Every finding on record at Woodview Home, Inc.

Based on record review and interview, the facility failed to report allegations of abuse to OSDH within two hours for 2 (#1 and #3) of 4 sampled residents reviewed for abuse.The administrator identified 40 residents resided in the facility. Findings: An Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated September 2022, read in part, Reporting Allegations to the Administrator and Authorities.3. 'immediately' is defined as: a. within two hours of an allegation involving abuse. 1. An initial incident report form, dated 06/11/25, showed Resident #3 had a diagnosis of severe dementia and they ambulated independently. The report, read in part, This morning [CNA #1] reported to the DON that they had observed [CNA #2] scream at [Resident #3] in the dining room yesterday evening. The facsimile receipt showed OSDH received the incident report on 06/12/25 at 4:41 p.m.2. A late entry nursing progress note for Resident #1, dated 01/26/26 at 8:09 p.m., showed on 01/25/26 at 8:00 p.m., Resident #1 came to the nursing staff and gestured to their breast and pointed to Resident #2 saying they had grabbed their breast. The note showed Resident #1 gestured they slapped the hand of Resident #2. The note did not show the allegation had been reported to the abuse coordinator. An initial incident report form, dated 01/25/26, showed the charge nurse reported to the DON and administrator Resident #1 communicated that their breast was touched by Resident #2. The facsimile received by OSDH was dated 01/26/26 at 2:55 p.m. On 02/03/26 at 11:30 a.m., the administrator nodded and was in agreement the allegations of abuse were not reported to OSDH timely.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from abuse for 1 (#1) of 4 sampled residents reviewed for abuse.The administrator identified 40 residents resided in the facility. Findings:1.On 02/02/26 at 11:00 a.m., Resident #1 was observed being assisted to the restroom by staff.On 02/02/26 at 11:35 a.m., Resident #1 was observed sitting in the common area in front of the nurses' station smiling and waving at the surveyor. A quarterly assessment for Resident #1, dated 11/05/25, showed the resident had diagnoses which included down syndrome and cerebral infarction. The assessment showed Resident #1 had a BIMS score of 02, which indicated they were severely cognitively impaired for daily decision making and required partial to moderate assistance with all activities of daily living except eating.A late entry nursing progress note for Resident #1, dated 01/26/26 at 8:09 p.m., showed on 01/25/26 at 8:00 p.m., Resident #1 came to the nursing staff and gestured to their breast and pointed to Resident #2 saying they had grabbed their breast.An initial incident report form, dated 01/26/26, showed the charge nurse reported to the DON Resident #1 communicated their breast was touched by Resident #2. The report showed staff immediately separated the two residents and no injuries were noted for either resident. The report showed supervision was initiated for Resident #2. The report showed staff in-service regarding abuse prevention and reporting was initiated and psychiatric care referrals were initiated.2.On 02/02/26 at 10:00 a.m., Resident #2 was observed being provided one-on-one supervision by the staff with no further incidents. A significant change assessment for Resident #2, dated 11/11/25, showed the resident had a BIMS score of 12, which indicated moderate cognitive impairment. The assessment showed diagnoses which included congestive heart failure, end stage renal disease, and diabetes mellitus. The assessment showed Resident #2 required set-up assistance for oral hygiene, toileting, showering, and partial to moderate assistance with personal hygiene.A care plan for Resident #2, dated 01/25/26, showed a problem of behavioral symptoms with a history of socially inappropriate and/or disruptive behavior. The goal was the resident was to remain free from exhibiting socially inappropriate and/or disruptive behaviors with some of the following approaches listed: administer medications as prescribed, allow distance in seating other residents, allow resident to have control over situations, and if possible, assess whether the behavior endangers the resident and/or others. Intervene to ensure all residents feel safe as necessary.Physician orders for Resident #2, dated 01/26/26, showed the resident was newly prescribed Provera (hormonal medication) 10 mg once a day and Paxil (an antidepressant) 30 mg once a day. A RE 1 on 1 sitting schedule form, dated 01/26/26 through 02/02/26, showed Resident #2 was provided on-on-one supervision each shift.A quality assurance form, dated 01/26/26, showed facility department heads, corporate staff, physician, and nurse practitioner had met to develop a plan to ensure the abuse would not happen again. The form showed safe surveys were done, psychiatric consults were completed, trauma informed care observations were initiated, progress notes were written, staff interviews were conducted, full body assessments were done, care plans were updated, and in-service of staff was completed.An in-service form reviewed, dated 01/26/26, showed all staff had been in-serviced on abuse by them signing the form.Safe Surveys reviewed, dated 01/26/26, showed residents were interviewed regarding abuse. The surveys showed residents were not abused.A final incident report form, received by OSDH on 01/30/26 at 8:28 p.m., showed the facility cameras were reviewed and the footage showed Resident #2 pulling their wheelchair beside Resident #1, lifting Resident #1's blanket and putting their hand on Resident #1's breast. The report showed the physician, law enforcement, and family were immediately notified. The report showed other residents were interviewed and not found to have experienced any abuse. The report showed Resident #2 continued to be supervised and was seen by a psychiatrist and medications adjustments were made. The report showed Resident #1 had no residual effects from the incident. The report showed Resident #2 had referrals sent to multiple inpatient psychiatric facilities but had been denied. The report showed Resident #2 would continue to be supervised, psychiatric consultations as needed, and provided additional interventions as needed. On 02/02/26 at 10:00 a.m., the DON was interviewed and reported other facilities had been sought out to transfer Resident #2 to. The DON stated due to Resident #2 having dialysis three times weekly, all the facilities that had been contacted had refused Resident #2. The DON stated Resident #2 had no behaviors before or since the incident with Resident #1. The DON stated Resident #2 remained on one-on-one with staff.On 02/03/26 at 9:40 a.m., CNA #3 stated they would report abuse to the abuse coordinator and knew all signs of abuse. On 02/03/26 at 9:43 a.m., licensed practical nurse #1 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 9:45 a.m., registered nurse #1 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 9:50 a.m., housekeeper #1 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 9:52 a.m., CNA #4 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 9:55 a.m., CNA #5 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 9:59 a.m., CNA #6 stated they would report abuse to the abuse coordinator and knew all signs of abuse.On 02/03/26 at 11:15 a.m., the administrator stated Resident #1 and Resident #2 were immediately separated after the incident on 01/25/26 and an investigation began. They stated Resident #2 was placed on one-on-one with staff.

