Every finding on record at Weiser Care of Cascadia

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure infection control practices were followed for hand hygiene during housekeeping tasks, hand hygiene during medication administration, and safe infection control practices in the laundry room. This failure affected all residents who receive medications and laundry services and created the potential for adverse outcomes related to cross contamination. Findings include:The facility's Hand Hygiene policy revised 9/15 25, documented hand hygiene was recognized as a cornerstone of effective infection control and was essential in preventing the transmission of healthcare-associated infections. All healthcare workers should perform hand hygiene at critical moments during resident care. These moments include but are not limited to:Immediately before and after touching a resident.After contact with objects and surfaces in the resident's environment.Immediately after PPE removal (gloves, gowns, eye protection, face mask).1. On 02/17/26 at 11:09 AM, the Maintenance Director was observed arriving at room [ROOM NUMBER]. He applied gloves, knocked on the door, announced himself, and entered the room holding a cleaning rag. He used the rag to wipe down frequently touched surfaces in the resident's room. He then returned to the housekeeping cart, placed the rag in the cart, and retrieved a broom. He swept the resident's room and returned the broom to the cart. The Maintenance Director was then observed repositioning the housekeeping cart and using a set of keys to access toilet cleaning supplies. After cleaning the toilet, he returned the supplies to the cart and retrieved an aerosol bottle, which he also returned to the cart after use. He then took a wet mop and mopped the resident's floor. After returning the mop to the cart, he removed his gloves and proceeded to the next room. The Maintenance Director knocked on the door of room [ROOM NUMBER], announced himself, returned to the cart, applied a new pair of gloves, and re entered the room to begin cleaning. No hand hygiene was observed between removing gloves after cleaning room [ROOM NUMBER] and applying new gloves before entering room [ROOM NUMBER]. On 02/17/26 at 11:25 AM, the Maintenance Director, stated he normally performs hand hygiene before he applies clean gloves but acknowledged he did not perform hand hygiene to prevent cross contamination. 2. On 2/20/26 at 2:49 PM, during a laundry room inspection, the Maintenance Director explained the laundry workflow. He stated that dirty laundry is placed on the designated dirty side of the laundry room, where staff sort the items and place them into the washer. After washing, the laundry is moved to the clean side of the laundry room to be dried. He stated staff then fold the clean laundry and load it into the clean laundry cart for return to residents. On 2/20/26 at 2:54 PM, when asked about the use of personal protective equipment (PPE) while sorting dirty laundry, the Maintenance Director stated that laundry staff do not use PPE during sorting. The Maintenance Director and the Administrator both confirmed that there is a high risk for cross contamination when staff handle dirty laundry without PPE and then move to the clean side of the laundry room to fold clean clothing. 3. On 2/18/26 at 3:30 PM, LPN #1 took the key from her pocket to open her medication cart and prepared Resident 6's medications. She then went to Resident #6's room to administer her medications. LPN #1 was not observed to perform hand hygiene before preparing Resident #6's medications. LPN #1 was also not observed to perform hand hygiene before entering and after exiting Resident #6's room. On 2/18/26 at 3:37 PM, LPN #1 prepared Resident #29's medications and placed them in a medication cup. LPN #1 then went to medication room and took Glucerna (a nutritional product designed for people with diabetes). LPN #1 went back to her medication cart and transferred 8 oz of Glucerna to a cup and took a straw. LPN #1 was not observed to perform hand hygiene before preparing Resident #29's medications. On 2/18/26 at 3:51 PM, LPN #1 took a pitcher and went to the medication room to fill the pitcher with water. LPN #1 went back to her medication cart and prepared Resident #14's medications. She then went to Resident #14's room and administered her medications. LPN #1 was observed to touch the pitcher, doorknob of the medication room, and the key to her medication cart. LPN #1 was not observed to perform hand hygiene before preparing the medications, and before entering and exiting Resident #14's room. On 2/18/26 at 4:10 PM, LPN #1 stated hand hygiene should be performed before and after exiting resident's room. LPN #1 also stated she should have performed hand hygiene before preparing the resident's medications. On 2/20/26 at 9:31 AM, the IP stated hand hygiene should be performed before entering and after exiting the resident's room and hygiene should also be performed before preparing resident's medications.

Based on observation, policy review, resident and staff interview, it was determined the facility failed to provide a clean, comfortable, sanitary, and homelike environment when trash and laundry services were not provided. This was true for 2 of 15 residents (#5 and #7) reviewed for frequency of laundry and housekeeping services. This deficient practice created the potential for psychosocial harm if residents' laundry and trash were not cleaned creating an unwelcome and unsanitary environment for residents and/or their visitors. Findings include:The facility's policies, Homelike Environment, revised 9/17/25, and Housekeeping & Laundry Services, dated 10/8/25, documented residents have the right to a safe, clean, comfortable, and homelike environment which promotes dignity, independence, and quality of life. Additionally, the facility should maintain a sanitary, orderly, and comfortable interior environment at all times, and housekeeping and laundry services are essential to a resident safety, dignity, and quality of life.The facility's daily cleaning task list documented staff are to empty trash cans, dust and check the floor, and wet mop the floor in each resident room.Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, epilepsy, and muscle weakness.Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including dementia, legal blindness, post-traumatic stress disorder (PTSD), and Bell's palsy (a condition that temporarily weakens or paralyses facial muscles).On 2/17/26 at 2:41 PM, it was observed in Resident #5 and #7's room, two trash cans were overfilled with garbage, a dirty paper towel or toilet tissue was on the floor in front of the resident's closet, a drawer had been broken with the outer section stuffed into the drawer area, and the pillowcase on Resident #7's bed was visibly soiled with brown residue. On 2/17/26 at 2:48 PM, Resident #5 and Resident #7 stated they were not sure when housekeeping had last cleaned their room. Resident #7 further stated he was not sure when facility staff had cleaned his bed linens.On 2/20/26 at 2:46 PM, the Maintenance Director stated the expectation was the housekeeping staff clean resident's rooms daily and Resident #5 and #7's room had not been cleaned.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure its Antibiotic Stewardship practices were followed by initiating antibiotic therapy without obtaining culture and sensitivity results to guide appropriate treatment. This was true for 1 of 1 residents (Resident #17) reviewed for antibiotic stewardship. This failure created the potential for inappropriate antibiotic use and development of antibiotic resistant organisms. Findings include:The facility's Antibiotic Stewardship Policy, revised 6/16/25, documented the facility focused on improving antibiotic use through an Antibiotic Stewardship Program to ensure appropriate antibiotic usage, promote therapeutic and cost effective care, and reduce the likelihood of developing multi drug resistant organisms. The policy also documented that the facility utilized McGeer's Criteria to validate infections and routinely reviews culture and sensitivity reports as part of infection surveillance.The Revised McGeer's Criteria for urinary tract infection (UTI) without an indwelling catheter require both of the following be present:1. At least one clinical sign or symptom, such as:Fever, rigors, or new onset hypotension (low blood pressure) with no alternate site of infectionAcute change in mental status or functional decline with leukocytosis (extremely high white blood cell counts.)New onset suprapubic pain or costovertebral angle tenderness (pain elicited at the angle formed by the 12th rib and spine) Purulent discharge or acute pain/swelling of the testes, epididymis (inflammation of the coiled tube at the back of the testicle that stores and carries sperm) or prostate2. At least one microbiologic criteria, such as: 10 cfu/mL of no more than two organisms in a voided urine sample 10^2 cfu/mL of any organism in a catheterized specimenResident #17 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness, lower back pain, and a need for assistance with personal care.Resident #17's care plan dated 12/29/25, directed staff to monitor, document, and report signs and symptoms of urinary tract infection to the provider as needed.Resident #17's record included a laboratory report documenting a urine specimen collected on 1/8/26 at 4:07 PM and received by the laboratory on 1/8/26 at 10:49 PM. The report indicated a culture and sensitivity test would be completed.A nursing progress note dated 1/9/26 at 6:49 PM, documented the provider was informed Resident #17's urine was positive with bacteria, and an order was received for Rocephin 1 gram via intramuscular injection for 7 days (an antibiotic). The note also documented the facility was still waiting for the culture and sensitivity results.A laboratory report dated 1/14/26 at 8:38 AM, documented the culture and sensitivity was cancelled due to no sample to perform the test.On 2/20/26 at 10:56 AM, the ADON stated the facility had been using McGeer's Criteria but had since transitioned to the Loeb Criteria. She confirmed the provider ordered antibiotic therapy before the culture and sensitivity results were available to determine appropriate therapy.

Based on observation, policy review, and staff interviews, it was determined the facility failed to provide a PASRR level II to the designated state agency. This was true for 1 of 1 residents (Resident #7) whose record was reviewed for PASRR documentation. This deficient practice created the potential for harm if Resident #7's coordination of care was not completed between the facility and the designated state agency, with interventions appropriately documented in Resident #7's care plan. Findings include:The facility's PASRR Process policy, revised 8/29/25, documented a positive PASRR Level I, necessitates an in-depth evaluation of the individual by the state-designated authority, known as a PASRR Level II. Recommendations from the PASRR Level II determination are to be incorporated into the person-centered care plan.Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including dementia and PTSD.A PASRR Level I, dated 8/13/25, documented Resident #7's diagnoses of dementia and PTSD, and referred him for further evaluation through the PASRR Level II. On 2/19/26 at 11:47 AM, the SA requested the facility provide a copy of Resident #7's PASRR Level II. The facility did not provide a PASRR Level II for Resident #7.On 2/19/26 at 3:22 PM, the Medical Records Manager stated it was her responsibility to complete the resident's PASRRs, and she was instructed to submit a PASRR Level II only if there were psychiatric medications listed. The Medical Records Manager confirmed Resident #7's PASRR Level I from 8/13/25 should have been forwarded for a PASRR Level II review.

Based on record review, policy review, and staff interviews, it was determined the facility failed to provide a required 30 day written notice of discharge for 1 of 1 residents (Resident #58) reviewed for discharge process. This failure created the potential for psychosocial harm when Resident #58 received a verbal notice and subsequently chose to leave the facility against medical advice. Findings include:The facility's Notice of Discharge and/or Transfer Policy, dated 10/7/25, documented the facility ensures that systems are implemented to provide a written notification to the residents prior to transfer.Resident #58 was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, obstructive sleep apnea, and a need for assistance with personal care.Resident #58's care plan, dated 10/23/25, documented he was an independent smoker and had been educated on the facility's smoking policy.A progress note dated 10/29/25 at 10:53 AM, documented Resident #58 was educated on appropriate smoking areas and informed that if he was not compliant, he would be issued a 30 day written notice as required by policy and regulation.A progress note dated 10/29/25 at 5:10 PM, documented Resident #58 was issued a 30 day notice due to smoking on facility grounds. The note did not reference a written notice was provided.A progress note dated 10/29/25 at 5:40 PM, documented Resident #58 requested to leave the facility against medical advice.Resident #58's record included the following:A discharge assessment, unsigned by Resident #58.An acknowledgment of risk for leaving the facility against medical advice signed by Resident #58.Resident #58's record did not include documentation of a written 30 day discharge notice.On 2/20/26 at 11:01 AM, the Administrator and the Resource Nurse stated the facility was unable to provide documentation a written 30-day discharge notice was provided to Resident #58.

Based on record review, policy review, and staff interview, it was determined the facility failed to implement the comprehensive person centered care plan according to the resident's identified needs. This was true for 1 of 15 residents (Resident #42) reviewed for comprehensive care planning. This failure created the potential for harm when Resident #42 was not monitored for signs and symptoms of withdrawal as directed in the care plan. Findings include:The facility's Resident Assessment Instrument (RAI) and Comprehensive Care Plans Policy, revised 9/3/25, documented the care plan is developed consistent with the resident's specific condition, risks, needs, behaviors, cultural preferences, and standards of practice.Resident #42 was admitted to the facility on [DATE] with multiple diagnoses including other stimulant use, depression, and nutritional deficiency.Resident #42's care plan, revised 10/13/25, directed staff to monitor and document for potential signs of withdrawal, including:respiratory distresscardiac decompensationnausea/vomitinganxietyhostilitybloodshot eyespinpoint pupilsdiaphoresis (excessive sweating)A review of Resident #42's medical record did not include documentation that staff monitored for signs or symptoms of withdrawal as directed in the care plan.On 2/20/26 at 10:54 AM, the Resource Nurse confirmed Resident #42's record did not include monitoring for withdrawal symptoms.

