Every finding on record at Aitkin Health Services

Based on observation, interview, and document review the facility failed to ensure linens were handled properly to help prevent the spread of infection. In addition, the facility failed to maintain a water management program which identified potential areas for water-borne bacteria and maintain records of water management activities. Findings include:Linen HandlingDuring an observation on entrance on 6/1/26 at 1:50 p.m., in an alcove next to the elevator down to the conference room, stood a three-shelved unit storing clean linens, the cover was observed up over the top of the unit and there were items stored up on top of the cover which was folded back. A sign on the cart indicated please close the cover. During an observation on 6/3/26 at 12:23 p.m., the linen cart was observed to be uncovered as it was on 6/1/26.During an observation and interview on 6/3/26 at 2:56 p.m., licensed practical nurse (LPN)-A, who identified as the facility infection preventionist (IP) observed the uncovered linen cart and stated this didn't meet his expectations and would be a risk for bacteria to get on them and then get spread all over.A policy, Linen Handling dated 3/10/26, identified its purpose was to provide clear and consistent guidelines for the safe handling of linen to protect residents, staff, and the environment from infection and occupational exposure. The policy didn't address clean linen handling practices.Water ManagementDuring an interview on 6/4/26 at 8:40 a.m., maintenance worker (MW)-A, who identified as the maintenance director and responsible for the water management plan stated he didn't know how the water flowed through the building and didn't have a diagram. MW-A identified that the faucets and showers were flushed daily by the housekeeping staff, but he didn't have it documented anywhere. MW-A wasn't aware of current municipal water quality. MW-A noted the monthly cleaning of air conditioner units but didn't have further documentation of water management activities.A map of the facility was supplied and identified where the water main shut-off valve was, identified three hot water heaters and a statement of facility has no water tempering or mixing valves. All hot water is controlled by the hot water heaters.A policy, Water Management Program Legionella Prevention dated 11/19/25, identified its purpose was to provide directions to staff to prevent, identify and manage hazardous conditions that inhibit the growth of and spread of Legionella. The most common form of Legionella transmission is inhalation of contaminated aerosols produced with water sprays, jets, or mists of contaminated water sources. The Water Management Program (WMP) reduces the threat of Legionella. The WMP will identify:Where the domestic water supply source enters the care center and the size of the water main.Where water is distributed to vulnerable dead leg or other bacteria growth sources including empty/non-used rooms, water features, ice machines, faucet fixtures, shower heads, ice machines, plumbed eye wash stations, etc.Where cold water is heated and to what temperature including water heaters that serve resident rooms, laundry, dietary and public restrooms.Changes in municipal water quality can increase sediment, lower disinfectant levels, increase turbidity or cause PH to be outside the recommended ranges.PH balance maintained through use of disinfectants are most effective within a narrow range of 6.5 to 8.5 PH.The policy also identified inadequate disinfectant in the water and therefore can allow Legionella spores to grow into harmful numbers. Water considered high quality entering the care center may have Legionella and processes such as heating, storing, and filtering can further degrade the quality of the water depleting the disinfectants. Water stagnation encourages biofilm growth by way of reduced water temperature and disinfectant levels. Common stagnation points include capped water supply lines and areas of reduced resident occupancy which results in water fixtures (faucets, showers, eye wash stations, etc.) being unused for an extended length of time.