Based on observation, record review, and interview the facility failed to ensure adequate safety measures during transportation to prevent accidents for 2 (#1 and #4) of 2 sampled residents reviewed for accidents. The administrator identified two residents who had experienced accidents during transportation in the past six months. An undated Facility Process to Authorize Company Vehicle Drivers policy, read in part, All persons who drive any company owned vehicle, including vans, ARE REQUIRED to be an authorized driver under the company's current auto insurance policy .The employee being considered must be [AGE] years of age or older .The facility will request a Motor Vehicle Record in the employee's name .The facility is to manage their list of drivers to include providing in-service training to transport. 1. Resident #1 had diagnoses which included chronic kidney disease, diabetes, and bilateral below the knee amputation. A quarterly assessment for Resident #1, dated 12/31/24, showed the resident was moderately cognitively impaired. The assessment showed the resident required assistance with activities of daily living. A progress note, dated 01/28/25 at 12:28 p.m., showed Resident #1 arrived to the facility via transport van from dialysis. The note showed the transport driver reported the resident was sitting in their wheelchair with the seatbelt on, and due to a dog running in front of the van, the transporter had to push on their brakes. The note showed when the transport driver pushed on the brakes, the resident fell out of their wheelchair onto the floor, hitting their face on a plastic crate that was sitting in front of the wheelchair. The note showed the nurse entered the transport van and observed the resident lying in a supine position and was noted with a laceration to the left side of their nose, extending to the cheek area. The nurse noted a hematoma to the left side of the resident's head with bleeding due to hitting their face on the plastic crate. The note showed first aid was provided and the resident denied losing consciousness. The note showed nursing staff positioned the resident to a sitting position and arrangements were made to have the resident transported to the emergency department for evaluation. An emergency department provider note, dated 01/28/25 at 2:38 p.m., showed Resident #1 received a computed tomography (CT) of the head with a diagnosis of subacute appearing mildly displaced bilateral nasal bone fractures, with no acute intracranial abnormality. The note showed final diagnoses of closed head injury, facial laceration, and abrasion of nose. On 02/12/25 at 9:15 a.m., Resident #1 was interviewed in their room regarding the injury they sustained during transport in the facility van. The resident stated they were doing pretty good and had recently had five sutures removed from a laceration sustained during the accident. The resident reported being strapped in their wheelchair, but fell forward out of the wheelchair and hit their head. The resident stated they were not fearful and felt safe traveling in the facility van. The resident denied any previous incidents during transportation. On 02/12/25 at 9:25 a.m., transport driver #1 reported they were driving the facility van when Resident #1 fell from their wheelchair. The driver stated they had stopped at a stop sign, made a turn, and a dog was in the road. The driver stated they had barely started accelerating after a complete stop, but pushed on the brake to avoid the dog. The driver reported Resident #1's wheelchair was secured to the floor of the van and stayed in place. The driver reported the resident also had a seatbelt around their waist and shoulder, but slipped through them. The driver reported the resident always leaned forward somewhat in their wheelchair, but perhaps did not have the seatbelt and harness tight enough that day. The driver was asked if anything like this had happened before and they stated the same thing happened with Resident #4 several months previous. The driver reported Resident #4 was also an amputee and did not have the shoulder strap in place at the time of the incident. 2. Resident #4 had diagnoses which included diabetes, chronic pain, osteoarthritis, and peripheral vascular disease. An incident report for Resident #4, dated 08/28/24 at 2:17 p.m., showed facility transport picked up the resident from an appointment. The report showed per the driver, a car stopped in front of the transport van causing the transporter to press on the brakes abruptly. The report showed the resident was sitting in their wheelchair with seatbelts on and flew forward out of the wheelchair. The report showed the director of nursing assessed the resident and they were sent to the emergency department for evaluation. In-service records, dated 08/29/24, showed transport staff received wheelchair restraint training and occupant securement demonstrations. A care plan for Resident #4, dated 01/14/25, showed the resident had a left above knee amputation and should be positioned for comfort with physical support as necessary. On 02/12/25 at 9:35 a.m., transport driver #1 reported the transport van had seatbelts and shoulder harnesses in place when the accident happened with Resident #4. The driver reported Resident #4 was wearing a seatbelt, but not wearing the harness because they had no idea what the harness was used for. The driver reported they had not been in-serviced on harnesses at the time of the incident. The driver reported after the accident with Resident #4, all of the transport drivers received in-service training on the use of seatbelts and harnesses. On 02/12/25 at 9:42 a.m., the facility transport van was observed to have seatbelts and shoulder harnesses in place. Transport Driver #1 demonstrated how the belts and harnesses were utilized to secure wheelchairs and residents during transport. On 02/12/25 at 10:15 a.m., Resident #4 reported they were not sure what happened when they fell from their wheelchair in the facility van. The resident stated they knew they were strapped in with a seatbelt and could not remember anything in particular that caused them to fall. The resident reported they were evaluated at the emergency department, but had no injury. The resident reported they have taken several trips in the facility van since the accident and they felt safe when being transported. On 02/12/25 at 11:54 a.m., corporate staff #1 reported when the accident with Resident #4 happened in August 2024, they had transport staff watch videos related to proper use of the harnesses. They stated a demonstration was done for staff in the facility van and then the transport staff did a return demonstration. On 02/12/25 at 12:04 p.m., transport staff #2 reported they had training a few months ago on seatbelts and harnesses. They stated when the incident happened with Resident #1 in January, corporate staff #1 and another staff member did a demonstration to make sure all of the transporters knew how to properly fasten the belts and harnesses. They stated they all took turns getting in the wheelchair and each of the transporters practiced putting the seatbelts and harnesses on, as well as removing them and rolling the wheelchair out of the van. They stated corporate staff #1 watched them load a resident a few days ago to ensure it was done properly. On 02/12/25 at 12:14 p.m transport staff #3 reported the transporters had seatbelt/harness training with videos and demonstrations in August 2024. They stated the most recent in-service in January was with corporate staff #1 in which they did a demonstration with the seatbelts and harnesses, then had each transporter do a return demonstration. They reported a nurse or aide observed them at least a couple of times a week when loading and securing residents in the van. They reported they had never had an accident with a resident and stated they were aware Resident #1 did not like the shoulder harness and was known to slide it off their shoulder during transport. On 02/12/25 at 1:00 p.m., in-service documentation was provided which included the following training for transport drivers: a. 08/28/24 - Van Seatbelt Safety, b. 08/29/24 - Van Safety, c. 08/29/24 - Wheelchair Restraint Training with videos, d. 01/29/25 - Defensive Driving/Van Safety, and e. 02/03/25 - Harness Use in Van/Proper Use of Safety Harness. On 02/12/25 at 1:15 p.m., corporate staff #1 provided a copy of the performance improvement plan, dated 01/28/24, which documented in-service training for appropriate use of seatbelts and harnesses, demonstrations and return demonstrations by transport staff, monitoring of transport staff while loading and securing residents, and audits conducted to be reviewed in the quality assurance and performance improvement meeting.

Based on observation, record review, and interview, the facility failed to remove a medication patch as ordered for one (#16) of 10 sampled residents observed during a medication pass. The administrator reported 44 residents resided in the facility. Findings: An Administering Medications policy, dated April 2019, documented medications were to be administered in accordance to prescriber orders, including any required time frame. Resident #16 had diagnoses which included Alzheimer's dementia, hypertension, diabetes, and pain. An MDS assessment for Resident #16, dated 09/13/24, documented the resident was severely impaired with cognition. A care plan for Resident #16, dated 09/16/24, documented the resident had pain and medications would be administered as ordered. A physician's order for Resident #16, dated 10/12/24, documented Lidoderm (lidocaine) adhesive medicated patch 5%, 1 topical, apply to lower back every day at 9:00 a.m., then remove patch every evening at 9:00 p.m. On 12/10/24 at 10:00 a.m., CMA #2 was observed to remove a patch from Resident #16 and observed to apply a new lidocaine patch. CMA #2 reported the patch they removed should have been removed on 12/09/24 at 9:00 p.m. The CMA reported the lidocaine patch was to be applied in the morning, left in place for 12 hours, then removed in the evening. On 12/11/24 at 9:18 a.m., the DON reported CMA #2 had reported the lidocaine patch was not removed as ordered. The DON provided a copy of a medication error report completed on 12/10/24 and reported the physician order was not followed.

Based on observation, record review, and interview, the facility failed to implement a fall prevention per the resident's care plan for one (#13) of three sampled residents reviewed for falls. The administrator reported 44 residents resided in the facility. A Falls - Clinical Protocol policy, dated March 2018, read in part, If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Resident #13 had diagnoses which included Alzheimer's disease, congestive heart failure, chronic pain, and a history of falls. An MDS assessment, dated 11/25/24, documented Resident #13 had severely impaired cognition. The assessment documented the resident had no falls since admission. A fall risk assessment for Resident #13, dated 11/26/24, documented the resident had a high risk for falls. An incident report, dated 12/02/24, documented Resident #13 was found on the floor. The report documented an intervention was a fall mat to be placed beside the bed and staff would monitor the intervention. A care plan for Resident #13, dated 12/03/24, documented the resident was at risk for falls due to psychotropic medication use and impaired balance. The care plan documented a fall mat would be placed beside the bed. On 12/11/24 at 3:03 p.m., Resident #13 was observed lying in bed asleep. There was no fall mat observed on the floor. On 12/11/24 at 3:07 p.m., CMA #1 checked Resident #13's room and reported there was no fall mat in the room. The CMA reported they were not aware a fall mat was supposed to be in use. On 12/11/24 at 3:27 p.m., the DON reported there should be a fall mat in place for Resident #13. They reported the updated care plan included the fall mat as an intervention to prevent falls.

Based on record review and interview, the facility failed to implement the facility fall policy to ensure repeated falls were assessed to determine a pattern, and fall interventions were re-evaluated, for one (#188) of four residents sampled for falls. The administrator reported 37 residents resided in the facility. Findings: The Falls-Clinical Protocol, dated March 2018, read in part, .After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already identified) and also reconsider the current interventions . A quarterly MDS assessment for Resident #188, dated 08/14/23, documented the resident was severely cognitively impaired. The assessment documented a history of falls. A care plan for Resident #188, dated 08/24/23, documented the resident was at risk for falls. The plan of care documented the same intervention to monitor the resident closely following falls which occurred on: 06/23/23, 07/12/23, 07/22/23, and 08/16/23. The care plan included numerous fall interventions which included the evaluation for hip protectors, implement exercise program that targets strength gait and balance, increase staff supervision with intensity based on resident need, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, and provide individualized toileting interventions based on needs/patterns. These fall interventions were listed on the resident's individualized plan of care but had not been implemented and did not correspond to specific falls. On 10/13/23 at 8:00 a.m., RN/MDS coordinator reported they used the event reports to create the plan of care for Resident #188. The RN/MDS coordinator reported the events dated 06/23/23, 07/12/23, 07/22/23, and 08/16/23 had the same intervention to monitor the resident closely. The RN/MDS coordinator reported other interventions listed, with the same date of 08/24/23, had not been implemented and were added to the care plan through a computer program template. On 10/13/23 at 8:35 a.m., the DON was asked about the fall interventions listed on resident #188's care plan. The DON reported the fall interventions without a corresponding fall date were not implemented. The DON stated they had informed the RN/MDS coordinator to delete the interventions on the care plan that were entered from the computer program template but not implemented for the resident.