Based on observation, record review and staff interview, it was determined the facility failed to ensure a medication was administered according to professional standards of practice. This was true for 1 of 8 residents (Resident #29) observed during medication administration. This deficient practice created the potential for Resident #29 to develop Candida albicans infection in her mouth (oral thrush - a fungal infection characterized by painful, creamy white, cottage cheese-like patches on the tongue, inner cheeks or throat) when she did not rinse her mouth with water after inhaling her steroid medication. Findings include:The Symbicort (an inhaler containing corticosteroid) Prescribing Information under Warning and Precautions documented Localized infections: Candida albicans infection of the mouth and throat may occur. Monitor patients periodically for signs of adverse effects on the oral cavity. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including asthma.A physician's order dated 11/24/25, documented Resident #29 was to receive Symbicort Inhalation (Budesonide-Formoterol Fumarate Dihydrate) two puff inhale orally two times a day related to moderate persistent asthma, rinse mouth with water and spit after use.On 2/18/26 at 3:46 PM, LPN #1 handed the Symbicort inhaler to Resident #29. Resident #29 shook the inhaler and took two puffs orally and gave back the inhaler to LPN #1. LPN #1 told Resident #29 she would get her some water. Resident #29 stated she did not need the water. LPN #1 left Resident #29 without educating her regarding the importance of rinsing her mouth after inhaling her Symbicort inhaler.On 2/18/26 at 4:07 PM LPN #1 stated Resident #29 did not want the water. When asked if Resident #29 should have been educated regarding rinsing her mouth after taking her inhaler orally, LPN #1 stated Yes, and I did not. On 2/19/26 at 12:39 PM, the Resource Nurse together with the DON stated Resident #29 should have been educated to rinse her mouth after using her inhaler orally.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the physician responded to the pharmacists' recommendation. This was true for 1 of 6 residents (Resident #48) reviewed for unnecessary medications. This created the potential for Resident #48 to develop Candida albicans infection in his mouth (oral thrush - a fungal infection characterized by painful, creamy white, cottage cheese-like patches on the tongue, inner cheeks or throat). Findings include:The facility's Pharmacist Consultation Policy revised 9/16/25, documented irregularities were reported to the provider, and the provider will provide documentation of accepting or rejecting recommendations with documentation present in the medical record.The Symbicort (an inhaler containing corticosteroid) Prescribing Information under Warning and Precautions documented Localized infections: Candida albicans infection of the mouth and throat may occur. Monitor patients periodically for signs of adverse effects on the oral cavity. Advice the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.A physician's order dated 9/26/25, documented Resident #48 was to receive Budesonide (Symbicort) inhalation orally two times a day related to chronic obstructive pulmonary disease.A Consultation Report dated 11/11/25, documented the Pharmacist's comment Please consider adding rinse mouth out and spit after use to budesonide 0.5mg/2 ml give one neb (nebulizer) PO BID for COPD. There was no documentation the physician responded to the pharmacist comment. A handwritten Standard of Care was noted at the bottom of the Consultation Report.Review of Resident #48's record did not show the physician's order for his Budesonide inhaler was updated with the pharmacist's recommendation.On 2/20/26 at 2:04 PM the DON stated the expectation for the nurses was to advise residents to rinse their mouth after inhaling a steroid inhaler. The DON stated the physician's order was not updated, it was a pharmacist recommendation. She added, nurses were trained in the standard of practice. The DON stated that going forward we will probably add the pharmacist recommendation just to remind the nurses as it was the best practice.Cross reference F658.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary medications. This was true for 1 of 6 residents (Resident #8) whose medication regimens were reviewed for unnecessary medications. This failure placed Resident #8 at risk for adverse outcomes from overmedication when he was receiving nicotine patches, had an order for nicotine gum, and was smoking cigarettes. Findings include: Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including incomplete quadriplegia (a spinal cord injury which causes paralysis in all four limbs but leaves some voluntary motor or sensory function below the injury level) and COPD. Resident #8's EHR documented he was assessed for independence with smoking on 1/15/26 and 2/11/26. Resident #8's physicians orders documented the following:- Nicotine Transdermal Patch 24 Hour 14 MG/24HR, Apply 1 patch transdermally one time a day for Nicotine, Make sure to remove old patch before placing new patch -Start Date- 1/8/26 -Discontinue Date- 2/17/26- Nicotine Polacrilex Mouth/Throat Gum 4 MG, Give 1 gum by mouth every 3 hours as needed for nicotine craving -Start Date- 1/7/26 -Discontinue Date- 2/17/26 Resident #8's MAR documented his nicotine patch was administered . On 2/20/26 at 2:50 PM, the DON stated Resident #8 was an infrequent smoker. She added, the facility could not provide documentation Resident #8 smoked infrequently while he still using the nicotine patches and had an order for nicotine gum.

Based on observation, policy review, and resident and staff interviews, it was determined the facility failed to ensure medications were safely stored when unattended by staff. This was true for 1 of 1 resident (Resident #18) whose medications were observed in his room. This deficient practice created the potential for harm if the medications were taken by another resident. Findings include:The facility's Medication Storage & Labeling policy released 10/13/25, documented the facility will ensure that medications were stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles to ensure safety, efficacy, and compliance. The policy stated for general medications: Store in locked compartments (cabinets, carts, medication room).Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including myocardial infarction (heart attack) and diabetes.A Comprehensive MDS assessment dated [DATE], documented Resident #18 was cognitively intact.On 2/17/26 at 11:05 AM, Resident #18 was awake in bed. A seven-day pill container containing white and blue tablets was observed on top of his bedside table. When asked about the pill container Resident #18 did not answer.On 2/17/26 at 1:52 PM, LPN #2 asked Resident #18 if he knew the medications inside the pill container, Resident #18 stated No. When asked if he had taken any of the medications from the pill container, Resident #18 stated he did not take any of the medications from the pill container since the staff were administering his medications. LPN #2 informed Resident #18 she would take the pill container from his room. LPN #2 stated Resident #18 should not be keeping the pill container containing the medications in his room.On 2/19/26 at 12:33 PM, the DON and the Resource Nurse stated the pill container with medication inside should not be in Resident #18's room.

Based on record review and staff interview, the facility failed to ensure the facility's Arbitration Agreement signed by the residents included the selection of venue that was convenient to both parties. This was true for 2 of 3 residents (#40 and #48) whose arbitration agreements were reviewed. This deficient practice created the potential for residents not to attend the arbitration process to resolve the dispute due to inconvenience of the venue. Findings include:1. Resident #40 was admitted to the facility on [DATE] and signed the Arbitration Agreement on 8/26/25.2. Resident #48 was admitted to the facility on [DATE] and his representative signed the Arbitration Agreement on 9/19/25.Resident #40 and Resident #48's Arbitration Agreement documented the following, An arbitration hearing arising under this Arbitration Agreement shall be held in the county where the Facility is located before a board of three arbitrators, selected from the American Arbitration Association ( AAA).On 2/19/26 at 11:36 AM, the admission Coordinator reviewed Resident #40 and #48's Arbitration Agreements. The admission Coordinator printed the facility's updated Arbitration Agreement which stated, An arbitration hearing under this Arbitration Agreement shall be held in a mutually agreed upon venue that is convenient to both parties before the board of three Arbitrators, selected from the American Arbitration Association. The admission Coordinator stated Resident #40 and Resident #48's should have been asked to sign the new Arbitration Agreement when the facility updated the arbitration agreement.

Based on record review, observation, policy review, and staff interview, it was determined the facility failed to ensure smoking paraphernalia was stored in a safe location for 2 of 3 residents (#6 and #42) reviewed for smoking. This failure created the potential for harm when Resident #6's smoking assessment was not accurate and when Resident #42 was observed sleeping in her bed while holding a vape device. Findings include:The facility's Non Smoking Campus Policy, revised 9/12/25, documented the facility maintained a smoke free environment to promote the health, safety, and comfort of residents, staff, visitors, volunteers, and contractors. The policy stated that smoking is not permitted anywhere on the premises, including buildings, grounds, and parking areas, and applied to cigarettes, cigars, pipes, e cigarettes, and vaping devices.1. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including kidney disease, diabetes, COPD (a progressive, treatable, but generally irreversible lung disease characterized by persistent, limited airflow), congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to back up into the lungs, legs, and abdomen), and asthma. Resident #6's care plan dated 1/8/26, documented Resident #6 was an independent smoker who could smoke when off the facility's property as she desires. Nursing progress notes dated 1/15/26, documented Resident #6 was assessed as a Dependent/Assisted smoker and to review the evaluation. A smoking assessment dated [DATE], documented Resident #6 was a dependent smoker and required assistance, but she could keep her smoking accessories locked in her room. On 2/17/26 at 10:15 AM, the Administrator stated the facility was a non-smoking facility, but residents' who chose to smoke off-campus/off-property were assessed to see if they were safe to smoke independently or were dependent on staff assistance to smoke safely. On 2/19/26 at 4:48 PM, the DON stated Resident #6's smoking assessment from 1/15/26 was not accurate as Resident #6 was an independent smoker. 2. Resident #42 was admitted to the facility on [DATE] with multiple diagnoses including other stimulant use, depression, and nutritional deficiency. Resident #42's care plan, revised 10/15/25, documented she was an independent smoker and had been educated on the facility's smoke/nicotine use policy. A Smoke Free Acknowledgment was located in Resident #42's record documenting the facility's smoke free policy and expectations. On 2/18/26 at 10:35 AM, Resident #42 was observed lying on her bed asleep with a vape device in her right hand. On 2/20/26 at 12:10 PM, the DON stated she was not aware that Resident #42 was using a vape. The DON confirmed Resident #42 was an independent smoker but stated the expectation is that all smoking paraphernalia be stored safely.

Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 hours a day, 7 days a week. This was true for 2 of 21 days reviewed. The failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all residents living in the facility. Findings include: On 9/25/24 at 4:20 PM, review of the Licensed Nurse time punches for 9/1/24 to 9/21/24 documented the facility did not have an RN on duty for 8 consecutive hours on 9/7/24 and 9/8/24. On 9/26/24 at 9:05 AM, the Medical Records Manager, stated the CNO was scheduled to work on 9/7/24 for 6 hours and RN #2 was scheduled to work intermittently on 9/8/24. On 9/26/24 at 9:40 AM, the CNO stated she worked from home and did not work in the building on 9/7/24 or 9/8/24. She stated she knew the facility had to have 8 hours of RN coverage but did not know the hours needed to be consecutive.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate, posted daily for each shift, and kept for review for 18 months. This failed practice had the potential to affect the 46 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The facility's Posting of Licensed and Unlicensed Direct Care Staff policy, dated 11/28/17, documented, the facility posts daily, the total number and actual hours worked by RNs, LPNs, CNAs, and the resident census. The policy documented the daily posting were to be retained for a minimum of 18 months or as required by State law, whichever is greater. On 9/22/24 at 12:00 PM, the Daily Posted Staffing sheet was observed with the date 9/20/24, indicating the facility had failed to post the last two days of nursing hours. On 9/22/24 at 2:07 PM, the Administrator stated the medical records person should have posted the weekend nursing hours on Friday but must have missed it. On 9/25/24 at 3:10 PM, the Administrator stated the facility had not retained the Daily Posted Staffing Sheets for 18 months. 51121

Based on observation, staff interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store and label food . This deficient practice had the potential to affect 25 of 26 residents who received meals in the facility and residents that eat snacks. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes, including food-borne illnesses. Findings include: Review of 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 5 C (41 F) 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 under Labeling and rotating food supply, 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 9/22/24 at 12:08 PM, observed a non-dated open container of Soy sauce in the food storage area. On 9/22/24 at 12:09 PM, Lead [NAME] #1 stated it should have been dated. On 9/22/24 at 12:12 PM, observed in the walk in refrigerator, an opened Soy sauce container with no used by date. On 9/22/24 at 12:13 PM, Lead [NAME] #1 stated it should have been dated. On 9/24/24 at 9:55 AM, observed the back hall snack refrigerator, with the Culinary Manager present, the refrigerator temperatures had not been checked and documented for September 22, 23, and 24. On 9/24/24 at 10:00 AM, the Culinary Manager stated nursing staff should have checked the temperatures for the refrigerator and freezer on those dates but had failed to do so.

