been pleasant and cooperative. Continue to observe." [DATE] - "IDT met to review poc (plan of care)... Afebrile, no respiratory symptoms... " There was no further nursing documentation until [DATE]. On [DATE] NNs documented the resident received a flu vaccine at her primary care physician's office. The resident's temperature, prior to receiving the flu vaccine, was documented as 97.5. On [DATE] nurses documented the resident experienced no adverse reactions to the flu vaccine. Her temperature was documented as 98.5. On [DATE] at 10:10 pm, the NNs documented, "Resident has been coughing much of the evening. Lung sounds clear (with) wheezing in right lower lobes. Breathing treatment given with fair results... V/S (vital signs) stable." Note: A Vital Sign tracking sheet documented the resident's [DATE] vital signs as ,[DATE] (blood pressure), 98.2 F. (Farenheit) oral temperature, 76 pulse/beats per minute, 28/minute respirations, and a SaO2 of 90%. The resident's prior respiratory rates and vital signs were on the Vital Sign sheet with ranges from 12 to 20 /minute between [DATE] and [DATE]. Her SaO2 for the same time frame was recorded as 90% on one occasion, 92% or 93% on 6 occassions and consistently 95% or above between [DATE] - [DATE]. There was no documentation that the resident's physician was notified of the coughing or bilateral wheezing noted on [DATE] at 10:10 pm. The NNs documented no further assessment of the resident's coughing or vital signs between [DATE] at 10:10 pm and [DATE] at 6:45 pm. On [DATE] at 6:45 pm, the NNs documented, "(Resident) has had no coughing heard from her room. When I went to see her she started coughing..." At 1930 the same nurse documented, "Aides say resident has a fever, V/S 100.6 A (Axillary temperature which is equivalent to 101.6 F. orally), 92 (pulse/beats per minute), 40 (respiration per minute), 92 % (SaO2), and ,[DATE] (blood pressure). Lung sounds were auscultated by 2 nurses. Lungs are clear bilaterally. [MEDICATION NAME] given X 2. V/S stable (V/S not documented). On alert charting." There was no indication of physician notification for the elevated temperature or rapid respirations reported by the aides on [DATE] at 7:30 pm. There was no further documentation of continued resident assessment and monitoring or physician notification until [DATE] at 8:00 am, 12 .5 hours after the elevated temperature and rapid respirations were reported. There was also no documentation that the residents POA was notified of the resident's change in condition. On [DATE] at 8:00 am, NNs documented, "... Noted resident to have an ashin(sic) coloring to skin tone. Assessed resident noting slight wheezing to lung sounds. Resident has non-productive cough. Gave SVN (treatment) with little relief. Placed resident on O2 (oxygen) at 2 lpm (liters per minute) via n/c (nasal cannula) with SaO2 going from 68% to 73%. Increased O2 to 3 lpm with slight increase to 75%. Notified on-call physician... order received to send to ER (emergency room ) for evaluation. Notified daughter... stated she would meet her mother at the ER." The resident's vital signs were recorded as ,[DATE], 24 (Respirations per minute), 100.4 F. temperature, 90 (pulse/beats per minute), and an SaO2 of 75% on 3 lpm. Resident #1 was transported to the ER by a non-emergent care ambulance at 8:25 am on [DATE]. The resident's SaO2 was recorded as 88% on 3 lpm of oxygen at the time of the transfer. A NN on [DATE] at 11:00 am, documented the facility called the ER and was told that Resident #1 was being admitted to the hospital with [REDACTED]. During an interview on [DATE] at 8:30 am, the DON stated the resident did not return to the facility and expired in the hospital. The omissions in assessment documentation and physician notification were discussed with the DON and Unit Manager. The DON stated that she would look for additional documentation to show the resident was assessed and monitored more frequently than documented in the nurses notes. No further documentation was provided. On [DATE] at 11:45 am, the Administrator, DON, Corporate Dietary Consultant, and Unit Manger were notified of the unresolved concerns with the lack of assessment, monitoring, and physician notification for Resident #1. No additional documentation was provided by the facility documenting physician notification, or POA notification, of the resident's condition change.