Based on interview and document review, the facility failed to ensure residents were educated about and offered the COVID-19 vaccination for 3 of 5 residents (R1, R4, R23) reviewed for vaccinations.Findings include:R1's quarterly minimum data set (MDS) dated [DATE], identified resident was rarely if ever understood and a cognitive assessment was not performed.R1's admission record identified an admission date of 11/1/2024, and diagnoses of congestive heart failure (CHF), atrial fibrillation, hypertension, and dementia.A report, Aitkin Health Services (AHS) Immunization Report dated 1/1/2005 to 6/30/26 identified R1 hadn't had the COVID-19 vaccinations.An undated form, Vaccination Consent, identified R1 hadn't had a COVID-19 vaccination and didn't want to receive one. The form didn't contain evidence the resident or resident representative was offered education regarding vaccination.R4's quarterly MDS dated [DATE], identified intact cognition and diagnoses of hypertension, chronic pain, gastroesophageal reflux disease (GERD), and hypokalemia.R4's admission record identified an admission date of 7/21/25.A report, AHS Immunization Report dated 1/1/2014 to 6/30/26 identified R4 hadn't had the COVID-19 vaccinations.An undated form, Vaccination Consent, identified R4 hadn't had a COVID-19 vaccination and didn't' want to receive one. The form didn't contain evidence the resident or resident representative was offered education regarding vaccination. The form was not signed by R4.R23's quarterly MDS dated [DATE], identified intact cognition and diagnoses of CHF, persistent atrial fibrillation, and diabetes mellitus.R23's admission record identified an admission date of 1/13/26.A report, AHS Immunization Report dated 1/1/2010 to 6/30/26, identified R23 had a COVID-19 vaccination on 4/10/21.A form, Vaccination Consent signed by R23 on 1/13/26, identified R23 didn't want to receive the COVID-19 vaccination. The form didn't contain evidence the resident or resident representative was offered education regarding vaccination.Policies regarding vaccination were requested but not received.

Based on observation and interview, the facility failed to date opened products, dispose of expired products, and failed to have a process to ensure stored food was labeled with an expiration date that staff could understand. This deficient practice had the potential to affect all residents who received food from facility kitchen.Findings include:During the initial kitchen tour on 6/1/26 at 2:39 p.m., with the kitchen manager (KM), the following was observed:In dry storage, there was an unopened jar of Molly's vegetable base with no discernable expiration date. KM stated they were not aware the product had no expiration date, and they would need to date the product when received so staff would know when to discard the product.In the walk-in cooler, there was an open, undated bottle of lemon juice with a best use by date of 10/6/25. KM removed the lemon juice from the cooler and stated they would discard it. They stated a concern for food quality when a product was beyond its best used by date.In freezer 2, there were 4 bags of corn and black bean fiesta mix dated 4/15/26 with no indication of what the date referenced. KM stated they received the frozen vegetable mix the previous week, and they needed to reach out to their supplier for clarification on the expiration date.During an interview on 6/1/26 at 4:27 p.m., KM stated per their food supplier, the date on the bags of corn and black bean fiesta mix was a packing date and the product was good for 547 days from the packing date. KM confirmed that the kitchen staff would not know the expiration date and stated they needed to label the product with an expiration date when received.During the observation in the Garden Terrace dining room on 6/3/26 at 10:57 a.m., there was an open, undated gallon of 1% milk and an open, undated half gallon bottle of chocolate milk in the kitchenette refrigerator.During the observation in the Bears Den dining room on 6/3/26 at 11:08 a.m., there was an open, undated half gallon bottle of chocolate milk in the kitchenette refrigerator.During an interview on 6/3/26 at 10:57 a.m., cook (C)-A stated milk should be dated when it was opened.During an interview on 6/4/26 at 9:07 a.m., KM stated milk should be dated when it was opened. They stated they would be concerned not knowing how long it was open and would dump any open, undated milk.Facility Non-Perishable Food Management policy instructed to clearly label all foods with the best by or use by dates upon receipt.Facility Perishable Food Management policy instructed products should be discarded one day past the use by date.