Based on record review and staff interview, it was determined the facility failed to complete a comprehensive MDS assessment when a resident experienced a significant change after developing a pressure ulcer to her right buttock. This was true for 1 of 5 residents (Resident #28) reviewed for pressure ulcers. This failure had the potential for harm if the facility staff did not recognize significant changes in the resident's health status and needs. Findings include: Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including dementia, diabetes, and osteoarthritis. A review of Resident #28's record documented the following: On 7/25/24, a Skin Inspection Evaluation documented a silver dollar size-open wound on the right buttock/leg. On 7/26/24, a Skin & Wound Evaluation documented a new MASD (Moisture Associated Skin Damage) to the coccyx, measuring 2.8 cm x 1.8 cm. On 7/29/24, a Skin & Wound Evaluation documented the MASD to the coccyx had now progressed into a pressure injury (damage to the skin and underlying tissue caused by prolonged or intense pressure). On 8/12/24, a Wound Clinic Note documented Resident #28 had a stage 3 pressure injury to her right buttock, measuring 2 cm x 1.6 cm. Resident #28's quarterly MDS dated [DATE], documented she did not have pressure ulcer. On 8/15/24, Resident #28's Pressure Ulcer Investigation documented she should have had a significant change MDS completed. Resident #28's medical record did not document a significant change MDS was completed. On 9/25/24 at 10:25 AM, the Regional Clinical Nurse (RCN) confirmed Resident #28's quarterly MDS did not document Resident #28 had a stage 3 pressure ulcer and should have. The RCN stated there should have been a modification to correct the quarterly MDS and a significant change MDS should have been completed within 14 days of diagnosing the pressure ulcer.

Based on observation, staff interview, policy and record review, the facility failed to follow comprehensive person-centered care plan for 1 of 4 residents (Resident #199) observed with wounds. This deficient practice created the potential for harm or adverse outcomes related to infection and skin breakdown. Findings include: Facility Prevention and Treatment of Pressure Ulcers and Other Skin Alterations policy revision date 7/13/18, documented 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 PU/PI (pressure ulcer/pressure injury) or non-pressure skin alteration should be documented. At a minimum, documentation should include the date observed and : A. Location, staging if applicable; B. Size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; C. Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; D. Pain, if present: nature and frequency; E. Wound bed: Color and type of tissue/character including evident of healing or necrosis, and; F. Description of wound edges and surrounding tissue . as appropriate. Resident #199 was admitted to the facility on [DATE], with multiple diagnoses including right shoulder infection and diabetes. On 9/22/24 at 2:26 PM, observed bandages dated 9/11/24, on Resident #199's legs and on his left toe. On 9/22/24 at 2:30 PM, RN #2 stated skin tear bandaging should only stay on for three days and then be changed.

Based on observation, review of policy, records review, and interviews, it was determined the facility failed to ensure Nursing Assistants (NAs) performed tasks which they had the knowledge, skills, and competences. This was true for 1 of 6 NAs observed in the facility. This had the potential for adverse effects and potential harm to residents medical and physical status. Findings include: Facility Indwelling Catheters policy Revision Date: 4/12/22, documented Infection control is followed in the care of indwelling catheters. Guidelines to prevent Catheter Associated Infections include but may not be limited to: Good hygiene is maintained at the catheter-urethral interface: cleaned daily with soap and water. Lippincott Nursing Procedures (9th edition) documented to avoid contaminating the urinary tract, always clean by wiping away from, never toward the urinary meatus. CDC Guidelines for Prevention of Catheter Associated Urinary Tract Infections 2009 documented, III. Proper Techniques for Urinary Catheter Maintenance, Do not clean the periurethral area with antiseptics to prevent CAUTI (Catheter Associated Urinary Tract Infection) while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care: HAIs/CAUTI (Healthcare Acquired Infection) dated 3/2017, documented to only use soap and water when performing peri-care. Review of the facility Admission Packet, Residents Rights section, documented, The Resident has the right to be treated with respect and dignity. On 9/24/24 at 4:10 PM, observed CNA #1 and NA #2 use a Hoyer lift (a mobility tool that helps caregivers safely move patients from one surface to another) to transfer Resident #35 from her wheelchair to bed. During the process the window blinds were left open, exposing Resident #35's bottom and perineum area (the area of the body between the anus and the vulva in females) toward the open window. On 9/24/24 at 4:17 PM, observed CNA #1 and NA #2 prepare Resident #35 for catheter care with the window blinds left open, exposing the resident's urinary meatus area toward the open window. On 9/24/24 at 4:18 PM, observed NA #2 use peri-care wipes to wipe toward, not away from the meatus. On 9/24/24 at 4:28 PM, NA #2 stated she should have wiped away from, not toward the meatus. On 9/24/24 at 4:30 PM, CNA #1 and NA #2 stated they should have close the window blinds before transferring the resident to the bed and before performing catheter care.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were dated and had not expired. This was true for 2 of 2 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: The facility's Medication Management policy, revision date 10/15/22, documented medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner. The facility's pharmacy Medication Storage and Administration Quick Reference Guide, revision date April 2024, documented injectable diabetes medications, pens, or vials, should have a label with resident identifiers, date opened, and expiration date. 1. On 9/23/24 at 10:29 AM, during the back hall medication cart audit, with RN #1 present, observed a box of Bisacodyl suppositories, with an expiration date of November 2023. On 9/23/24 at 10:31 AM, RN #1 stated the expired medication should have been taken off the medication cart. 2. On 9/23/24 at 10:33 AM, during the front hall medication cart audit, with RN #2 present, 2 insulin pens, not dated, were observed inside the top drawer of the medication cart. On 9/23/24 at 10:37 AM, RN #2 stated she was not sure if the insulin pens were used. She also stated the insulin pens should be dated when opened. On 9/25/24 at 9:09 AM, RN #2 stated the insulin pen was not dated and should have been.

Based on observation and staff interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 2 of 46 Residents (#28, #199) whose rooms were observed. This deficient practice created the potential for diminished quality of life and safety risk. Finding include: 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including dementia, diabetes, and osteoarthritis. On 9/23/24 at 11:15 AM, observed in Resident #28's room, the walls had scrapes, chipped paint , and holes. On 9/24/24 at 3:10 PM, the Administrator with the CNO present, stated the walls should have been repaired after last resident moved. 2. Resident #199 was admitted to the facility on [DATE], with multiple diagnoses including right shoulder infection and diabetes. On 9/22/24 at 2:26 PM, observed in Resident #199 room, the base board by the sink was missing and part of the base board was sticking out having the potential to cause a skin tear. On 9/25/24 at 1:02 PM, the Maintenance Manager stated the base board should have been fixed. 50983

Based on observation, staff interview, and review of facility policies, resident records, and I and A Reports, it was determined the facility failed to prevent the development and worsening of a pressure ulcer. This was true for 1 of 1 sampled residents (#29) reviewed for pressure ulcers. This deficient practice caused harm to Resident #29 when she developed a blister on her coccyx (tailbone area) that deteriorated and became an unstageable pressure ulcer. Findings include: The facility's policy and procedure for Prevention and treatment of [REDACTED]. * Residents at risk for developing pressure ulcers are identified by using the Braden Scale. * Interventions for pressure ulcers and other wound and skin issues are developed by collaborating with the interdisciplinary team and are implemented to identify, prevent, or decrease the risk of developing pressure and/or non-pressure wounds. * Basic or routine care could include but was not limited to: redistribute pressure, minimize moisture contact with the skin and keep the skin clean, provide appropriate, pressure-redistributing, support surfaces, providing surfaces that are not irritating to skin, and maintain or improve nutrition and hydration status, where feasible. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility, and muscle wasting atrophy. Resident #29's quarterly MDS assessment, dated 4/26/18, documented she was at risk for developing pressure ulcers and no pressure ulcers were present. Resident #29's Braden Scale for Predicting Pressure Sore risk, dated 5/1/18 at 11:33 AM, documented a moderate risk for developing pressures sores. Resident #29's significant change MDS assessment, dated 5/23/18, documented she was at risk for developing pressure ulcers and had one unstageable pressure ulcer measuring 2.0 (length) by 2.0 (width) by 0.2 deep. Resident #29's physician orders [REDACTED]. Resident #29's current care plan directed staff to provide the following interventions: * Assess skin weekly and as needed, and was initiated on 7/9/14. * A pressure relieving mattress to the bed and a pressure reducing cushion to the wheelchair, and was initiated on 2/16/17. * Reposition the resident in bed during rounds and as needed, and was initiated on 2/11/15. * When out of bed, change the resident's position by toileting, uploading, shifting weight, ambulating or return to bed for rest. When in bed, turn and reposition q (every) 2 hours, and was was initiated on 7/30/15. The following interventions were initiated on 5/22/18: * Assess for pain every shift/as needed before changing the dressing, and give medication per the physician's orders [REDACTED]. * Complete the Daily Monitoring Pressure Ulcer Report. * Encourage frequent position changes every 2 hours. * Follow physician's orders [REDACTED]. * Specialty mattress-air mattress. * Resident #29 out of bed only for meals, initiated on 5/25/18. Resident #29's Weekly Skin Checks documented the following: * On 5/15/18 at 9:27 PM: No skin conditions, changes, ulcers, or injuries. * On 5/22/18 at 12:27 PM: An open wound on the coccyx with slough (yellow, devitalized tissue). * On 5/29/18 at 11:36 PM: Skin warm, dry and very fragile. Cont(inue) present treatment to wound on coccyx, dressing clean dry and intact. * On 6/6/18 at 3:17 AM: Skin warm and dry but at times moist due to incontinence. Coccyx area red . * On 6/12/18 at 11:17 PM: Skin warm, dry and very fragile. Wound on coccyx covered with dressing. Dressing clean, dry and intact. Resident #29's Weekly Skin Alteration Reports documented the following: * On 5/11/18 at 1:46 PM: A fluid-filled blister below the coccyx, circular in shape and measuring 2 cm in diameter. It was first observed on 5/11/18. * On 5/25/18 at 1:46 PM: A 2 cm by 2 cm wound on the coccyx was first observed on 5/18/18, it was healing slowly, and calcium alginate and [MEDICATION NAME] dressing were continued daily. Resident #29's Weekly Pressure Ulcer BWAT Reports documented the following: * On 5/21/18 at 10:36 AM: A new onset pressure ulcer on the coccyx, measuring 2 cm (length) by 2 cm (width) by 0.2 cm (depth) and was unstageable. The ulcer was first observed on 5/11/18 and required the following treatment: wound cleanser, skin prep to surround tissue, [MEDICATION NAME] alginate to the wound bed, and cover with a [MEDICATION NAME] foam dressing. * On 5/28/18 at 10:36 AM: The pressure wound on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. Wound care was updated to [MEDICATION NAME] ointment on the wound bed and cover with an Alevyn dressing. * On 5/31/18 at 1:57 PM: The pressure wound to the coccyx measured 2 cm by 1.8 cm by 0.5 cm and was Stage 2. The wound was healing nicely, bed visible, beefy red. Size decreasing . *On 6/7/18 at 1:57 PM: The pressure wound to the coccyx measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. The Treatment/Evaluation of Effectiveness was to continue the current plan of care. Resident #29's I and A Reports documented the following: * An I and A Investigation, dated 5/11/18, documented a small fluid-filled blister was discovered below the coccyx, the site was cleansed, and a dressing was applied. The event was described as a shear/rub causing a blister. It was recommended to use a cushioned dressing and change the dressing routinely. * On 5/21/18, a stage 3 pressure sore measuring 2 cm by 2 cm by 0.2 cm was present on the coccyx. The Pressure Ulcer Investigation documented the following: (A) clear blister on (the) coccyx (was) reported on 5/13/18, (a) foam/sponge drsg (dressing) (was) applied and staff cont(inue) turning q 2 hours. Family to come and pick up recliner. Over (the) wkend (weekend) (the) wound changed to (a) pressure wound 2 cm-2cm by 0.2 cm with off white slough across (the wound) bed. Surrounding tissue (was) intact, no adipose tissue (fat) noted between skin and bone, tissue loose and moveable. It was recommended to use a dressing, remove the recliner, use an air mattress, change the wheelchair, provide incontinence care, reposition side to side, and strongly encourage fluids. Resident #29's Progress Notes documented the following: * On 5/11/18 at 1:13 PM, a small fluid-filled blister was noted below the coccyx measuring 2 cm in diameter and was circular in shape. * On 5/11/18 at 4:53 PM, a fluid-filled blister was noted in the coccyx area, and it appeared to be caused by the incontinence brief pinching the tissue. The area was cleansed and a [MEDICATION NAME] dressing was applied. The wound measured 2.1 cm by 1.8 cm. * On 5/14/18 at 8:47 AM, the fluid-filled blister remained and was discussed by the event committee. The area was cleansed and a cushioned dressing was applied. Will continue to monitor and change dressing via altered skin evaluations. Nurse supervisor to do this. * On 5/15/18 at 1:30 PM, A blister was present on the buttock area and it measured 1.2 cm by 1 cm. The site was cleansed and a foam dressing was applied. An order was requested for physical therapy because the resident was no longer bearing weight during transfers. She required one person assistance to transfer a month prior. * On 5/16/18 at 7:17 PM, the physician was notified regarding the blister on the buttocks and continued care with a cushioned dressing. The nurse supervisor was to change the dressing. * On 5/21/18 at 1:36 PM, staff reported a change in the coccyx wound over the weekend. The wound depth had increased to 0.2 cm and it was 2 cm in length. The wound bed was filled with slough except for a small area at the base of the wound. The wound was round, crater-like with definite edges, no undermining. Wound care was provided including wound cleanser, skin prep to the surrounding intact tissue, [MEDICATION NAME] Alginate to the wound bed, and a [MEDICATION NAME] sponge dressing was applied to cover the wound. Will inform Dr (doctor) of change. * On 5/22/18 at 9:20 AM, the event committee discussed the blister to the coccyx that was noted on 5/11/18 and a foam dressing was applied. The area was now an unstageable pressure ulcer. The family was to remove the resident's recliner from her room, treatments were in place for wound care, and an air mattress was to be applied to the bed. The dietician was to review nutritional interventions and the wheelchair cushion was changed. The care plan was updated and physician were to be notified. * On 5/22/18 at 5:15 PM, the slough was separating from the wound bed on the right side, pink tissue was visible underneath, and the wound measured 2 cm by 2 cm and was a Stage 2 pressure wound. * On 5/28/18 at 10:36 AM, the pressure ulcer on the coccyx measured 2 cm by 2.1 cm by 0.8 cm and was Stage 2. The dressing was updated to [MEDICATION NAME] ointment on the wound bed and Alevyn dressing to cover the wound. * On 5/30/18 at 1:32 PM, the resident cried out quite often, ate poorly, and was medicated with [MEDICATION NAME] (narcotic pain medication) twice for pain. The dressing was changed on the coccyx by the nurse supervisor. * On 5/31/18 at 1:57 PM, the pressure ulcer to the coccyx measured 2 cm by 1.8 cm by 0.5 cm. The wound was healing nicely, the wound bed was visible and beefy red. * On 6/1/18 at 12:44 PM, a new order was received for a [MEDICATION NAME] (narcotic pain medication) patch 25 mcg. * On 6/1/18 at 2:24 PM, the wound dressing was changed, the wound was red and beefy, the edge of the wound was pink, and the wound bed measured .02 deep. * On 6/4/18 at 4:03 PM, the pressure ulcer continued to improve with [MEDICATION NAME] and an Alevyn dressing, and it measured 1.8 cm by 1.4 cm by 0.6 cm. * On 6/6/18 at 10:24 AM, the wound dressing regimen was changed to include Alginate to a small area on the right side of the wound bed due to slough, and the wound measured 1.7 by 1.8 by 0.4 cm. * On 6/6/18 at 11:06 AM, there was a care plan conference that discussed the resident was declining, now required total assistance for cares, exhibited worrying, nervousness, and yelling, and increased antidepressant medication in May. A medication patch was ordered for pain management. Resident #29's family member believed she was trying to pass away. She lost 6.2 pounds in a month, oral intake was refused to 25%, and nutrition interventions were in place. Other than getting up for meals, Resident #29 was on bed rest and the coccyx wound was being monitored for healing. * On 6/7/18 at 1:57 PM, the coccyx wound measured 1.2 cm by 1.6 cm by 0.4 cm and was Stage 2. * On 6/10/18 at 11:08 AM, the dressing was changed to the coccyx and the area was red with signs of healing. [MEDICATION NAME] was applied to the wound and an Alevyn dressing was applied. [MEDICATION NAME] was administered twice for pain and the [MEDICATION NAME] was continued. * On 6/11/18 at 3:09 PM, the dressing was changed to the coccyx. The wound bed was red and beefy without slough and the edge was pink. New tissue was noted throughout the wound. The current dressing order was continued. * On 6/12/18 at 2:20 PM, the dressing was changed and the wound measured 1.2 cm by 2 cm by 0.4 cm. The wound bed was red, beefy and signs of healing were present. Resident #29's (MONTH) (YEAR) TAR (Treatment Administration Record) documented a daily dressing change to the coccyx was performed each day from 5/22/18 through 5/31/18, except for 5/29/18. Resident #29's (MONTH) (YEAR) TAR documented a daily dressing change to the coccyx was performed each day from 6/1/18 through 6/5/18 and on 6/11 and 6/12/18. On 6/12/18 at 1:52 PM, RN #2 was observed changing the dressing on Resident #29's coccyx. An ulcer was present that measured 1.2 cm by 2 cm by 0.4 cm. RN #2 said the wound was healing. On 6/13/18 at 1:59 PM, CNA #3 said Resident #29 was more alert at the end of (MONTH) and would feed herself. CNA #3 said they reposition Resident #29 every two hours and it should be documented but it was not. On 6/13/18 at 2:48 PM, RN #2 said Resident #29 was doing fairly well until she got a blister on her bottom. It started as a clear blister and she did not know what caused it. The cushion was changed in her wheelchair in case it had pinched her skin, and a dressing was applied to the coccyx. RN #2 said the next time she saw the wound it was an open wound with slough. RN #2 said she applied silver alginate, and in two days the slough was gone and it was a stage 2 ulcer. The dressing was then changed to [MEDICATION NAME] and Alevyn. RN #2 said a blister could be from pressure, and when it was first brought to her attention that Resident #29 had a blister on her coccyx the staff was instructed to change the cushion in her wheelchair and keep the wrinkles out of her sheets. RN #2 said the first time she saw Resident #29's blister she thought it from being pinched, and she assumed if she put a clear dressing on it would absorb and she depended on the nurses to check on it. RN #2 said the next time she saw the blister it was an ulcer and she was not aware until sometime after the weekend that it had changed. RN #2 said she thought it was appropriate to initiate the air mattress 11 days after the blister was noticed on Resident #29's coccyx, after it became an unstageable ulcer. On 6/14/18 at 1:48 PM, RN #3 said CNAs do not document repositioning residents every two hours, and the only way to know it was done was by observation. On 6/15/18 at 9:23 AM, the DON said when Resident #29 developed a blister on her coccyx, the blanket and chair were removed. The DON said there were concerns about the incontinence briefs causing the blister, and they tried putting her in bed to keep pressure off the area. The DON said a good mattress was being used and the blister was not thought to be pressure related, and once the wound was determined to be pressure related an air mattress was implemented. The DON said an incident form was completed when the skin issue was first noticed, then another incident form was done when the wound changed.