Based on record review and interview, the facility failed to update and implement comprehensive person-centered care plans to include relevant interventions for two (#35 and #188) of four residents sampled for falls. The administrator reported 37 residents resided in the facility. Findings: The Using the Care Plan policy, dated August 2006, read in part, .Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . 1. A care plan for Resident #35, dated 08/16/23, read in part, .Approach: 05/17/23: Resident to use call light for assist; 07/11/23: Resident to use call light for assist; 07/29/23: Educated resident on the importance of locking wheelchair before trying to transfer; 08/07/23: Fall no injury-encourage resident to utilize call system when needing transfer assist; 08/24/23: Allow staff to assist with her needs. Created: 09/17/23. The interventions dated on 08/16/23 consisted of the following: Assessment and treatment for postural/orthostatic hypotension, evaluate need for bed/chair alarms, evaluate need for hip protectors, implement exercise program that targets strength, gait, and balance, increased staff supervision with intensity based on resident need. Obtain order for Vitamin D supplements of at least 800 units daily, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk . The fall interventions dated on 08/16/23 were listed on the plan of care; however, they were not implemented. An event report, dated 08/24/23, documented the resident had an unwitnessed fall in the bathroom which resulted in a hematoma. The report documented new intervention to prevent reoccurrence: Needs to call for help. Staff to ask Q2 hour if required toileting and assist as needed. The intervention was not added to the care plan. An event report, dated 08/27/23, documented the resident had a fall which resulted in a skin tear and bruise. The report documented new intervention implemented to prevent reoccurrence: Resident instructed to ask for assist with needs. Staff to ensure that table, drinks, and call light to remain within reach at all times. The care plan was not updated. An event report, dated 08/29/23, documented the resident had an unwitnessed fall in their room with no apparent injury. The report documented new intervention implemented to prevent reoccurrence: Exchanged w/c for larger w/c. The care plan was not updated. On 10/13/23 at 8:15 a.m., the RN/MDS coordinator reported the interventions listed on the care plan, dated 08/16/23, had not been implemented for the resident. The RN/MDS coordinator reported those interventions were added from a computer program template, but not implemented. On 10/13/23 at 08:35 a.m., the DON reported fall interventions listed on the care plan without a date came from a computer program template and had not been implemented. The DON reported they had informed the RN/MDS coordinator to delete the interventions on the care plan that came from the template. 2. A quarterly MDS assessment, dated 08/14/23, documented Resident #188 was admitted to the facility with diagnoses which included anemia, UTI, and Alzheimer's. The assessment documented the resident was severely cognitively impaired. The assessment documented a history of falls. A care plan for Resident #188, dated 08/24/23, documented the resident was at risk for falls. The plan of care documented repeated interventions to monitor the resident closely after each of the following falls that occurred on 06/23/23, 07/12/23, 07/22/23, and 08/16/23. The care plan included numerous fall interventions which included an evaluation for hip protectors, implement exercise program that targets strength gait and balance, increase staff supervision with intensity based on resident need, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, and provide individualized toileting interventions based on needs/patterns. The fall interventions were listed on the resident's individualized plan of care; however, the interventions were not implemented and did not correspond to falls. On 10/13/23 at 8:00 a.m., the RN/MDS coordinator reported they used the event reports to create the plan of care. The RN/MDS coordinator reported the events dated 06/23/23, 07/12/23, 07/22/23, and 08/16/23 had the same interventions to monitor Resident #188 closely. The RN/MDS coordinator reported the other interventions listed with the date of 08/24/23 were not implemented, but added to the care plan through a computer template. On 10/13/23 at 8:35 a.m., the DON reported the fall interventions for Resident #188's care plan, which did not have a date, had not been implemented. The DON reported they had informed the RN/MDS coordinator to delete the interventions from the care plan if they were generated from the computer program template and not implemented for the individual resident.

Based on record review, observation, and interview, the facility failed to ensure the ice machine was clean and sanitary. The dietary manager reported 34 residents received daily ice from the machine. Findings: A maintenance log record documented monthly cleaning of the ice machine. The record documented 5/20/22 as the last date the ice machine had been cleaned and checked. On 06/07/22 at 10:08 a.m., the ice machine was observed to have a slimy film, with brown and black residue, on the ice guard plate inside the machine. At 10:21 a.m. the dietary manager was shown the residue and agreed it was not clean and sanitary for resident use.

Based on observation, interview, and record review, it was determined the facility failed to ensure basic infection control procedures were followed for two (#24 and #45) of two residents reviewed with an indwelling urinary catheter. The facility reported two residents required an indwelling urinary catheter. Findings: 1. Resident #24 was admitted with a [DIAGNOSES REDACTED]. An admission assessment, dated 08/13/18, documented the resident had an indwelling urinary catheter. An updated care plan, dated 08/24/18, documented the resident required an indwelling urinary catheter. The care plan documented the catheter tubing or any part of the drainage system would not touch the floor. On 11/26/18 at 9:43 a.m., the resident was observed sitting in a recliner with the catheter collection bag touching the floor. On 11/28/18 at 8:28 a.m., the resident was observed with the catheter collection bag touching the floor. 2. Resident #97 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/19/18, documented the resident was occasionally incontinent of bladder and always continent of bowel. A physician's orders [REDACTED]. A care plan, dated 11/19/18, documented the resident required an indwelling urinary catheter. The care plan listed an approach for the staff to not allow the tubing or any part of the drainage system to touch the floor. On 11/28/18 at 8:15 a.m., the resident was observed in the dining room eating breakfast. The indwelling urinary catheter tubing was observed to be touching the floor. On 11/28/18 at 11:53 a.m., the DON reported she expected staff to ensure the catheter tubing did not touch the floor.

Based on observation, interview, and record review, it was determined the facility failed to provide a baseline care plan with person centered, measurable goals for two (#24 and #45) of three residents reviewed. Findings: 1. Resident #24 was admitted with a [DIAGNOSES REDACTED]. A comprehensive assessment, dated 08/13/18, documented the resident had an indwelling urinary catheter. A baseline care plan, dated 8/14/18, documented the resident had an indwelling Foley catheter. The baseline care plan contained no documentation related to the care of the indwelling Foley catheter. On 11/26/18 at 9:43 a.m., the resident was observed sitting in a recliner with the catheter collection bag touching the floor. On 11/28/18 at 11:55 a.m., the DON reported the baseline care plan should have documented directions for care of the catheter with measurable goals. 2. Resident #45 was admitted with [DIAGNOSES REDACTED]. A baseline care plan, dated 10/16/18, contained no documentation for resident centered care or measurable goals. A comprehensive assessment, dated 10/22/18, documented the resident required extensive assistance with all ADLs, daily skin treatments with dressings, and assistance with incontinent care. On 11/26/18 at 11:15 a.m., the resident was observed in the dining room for the noon meal. On 11/28/18 at 11:55 a.m., the DON reported the baseline care plan should have included directions for care and measurable goals.

Based on observation and interview, it was determined the facility failed to provide dignity while assisting with meals for three (#5, 9, and #35) of three residents reviewed. The facility reported 16 residents required assistance with meals. Findings: On 11/26/18 at 11:37 a.m., LPN #1 was observed standing while feeding residents #35 and #5. On 11/26/18 at 11:52 a.m., LPN #1 continued to stand while feeding resident #35. On 11/28/18 at 8:11 a.m., LPN #1 was observed to stand while feeding resident #9. On 11/28/18 at 9:31 a.m., LPN #1 reported she helped to feed residents frequently. She reported she always stood while feeding residents. The LPN reported she was unaware standing while feeding the residents was unacceptable. On 11/28/18 at 9:37 a.m., the DON reported staff should not be standing while feeding the residents.

Based on observation and interview, it was determined the facility failed to ensure the environment was free from accident hazards by not having proper storage for excess equipment in a hallway for four of four days of the survey. Seven of 30 residents sampled were reviewed for wandering behavior. The ADM reported 47 residents lived in the facility. Findings: On [DATE] at 10:16 a.m., a large bucket of all purpose joint compound, two ladders, a step ladder, and a stand-up hand truck (moving dolly), two large framed pictures with glass which faced outward, and one full bed rail were observed to be up against the wall in a short hallway which led to the maintenance office/closet. The hallway was where the public restrooms were located and the residents had access to the hallway and the bathrooms. On [DATE] at 1:45 p.m., the excess maintenance equipment was observed to remain in the hallway. On [DATE] at 4:30 p.m., the excess equipment was observed to remain in the hallway minus one ladder. On [DATE] at 8:30 a.m., the equipment was observed to remain in the hallway. On [DATE] at 5:00 p.m., a ladder and a hand truck were observed to remain in the hallway. On [DATE] at 8:10 a.m., a ladder and upright hand truck were observed to remain in the hallway. On [DATE] at 4:05 p.m., the DON was informed of the equipment in the hallway. The DON reported it would be addressed. No residents were observed in the short hallway during the survey although the facility had residents who were ambulatory and mobile by wheelchair who exhibited wandering behavior. On [DATE] at 8:10 a.m., two ladders, one wheelchair, a floor buffer, and an upright hand truck were observed in the short hallway. On [DATE] at 8:45 a.m., the DON was informed of the additional equipment observed in the hallway and the DON reported the issue would be remedied .