Based on a complaint from the community, medical record review and staff interview, it was determined the facility failed to ensure a resident, who was treated for [REDACTED]. This resulted in harm to the resident when, within 12.5 hours of developing an elevated temperature and rapid respirations, developed severe [MEDICAL CONDITION] and required transportation to the hospital for emergency treatment. The resident was diagnosed with [REDACTED]. The lack of adequate monitoring of a decline in medical condition was true for 1 of 4 sampled residents (#1). Findings include: A complaint from the community documented that an identified resident (Resident #1)developed a cough in September. The resident later developed bilateral crackling in her lungs. The resident received breathing treatments and cough syrup at the time but her lungs were not checked by the nurses. The complainant stated that the resident's primary care physician was not notified of the condition change. Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment coded: * Short term and long term memory problems with moderately impaired daily decision making skills. * Usually understood others - may miss some part/intent of message. * Dependent on extensive assistance of at least one person for bed mobility, transfers, dressing, toileting, and personal hygiene. * Required no special treatments such as oxygen therapy or monitoring of an acute medical condition. Interdisciplinary (IDT) Progress Notes for [DATE] through [DATE] documented the resident was diagnosed and treated for [REDACTED]. [DATE] - "Resident with increased confusion (and) behaviors." Note: The resident's primary care physician's office was notifed and the facility was instructed to do a urinalysis. The urninalysis was negative for infection. [DATE] - "Received... order from (physician) (for) [MEDICATION NAME] 100 mg (by mouth) BID (twice per day) times 10 days (for) URI (Upper Respiratory Infection). [MEDICATION NAME] SVN (single volume nebulizer) every 4 - 6 hours PRN wheezing." [DATE] - ,[DATE] - documented the resident received the [MEDICATION NAME] as ordered without adverse reactions. The nursing notes (NNs) documented respiratory and lung assessments on a daily basis. [DATE] - " [MEDICATION NAME] completed... has been pleasant and cooperative. Continue to observe." [DATE] - "IDT met to review poc (plan of care)... Afebrile, no respiratory symptoms... " There was no further nursing documentation until [DATE]. On [DATE] NNs documented the resident received a flu vaccine at her primary care physician's office. The resident's temperature, prior to receiving the flu vaccine, was documented as 97.5 degrees Fahrenheit. On [DATE] nurses documented the resident experienced no adverse reactions to the flu vaccine. Her temperature was documented as 98.5. On [DATE] at 10:10 pm, the NNs documented, "Resident has been coughing much of the evening. Lung sounds clear (with) wheezing in right lower lobes. Breathing treatment given with fair results... V/S (vital signs) stable." Note: A Vital Sign tracking sheet documented the resident's [DATE] vital signs as ,[DATE] (blood pressure), 98.2 oral temperature, 76 pulse, 28/minute respirations,and a SaO2 of 90%. The resident's respiratory rate was documented on the Vital Sign sheet with ranges from 12 to 20 per minute between [DATE] and [DATE]. The resident's SaO2s, for the same time frame, were recorded as 90% on one occasion, 92 or 93 on 6 occassions and consistently 95 or above between [DATE] - [DATE]. No further vital signs were documented until [DATE]. Note: The NNs documented no further assessment of the resident's coughing or vital signs between [DATE] at 10:10 pm and [DATE] at 6:45 pm. On [DATE] at 6:45 pm, the NNs documented, "(Resident) has had no coughing heard from her room. When I went to see her she started coughing..." At 7:30 pm the same nurse documented, "Aides say resident has a fever, V/S 100.6 A (Axillary temperature which is equivalent to 101.6 F. orally), 92 (pulse/beats per minute), 40 (respiration per minutes), 92 (% SaO2), and ,[DATE] (blood pressure). Lung sounds were auscultated by 2 nurses. Lungs are clear bilaterally. [MEDICATION NAME] given X 2. V/S stable (but not documented). On alert charting." There was no indication that the resident's physician was notifed of the elevated temperature or rapid respirations reported by the aides on [DATE] at 7:30 pm. In addition, there was no further documentation of resident assessment and monitoring between [DATE] at 7:30 pm and [DATE] at 8:00 am. On [DATE] at 8:00 am, NNs documented, "... Noted resident to have an ashin(sic) coloring to skin tone. Assessed resident noting slight wheezing to lung sounds. Resident has non-productive cough. Gave SVN (treatment) with little relief. Placed resident on O2 (oxygen) at 2 lpm (liters per minute) via n/c (nasal cannula) with SaO2 going from 68% to 73%. Increased O2 to 3 lpm with slight increase to 75%. Notified on-call physician... order received to send to ER (emergency room ) for evaluation. Notified daughter... stated she would meet her mother at the ER." The resident's vital signs at 8:00 am were recorded as ,[DATE], 24 (respirations per minute), T 100.4 F., 90 (pulse/beats per minute), SaO2 75% on 3 lpm. Resident #1 was transported to the ER by a non-emergent care ambulance at 8:25 am on [DATE]. The resident's SaO2 was recorded as 88% on 3 lpm of oxygen at the time of the transfer. A NN on [DATE] at 11:00 am, documented the facility called the ER and was told that Resident #1 was being admitted to the hospital with [REDACTED]. During an interview on [DATE] at 8:30 am, the DON stated the resident did not return to the facility and expired in the hospital. The omissions in assessment documentation and physician notification were discussed with the DON and Unit Manager. The DON stated that she would look for additional documentation to show the resident was assessed and monitored more frequently than documented in the nurses notes. No further documentation was provided. On [DATE] at 11:45 am the Administrator, DON, Corporate Dietary Consultant, and Unit Manager were notified of the unresolved concerns with the lack of assessment, monitoring, and physician notification for Resident #1. No additional documentation was provided by the facility indicating the nursing assessment, monitoring, or physician notification occured. Resident #1 was harmed when facility nurses failed to notify the resident's physician of the resident's new signs and symptoms of a respiratory infection between [DATE] and [DATE], and the elevated temperature and rapid respirations reported by the aides on [DATE] at 7:30 pm. In addition, the nurses failed to consistently assess and monitor the resident's condition after the development of a cough on [DATE]. The nurses also failed to assess Resident #1's condition for 12 ,[DATE] hours after she developed an elevated temperature and rapid respirations on [DATE] at 7:30 pm. On [DATE] at 8:00 am, the resident was found hypoxic with a SaO2 level of 68 %, ashen in color, and running a temperature equivalent to 101.6 degrees. This resulted in the resident's hospitalization for treatment. The resident expired while in the hospital.