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to provide sufficient supervision to meet resident's needs. This was true for 2 of 3 residents (#4 and #20) reviewed for supervision and accidents. Resident #20 was harmed when she sustained multiple injuries requiring medical evauation and care when the facility failed to implement interventions to prevent reoccurring falls. Resident #4 had multiple falls related to failure to implement the plan of care, ensure the bariatric extenders were locked . Findings include: The facility's policy and procedure for Fall Response and Management dated 11/28/17, directed staff to implement immediate interventions to prevent a repeat fall, to complete a post-fall investigation and event report, to review the post-fall evaluation and investigation, determine the cause, and to revise the care plan with interventions. The facility's policy and procedure for Accidents and Supervision to Prevent Accidents, dated 11/18/17, documented the following: *The facility staff observed, identified, and resolved potential hazards in the environment, while they took into consideration the unique characteristics and abilities of each resident. * The staff examined hazard and accident risk information for potential causes of accidents, and created interventions to reduce the risk of the hazard. * The facility monitored to confirm interventions were in place, evaluated interventions for efficacy, and changes and/or replaced interventions that were not effective. * The facility provided sufficient supervision to avoid accidents. The above policies were not followed. Examples include: 1. Resident #20 was readmitted to the facility 2/5/18 with multiple [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], documented Resident #20 was moderately cognitively impaired. Resident #20 experienced four falls in (MONTH) (YEAR). a) A Post Fall Investigation, dated 4/3/18 at 12:35 AM, documented Resident #20 was in bed under a weighted blanket. Resident #20 got out of bed and the floor alarm sounded. Resident #20 fell and hit her head on the corner of her night stand. A Progress Note dated 4/3/18 at 12:35 AM, documented Resident #20 had an unwitnessed fall. She was found in her room at 12:35 AM, lying on her left side. Resident #20 was bleeding from a laceration to her left forehead. Resident #20 complained of left hip pain and neck pain. She was sent to the emergency room . A Progress Note dated 4/3/18 at 3:30 AM documented Resident #20 returned to the facility at 3:30 AM with negative x-ray results and that her head was glued and ster stripped. A progress note dated 4/4/18 at 10:02 AM, documented Resident #20 sustained a laceration to her left forehead and bruising to her left face as result of the 4/3/18 fall. A Resident Monitoring Tool dated 4/3/18, documented Resident #20 was observed at 12:15 AM and 12:30 AM in bed and asleep. An Event Committee Follow Up Note dated 4/3/18 at 10:02 AM, documented Resident #20 was wearing regular socks, and the facility would re-educate staff to provide Resident #20 with no-skid socks. A care plan, dated 2/5/18, documented Resident #20 had no-skid socks were initiated on 2/26/18. b) A Post Fall Investigation dated 4/21/18 at 9:45 PM, documented Resident #20 stood up from her wheelchair and fell on her right side. She hit her head on the door frame, sustained a bump on her right forehead, and sustained two small skin lacerations on her arm. A progress note dated 4/22/18 at 9:00 AM, documented Resident #20 was transported to a clinic due to complaints of side pain. The physician diagnosed a right rib fracture and pneumonia. A Resident Monitoring Tool dated 4/21/18, documented Resident #20 was not monitored with 15-minute checks from 6:00 PM to 10:00 PM. An Event Committee Follow Up Note, dated 4/23/18 at 9:37 AM, documented checks would be done every 15 minutes from 6:00 PM to 6:00 AM. Resident #20's care plan dated 2/5/18, directed staff to perform 15-minute checks from 6:00 PM to 6:00 AM, and was initiated on 2/26/18. c) A Post Fall Investigation dated 4/26/18 at 7:45 PM, documented Resident #20 was found in a seated position near her bed. Resident #20 stood up at the bedside from her wheelchair and the wheelchair rolled backwards. She was uninjured. Resident #20 was last seen at 7:00 PM. A Resident Monitoring tool dated 4/26/18, documented Resident #20 was in the bathroom and engaged with staff from 7:30 PM to 8:15 PM. The documentation was written over to say in bed and engaged with staff. This was inconsistent with the Post Fall Investigation which stated Resident #20 was last seen by staff at 7:00 PM. Resident #20's care plan dated 2/5/18, documented anti-roll back brakes were initiated for Resident #20 on 4/27/18. d) A Post Fall Investigation dated 4/30/18 at 7:30 PM, documented Resident #20 had an unwitnessed fall with significant injury. Resident #20 was found on the floor in her room. She was on her right side and found to have a cut over her right eye. She stated she hurt her head. She had been in her wheelchair. A Resident Monitoring tool dated 4/30/18, documented Resident #20 was seated in her chair from 6:30 PM until her fall at 7:45 PM. Resident #20 was engaged with staff while seated in her chair at 7:00 PM. On 6/14/18 at 9:43 AM, the DON stated to prevent falls, the facility would place the resident on the Falling Star Program, place them on every 15-minute checks, and/or use a weighted blanket to help residents feel safer in bed. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including a history of falling, other abnormalities of gait and mobility, and [MEDICAL CONDITION] without behavioral disturbance. Resident #4's annual MDS assessment, dated 12/26/17, documented a moderate cognitive impairment, setup help only with transfers, one person physical assistance with ambulation, and one fall since the prior assessment. Resident #4's quarterly MDS assessment, dated 3/22/18, documented a moderate cognitive impairment, two person physical assistance with transfers, one person physical assistance with ambulation, and two or more falls since the prior assessment. Resident #4's current care plan documented he was at risk for falls, and had a history of [REDACTED]. * Assess his fall risk, completing assessments to identify the risk for falls. * Ensure the call light is within reach and encourage him to use it. * Encourage him to request assistance with ambulating. * Follow the facility fall protocol was initiated on 2/20/17. * The falling star program to identify his fall risk was initiated on 2/20/17 and revised on 4/24/18. * Non-skid footwear, non-skid socks was initiated on 2/20/17 and revised on 1/3/18. * PT to evaluate and treat and non-skid strips by the bed were initiated on 1/3/18. * Self-locking brakes to his wheelchair and non-skid strips on the bathroom floor were initiated on 3/21/18. * Encourage him to sit in the wheelchair while bedding is changed was initiated on 6/5/18. Resident #4's I and A reports documented the following: * A fall on 1/2/18 at 9:15 PM when he was in the wheelchair, attempted to remove his socks, and his feet slipped. * A fall on 2/8/18 at 7:00 AM when he fell out of bed while trying to reach the television's remote control. * A fall on 3/20/18 at 10:25 AM when he was unattended in the bathroom and lost his balance after standing up from the toilet. * A fall on 3/20/18 at 9:05 PM, when he attempted to self-transfer from the wheelchair to bed, forgot to lock the wheelchair brakes, and the wheelchair slid out of under him. * A fall on 6/5/18 at 5:15 AM when he was sitting on the edge of the bed as the CNA changed the bedding and he slipped off the edge of the bed. Resident #4's Progress Notes documented the following: * On 1/3/18 at 9:18 AM: He fell on [DATE] at 9:15 PM when standing by his bed to turn down the bedding. He was wearing socks and no shoes. Non-skid strips were added by the bed, non-skid socks were provided, and therapy was to continue. * On 2/9/18 at 7:04 AM: A large abrasion and red area were present on his abdomen. Neuro checks were good and he continued to self-transfer. On 2/9/18 at 2:38 PM: An environmental review was performed by the maintenance supervisor, and it was found the bariatric extenders were not locked into place. Will educate housekeepers and all staff when moving bed from one room to another to ensure (the) frame (is) locked into position on bariatric beds. * On 3/20/18 at 11:20 AM: The nurse was notified at 10:25 AM that the resident was found sitting on the bathroom floor, and he said he slipped when getting up from using the bathroom. Staff reported the resident was depressed the day before and was slightly confused. * On 3/20/18 at 9:05 PM: He was found on the floor between the wheelchair and bed, and said he attempted to transfer from the wheelchair to the bed, forgot to lock the wheelchair brakes, and the wheelchair rolled out from under him. He was asked to wait for assistance with transfers. * On 3/21/18 at 9:34 AM: The event committee discussed the falls on 3/20/18. Non-skid strips were added to the floor in front of the toilet, self-locking brakes were added to the wheelchair, therapy was to continue, and the resident was educated to wait for assistance with transfers. * On 6/5/18 at 7:09 AM: He was assisted to the floor by a CNA as she was changing his bed. * On 6/5/18 at 7:29 AM: The nurse was called to the resident's room and the resident was sitting/kneeling on his knees. He was assisted back to bed with 3 person assistance and a Hoyer lift. * on 6/5/18 at 9:02 AM: The event committee discussed the fall on 6/5/18. Resident #4 slid off the side of the bed and the CNA assisted him to his knees. Staff were inserviced regarding having the resident sit in the wheelchair while changing the bedding, the resident was encouraged to sit in the wheelchair while staff change his bedding, and therapy was continue. On 6/12/18 at 9:38 AM, Resident #4 said a couple of weeks ago and his legs gave out, and he had fallen quite a bit since being admitted to the facility. On 6/15/18 at 10:54 AM, CNA #6 said Resident #4 had fallen, one time from his chair and one time out of bed. CNA #6 said staff was helping him in the morning, made sure he was scooted back in his bed, therapy was working with him, and the staff walked with him at meal times. On 6/15/18 at 11:24 AM, RN #2 said Resident #4 had fallen, he slid to the floor during the previous week and he was kneeling next to his bed. RN #2 said the CNA was there when the resident slid to the floor, and RN #2 thought he was out too far on the bed. Staff were educated that sitting on the edge of the bed was not the best place for the resident when making the bed. RN #2 said Resident #4 had issues with spontaneity, non-skid strips were added next to the toilet, and the resident was educated about wearing non-skid socks. RN #2 said there was another fall when Resident #4's wheelchair rolled out from under him, and non-rolling brakes were added to the wheelchair. On 6/15/18 at 12:10 PM, the DON said Resident #4 fell on [DATE] and the physician should have been notified. The DON acknowledged there were blank areas on the Accident and Investigations and said there were blank areas that should have been filled in. The DON said staff were inserviced after the fall on 2/8/18 to make sure Resident #4 could reach the remote control.