Based on observation, record review, and interview, it was determined the facility failed to ensure consistent professional standards of practice for assessing and monitoring a [MEDICAL TREATMENT] shunt site for one (#4) of one resident identified by the ADM who received [MEDICAL TREATMENT]. The ADM reported 47 residents lived in the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 04/26/17, documented the resident required [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. A long term goal was for the resident not to exhibit signs or symptoms of infection or clotting at the shunt site. Approaches listed included for the staff to assess, monitor, and document the patency of the vascular access every shift. The staff were to observe the resident's skin condition surrounding the [MEDICAL TREATMENT] shunt site. The staff were to monitor and report signs of localized infection, localized swelling, redness, pain, tenderness, purulent drainage, or a loss of function. The resident's treatment administration record documented the staff assessed and monitored the [MEDICAL TREATMENT] site for thrill and bruit. The clinical record did not contain documentation the staff assessed and monitored the [MEDICAL TREATMENT] shunt site for bleeding or signs of infection when the resident returned from [MEDICAL TREATMENT]. The clinical record did not contain assessment of the resident's [MEDICAL TREATMENT] shunt when the resident returned from [MEDICAL TREATMENT]. A quarterly assessment, dated 10/10/17, documented the resident was cognitively intact, did not ambulate, was independent for transfers, dressing, and hygiene. The assessment documented the resident was frequently incontinent of bowel and bladder. The assessment documented the resident received [MEDICAL TREATMENT] treatments. On 10/24/17 at 2:15 p.m., the resident was observed in the hallway. The resident was observed self-propelling her wheelchair. The resident was well groomed and dressed for the season. On 10/25/17 at 3:30 p.m., the DON was interviewed. The DON was asked, when a resident had received [MEDICAL TREATMENT] treatments, were the staff expected to assess and monitor the shunt site for bleeding or signs and symptoms of infection. The DON reported yes. The DON reported the issue would be addressed.

Based on observation and interview, it was determined the facility failed to ensure equipment was not stored in a common area for three of four days of the survey. The ADM reported 47 residents lived in the facility. Findings: On 10/23/17 at 10:30 a.m., during the initial tour, two mechanical lifts were observed in the sunroom of South Hall. On 10/23/17 at 3:30 p.m., two mechanical lifts were observed in the sunroom of South Hall. On 10/24/17 at 9:00 a.m., two mechanical lifts were observed in the sunroom of South Hall. A resident was observed sitting in a chair in the sunroom. On 10/25/17 at 3:00 p.m., an unidentified resident and a visitor were observed sitting in the sunroom. Resident #51, who exhibited wandering behavior, was observed standing behind the resident's wheelchair and next to a mechanical lift. On 10/26/17 at 10:30 a.m., the ADM reported the storage of the lifts in the sunroom would be addressed.

Based on observation and interview, it was determined the facility failed to ensure call lights worked adequately in the bathrooms for two (#42 and #53) of 30 residents reviewed for call lights. The ADM reported 47 residents lived in the facility. Findings: On 10/24/17 at 8:10 a.m., resident #53's bathroom call light did not activate outside of the resident's room or at the light apparatus in the bathroom. On 10/24/17 at 9:46 a.m., resident #42's bathroom call light did not activate outside of the resident's room or at the light apparatus in the bathroom. On 10/26/17 at 8:10 a.m., the maintenance supervisor was informed of the call light situation for the two residents. He reported the call lights would be addressed.

Based on observation, record review, and interview, it was determined the facility failed to ensure call light cords were a sufficient length for resident use for two (#26 and #38) of 30 residents reviewed for accommodation of needs and services. Findings: 1. On 10/24/17 at 8:36 a.m., resident #26 was observed to be awake and lying on his bed. The resident's call light activation switch was on the wall with two strings attached to a single lever. One cord was observed to be approximately one foot in length. The second cord connected to the call light activation system was lying on the resident's roommate's bed. At that time,the resident was asked if he could reach the call light. The resident stated, No. 2. On 10/24/17 at 8:53 a.m., the call light activation switch in resident #38's room was observed to have a single cord, approximately 10 inches in length. The cord reached the top of the chair which was situated under the activation switch. The call light cord could not be reached if the resident was in bed or if the resident was sitting in the chair. On 10/24/17 at 9:10 a.m., the resident was observed to ambulate in and out of her room. On 10/25/17 at 8:30 a.m., the maintenance supervisor was informed of the call light cords being too short to be reached. The maintenance supervisor reported he would check on the cords and replace them. On 10/26/17 at 9:30 a.m., the maintenance supervisor reported the cords had been replaced and would have been replaced before the survey if the staff had notified him of the situation.

Based on observation, record review, and interview, it was determined the facility failed to ensure sanitary conditions were maintained in the dietary department by ensuring stored items were not wet or soiled, by ensuring drink dispensers were labeled, by ensuring a staff member covered facial hair, and by ensuring non-food preparation items were not stored in cabinet drawers. The dietary manager (DM) identified 49 residents who received their meals from the dietary department. Findings: On 08/08/16 at 2:00 p.m., a tour was conducted of the facility's dietary department. In the refrigerator, two drink dispensers were observed to have no labels identifying their contents or the date prepared. Cook #1 reported the previous shift was in a hurry to leave and forgot to label the drink dispensers. One cabinet drawer contained two ladles and one scoop which were stored wet and one scoop with a dried substance on it. One cabinet drawer contained two commercial plastic sacks. The drawer contained a funnel and other food preparation items. The cook removed the sacks and reported the kitchen had new staff who did not know where to store items. One drawer contained a ProAir inhaler with no identification label. The drawer contained the thermometer used for food temperature testing. The cook reported the inhaler belonged to a staff member. One tray and one plastic container were observed to be stored wet on the lower shelves of the food preparation island. In the pantry, one light fixture was cracked. On 08/08/16 at 2:55 p.m., one of three coffee cups provided for the surveyors smelled of coffee prior to use. The cup had a scratched inner surface. On 08/08/16, during the evening meal service, dietary aide #1 was observed to have a hair net over his beard which did not cover his mustache. A dietary staff member informed the dietary aide to cover his mustache. The dietary aide covered his mustache but did not maintain coverage during the remainder of the meal service. On 08/09/16 at 8:30 a.m., one of three coffee cups provided for the surveyors smelled of coffee prior to use. The cup had a scratched inner surface. On 08/11/16 at 8:50 a.m., the ADM and the DM were informed of the dietary observations. The DM reported the dietary aide had shaved. The DM reported staff would be in-serviced to not store items wet and to label and date items. The ADM reported the areas would be addressed.