Based on interview and document review, the facility failed to consistently educate, offer, or administer influenza and pneumococcal immunizations for 4 of 5 residents.Findings include:R1's quarterly minimum data set (MDS) dated [DATE], identified resident was rarely if ever understood and a cognitive assessment was not performed.R1's admission record identified an admission date of 11/1/2024, and diagnoses of congestive heart failure (CHF), atrial fibrillation, hypertension, and dementia.A report, Aitkin Health Services (AHS) Immunization Report dated 1/1/2005 to 6/30/26 identified R1 hadn't had influenza or pneumococcal vaccinations.An undated form, Vaccination Consent, identified R1 hadn't had an influenza, but wished to receive one. Also, R1 hadn't had a pneumococcal vaccination and there was no entry indicating if she did or didn't want to receive one. The form didn't contain evidence the resident or resident representative was offered education regarding vaccinations.R4's quarterly MDS dated [DATE], identified intact cognition and diagnoses of hypertension, chronic pain, gastroesophageal reflux disease (GERD), and hypokalemia.R4's admission record identified an admission date of 7/21/25.A report, AHS Immunization Report dated 1/1/2014 to 6/30/26 identified R4 had the influenza or pneumococcal vaccinations on 3/22/18.An undated form, Vaccination Consent, identified R4 hadn't had an influenza or pneumococcal vaccination and didn't' want to receive either. The form didn't contain evidence the resident or resident representative was offered education regarding vaccination. The form was not signed by R4.During an interview on 6/4/26 at 10:50 a.m. licensed practical nurse (LPN)-A, who identified as the facility infection preventionist (IP) stated the vaccinations were reviewed by whichever nurse was doing the admission, the facility's process was to use the CDC PneumoRec application. The IP confirmed the Vaccination Consent form didn't contain evidence of education provided.R23's quarterly MDS dated [DATE], identified intact cognition and diagnoses of CHF, persistent atrial fibrillation, and diabetes mellitus.R23's admission record identified an admission date of 1/13/26.A report, AHS Immunization Report dated 1/1/2010 to 6/30/26, identified R23 had a Prevnar 13 on 9/10/15, and Pneumovax 23 on 9/26/20. R23 didn't have any history of receiving influenza vaccinations.A form, Vaccination Consent signed by R23 on 1/13/26, identified R23 wanted to receive a pneumococcal vaccination, but didn't want to receive the influenza vaccination. The form didn't contain evidence the resident or resident representative was offered education regarding vaccination. According to the Centers for Disease Control (CDC) PneumoRec application, R23 would have been eligible for shared decision making with her provider regarding a pneumococcal vaccination.R39's admission record dated 6/4/26, identified an admission date of 5/18/26 and diagnoses of lymphedema, hypothyroidism, diabetes mellitus, and chronic kidney disease.A report, AHS Immunization Report dated 1/1/2007 to 6/30/26, identified R39 had Prevnar 13 on 11/4/16, and PPSV23 on 1/4/18A form, Vaccination Consent signed by R39 on 5/18/26, identified he had received pneumococcal vaccinations, would like to receive one, and had received the education. However, there is no evidence R39 received the vaccine. According to the Centers for Disease Control (CDC) PneumoRec application, R39 would have been eligible for shared decision making with his provider regarding a pneumococcal vaccination.During an interview on 6/4/26 at 10:55 a.m., the IP confirmed the missing education for the residents, the missing vaccinations for those residents wishing to receive one and stated the risks of not being vaccinated would be they could catch and spread illness, and without education they can't really say what the vaccine would do for them. Policies regarding vaccinations were requested as part of the infection control program but were not received.