Based on observation, record review, and review of manufacturer's recommendations, and staff interviews, it was determined the facility failed to ensure 2 of 3 residents (#4 and #6) requiring the use of mechanical devices for assistance with transfers, were monitored and re-evaluated for the continued appropriateness and safety of the devices; and staff were trained how to use the devices. These failures placed the health and safety of Residents #4 and #6, who required the use of a sit-to-stand device for transfers, in immediate jeopardy of serious injury, harm, or death. Findings include: 1. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand device. LN #1 did not provide guidance to the CNA related to supporting Resident #4 during the preparation for transfer, appropriate height of the bed, or the inappropriateness of Resident #4's transfer position on the lift. An incident investigation, dated 8/7/16, involving Resident #4, documented 2 aides (CNA #6 and CNA #7) were assisting Resident #4 to sit on the edge of the bed to attach the (sling) harness, when he fell backward on the bed. According to the report, Resident #4, at that time, complained of mild ache-like pain between his shoulder blades. The PI (Performance Improvement) Recommendations noted on the incident documented no change to plan of care, CNA re-education. Resident #4's care plan, revised on 10/7/16, included a focus on Impaired physical mobility related to CVA. An accompanying goal was for Resident #4 to maintain independence in wheelchair locomotion. There was no mention of transferring him utilizing the sit-to-stand. During an interview with the Physical Therapy Director, on 10/18/16 at 2:38 pm, the therapist said the sit-to-stand was still the appropriate method of transfer for Resident #4. She said after the staff told her about the transfer observed at 9:30 am earlier on the same day, she provided training on the correct way to transfer Resident #4. When the surveyor asked if she observed the staff perform the transfer prior to providing the training, she said she had not. The therapist was asked if she was aware of the resident's previous (8/7/16) accident resulting in the same outcome during a transfer. The therapist said she was not aware that this type of accident had occurred before with Resident #4. During an interview on 10/19/16 at 6:30 pm, the SDC stated the licensed nursing staff were not required to complete a competency evaluation for the use of the sit-to-stand mechanical lift. The SDC further shared the licensed nursing staff were responsible for signing off the CNAs for the use of the sit-to-stand. LNs having no evaluation of their own competency for the use of the sit-to-stand, were required to evaluate competency for the CNAs. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. Prior to the transfer, Resident #6 was observed sitting in a wheelchair at bedside. The staff placed the sit-to-stand device in front of Resident #6 and proceeded to secure the harness. They instructed Resident #6 to hold onto the handgrips on the device. After securing Resident #6, the sit-to-stand was engaged to lift her from the wheelchair. As she was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 CNAs provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. Resident #6's care plan, dated 4/14/16 and revised on 9/26/16, included a focus on ADL (activities of daily living) Self Care Performance deficit r/t (related to) end stage renal failure with hemodialysis. A related goal was to improve transfers. The care plan not include interventions related to the sit-to-stand device used for the transfer. On 10/19/16 at 6:30 pm, an interview was conducted with the Staff Development Coordinator (SDC). During the interview the SDC was informed of the observations of Resident #4 and Resident #6's transfers with the sit-to-stand. The SDC stated the CNAs would be the first to notice a decline in residents' transfer status. She indicated an assessment to determine appropriateness of a transfer method or a change in that method, would depend on the CNAs or nurses noticing and reporting a decline. The SDC further stated if injuries were noted, part of the investigation would be a review of the transfer equipment. She was unaware of any consistent follow-up observations of the aides demonstrating competency of the mechanical devices, specifically the sit-to-stand, or to determine the continued appropriateness for the device for the residents. The manufacturer's handbook for the sit-to-stand, copyright 2014, stated the sit-to-stand device should only be used for residents/patients who can support at least 20% of their body weight. The manual further instructed the facility to assure only trained personnel was permitted to operate the lift. The manual further noted Untrained operators can cause injury or be injured. The manufacturer's instruction were not followed prior to 10/20/16. The SDC was not trained in the use of the device until 10/20/16 and competencies with return demonstrations were not completed for LNs or CNAs prior to 10/20/16. Removal of Immediate Jeopardy: The Administrator, DON, SDC, and Corporate Representative were informed of the Immediate Jeopardy on 10/20/16 at 12:23 pm. Subsequently, the facility responded by providing a performance improvement action plan for removal of the Immediate Jeopardy situation. The plan included: * The Rehabilitation Program Director to oversee lift transfer program. Rehabilitation Program Director will train the SDC on the sit-to-stand transfer. * The SDC will complete training to 1 LN and 1 CNA with return demonstration with satisfactory outcome. The trained LN and CNA to assist in training other LN and CNA staff. Therapy to assist. Staff will be able to verbalize what to do if a patient (resident) is not able to complete a sit to stand transfer safely. * The SDC and RN Supervisors will train LNs and CNAs on sit-to-stand transfer prior to their next scheduled shift, utilizing the skills checklist. LNs and CNAs will complete a return demonstration and must complete all areas as satisfactory before competency is completed. Staff will be able to verbalize what to do if the patient (resident) is not able to complete a sit to stand transfer safely (10/20/16 start and will continue until all staff are trained). * Surveillance observations to occur during sit-to-stand transfer at least weekly for 4 months, bi-weekly for 2 month, monthly for 6 month by SDC or RN Supervisor. * Sit-to-stand competencies for CNAs and LNs will be completed on hire, annually, and as needed, by SDC or designee. * The Rehabilitation Program Director or therapy designee will assess the competencies of trainers annually. * Residents transferred using a sit-to-stand will be observed quarterly, and as needed with change of condition, by physical therapy and SDC or RN Supervisor. * Training for new hires will utilize skills checklist and include return demonstration with satisfactory outcome from SDC or RN Supervisor. * Therapy will provide demonstration to new hires in general orientation and quarterly x2 during general staff meetings on how to complete a sit-to-stand transfer and what to do when a sit-to-stand transfer does not go well. * Unsafe sit-to-stand observations will be reported to the physical therapist and/or designee for immediate review and intervention. * Sit-to-stand competencies and surveillance outcomes will be reviewed at monthly performance improvement meetings for 6 months. Along with the action plan, the facility provided proof of competencies for all staff, and return demonstrations of competencies. The plan was reviewed, the evening shift was trained prior to working, and the night/day shifts were called in for training and told they would not be able to work until the training/competency was completed. The SDC was trained and completed return demonstration. Surveyors then observed her as she trained staff. The SDC was observed performing a sit-to-stand transfer with a CNA. All nursing staff were required to take a competency test prior to working their next shift. After everything was validated, the Administrator, DON, and Regional Nurse Consultant, were informed the Immediate Jeopardy was removed on 10/20/16 at 4:40 pm.