Based on observation, record review, and interview, it was determined the facility failed to: a) Ensure one (#9) of two residents observed for ambulatory assistance was properly ambulated. The resident census and conditions form documented 13 residents required assistance with ambulating. b) Ensure one (#2) of eight residents reviewed for accurate code status was consistently documented on a physician's orders [REDACTED]. The census and conditions report documented 50 residents resided in the facility. c) Ensure a housekeeping closet with cleaning supplies was locked on the Northeast hall. The DON identified four residents who wandered. d) Ensure an exposed metal strip was covered on the lower wall trim entering the dining room. The census and conditions report document 50 residents resided in the facility. Findings: 1. On 08/08/16 at 5:30 p.m., upon entering the dining room, an approximately three inch strip of metal was exposed and loose, on the lower wall rail. On 08/09/16, 08/10/16, and 08/11/16, the strip of metal remained exposed. Residents were observed to enter the dining room for meals and activities. On 08/11/16 at 2:00 p.m., the maintenance supervisor was shown the exposed metal strip. The maintenance supervisor reported the issue would be addressed. 2. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 05/22/16, documented the resident was severely impaired in cognition. A care plan, dated 06/06/16, documented the resident had a DNR (do not resuscitate) as a code status if found with no breathing or pulse. The computerized clinical record documented a DNR (hospice) code status on the resident's face sheet. The August 2016 computerized physician's orders [REDACTED]. The physician order [REDACTED]. On 08/08/16 at 5:15 p.m., the resident was observed to be seated at a dining room table, sitting in a wheelchair. The resident appeared clean and well-groomed. On 08/10/16 at 10:45 a.m., the DON and ADON were shown the discrepancy between the resident's face sheet and the physician's orders [REDACTED]. The DON was asked where do the staff look for the residents' code status. The DON reported the staff would look at the face sheet for the code status. The DON was asked if the physician's orders [REDACTED]. The DON reported yes. The ADON reported the full code on the physician's orders [REDACTED]. The ADON reported he would take care of the issue and change the code status on the physician's orders [REDACTED]. 3. On 08/11/16 at 8:15 a.m., an environmental tour was conducted on the Northeast Hall. The housekeeping supply room's door was unlocked. A housekeeping cart with cleaning chemicals was located inside the supply room. No staff was present in the room. On 08/11/16 at 9:10 a.m., the DON was asked if the housekeeping supply room's door should be kept locked. The DON reported yes. 4. The facility's restorative care policy for ambulation guidelines documented for the staff to encourage erect posture for the resident, with head, shoulders, hips, knees, and feet in alignment; and for the staff to stay close to the resident at all times, standing a little behind the resident. Resident #9 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 02/16/16, documented the resident needed assistance with ADLs. One approach was for the staff to provide supervision with walking, locomotion, and eating. A quarterly assessment, dated 05/06/16, documented the resident was moderately impaired in cognition, exhibited minimal depression symptoms, and exhibited wandering behaviors daily. The assessment documented the resident required supervision with ambulation and had experienced two falls since the prior assessment. The resident's care plan documented the resident had fallen seven times in the past seven months. On 08/08/16 at 5:15 p.m., NAT #1 was observed to be walking in front of the resident, pulling the front of the resident's four-wheeled walker. The NAT was an arm's length in front of the walker. The resident was bent at the waist and was an arm's length behind the walker. On 08/09/16 at 12:40 p.m., the DON was asked what was the facility's policy on ambulating residents. The DON reported the facility had no policy in regard to the nurse aides ambulating residents. At that time, the DON was informed of the observation of the staff member pulling the resident's walker. The DON reported she would in-service the staff immediately.

Based on observation, record review, and interview, it was determined the facility failed to ensure self-administration of medication assessments and monitoring were conducted for two (#4 and #8) of two residents reviewed for self-administration of medication. The DON identified four residents who self-administered medications. Findings: A facility policy on self-administration of medication documented, .Procedures for Self-Administration of Drugs a) Medications for self-administration will be stored in the resident's room, under proper security conditions .means that the medications are either put behind a locking mechanism, or if more appropriate for the resident's use, kept in a place that is out of sight of other residents . c) Each shift, the nursing staff will question the resident as to whether or not the resident administered these medications by putting their initials on the Medication Administration Record [REDACTED]. 4. If the resident self-administers medication, the care plan will so indicate. 5. If there is a change in condition, the resident must be re-evaluated by the interdisciplinary team to assess the ability to self-administer . 1. Resident #4 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. check amount remaining on Sunday (Dx: Other specified disorders of the skin and subcutaneous tissue) . A comprehensive assessment, dated 07/25/16, documented the resident was cognitively intact, exhibited symptoms of mild depression, and exhibited no behavioral symptoms. The assessment documented the resident was independent with all ADLs. The resident's treatment administration history, dated July 28, 2016 through August 10, 2016 contained nurses' initials on each day, with the exception of the days the resident was on therapeutic leave. The treatment administration history contained no area to record the staff had checked the amount of medication remaining. On 08/09/16 at 4:15 p.m., the DON was asked where the self-administration assessments would be located. The DON reported the assessments should be in the clinical record. The resident's clinical record contained no assessments of the resident's ability to self-administer medications. On 08/10/16 at 9:00 a.m., the DON reported the resident should have self-administration assessments completed when the medication order was received and completed quarterly. The DON reported the staff should monitor the amount of medication the resident used weekly. On 08/10/16 at 1:45 p.m., the resident was interviewed. The resident was alert, oriented, and well-groomed. During the interview, the resident's room was observed for the presence of medication at bedside. The resident reported she kept her medication in a drawer because some residents have been known to come into her room. A care plan, with a problem start date of 08/10/16, documented, Resident wants to keep [MEDICATION NAME] at bedside and self administer. The approaches documented for the staff to conduct a self-administration assessment on the resident prior to obtaining a may keep at bedside order, to monitor the resident's use of the medication weekly, and to perform quarterly assessments to determine the resident's continued ability to self-administer medication. 2. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].may keep at bedside and self administer, record use every Sunday on 6-2 shift . An observation report for the self-administration of medication, dated 06/18/14, documented the resident would like to administer [MEDICATION NAME] tablets, was appropriate to self-administer medications, and a plan of care would be initiated. A quarterly assessment, dated 07/18/16, documented the resident was cognitively intact, exhibited mild depression symptoms, and exhibited no behavioral symptoms. The resident was independent with ADLs. On 08/09/16 at 4:15 p.m., the DON was asked where other self-administration assessments would be located. The DON reported the assessments should be in the clinical record. The resident's medication administration history, dated 07/28/16-08/10/16, documented the Artificial Tears one drop to each eye as needed, may keep at bedside and self administer, and the staff was to record use on Sundays. The areas to document the resident's usage of the eye drops on 07/31/16 and 08/07/16 were blank. The resident's medication history did not address the resident's us of [MEDICATION NAME] tablets. On 08/10/16 at 8:30 a.m., the resident was interviewed. The resident was observed to be alert, oriented, and well-groomed. The divider curtain was observed to be pulled between the resident and the door to the hallway. On the resident's overbed table, a container of artificial tears eye drops and a container of anti-gas tablets were observed. The medications were not labeled with the resident's name or indication for use. At that time, the resident was asked if the staff were aware she had the medications at bedside. The resident reported one nurse told her she was using too much eye drop solution. The resident reported she used the eye drops when her eyes were dry. The resident reported she ordered medication by mail if it was something she needed. The resident reported she had ordered folic acid for her legs. Folic acid was not observed at the resident's bedside. On 08/10/16 at 9:00 a.m., the DON reported the resident should have self-administration assessments completed when the medication order was received and completed quarterly. The DON reported the staff should monitor the amount of medication the resident used weekly. A care plan, with a problem start date of 08/10/16, documented, Category Safety Resident wants to keep artificial tears and [MEDICATION NAME] at bedside and self-administer. The approaches documented, .Monitor use of (may keep at bedside) medication weekly .Quarterly assessment to determine continued ability to self administer medication .

Based on record review, observation, and interview, it was determined the facility failed to ensure toenails were trimmed for two (#2 and #7) of eight residents who required assistance with toenail care. The census and conditions report documented 50 residents resided in the facility. Findings: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/29/16, documented the resident was independent with ADLs. The care plan did not address who was responsible for maintaining the resident's toenails in good condition. A quarterly assessment, dated 05/16/16, documented the resident was moderately impaired in cognition, had impaired vision, and required a rolling walker for assistance with ambulating. On 08/10/16 at 11:30 a.m., the resident was observed lying in her bed. The resident's fingernails were observed to be well-shaped, with chipped and peeling nail polish. The resident was asked who assisted her with her fingernails. The resident reported the staff did. The resident reported the staff filed and polished her fingernails. The resident reported she was a nervous person and she would pick the nail polish off of her fingernails. The resident's toenails were observed to be long and thick. The resident was asked who took care of her toenails. The resident reported the staff took care of her toenails. The resident was asked when her toenails had last been cared for. The resident reported it had been a long time. The resident reported she had told the staff on several occasions she needed her toenails cared for and no one had helped her. The resident was asked if she would like her toenails trimmed. The resident reported yes. On 08/10/16 at 3:30 p.m., the DON was interviewed. The DON was notified of the observation regarding the resident's long thick toenails. The DON was asked who was responsible for providing toenail care for the resident. The DON reported the nurses were responsible for taking care of the resident's toenails. At that time, the DON was asked for documentation when the resident had last received toenail care. The DON reported no documentation was available. The DON reported the CNAs recently reported the residents had not been receiving toenail care. The DON reported the nurse who was responsible for toenail care was no longer working at the facility. The DON reported she was in the process of addressing the situation. 2. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 05/22/16, documented the resident was severely impaired in cognition. The assessment documented the resident required extensive staff assistance with ADLs which included personal hygiene. A care plan, dated 06/06/16, documented the resident required staff assistance with ADLs. The care plan documented the staff was to provide extensive assistance with personal hygiene. The care plan documented the resident had diabetes mellitus. On 08/09/16 at 3:45 p.m., the resident's toenails were observed. The toenail on the resident's right great toe was long and curved inward. The toenail on the resident's left great toe was long and curved downward. Two CNAs in attendance of the observation were asked who were to cut the resident's toenails. The CNAs reported the nurses cut the resident's nails since the resident had diabetes. On 08/10/16 at 2:55 p.m., the DON was asked about the resident's long toenails. The DON reported the toenails had already been taken care of and cut. The DON reported the toenails on the resident's great toes definitely needed cut.