Based on observation, interview and document review, the facility failed to initiate orders and maintain documentation to ensure oxygen supplies were properly cleaned and maintained for 1 of 1 resident (R1) reviewed for respiratory care.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. Diagnoses included atrial fibrillation, heart failure, hypertension, pneumonia, non-Alzheimer's dementia.R1's care plan did not include oxygen use.R1's had a provider order dated 1/6/26, for oxygen 2 liters as needed (prn) to keep oxygen saturations above 90% and as needed for shortness of breath.R1's treatment administration record (TAR) reviewed on 6/2/26, included oxygen 2 liters prn to keep oxygen saturations above 90% as needed and for shortness of breath as needed, but had no instructions for cleaning, maintenance, or changing of oxygen tubing. TARs dated 3/2026, 4/2026, and 5/2026, also had no instructions for cleaning, maintenance, or changing of oxygen tubing. During an observation on 6/2/26 at 1:07p.m., R1's oxygen concentrator was in their room with undated oxygen tubing connected, hanging off the concentrator and cascading to floor, and an undated, partially filled humidifier attached.During an interview on 6/3/26 at 10:03 a.m., nursing assistant (NA)-F stated R1 had used oxygen with an illness but had not needed oxygen for several weeks. They indicated the concentrator was in R1's room to be used as needed. NA-F confirmed the tubing and humidifier were undated and stated oxygen tubing and humidifiers were usually changed weekly, should be dated, and the nurse would check off the change on the TAR.During an interview on 6/3/26 at 1:04 p.m., assistant director of nursing (ADON) stated R1 had used oxygen with an illness but had not needed oxygen for several weeks. They stated oxygen tubing and humidifiers were changed on Sundays, and staff were instructed to date and label the humidifier and all connecting tubing. The ADON had concern for potential bacteria growth if the tubing was not changed, confirmed there was not an order on R1's TAR, and stated they would add it.During an interview on 6/4/26 at 7:41 a.m., director of nursing (DON) stated oxygen tubing and humidifier should be changed weekly and scheduled on the TAR. The DON had concern for potential risk of infection.Facility policy Oxygen did not address maintenance, cleaning, and changing of oxygen tubing.Facility policy related to oxygen administration and tubing change was requested but not received.

Based on observation, interview and record review, the facility failed to offer annual audiology services or assist with routine hearing aid care for 1 of 1 resident (R3) reviewed for hearing maintenance.Findings include:R3's significant change is status (SCSA) minimum data set (MDS) dated [DATE], identified intact cognition and moderate difficulty hearing with hearing aids in place. R3 was dependent on staff for upper and lower body dressing, personal hygiene, and bed mobility. R3's care plan dated 2/26/25, identified a focus statement for being hard of hearing with a goal for her hearing aid to be accessible, clean, and available for use. Interventions included assisting to place and remove hearing aids daily, assist with charging, to review hearing status quarterly, and to offer audiology services annually. The care plan didn't identify to check or clean hearing aid filters.R3's provider orders didn't contain hearing aid maintenance.An assessment, Long Term Care Evaluation dated 12/15/25, identified R3 had minimal difficulty hearing with hearing aids. A form, Care Conference dated 3/6/26, was incomplete and unsigned.R3's electronic medical record (EMR) identified R3 was seen for an initial hearing aid fitting on 4/3/25. During a follow up visit on 5/1/25, it was noted the hearing aid filters were partially plugged.R3's progress notes didn't contain an entry regarding a March 2026 care conference or offering of audiology services.During an interview on 6/1/26 at 5:24 p.m., it was observed R3 was having difficulty hearing at level of conversation, she was wearing bilateral hearing aids. R3 stated when she first got her hearing aids she could hear everything, now she can't hear very well. During an interview on 6/2/26 at 2:52 p.m., registered nurse (RN)-A stated there had been issues in the past with charging R3's hearing aids, but now they have been fine and R23 didn't have any problems hearing her. RN-A stated she would look at the care conference notes to see if audiology was offered. The director of nursing (DON) added that residents were asked at every care conference if they wanted to go to audiology. If they did, the social worker would let the scheduler know and help them make arrangements. At 3:08 p.m., RN-A stated she thought she knew what might be wrong with R3's hearing aids; they had filters that needed to be cleaned.During an interview on 6/3/26 at 9:04 a.m., the DON stated they didn't see that R3 had a care conference, but the social service designee (SSD) was not available to ask about what happened. The DON added R3 wasn't in the facility at the time of her scheduled care conference, and there were no notes as to rescheduling or what happened.During an interview on 6/4/26 at 12:56 p.m., RN-A stated she assessed R23's hearing for the MDS cycle by talking with her. RN-A added it appeared the SSD never rescheduled R23's care conference and it was forgotten about; normally they offer those services at the RCC.A policy regarding hearing aid care was requested but not received.