Based on staff interview and medical record review, it was determined the facility did not ensure changes in residents' pain levels were accurately assessed, did not respond timely to complaints of pain, and did not notify the resident's physician of continued complaints of pain after resident falls. Residents also did not receive interventions per physician's orders [REDACTED].#s 1, 2, and 5) sampled for pain and bowel care. The deficient practice caused harm to Resident #2 when there was a delay in treatment after hs falls. Resident #s 1 and 5 had the potential to experience more than minimal harm if they developed constipation. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS, dated [DATE], coded: -BIMS of 5 (severely impaired cognitive skills..) -Extensive assistance of two persons for transfers. -Limited assistance of one person for ambulation. -Extensive assistance of two persons for toilet use. -Continent of bowel and bladder. -Occasional pain level of 5, on a 0 to 10 scale. Resident #2's Change of Condition MDS, dated [DATE], coded: -BIMS of 4 (severely impaired cognitive skills.) -Extensive assistance of 2 persons for transfers. -Did not ambulate. -Extensive assistance of 2 persons for toilet use. -Frequently incontinent of bowel and bladder. -Almost constant pain level of 8, on a 0 to 10 scale, indicating increased frequency and intensity of pain. a. Beginning 2/3/13, Resident #2's Resident Progress Notes (PNs) documented: On 2/3/13 at 8:45 PM, Condition Change Form, "Resident fell getting up out of bed to use the bathroom. He has an abrasion on his (right) temple and complained about (right) shoulder pain..." (NOTE: There was no documentation of Resident #2's range of motion to his right arm after the fall. There was no documentation of pain interventions implemented, nor the effectiveness of any interventions. There was no documentation of additional assessments compelted.) -2/4/13 at 2:30 AM "...Cont to c/o (complain of) (right) shoulder pain. (Right) ice/heat therapy..." (NOTE: 5 hours, 45 minutes had elapsed since the time of the fall. There was no documentation of the effectiveness of the ice and heat implemented for Resident #2's pain. There was no documentation range of motion had been assessed for Resident #2's right arm. There was no documentation Resident #2's physician had been informed of the continued complaints of pain.) -2/4/13 at 4:15 PM, "Res (with) c/o (right) shoulder/arm pain today (related to) previous fall. Tylenol helpful (with) pain." (NOTE: 19 hours, 30 minutes had elapsed since the time of the fall. There was no documentation Resident #2's physician had been notified of Resident #2's continued complaints of pain. There was no documentation of range of motion being assessed on Resident #2's right arm.) -2/5/13 at 2:30 PM, "Res still (with) c/o (right) shoulder pain (related to) previous fall. (No) bruising visible. ROM adequate to (right) arm..." (NOTE: 29, hours 45 minutes had elapsed since Resident #2's fall. There was no documentation Resident #2's physician had been notified of continued complaints of pain.) -2/7/13 at 9:20 AM, Condition Change Form, "Res continues to c/o (right) shoulder pain. c/o (increased) pain (with) movement. Unable to raise arm above shoulder height this AM. (Right) shoulder and upper arm with [MEDICAL CONDITION]." The form indicated Resident #2's physician was notified at this time. (NOTE: 3 days, 12 hours, 35 minutes had elapsed since Resident #2's fall. There was no documentation of Resident #2's pain levels or assessment of his range of motion documented in the PNs for 2/6/13.) -2/7/13 at 4:10 PM, Condition Change Form, "Phys(ician) phoned res (with) fx (fracture) (right) clavicle. (New order) for pain medication received." Please see F 323 as it pertains to falls and supervision. On 3/12/13 at 4:30 PM, the DNS and DDCO were interviewed regarding Resident #2's fall, and the timing of the assessment of his continued complaints of pain before the fracture was diagnosed . The DNS stated she recalled discussions with the nursing staff regarding this issue. The DNS stated Resident #2 reported pain, but seemed to go about his normal daily routine, including ambulating and smoking, so the nurses did not feel the need to follow up with the physician. The DNS stated, "I recall conversations with the nurses regarding his range of motion, although the assessments don't reflect that. They should have been documenting that." The DNS stated the first changes in Resident #2's range of motion were noted on 2/7/13, so an x-ray was not done until that time. On 3/13/13 at 6:15 PM, the Administrator, DNS, DDCO, and SDC were informed of these findings. The facility offered no further information to resolve the concern. b. Beginning 2/15/13, Resident #2's PNs documented: -2/15/13 at 8:20 PM, Condition Change Form, "Returning to bed from BR (bathroom) (with) walker, found sitting on floor next to bed. (No) injuries noted." (NOTE: There was no documentation of Resident #2's range of motion after the fall. There was no documentation of an assessment of Resident #2's pain after the fall. There was no documentation in Resident #2's PNs until 12:30 PM the following day.) -2/16/13 at 12:30 PM, "Resident has been complaining of severe pain in his (right) groin area since 0730 (7:30 AM) today, calls out in pain frequently. Resident cannot walk, requires two-assist for transfer. Temp 101.3 (degrees). Resident was found sitting on floor on 2/15 PM shift. Groin (right) is tender to light palpation...Medicated for pain and fever X 2 with [MEDICATION NAME], applied ice pack to groin. Informed (physician's name) via telephone about resident's condition at 1230 hrs (12:30 PM). (Physician's name) stated that he can evaluate the resident on 2/17 Sunday, and directed me to ship resident to the ER (emergency room ) if anything worsens..." (NOTE: 5 hours elapsed between the time Resident #2 complained of severe pain, and the time his physician was notified. There was no documentation of Resident #2's range of motion at the time of the onset of his pain complaints.) -2/16/14 at 2:20 PM, "Severe difficulty moving (right) leg, still c/o severe pain '9/10.' Temp 102.1. Shipped to (name of hospital) ER..." -2/16/13 at 9:00 PM, "(Resident #2) returned approx. (7:30 PM) from the (name of hospital) (with) fx of the pubic remus (sic) and ischial body..." Resident #2's MAR for February 2013 documented one [MEDICATION NAME] 7.5/325 mg tablet given on 2/15/13 and 2/16/13 as follows: -2/15/13 at 5:30 PM (before the fall) for right shoulder pain -2/16/13 at 8:40 AM for severe groin pain, unresolved (This was the first documented dose given after the fall. 12 hours, 10 minutes had elapsed since the time of the fall. 70 minutes had elapsed since the resident had complained of "severe pain.") -2/16/13 at 12:15 PM for pain in the right groin and clavicle, unresolved. On 3/12/13 at 4:30 PM, the DNS and DDCO were asked about the timeframe between Resident #2's fall on 2/15/13, his complaints of pain, and physician notification. The DNS stated Resident #2 was medicated for pain following his fall, but was still complaining of pain the next morning. The DNS could not say for sure how long after the fall Resident #2 was medicated for pain. The DNS stated the nurse on duty the next day, when complaints of severe pain were present, tried ice and pain medication to address Resident #2's pain. The DNS stated when those measures were not effective the nurse notified the physician. The DNS stated the physician planned to see the resident the following day, but to send the resident to the ER if he continued to worsen. The DNS stated Resident #2 continued to experience pain, and his temperature rose, so he was sent to the ER. The DNS was unable to offer information regarding Resident #2's range of motion between the time of the fall and the time Resident #2 complained of pain, or between the time of the fall and the time he was sent to the ER. The DNS stated she was unable to offer further clarification as to why Resident #2's initial complaints of severe pain were not relayed to the physician as soon as they occurred. On 3/13/13 at 10:15 AM, the DNS reported she had spoken to the nurse caring for Resident #2 about the timing of the events on 2/16/13. The DNS stated when Resident #2 first complained of pain to the nurse on duty that day, the resident told the nurse it felt like a hernia. Based on that statement from the resident, the nurse felt it would be appropriate to treat with medications and ice to see if those interventions were helpful before notifying the physician. The DNS stated, "It didn't get documented." The DNS was asked if the physician should have been notified of the resident's pain complaints, regardless of the presumed cause. The DNS stated, "yes." The DNS was asked if the physician should be notified of a resident developing a hernia. The DNS stated, "yes." On 3/13/13 at 6:15 PM, the Administrator, DNS, DDCO, and SDC were informed of these findings. The facility offered no further information to resolve the concern. 2. Resident #5 was originally admitted the facility on 10/6/10, and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/21/13, coded in part: * Moderate cognitive impairment with a BIMS score of 11; * Able to understood others and to be understood by others; * Extensive assistance of 2 people for bed mobility and toileting; * Total assistance of 2 people for transfers; and * Always incontinent of bowel. The resident's annual MDS assessment, dated 8/7/12, coding included constipation was a bowel pattern. On 10/14/10, Resident #5's care plan identified the problem, "Bowel Elimination, Impaired: Constipation." Approaches and their date of incorporation into the care plan included: * "10/14/10 Administer medications as ordered" * "4/12/12 Monitor frequency and consistency of stools Notify MD (physician) if med(ication) ineffective." A recapitulation of the resident's March 2013 physician's orders [REDACTED]. * Ten medications (or meds) with constipation listed as a potential adverse reaction (according to the Nursing 2013 Drug Handbook) which included: [MEDICATION NAME] (long acting pain med), routine use of [MEDICATION NAME] for pain, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] and Atorvastatin for high cholesterol, [MEDICATION NAME] for stroke prevention, [MEDICATION NAME] for hypertension, [MEDICATION NAME] sulfate for [MEDICAL CONDITION], [MEDICATION NAME] for depression, and [MEDICATION NAME] for hallucinations. * Two as needed, or PRN, meds for constipation: Milk of Magnesia (MOM) 30 centimeters at bedtime PRN and [MEDICATION NAME] 10 milligram suppository per rectum every day PRN. Review of Flow Sheet Records for January and February 2013 revealed interventions were not implemented when the resident did not have a BM for 3 or more days on: * January - 1/5-1/8 (4 days), 1/12-1/15 (4 days), 1/21-1/23 (3 days), and 1/25-1/31 (7 days); and * February - 2/2-2/5 (4 days), 2/7-2/9 (3 days), 2/11-2/13 (3 days), 2/16-2/19 (4 days), and 2/22-2/25 (4 days). On 3/13/13 at 6:10 p.m., the DNS was asked what, if any, interventions were implemented when Resident #5 did not have a BM for 3 or more days as noted above. The Divisional Director of Clinical Operations was present during the interview. The DNS reviewed the resident's clinical record then stated the aforementioned PRN bowel med interventions were not consistently documented. On 3/14/13 at 4:00 p.m., the Administrator was also informed of the issue. However, no other information or documentation was received from the facility. 3. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Hospice services started on 5/30/12 for end stage [MEDICAL CONDITION]. The resident's most recent quarterly MDS assessment, dated 2/18/13, coded in part: * Moderate cognitive impairment with a BIMS score of 12; * Able to understood others and to be understood by others; * Extensive assistance of 1 person for bed mobility, transfers, and toileting; and * No bowel incontinence. A recapitulation of the resident's March 2013 physician's orders [REDACTED]. * Seven medications (or meds) with constipation list as a potential adverse reaction (according to the Nursing 2013 Drug Handbook) which included: routine and PRN (as needed) [MEDICATION NAME] for pain, PRN liquid [MEDICATION NAME] sulfate (fast acting pain med), [MEDICATION NAME] for hypertension, calcium with vitamin D as a supplement, [MEDICATION NAME] for schizo-affective disorder, PRN [MEDICATION NAME] for agitation, and routine and PRN [MEDICATION NAME] for restlessness/anxiety/agitation. * Milk of Magnesia (MOM) 30 centimeters at bedtime if no BM. Review of Flow Sheet Records for January and February 2013 revealed interventions were not implemented when the resident did not have a BM for 4 days on 1/12-1/15 and 2/16-2/19. On 3/13/13 at 2:25 p.m., the DNS was asked what, if any, interventions were implemented when Resident #1 did not have a BM for days as noted above. The Divisional Director of Clinical Operations was present during the interview. The DNS indicated she would review the resident's clinical record and get back with the surveyor. At 5:50 p.m., the DNS stated, "I have no further information." The DNS confirmed there were no interventions documented when Resident #1 did not have a BM as noted above. The SDC was present during the interview. On 3/14/13 at 4:00 p.m., the Administrator was also informed of the issue. However, no other information or documentation was received from the facility.