Based on record review and staff interviews, it was determined the facility failed to complete consistent assessments and notify the physician to obtain interventions when there were changes in a pressure ulcer, which resulted in actual harm for one (#5) of three sampled residents who had a pressure ulcer. The resident was admitted to the hospital and subsequently had an above the knee amputation. This had the potential to affect two other residents, identified by the Resident Census and Conditions of Residents form, who had pressure ulcers. Findings: Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. A care plan with the initial date of 08/29/13, documented the resident had a potential for impaired skin integrity as a problem. The goal was for the resident to have intact skin. One intervention was for the staff to audit the resident's skin at least weekly. A weekly head to toe skin assessment, dated 01/06/14, documented the resident's skin was intact. An Individual Wound Assessment form, dated 01/09/14, documented a Stage III pressure ulcer was discovered on the resident's inner side of her right great toe. The pressure ulcer measurements were 1.25 cm x 1.25 cm x 0.5 cm. The assessment documented there was no drainage and the wound bed and surrounding tissue was whitish. The assessment documented the resident's 2nd digit (toe) anatomically crossed over the great toe. A care plan, dated 01/09/14, documented the resident had a problem of a right great toe wound. The goal was for the pressure ulcer to resolve without complication in the next 30 days. Interventions listed were for the staff to notify the physician if treatment was not effective and to report to the physician any redness, [MEDICAL CONDITION], purulent discharge and fever. A nurse's note, dated 01/11/14 at 9:00 a.m., documented the dressing to the resident's right great toe was completed and there was a foul odor. The nurse's note further documented a new area, a Stage I pressure ulcer to the base of the resident's right great toe. The nurse's note documented the Stage I wound had a bluish discoloration. The nurse's note documented the ADON was made aware of both pressure ulcers. An Individual Wound Assessment form, dated 01/11/14, documented a Stage I pressure ulcer which measured 1.5 cm x 1.5 cm. There was no documentation the staff reported the foul odor to the physician. There were no daily wound assessments forms documented on 01/12/14, 01/13/14, 01/14/14, 01/15/14/, 01/16/14, 01/17/14, 01/18/14, 01/19/14 and 01/20/14 which included measurements and assessments. A nurse's note, dated 01/15/14 at 9:00 a.m., documented the pressure ulcer had no change in size. A nurse's note, dated 01/15/14 at 5:00 p.m., documented, "...No drainage c foul smell...slight redness to big toe..." A physician's progress note, dated 01/21/14, documented a scheduled interval visit was made by the physician. The progress note documented the patient had no acute issues this month. The progress note documented, "Discussion with the nursing staff reveals no significant change in her chronic status either...Extremities: No [MEDICAL CONDITION] and or acute change Skin: Intact, without breakdown..." A nurse's note, dated 01/21/14 at 8:00 p.m., documented the pressure ulcer "...still has odor..." There was no documentation to show the physician was notified of the pressure ulcer odor. A daily wound assessment, dated 02/01/14, documented the pressure ulcer had increased in depth and had creamy colored tissue with drainage, odor and with pain present. A nurse's note, dated 02/01/14 at 1:00 p.m., documented the Stage III pressure ulcer had increased in depth with necrotic tissue on the wound bed. The nurse's note documented, "...To report to (ADON name deleted) when comes in to work on night shift tonight-on call supervisor." The physician had not been notified for interventions when the pressure ulcer depth and wound bed had changed. A nurse's note, dated 02/02/14 at 10:00 a.m., documented the right great toe had a foul smell and brownish drainage. A daily wound assessment, dated 02/02/14 documented slight swelling to the toe with drainage, odor and pain present. A daily wound assessment, dated 02/03/14, documented the wound bed was bloody with odor and pain present. A care plan, dated 02/04/14, documented a problem of a pressure ulcer infection site of the resident's right great toe as evidenced by drainage and pain. One approach listed was for the staff to administer/monitor effectiveness of treatment. Another approach was for the staff to assess/record signs and symptoms of infection such as redness, inflammation, swelling, temperature and report to the physician. A daily wound assessment, dated 02/05/14, documented, "...Resident screamed when messed c toe even a gentle touch..." The pressure ulcer continued with swelling, drainage, odor and pain. The assessment documented the resident's toe was purplish in color. There were no documented assessments since the Stage I medial pressure ulcer was discovered on 01/11/14, until 02/05/14. The assessments for the Stage I medial pressure ulcer on the right great toe were dated daily from 02/05/14 through 02/12/14. A nurse's note, dated 02/07/14 at 12:00 a.m., documented malodorous odor to right great toe. A daily wound assessment, dated 02/08/14, documented the Stage I pressure ulcer to the medial right great toe measured 1 cm x 1 cm with swelling. A daily wound assessment, dated 02/08/14, documented the Stage III pressure ulcer size as 2 cm x 2 cm x < 0.5 cm. A nurse's note, dated 02/08/14 at 10:00 a.m., documented, "...R great toe c very foul smell & painful to touch..." At 2:00 p.m., a nurse's note documented, "...whitish necrotic tissue to center of wound bed..." There was no documentation to show the physician was notified of the foul smell, the increased size or the necrotic tissue. A nurse's note, dated 02/10/14 at 10:30 a.m., documented the treatment continued to the right great toe with no improvement noted. A nurse's note at 4:00 p.m., documented the resident was grimacing in pain. There was no documentation to show the physician was notified concerning the lack of pressure ulcer improvement and the need for further interventions. On 02/11/14, the resident was transported to an appointment with a podiatrist. The podiatrist's report, dated 02/11/14, documented the resident presented with an ulcerative area on her right great toe with a foul odor. The resident had weakly palpable dorsalis pedis and posterior tibial pulses to the right lower extremity. There was no capillary refill in the toe. The ulceration was matted with necrotic tissue in the inner portion of the right great toe. The foot was swollen and had a foul odor. The report documented there was the appearance of early gangrene in the right great toe. Radiographs were taken which showed osteo[DIAGNOSES REDACTED] in the proximal bone of the toe. The report documented there was a pathological fracture associated with the toe. A quarterly assessment, dated 02/12/14, documented the resident was severely impaired in cognition with short and long-term memory problems. The resident required extensive one to two person assistance for transfer, bed mobility, dressing, eating, personal hygiene and bathing. The assessment documented the resident was at risk for a pressure ulcer and had one Stage IV pressure ulcer with slough tissue. The assessment documented the resident had an infection of the foot with pressure ulcer care and the application of a dressing. On 02/12/14, the resident was admitted to the hospital for debridement of the toe. A physician's progress note, dated 02/18/14, documented, "Gone is at (hospital name deleted) having her toe amputated apparently...Discussion with the nursing state revealed no significant change in their chronic status either....Extremities: No [MEDICAL CONDITION] and or acute change Skin: Intact, without breakdown..." A hospital discharge summary, dated 02/24/14, documented the resident had been admitted with a gangrenous R great toe. The resident underwent [REDACTED]. The discharge summary documented the resident had poor wound healing with no real improvement thought to be due to her poor blood supply and [MEDICAL CONDITION]. The resident underwent [REDACTED]. No previous [DIAGNOSES REDACTED]. On 07/29/14 at 11:30 a.m., the ADON was asked about RN #1's documentation in the nurse's notes on 02/01/14, about notifying him (the ADON) regarding the resident's pressure ulcer changes. The ADON reported, he did not remember the RN notifying him of the resident's pressure ulcer. The ADON reported, he did not know why the RN did not notify the physician herself. At 1:50 p.m., the physician was interviewed by telephone. The physician was asked if the staff had notified him of the foul odor, increase of pressure ulcer size or the presence of necrotic tissue. The physician reported he did not have recollection of staff calling about pressure ulcer changes. The physician reported he could not remember. The physician reported the resident had vascular insufficiency (poor circulation) and that antibiotics, wound cultures and treatment changes would not have helped. The physician reported he saw the resident's toe when it was black. At 2:25 p.m., RN #1 was interviewed and asked if she had notified the physician for interventions when the odor was detected on 01/11/14. The RN reported she had told the ADON, but she did not remember calling the physician. The RN was asked, when she had documented in the nurses' notes on 01/21/14, about the continuance of odor to the toe, had she notified the physician. She reported the resident had her socks on and thought her feet smelled. RN #1 was asked if she had notified the physician, when she documented in the nurses' notes on 02/01/14, the wound had increased in depth with necrotic tissue on the wound bed. The RN reported, she had reported it to the ADON and she had not called the physician. RN #1 was asked if she had notified the physician when on 02/08/14 the pressure ulcer increased in size with necrotic tissue. The RN reported she had informed the supervisor to pass the information on. The RN reported she had not notified the physician. On 07/30/14 at 10:55 a.m., the DON was asked if the staff should have called the physician when there were changes in the pressure ulcer for possible interventions. The DON stated, "Yes."