Based on observation, interview, and record review the facility failed to provide edema management and provide root cause analysis, care, and monitoring for a skin injury for 1 of 1 resident (R23) reviewed for quality of care.Findings include:R23's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of chronic congestive heart failure (CHF, a condition whereby the heart can't pump blood efficiently to meet the body's needs and may lead to accumulation of fluids in the lungs, legs and other areas), and peripheral vascular disease (PVD, a disorder of the blood vessels). R23 had impaired range of motion (ROM) on one upper extremity and both lower extremities (LE) and needed moderate assistance with putting on or taking off footwear.R23's care plan dated 2/17/26, identified the need for assistance donning and doffing TEDs (compression stockings) or [NAME] (specific brand of compression stockings) stockings. On 1/15/26, a focus statement for the risk of increased edema (collections of fluid) related to CHF. Interventions included applying ACE wraps to both LE daily, to elevate LE while in bed, to inspect skin weekly, to observe for edema, including blisters and weeping edema, and to observe skin daily with cares. On 1/15/26, a focus statement for DM including interventions to check for breaks in skin and treat promptly as ordered by the doctor, inspect feet daily for open sores, pressure areas, blisters, edema or redness, and ensure proper footwear when mobilizing wheelchair. R23's care plan didn't include recusals of care.R23's provider order dated 1/13/26, to apply TEDs or [NAME] stockings in the morning and remove in the evening. On 1/23/26, an order to elevate LE as much as possible every shift, and to elevate legs in bed in the morning and afternoon for one hour as resident allowed. An order on 6/2/24 to have occupational therapy see R23 for lymphedema treatment. R23's provider orders didn't contain an order for treatment to the injury on her third toe of the right foot.R23's progress notes didn't contain refusals of care, or identification of an injury to resident's toe.R23's TAR, identified resident refused TEDs on 6/1 and 6/3/26, but charted as wearing them on 6/2 and 6/4/26.During an observation and interview on 6/1/26 at 5:44 p.m., R23 had a band-aid on the third toe of her right foot, both LE and feet were noted to be edematous, R23 was bare-footed. R23 stated she snagged it on something in her room, either her wheelchair or something else but she wasn't sure. A pair of edema shoes were noted on a chair in R23's room. During an observation on 6/3/26 at 9:55 a.m., R23 was sitting in her wheelchair in her room with feet flat on the floor, had no socks or shoes on, both feet appeared red and edematous. During an observation on 6/3/26 at 12:33 p.m., R23 was observed sitting in her wheelchair in her room visiting with family. R23 was wearing edema shoes, but no compression socks.During an interview on 6/3/26 at 12:59 p.m., nursing assistant (NA)-C stated R23 got herself dressed most days and didn't know if she could put socks on but did know she could put the slipper shoes on. NA-C also stated R23 did tub grips (a type of light compressing tubing) but didn't like to wear them all the time, most of the time she refuses.During an interview on 6/3/26 at 1:13 p.m., trained medication assistant (TMA)-A stated R23 hated the compression socks so she didn't wear them and refused the tubi-grips and would pull the ACE wraps off when they put them on. TMA-A stated she could chart refusals on the treatment administration record (TAR). TMA-A added she wasn't working when R23 hurt her toe, but they do normally fill out incident reports for that.During an observation on 6/4/26 at 7:24 a.m., R23 was up in her wheelchair, dressed in clothes and edema shoes, but didn't have any compression socks on.During an interview on 6/4/26 at 12:24 p.m., Registered Nurse (RN)-A who identified as the nurse manager for R23 stated R23 was able to put on her own socks and shoes, but the NAs would be responsible for applying (compression) stockings and added R23 preferred to be barefoot. RN-A confirmed she didn't see an incident report or orders for treating R23's third toe of her right foot and the risks for her could be needing her toe amputated. RN-A stated she would still expect staff to offer compressing stockings even if she refused, and if she did refuse then staff should let the nurse know and document it. During an interview on 6/4/26 at 2:03 