Based on observation, staff interview, and record review, it was determined the facility did not ensure each resident received adequate supervision to prevent falls, and did not ensure supervision as required at meal times. This was true for 2 of 9 residents (#'s 2 and 4) sampled for supervision. Resident #2 was harmed when he experienced decreased ability to complete ADLs, decreased ability to ambulate, increased incontinence and increased pain from fractures sustained as a result of his falls on 2/3/13 and 2/15/13. Resident #4 had the potential for more than minimal harm when he was placed in a room without direct supervision or physical assistance at meals. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS, dated [DATE], coded: -BIMS of 5 (severely impaired cognitive skills.) -Extensive assistance of two persons for transfers. -Limited assistance of one person for ambulation. -Extensive assistance of two persons for toilet use. -Continent of bowel and bladder. -Occasional pain level of 5, on a 0 to 10 scale. Resident #2's Change of Condition MDS, dated [DATE] , coded: -BIMS of 4 (severely impaired cognitive skills.) -Extensive assistance of 2 persons for transfers. -Did not ambulate. -Extensive assistance of 2 persons for toilet use. -Frequently incontinent of bowel and bladder. -Almost constant pain level of 8, on a 0 to 10 scale, indicating increased frequency and intensity of pain. The CAA summaries associated with the 2/28/13Change of Condition MDS documented: -Urinary Incontinence and Indwelling Catheter, "Res (with) decline in continence (related to) decline in ADL's (related to) fractures (and) non-wt. bearing status...Staff using bedpan and bedside commode for res elimination needs..." -Falls, "Res (with) 3 falls since last assessment - 2 (with) major injury. Fall 2/3/13 (with) shoulder pain (and) lateral clavicle fx (and) (left) 3rd rib fx (fracture) resulting. Fall 2/15/13 (with) resulting fx of anterior acetabulum. Mobility impaired (related to) fx (and) pain. Hx of seizure activity though falls (with) fx appear to be unrelated to seizures..." -Pain, "Res (with) pain (related to) pelvic fx. Norco QID (four times daily) ordered 2/8/13..." Resident #2's care plan for the problem area "Risk for Falls", initiated 9/20/10, documented: -"Assess cause, pattern of previous falls (and) act on resolvable factors." Date initiated 9/23/10. -"BSC or bedpan for bowel urgency." Date initiated 2/28/13. -"Vertical bar to outside of bathroom for safe transfers." Date initiated 10/4/10. -"Bed against wall to provide resident with spacial perimeter and security." Date initiated 12/15/10. -"Non-skid strips by bed." Date initiated 8/9/11. -"If staff has knowledge of resident using bathroom, place walker so resident can push rather than pull walker when using bathroon." Date initiated 12/19/11. On 1/24/13 at 6:45 PM, a Condition Change Form in Resident #2's Resident Progress Notes (PNs) documented, "Res found sitting on floor (with) walker in front of him. Amb(ulating) to BR (bathroom)..." On 1/24/13 at 6:45 PM, a facility "Post-Event Investigation/Interviews" form documented: -Event description as, "Res(ident) sitting on floor next to wall. Res slid down wall to sit on floor with walker in front of him." -The "What happened?" area of the form documented, "Res transferring to BR, became weak." -The "Why did it happen?" area of the form documented, "Res is unsteady with ambulation at times." -The "Fall Description" area of the form documented Resident #2 as "Indep(endent)" with toileting. -The "PI Recommendations" area of the form documented, "No (change) to plan of care (POC)." -The "Condition Change Form" area of the form documented, "Res had not used BR prior to fall...nothing out of the ordinary to allow staff to predict fall. (No change) POC." On 2/3/13 at 8:45 PM, a Condition Change Form in Resident #2's PNs documented, "Resident fell getting up out of bed to use the bathroom. He has an abrasion on his (right) temple and complained about (right) shoulder pain..." On 2/3/13 at 8:45 PM, a facility "Post-Even Investigation/Interviews" form documented: -Event Description as, "Heard a crashing noise went to look for the cause and found resident on the floor on his right side with his right arm above his head and his head resting on his right arm. He stated he needed to go to the bathroom..." -The "What happened?" area of the form documented, "I think (Resident #2) was getting up to go to the bathroom and tried to use his table to get up and his table moved and he fell ...has a(n) abrasion on the right temple and he states his right shoulder hurts." -The "Why did it happen?" area of the form documented, "He became off balanced trying to use the bedside table to get up." -The "Fall Description" area of the form documented the time Resident #2 was last toileted as, "Self." -The "PI Recommendations" area of the form documented, "(Changed) that stationary over the bed table in place." -The "Condition Change Form" area of the form documented, "Upon investigation res got OOB (out of bed) (independently) per usual routine (and) fell hitting his (right) temple (and) shoulder on over bed table. Res needing to use the bathroom..." On 2/7/13 at 9:20 AM a facility Condition Change Form in Resident #2's PNs documented, "Phys(ician) phoned res (with) fx rt clavicle. (new order) for pain medication received." (NOTE: Please see F 309 as it pertains to the timeframe between the fall and [DIAGNOSES REDACTED]. On 2/15/13 at 8:20 PM, A Condition Change Form in Resident #2's PNs documented, "Res returning to bed from BR (with) walker, found sitting on floor next to bed. (No) injuries noted." On 2/15/13 at 8:20 PM, a "Post-Event Investigation/Interviews" form documented: -Event Description as, "Heard res yell 'Help.' Res sitting on floor (with) back to bed..." -The "What happened?" area of the form documented, "Res returning from BR (with) walker. Backed up to bed to sit down, sat on floor." -The "Why did it happen?" area of the form documented, "Res unsteady." -The "Fall Description, Recreate the life of the resident prior to the fall" area of the form documented, "(Up) to BR." -The "PI Recommendations" area of the form documented, "Request PT eval(ulate) and (treat). -The "Condition Change Form" area of the form documented, "Res (with) fall 2/15/13 at (8:20 PM) when returning to bed from bathroom (with) walker (and) backed up to bed to sit down (and) sat on floor...Fx (fracture) of pelvic remus (and) ischial body noted..." (NOTE: Please see F 309 as it pertains to the timeframe between the fall, [DIAGNOSES REDACTED].) On 2/16/13 at 2:30 PM, Resident #2 was seen in the emergency room at (hospital name.) Resident #2's emergency room Record documented, in part, "...x-rays of the right hip and...pelvis...showed pelvic fracture along the medial aspect of the right acetabulum...patient is nonambulatory at this time due to pain...he can remain at bed rest at that facility (the SNF) and have orthopedic consult regarding the medical acetabular fracture..." On 2/20/13, a Physical Therapy Evaluation form in Resident #2's record documented, in part, "Pt fell sustaining (right) clavicle (fracture) 2/7/13. Then he fell again (and) fractured (right) pelvis. He is non-wt (weight) bearing on (right) LE (lower extremity.)" On 3/7/13 at 7:00 PM, a Condition Change Form in Resident #2's PNs documented, "Res (up) self transferring to BSC (bedside commode) next to bed. Found on knees in front of BSC (with) apx (approximately) 2 inch laceration to rt (right) eyebrow..." On 3/7/13 at 7:00 PM, a "Post-Event Investigation/Interviews" form documented: -Event Description as "Heard yell help me. Res on knees next to BSC with blood drops on the floor." -The "What happened?" area of the form documented, "Had to go to the bathroom." -The "Why did it happen?" area of the form documented, "I don't know." -The "PI Recommendations" area of the form documented, "(15 minute checks.) Floor mat alarm." -The "Condition Change Form" area of the form documented, "Res found on floor on knees next to BSC (with) pants/depends down per staff report. Res had self-transferred to (and) used commode (and) fell when transferring off commode. Laceration to (right) eyebrow..." On 3/12/13 at 4:30 PM, the DNS and the DDCO were asked about Resident #2's falls. The DNS stated the facility's interdisciplinary team (IDT) usually met to discuss resident events the next business day after they occurred, then met to review how successful the facility's new interventions were about a week later. Regarding Resident #2's falls, the DNS stated the following: -For the fall on 1/24/13, Resident #2 had been seen lying in bed 15 minutes prior to the fall, and had likely gotten up to take himself to the bathroom, became weak, and fell to the floor. The DNS stated staff would not have been present to assist, as Resident #2 was independent with this activity. The DNS was asked about Resident #2's MDS from 1/9/13 which coded Resident #2 as needing extensive assistance of two persons for toileting, and limited assistance of one person for ambulation. The DNS stated that information was surprising to her, as she knew Resident #2 to be independent with ambulation and toileting. The DNS stated the facility's IDT had reviewed the event, and determined the care plan interventions in place at the time were appropriate, and no changes were warranted. The DNS was asked about what interventions were in place on Resident #2's care plan at the time of that fall. The DNS stated that she did not recall that information, and would have to look it up. However, this information was not provided. -For Resident #2's 2/3/13 fall, the DNS stated the IDT focused on Resident #2's bedside table as his room floor had been waxed shortly before the fall, and a different bedside table was placed in his room after it was waxed. The DNS re-iterated Resident #2 was noted to be independent with toileting and ambulation, and she would have to follow up on the information in Resident #2's MDS. The DNS was asked if Resident #2's toileting pattern or care plan was looked at as a result of this fall. The DNS stated the IDT had focused primarily on the environment, and had not discussed toileting as a possible contributing factor to Resident #2's falls. -For Resident #2's 2/15/13 fall, the DNS stated Resident #2 had just gone to the bathroom, backed up to sit on his bed, and fell to the floor. She stated no staff were present, as Resident #2 was noted to be independent with toileting and ambulation. The DNS stated even though all of these falls had been in the evening hours and related to toileting needs, Resident #2's voiding patterns and care plan had not been re-evaluated. -The DNS stated Resident #2 did have an increase in his pain level as a result of the fractures he sustained in the falls, but his pain level seemed to be returning to baseline as his fractures healed. The DNS stated while Resident #2 technically required more assistance for ADLs after his falls, "He was non-compliant, so his restrictions didn't really slow him down." The DNS stated Resident #2 did show increased incontinence due to the use of lactulose for his Hepatitis C, which caused him to have a sense of urgency with his bowels. She stated he had used that medication for a long time, and urgency with his bowels was not a new development for Resident #2. On 3/13/13 at 10:15 AM, the DNS and DDCO were asked about Resident #2's fall on 3/7/13 The DNS stated at that time, Resident #2 was to have assistance with toileting, as he was made non-weight bearing as a result of his fall on 2/15/13. The DNS stated Resident #2 had stood after using the commode, and attempted to return to bed before pulling his pants up. The DNS stated the resident had put himself on the commode, and no staff were present when he fell . The DNS stated the facility had not evaluated Resident #2's voiding patterns or updated his care plan as a result of his fall. The DNS did state the facility placed a floor mat alarm at Resident #2's bedside as a result of this fall. On 3/13/13 at 2:30 PM, the MDS nurse was interviewed about Resident #2's 1/9/13 MDS and functional status. The MDS nurse stated she had based the MDS information on the instructions in the RAI. The MDS nurse stated, "The RAI states if a resident needs physical assistance 3 or more times during the look-back period, then it must be coded on the MDS. (Resident #2) was different in the evenings. He needed more physical help." The MDS nurse stated the information on the 1/9/13 MDS was accurate. On 3/13/13 at 6:15 PM, the Administrator, DNS, DDCO, and SDC were informed of the surveyors findings. The DNS stated the facility had started tracking Resident #2's voiding patterns the previous evening, and would be reviewing the information to update Resident #2's care plan once the data collection was complete. However, this information did not resolve the concern regarding the facility's evaluation of Resident #2's voiding patterns and need for assistance prior to the falls and fractures, nor the concern with the implementation of supervision and assistance as a result of those evaluations. Resident #2 was harmed when he fell in the facility on four occasions (1/24/13, 2/3/13, 2/15/13, and 3/7/13), and sustained fractures on two of those occasions. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Annual MDS assessment, dated 2/18/13, coded: -Unable to complete the BIMS, assessed by staff with moderately impaired decision making skills. -Extensive assistance of two persons for transfers. -Limited physical assistance from one person to eat meals. -Has had two or more falls without injury since the last assessment. Resident #2's care plan documented: -5/2/12, Problem description, "Swallowing, impaired, R/T dysphagia." -5/2/12, Approach, "Instruct family about feeding techniques." -1/16/13, Approach, "Maintain in optimum position for eating (and) digesting food." (NOTE: There were no care plan approaches describing what optimum positioning would entail. There were no care plan approaches for staff to supervise or assist Resident #2 during meals. There were no care plan approaches for Resident #2 to dine in a room by himself.) On 3/12/13 at 8:30 AM, Resident #4 was observed to be eating his breakfast meal in the Willow Room. He was the only person in that room. The DNS entered the room at 8:30 AM, approached Resident #2, asked if he was close enough to the table to eat, then left the room. Resident #2 was then in the room alone, with no other residents or staff, until 8:37 AM. At 8:37 AM, the DNS returned to the Willow Room, cued Resident #4 to eat his roll and drink his juice, then adjusted his lap tray. At 8:40 AM, the DNS left the Willow Room and Resident #4 was again unattended. At 8:45 AM, Resident #4 was approached by LPN #2, and cued to eat his roll. The DNS briefly returned to the room, but both LPN#2 and the DNS left the room after approximately one minute. Resident #4 was unsupervised and unassisted for the remainder of the breakfast meal. (NOTE: Resident #4 was not offered physical assistance to eat his meal, as identified in the MDS. LPN#2 was periodically in the hallway outside the Willow Room at the med cart, pouring medications, but once the medications were poured, LPN #2 left the hallway. Please see F 221 as it pertains to Resident #4's positioning during the meal.) On 3/12/13 at 3:30 PM, during a family interview, (Resident #4's family member) stated, 'My only concern, and this was at his previous facility, he (Resident #4) was not supervised enough at meals, and he developed aspiration pneumonia and was sent to the hospital." On 3/13/13 at 10:25 AM, the DNS was interviewed about supervision and assistance for Resident #4 at meals. The DNS reported there had been a speech therapy evaluation and Resident #4 was determined not to be at risk for aspiration pneumonia. On 3/13/13 at 6:15 PM, the DNS provided documentation of a speech therapy discharge summary dated 11/28/12. The discharge summary documented, in part, "Swallow: now self-feeds; minimal s/sx (signs and symptoms) of aspiration...can attend (approximately) 10-15 minutes 40-50 (percent) of the time (with) max cues...Nursing staff and family educated to provide maximal context (tactile, visual, environmental) to support meaningful communication and (increased) attention; family trained to feed pt (patient) safely and recognize s/sx of aspiration." However, this information did not resolve the concern for supervision and assistance for Resident #4 at meals.