Based on record review and staff interviews, it was determined the facility failed to: a) Develop a pain management program which resulted in actual harm to one (#5) of four sampled residents who experienced pain. This had the potential to affect all 50 residents who resided in the facility. b) Administer [MEDICATION NAME] when the systolic BP was greater than 160 as ordered for one (#5) of three sampled residents who had antihypertensive medications ordered as needed. This had the potential to affect four residents, identified by the DON, who received antihypertensive medications as needed. c) Ensure the application of a heel protector for one (#5) of one sampled resident who had a heel protector ordered. This had the potential to affect one resident, identified by the DON, who had heel protectors ordered. d) Ensure a pressure ulcer treatment was not administered without a physician's orders [REDACTED].#5) of three sampled residents who had pressure ulcer treatments. This had the potential to affect two other residents, identified by the Resident Census and Conditions of Residents form, who had pressure ulcers. e) Ensure the DNR status was current for one (#2) of eight sampled residents who required their code status be documented. This had the potential to affect all 50 residents who resided in the facility. Findings: 1. Resident #5 was admitted on [DATE],with [DIAGNOSES REDACTED]. a) A weekly head to toe skin assessment, dated [DATE], documented the resident's skin was intact. An Individual Wound Assessment form, dated [DATE], documented a Stage III pressure ulcer was discovered on the resident's inner side of her right great toe. The pressure ulcer measurements were 1.25 cm x 1.25 cm x 0.5 cm. The assessment documented there was no drainage and the wound bed and surrounding tissue was whitish. The assessment documented the resident's 2nd digit (toe) anatomically crossed over the great toe. A care plan, dated [DATE], documented the resident had a problem of [REDACTED]. The goal was for the wound to resolve without complication in the next 30 days. Interventions listed was for the staff to notify the physician if treatment was not effective and to report to the physician any redness, [MEDICAL CONDITION], purulent discharge and fever. A [DATE] Medication PRN form documented the resident was to receive [MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg ([MEDICATION NAME] ,[DATE]) one tablet by mouth twice a day as needed for pain. This was originally ordered [DATE] A nurse's note, dated [DATE] at 1:20 p.m., documented the resident complained of pain during the pressure ulcer treatment. No medication for pain relief was administered on [DATE]. Daily wound assessments, dated [DATE], [DATE], [DATE], [DATE] and [DATE] documented pain was present. No medication for pain relief was administered on the five days listed above. Daily wound assessments, dated [DATE], [DATE], [DATE] and [DATE] documented pain was present. No medication for pain relief was administered on the four days listed above. A care plan, dated [DATE], documented a problem of a wound infection site of the resident's right great toe as evidenced by drainage and pain. One approach listed was for the staff to administer/monitor effectiveness of medication as ordered. There was no specific interventions listed for the resident's pain on the care plan. A daily wound assessment, dated [DATE], documented, "...Resident screamed when messed c toe even a gentle touch..." The pressure ulcer continued with swelling, drainage, odor and with pain present. On [DATE], the resident was transferred to an appointment with a podiatrist. The podiatrist's report, dated [DATE], documented the resident presented with an ulcerative area on her right great toe with a foul odor. The resident had weakly palpable dorsalis pedis and posterior tibial pulses to the right lower extremity. There was no capillary refill in the toe. The ulceration was matted with necrotic tissue in the inner portion of the right great toe. The foot was swollen and had a foul odor. The report documented there was the appearance of early gangrene in the right great toe. Radiographs were taken which showed osteo[DIAGNOSES REDACTED] in the proximal bone of the toe. The report documented there was a pathological fracture associated with the toe. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognition with short and long term memory problems. The resident required extensive one to two person assistance for transfer, bed mobility, dressing, eating, personal hygiene and bathing. The assessment documented the resident was at risk for a pressure ulcer and had one Stage IV pressure ulcer with slough tissue. The assessment documented the resident had an infection of the foot with pressure ulcer care and the application of a dressing. The staff assessment for pain documented resident indicators for pain were non-verbal sounds such as crying and moaning and vocal complaints of pain which occurred daily. On [DATE] at 9:20 a.m., CNA #5 was asked about the resident's pain during [DATE] and February 2014 prior to the resident's above the knee amputation. The CNA reported the resident could not actually verbalize pain, but she would cry out at times and even be combative with care. The CNA reported when the resident's foot was moved the resident acted worse and yelled. At 9:35 a.m., CNA #6 was asked about the resident's pain during [DATE] and February 2014 prior to the resident's above the knee amputation. The CNA reported she had thought something was wrong and then one staff member discovered the pressure ulcer to her toe. The CNA reported when the resident's socks were applied the resident acted like it hurt her by yelling. At 9:50 a.m., RN #1 was asked about the times she documented pain was present with daily wound assessments. The RN was asked if the resident experienced pain when her foot was handled. The RN stated, "Yes." At 10:50 a.m., LPN #1 was asked if a physician's orders [REDACTED]. The LPN reported there was not an order for [REDACTED]. An individualized pain management program was not developed. Interventions such as medicating the resident before daily pressure ulcer treatments were not implemented. The resident remained on the same prn pain medication as ordered on [DATE], and continued to have pain. At 11:00 a.m., the DON was shown the daily wound assessments. The DON was asked if the resident should have had pain medication when the assessments documented pain was present. The DON stated, "Yes." The DON reported she would have given the resident pain medication before her treatments. b) A physician's orders [REDACTED].#5 was to receive [MEDICATION NAME] 0.1 mg every six hours as needed. The instructions were to administer the [MEDICATION NAME] when the resident's systolic blood pressure was greater than 160. A significant change assessment, dated [DATE], documented the resident was severely impaired in cognition with short and long-term memory problems. A nurse's note, dated [DATE] at 1:53 p.m., documented, "BP this morning ,[DATE]. Retaken manually ,[DATE]." A prn medication administration history form, dated [DATE], documented no [MEDICATION NAME] had been administered. When the MDS coordinator brought the copies of the MAR and nurse's note to the surveyor, he reported no [MEDICATION NAME] had been administered. c) A care plan for resident #5, initial date of [DATE], documented the resident had a potential for skin integrity problems. One intervention was for the staff to apply heel guards as necessary. A physician's progress note, dated [DATE], documented, "Continue c heel protector L at all times." The progress note had been noted by a licensed staff member. A podiatrist's report, dated [DATE], documented, "...We wrote orders for continued use of the heel protectors." A significant change assessment, dated [DATE], documented the resident was severely impaired in cognition with short and long-term memory problems. The resident required two person extensive assistance with bed mobility, transfers and dressing. On [DATE], no left heel protector was on the resident during the noon and evening meal observations. On [DATE], no left heel protector was on the resident at the breakfast and noon meal. The heel protector was not on the resident when she was in bed during an incontinent care observation. When the resident was transferred to her Broda chair, there was no heel protector applied when she exited her room. On [DATE] , the resident did not have a heel protector on at the breakfast meal. At 9:10 a.m., the DON was shown the physician's orders [REDACTED]. At 9:15 a.m., CNA #7 reported she had taken care of resident #5. The CNA was asked if the resident wore a heel protector on her left leg. The CNA stated, "No." At 9:24 a.m., the DON reported she would take care of the issue. d) A physician's telephone order, dated [DATE], documented, "Cleanse Stage III sore to R inner big toe c NS pat dry Apply [MEDICATION NAME] ointment & cover c foam pad daily till healed..." A nurse's note, dated [DATE] at 12:00 p.m., documented, "...Cleanse c wound cleanser. Collagen & 2 x 2 gauze applied & secured c tape..." A physician's telephone order, dated [DATE], documented, "Change treatment to R big toe c Cleanse c NS; pat dry place Collagen & 2 x 2 gauze & secure c tape daily till healed." On [DATE] at 2:25 p.m., RN #1 was asked why she had treated the resident's pressure ulcer with Collagen the day before it was ordered. The RN reported, she wanted to try the Collagen as a treatment so she could see what would happen and to let "them" know. At 4:15 p.m., the DON was asked if RN #1 should have administered the Collagen treatment without a physician's orders [REDACTED]." 2. Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The medical record reflected the resident was a full code. A notation in the [DATE] nurses' notes documented a DNR was discussed with the resident's son. The documentation reflected the son was given a DNR form to take home and the son would return the form at a later time. There was no further documentation of the DNR form or status in the nurses' notes. The DON was asked if the DNR form had been returned to the facility. She reported she was not working at the facility at that time and the medical record reflected the resident was currently a full code. On [DATE] at 9:00 a.m., the resident's family was asked about the DNR form being returned to the facility. The family reported it was signed and returned to the facility. The family member reported the resident had a couple of episodes of not doing well and the family had discussed with the resident what her wishes were. The resident told them she wanted nothing more done. She wanted medical treatment for [REDACTED]. At 10:30 a.m., the corporate nurse was asked about the DNR form. She returned later with a copy of a signed DNR form dated [DATE]. She reported the medical record had now been updated to reflect this change. At 11:00 a.m., the DON was asked, if the resident had stopped breathing or her heart had stopped beating, what action would she have taken. She reported, looking at the record, she would have started CPR and called the ambulance. The DON reported the medical records would be reviewed to ensure records were current.

Based on record review and staff interviews, it was determined the facility failed to notify the physician with changes in a pressure ulcer and the associated pain involved, which resulted in actual harm for one (#5) of three sampled residents who had a pressure ulcer. This had the potential to affect two other residents, identified by the Resident Census and Conditions of Residents form, as having pressure ulcers. Findings: Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. A care plan with the initial date of 08/29/13, documented the resident had a potential for impaired skin integrity as a problem. The goal was for the resident to have intact skin. One intervention was for the staff to audit the resident's skin at least weekly. A weekly head to toe skin assessment, dated 01/06/14, documented the resident's skin was intact. An Individual Wound Assessment form, dated 01/09/14, documented a Stage III pressure ulcer was discovered on the resident's inner side of her right great toe. The pressure ulcer measurements were 1.25 cm x 1.25 cm x 0.5 cm. The assessment documented there was no drainage and the wound bed and surrounding tissue was whitish. The assessment documented the resident's 2nd digit (toe) anatomically crossed over the great toe. A care plan, dated 01/09/14, documented the resident had a problem of [REDACTED]. The goal was for the wound to resolve without complication in the next 30 days. Interventions listed were for the staff to notify the physician if treatment was not effective and to report to the physician any redness, [MEDICAL CONDITION], purulent discharge and fever. A nurse's note, dated 01/11/14 at 9:00 a.m., documented the dressing to the resident's right great toe was completed and there was a foul odor. The nurse's note further documented a new open area, Stage I pressure ulcer to the base of the resident's right great toe. The nurse's note documented the Stage I pressure ulcer had a bluish discoloration. The nurse's note documented the ADON was made aware of both pressure ulcers. An Individual Wound Assessment form, dated 01/11/14, documented a Stage I pressure ulcer which measured 1.5 cm x 1.5 cm. There was no documentation the staff reported the foul odor to the physician. A nurse's note, dated 01/12/14 at 1:20 p.m., documented the resident complained of pain during the pressure ulcer treatment. There was no physician notification documented in the clinical record which addressed the pain in the resident's toe. A nurse's note, dated 01/15/14 at 5:00 p.m., documented, "...No drainage c foul smell...slight redness to big toe..." There was no physician notification documented in the clinical record concerning the redness. A physician's progress note, dated 01/21/14, documented a scheduled interval visit was made by the physician. The progress note documented the patient had no acute issues this month. The progress note documented, "Discussion with the nursing staff reveals no significant change in her chronic status either...Extremities: No [MEDICAL CONDITION] and or acute change Skin: Intact, without breakdown..." A nurse's note, dated 01/21/14 at 8:00 p.m., documented the pressure ulcer "...still has odor..." There was no physician notification documented in the clinical record which addressed the odor. Daily wound assessments, dated 01/21/14, 01/22/14, 01/24/14, 01/25/14, 01/27/14, 1/29/14 and 01/31/14 documented pain was present. There was no physician notification documented in the clinical record which addressed the resident's pain. A daily wound assessment, dated 02/01/14, documented the pressure ulcer had increased in depth and had creamy colored tissue with drainage, odor and pain present. A nurse's note, dated 02/01/14 at 1:00 p.m., documented the Stage III pressure ulcer had increased in depth with necrotic tissue on wound bed. The nurse's note documented, "...To report to (ADON name deleted) when comes in to work on night shift tonight-on call supervisor." There was no documented physician notification of the change in the wound bed color and depth. A nurse's note, dated 02/02/14 at 10:00 a.m., documented the right great toe had a foul smell and brownish drainage. A daily wound assessment, dated 02/02/14 documented slight swelling to the toe with drainage, odor and pain present. A daily wound assessment, dated 02/03/14, documented the wound bed was bloody with drainage, odor and pain present. A care plan, dated 02/04/14, documented a problem of a wound infection site of the resident's right great toe as evidenced by drainage and pain. One approach listed was for the staff to administer/monitor effectiveness of treatment. Another approach was for the staff to assess/record signs and symptoms of infection such as redness, inflammation, swelling, temperature and report to the physician. A daily wound assessment, dated 02/05/14, documented, "...Resident screamed when messed c toe even a gentle touch..." The pressure ulcer continued with swelling, drainage, odor and pain. The resident's clinical record contained no documentation the physician had been notified of the resident's condition. A nurse's note, dated 02/07/14 at 12:00 a.m., documented malodorous odor to the right great toe. A daily wound assessment, dated 02/08/14, documented the pressure ulcer size as 2 cm x 2 cm x < 0.5 cm. The assessment documented the resident's toe continued to have swelling, drainage, odor and pain. A nurse's note, dated 02/08/14 at 10:00 a.m., documented, "...R great toe c very foul smell & painful to touch..." At 2:00 p.m., a nurse's note documented, "...whitish necrotic tissue to center of wound bed..." There was no documented physician notification of the increased size of the pressure ulcer with necrotic tissue or the foul odor. A nurse's note, dated 02/10/14 at 10:30 a.m., documented the treatment continued to the right great toe with no improvement noted. A nurse's note at 4:00 p.m. documented the resident was grimacing in pain. There was no documented physician notification of the lack of improvement of the wound. On 02/11/14, the resident was transported to an appointment with a podiatrist. The podiatrist's report, dated 02/11/14, documented the resident presented with an ulcerative area on her right great toe with a foul odor. The resident had weakly palpable dorsalis pedis and posterior tibial pulses to the right lower extremity. There was no capillary refill in the toe. The ulceration was matted with necrotic tissue in the inner portion of the right great toe. The foot was swollen and had a foul odor. The report documented there was the appearance of early gangrene in the right great toe. Radiographs were taken which showed osteo[DIAGNOSES REDACTED] in the proximal bone of the toe. The report documented there was a pathological fracture associated with the toe. A quarterly assessment, dated 02/12/14, documented the resident was severely impaired in cognition with short and long-term memory problems. The resident required extensive one to two person assistance for transfer, bed mobility, dressing, eating, personal hygiene and bathing. The assessment documented the resident was at risk for a pressure ulcer and had one Stage IV pressure ulcer with slough tissue. The assessment documented the resident had an infection of the foot with pressure ulcer care and the application of a dressing. The staff assessment for pain documented resident indicators for pain were non-verbal sounds such as crying and moaning and vocal complaints of pain which occurred daily. On 02/12/14, the resident was admitted to the hospital for debridement of the toe. A hospital discharge summary, dated 02/24/14, documented the resident had been admitted with a gangrenous R great toe. The resident subsequently underwent an above the knee amputation. On 07/29/14 at 11:30 a.m., the ADON was asked about RN #1's documentation in the nurse's notes on 02/01/14, of notifying him (the ADON) regarding the resident's pressure ulcer changes. The ADON reported, he did not remember the RN notifying him of the resident's pressure ulcer. The ADON reported, he did not know why the RN did not notify the physician herself. At 1:50 p.m., the physician was interviewed by telephone. The physician was asked if the staff had notified him of the foul odor, increase of wound size or the presence of necrotic tissue. The physician reported he did not have recollection of staff calling about wound changes. The physician reported he could not remember. The physician reported he saw the resident's toe when it was black. At 2:25 p.m., RN #1 was interviewed and asked if she had notified the physician when the odor was detected on 01/11/14. The RN reported, she had told the ADON, but she did not remember calling the physician. The RN was asked, when she had documented in the nurses' notes on 01/21/14, about the continuance of odor to the toe, if she had notified the physician. She reported, the resident had her socks on and she thought her feet smelled. RN #1 was asked if she had notified the physician, when she documented in the nurses' notes on 02/01/14, the pressure ulcer had increased in depth with necrotic tissue on the wound bed. The RN reported, she had reported it to the ADON, and had not called the physician. The RN was asked if she had notified the physician when on 02/05/14, the resident screamed out in pain with gentle touch. The RN reported, she could not remember if the physician was notified. The RN reported, when she would observe something with care she would notify a supervisor to handle the situation in the day time. RN #1 was asked if she had notified the physician when on 02/08/14, the pressure ulcer increased in size with necrotic tissue. The RN reported, she reported it to a supervisor to pass the information on. The RN reported, she had not notified the physician. On 07/30/14 at 10:55 a.m., the DON was asked if the staff should have called the physician when there were changes in the pressure ulcer. The DON stated, "Yes."