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents did not develop pressure ulcers after their admission. This was true for 2 of 2 (#s 1 and 2) residents sampled for pressure ulcers. Resident #1 was harmed when he developed a Stage 4 pressure ulcer to his left heel and Resident #2 was harmed when he developed two Stage 2 pressure ulcers to his bilateral ischial tuberosities (or gluteal folds). Residents #s 1 and 2 were harmed when the facility failed to: * modify care plans to meet resident needs related to pressure ulcer care, * provide and document interventions when problems occurred, and * implement care planned interventions. Findings included: 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 10/21/11, documented the following: * Understood and able to understand others * Moderately impaired cognitive skills for daily decision making * No rejection of care * Independent, requiring no set up or physical help from staff, for bed mobility * Extensive assistance requiring one person for physical assistance with transfers and toilet use * Limited assistance requiring one person for physical assistance with walking and locomotion on and off the unit * Occasional urinary incontinence * Always continent of bowel * At risk for development of pressure ulcers * No pressure ulcers * Pressure reducing device for chair and bed The resident's quarterly Patient Nursing Evaluation, dated 10/26/11, documented the following: * Braden Scale for Predicting Pressure Sore Risk of 18, Low Risk. * No issues identified for Skin Inspection Anatomy Diagram The November 2011 Physician (recapitulation) Orders documented the following: * Nutritional supplement 60 cc (cubic centimeters) by mouth twice daily, Order Date 9/28/11 * Baza protect twice daily to superficial open areas to bilateral inner buttock until resolved, Order Date 8/18/11 * Knee high TED ([MEDICAL CONDITION] decompression) hose bilaterally for [MEDICAL CONDITION], Order Date 10/17/11 (NOTE: Discontinued on 11/5/11, stated resident did not like to wear them.) Resident #1's Care Plan, dated 7/18/11, documented the problem, "Skin Integrity, Impaired Potential," and included the following interventions: * Cue to turn and reposition when in bed. Avoid skin to skin contact. Use pillows as needed. * Float heels when in bed. * Air mattress. * Pressure reduction cushion to wheelchair. * Avoid pressure from drain tubes, casts, orthotics, braces, cervical collar, ill-fitting footwear, etc. * Apply moisturizing lotion to extremities at HS (bedtime). * Weekly Skin At Risk (SAR) checks per Facility Protocol. * Padding to oxygen cannula tubing. Resident #1's Comprehensive Care Plan Report, dated 8/2/11, documented the problem, "Skin/Tissue Integrity Impaired: Potential, r/t (related to) impaired mobility, r/t pain, r/t steroid use, r/t hx (history) [DIAGNOSES REDACTED]r/t [DIAGNOSES REDACTED]," and included the following additions to interventions listed above: * Use positioning and pressure reducing device in bed and wheelchair (handwritten note) and recliner. (dated 9/7/11) * Report any red or open areas. This care plan did not include the intervention for cueing the resident to turn and reposition when in bed, although his flow sheet continued to document this area. Resident #1's Comprehensive Care Plan Report, dated 9/8/11, documented the same problem area but discontinued the following interventions: * Float heels when in bed, discontinued on 9/28/11. * Avoid pressure from drainage tubes, casts, orthotics, braces, cervical collars, and ill-footing footwear, discontinued 9/28/11. The facility's Preventative Skin Care policy, dated 4/28/11, included the following procedure: * Assess patient from head to toe for skin breakdown and effectiveness of care plan interventions at least weekly. The Resident Weekly Skin Check Sheet for Resident #1 dated 10/27/11, no time documented, "Skin W/D/I (warm, dry, intact), 3 plus [MEDICAL CONDITION] bil lower ex (bilateral lower extremities), buttocks improved." NOTE: This head to toe skin check did not document any skin issues, including the resident's heels. A Condition Change Form for Resident #1, dated 10/27/11 at 5:15 pm, documented, "During bath CNA found open area to R (right) heel. Area oval 0.7 (centimeters or cm) x 1.2 (cm) x 0.1 cm. No redness surrounding pink center. Will investigate and tx (treat) with [MEDICATION NAME] ulcer." NOTE: This notation was incorrectly documented as the right heel when in fact, it was the left heel, as confirmed by the DON. A Condition Change Form for Resident #1, dated 10/31/11 at 5:00 pm, documented, "Res (resident) has had LE (lower extremity) [MEDICAL CONDITION] approximately 2 months. TED hose were being worn until about 1 wk (week) ago. [MEDICAL CONDITION] 2-3 plus. Res amb (ambulating) short distance or propels self in w/c (wheelchair). Air mattress remains in place on bed. Sits in recliner with feet elev (elevated) during day. On 10/27/11 res found with ulcer to back of R heel. Investigation reveals res declines removing socks at noc (night) and has stopped wearing TED hose to help [MEDICAL CONDITION]. Even heel with [MEDICAL CONDITION]. Res sleeps to back for comfort. LE [MEDICAL CONDITION]/poor circulation and pressure in bed likely factors and unavoidable considering res preferences...." The Weekly Pressure Ulcer BWAT (Bates Weekly Assessment Tool) Report documented the left heel ulcer as a Stage 4 as of 11/24/11, measuring 1.2 cm x 1.2 cm, no depth documented, with firmly adherent, soft, black eschar. This necrotic tissue was not present on previous documentation. The left and right heels of the resident were observed by the surveyor on 11/29/11 at 10:02 am, with the DON present. The surveyor observed an open black area on the resident's left heel, approximately 2 cm x 2 cm, depth unknown. The resident's right heel was not red nor open. The Flowsheet Record for October 2011 documented in the area, "Cue to turn and reposition Q 2 hrs (every 2 hours) while in bed. Assist as needed to complete task," that from 10/1-10/27 the resident turned and repositioned himself for 25 of 27 night shifts, 9 of 27 day shifts, and for 6 of 27 evening shifts. A Resident Event Report Worksheet for Resident #1's left heel ulcer, dated 10/27/11, documented the following: * The LN who performed the head to toe skin check stated she was going to remove the resident's socks during the 10/27/11 SAR assessment but got called out of the room and never went back to check. (Please note the LN assessment which documented no skin issues.) * A CNA documented the resident refused to remove socks in bed. A second CNA stated the resident slept in his socks and usually slept on his back. A third CNA documented the resident had been refusing to wear his TED hose for the week prior and that his shoes fit "okay." NOTE: There was no documentation of physician notification for the resident's refusal to wear his TED hose, as ordered, until after the development of the Stage 2 pressure ulcer to the resident's left heel. The order to discontinue the TED hose was noted on 11/5/11. The facility failed to properly assess and implement care planned and physician ordered interventions to prevent the resident from being harmed with the development of a Stage 4 pressure ulcer to his left heel. The care planned interventions to float his heels and to cue for repositioning were discontinued due to "activity." In an interview with the DON on 11/29/11 at 10:02 am, she stated the resident was up and ambulating in the facility so the orders were discontinued. NOTE: The facility continued to document his positioning and in fact, showed they provided no assistance at night, when they stated he preferred to lay on his back, but that he repositioned himself. The facility was aware of his positioning and did not implement interventions to float his heels when in bed, therefore failing to utilize appropriate pressure reduction support surfaces. The facility failed to consistently monitor and assess the resident from head to toe when his socks were not removed during his weekly SAR assessment. It was unclear how staff were applying lotion to his extremities nightly as required in his care plan, if they never removed his socks except to bathe him. The resident's wish to wear socks in bed for comfort would not preclude the facility from inspecting his skin and then reapplying his socks for comfort. The facility stated they felt pressure in bed and possibly [MEDICAL CONDITION] in his heels were factors, after he developed the pressure ulcer. These risk areas were known to the facility, but appropriate interventions were not instituted to prevent harm to the resident. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent admission MDS assessment, dated 10/6/11, documented the following: * Sometimes understands others and is sometimes understood * Severely impaired cognitive skills for daily decision making * No rejection of care * Extensive assistance requiring two persons for physical assist with bed mobility * Total dependence requiring two persons for physical assist with transfers and toilet use * Extensive assistance requiring one person for physical assist with locomotion on and off the unit, eating, personal hygiene, and bathing * Not steady and only able to stabilize with human assistance for surface-to-surface transfers * Bilateral impairment with functional limitation in range of motion for upper and lower extremity * Always incontinent of bowel and bladder * At risk for developing pressure ulcers * No pressure ulcers present. The resident's admission Patient Nursing Evaluation, dated 9/29/11, documented the following: * Braden Scale for Predicting Pressure Sore Risk of 11, High Risk * Extrinsic risk factors: Requires staff assist to move to relieve pressure over any one site * Skin Inspection Anatomy Diagram noted, "sm (small) healing sore L great toe. Old scar to coccyx and R side scrotum both healed." * Hoyer Lift The resident's Care Plan, dated 9/29/11, documented the problem area, "Skin Integrity, Impaired Potential, r/t DM (diabetes mellitus), r/t [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]), r/t steroid use, r/t psychoactive rx (prescription), r/t dementia/confusion, r/t impaired mobility, r/t hx of pressure ulcers coccyx, and r/t dry skin LE." The following interventions were included: * Turn and reposition when in bed. Avoid skin on skin contact. Use pillows as needed. * Pressure reduction cushion to wheelchair (handwritten note) and bed. * Treatment as per MD order. Notify MD of adverse changes in healing process. * Apply protective barrier cream after each incontinence and/or with AM & PM cares. * Apply moisturizing lotion to extremities at HS. * Weekly Skin At Risk (SAR) checks per Facility Protocol. The resident's Comprehensive Care Plan Report, dated 9/30/11, documented the problem area, "Physical Mobility, Impaired," and included the goal, "Will be able to sit in w/c comfortably and with good body alignment for 1-2 hrs at a time 2-3 times/day." This problem included the intervention, "Use positioning and pressure relieving device: w/c cushion." This care plan included the problem area, "Skin/tissue integrity impaired: potential," dated 10/7/11, and included the following new interventions: * Turn and reposition Q 2 hrs while in bed during the day; Q 4 hours at noc and prn (as needed). * Use positioning and pressure relieving device: cushion in wheelchair, pressure relieving mattress on bed. NOTE: Pressure relieving mattress on bed had a line drawn through and a handwritten addition of "air mattress," dated 11/27/11. * Report any red or open areas. The facility's Resident Weekly Skin Check Sheet for Resident #2 indicated the skin was warm, dry, and intact until 10/27/11 when it was documented, "Skin w/d, has old area on scrotum, red and 2 open areas to coccyx." The diagram indicated bilateral ischial tuberosities or the gluteal folds. A Resident Event Report Worksheet for Resident #2, dated 10/30/11, documented two open areas, Stage 2 pressure ulcers, to the resident's ischial tuberosities. One CNA documented not seeing any open areas as of 10/28/11 and that the hoyer sling was left under the resident. One LN documented she was unaware of any breakdown but stated the week prior the buttocks/coccyx was red and was of concern for breakdown. Stated staff were instructed to lay resident down between meals but one CNA stated the resident refused and verbalized in Spanish to this CNA. Also documented was a Braden Scale Score of 13 as of 10/26/11, which indicated medium risk. The resident had been assessed by Physical Therapy and Occupational Therapy for positioning. A Condition Change Form for Resident #2, dated 10/31/11, documented, "Skin Review: Res high risk for breakdown r/t hx of pressure ulcers to coccyx at previous facility. Res positioned (sic) change Q 2 hrs and up last/first down and Baza Protect used. On 10/27/11 SAR check LN noted opening to coccyx; res has had scar tissue and redness there; today area intact. However bil gluteal folds with superficial 1 x 1 x less than 0.1 cm Stage II areas. Res slouches in w/c even though seating system (sic) and sits on lift sling contributing factors. Will place res on air mattress, cont Baza (protective barrier cream) and update CP (care plan). Further investigation reveals res has been refusing to lay down and verbalizing to Spanish speaking staff over last wk." NOTE: There was no documentation of these refusals in the nurses' notes, or notification to the physician of such. In addition, the directive to get the resident out of bed last and lay down first was not in the care plan. It was included in an inservice to staff, dated 10/31/11. In addition, the Treatment Record documented the Baza Protect to bilateral gluteal folds was begun 10/31/11. There was no indication why treatment was not initiated until 3 days after the discovery of the wounds. The Weekly Pressure Ulcer BWAT Reports for the two Stage 2 pressure ulcers to the resident's bilateral ischial tuberosities documented a date of first observation of 10/30/11, even though the SAR assessment documented the first observation on 10/27/11. Resident #2 was harmed when the facility failed to properly assess his wheelchair positioning and the effect of the mechanical lift sling to his ischial tuberosities. The resident was dependent upon staff for positioning and had contractures in his lower extremities that impaired his ability to lay on his back while in bed. Resident #2 was observed over a 3 day period by the surveyor and was only awake, with his eyes open, once during those observations. The resident appeared somnolent, even while at the dining room table, and was difficult for staff to arouse. There was no documentation of his refusals to lay down until after the discovery of his two Stage 2 pressure ulcers. The facility documented they were aware he had positioning issues of slouching in his chair, but did not seek to have the resident re-evaluated for a different seating system that would distribute weight appropriately for the resident. On 11/30/11 at 9:00 am, the surveyor observed the pressure ulcers, along with the DON. These two pressure ulcers were observed to be medial and not lateral, which would indicate he would have been in a sitting or supine position for these areas to be affected. As the resident was completely dependent on staff for positioning, these pressure ulcers were avoidable if staff followed the care planned interventions of good body alignment and positioning while in his wheelchair and in bed. The facility identified these issues only after the development of the pressure ulcers, and therefore were responsible for proper assessment, implementation, and re-evaluation of care plan interventions. The Administrator, DON, and Regional Nurse Consultant were informed of these issues on 12/1/11 at 11:00 am. No further information regarding this matter was received from the facility.