p.m., the director of nursing (DON) stated she would expect staff still offer R23 her compression socks when she got dressed in the morning and would expect licensed nurses to be looking at the foot, depending on stage of healing, if not every day, then every other day. A policy, Skin Integrity dated 3/10/26, identified its purpose was to provide guidance to nursing staff on preventing, identifying, evaluating and monitoring resident skin integrity. Appropriate interventions will be promptly implemented to prevent the development of skin integrity issues. Licensed nurse will:i. Assess the area and identify the cause, if possible.ii. Remove any source of pressure or trauma to the area.iii. Clean the area and provide treatment per care center House Standing Orders.iv. Determine if the skin integrity issue is reportable to the State Agency (SA). If yes, notify the Administrator and Director of Nursing and proceed with the SA reporting process. (CCEP.MP.SNF.005 Maltreatment Investigation & Reporting)v. Complete a Skin Incident report in the resident EHR.vi. Notify resident and/or responsible party.vii. Notify Provider and request treatment orders, if applicable.viii. Notify the Nurse Manager, Wound Nurse, or designee.ix. Initiate a new tissue tolerance for any newly opened area or redness.x. Initiate appropriate preventive measures based on the immediate root cause.For evaluation:a. Nurse Manager, Wound Nurse, or designee will assess and complete a root cause analysis.b. Interdisciplinary Team (IDT) will review the skin incident report and evaluation of root cause for further recommendations.c. The provider will review, to diagnosis, if root cause was not related to an injury (i.e., skin tear, bruise), make recommendations, and/or initiate order(s).

Based on observation, interview and document review, the facility failed to ensure activities of daily living (ADL) tasks were performed for a resident dependent on others to complete ADLs for 1 of 1 resident (R3) reviewed for ADLs.Findings include:R3's significant change in assessment (SCSA) minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of hemiplegia and hemiparesis of the right side related to a cerebral vascular accident (CVA, or stroke), fracture of the upper and lower end of the left fibula, unspecified fracture of the upper end of the left tibia, other fracture of the upper and lower end of the right fibula, unspecified fracture of upper end of right tibia, and unspecified fracture of the shaft of the right fibula. The MDS also identified R3 was dependent for personal hygiene.R3's care plan dated 2/26/25, identified a focus statement for ADL self-care deficit and included interventions for a bath scheduled Sunday afternoons and preferred to be shaved if facial hair was present. R3 needed assistance with set-up for personal and oral hygiene.R3's electronic medical record (EMR) confirmed she had a bed bath on 5/31/26.During an observation on 6/1/26 at 5:17 p.m., R3 was observed wearing a hospital gown and had white chin hair of about one-third of an inch, she stated she had just come from the dining room. There were food and coffee stains on the front of the gown. R3 stated she was supposed to have a bath yesterday, but she still hadn't gotten it and she didn't know why. During an observation on 6/2/26 at 12:21 p.m., R3 was observed in her bed and stated again she didn't get her bath on Sunday and asked if her chin hair was visible while she was feeling it with her hand. On observation, R3 did have white chin hair of about one-third of an inch.During an interview on 6/2/26 at 1:23 p.m. nursing assistant (NA)-A stated they would look in Point Click Care (PCC, an electronic medical record) for the Kardex to see what to do with each resident, and there was a bath schedule in the nursing station, or in PCC. NA stated she hadn't gotten R3 ready this morning, so she didn't really notice if she had chin hair. At 1:38 p.m., NA-A confirmed there was visible chin hair. During an interview on 6/2/26 at 2:45 p.m., the director of nursing (DON) stated since R3 had had her injury she had been getting a bed bath but would expect to at least offer to shave R3's chin with daily care if there were hair visible. During an interview on 6/4/26 at 12:56 p.m., registered nurse (RN)-A identified she was the nurse manager for R3 and would have expected her to still be shaved, even with a bed bath.

Based on observation, interview and document review, the facility failed to review and revise the resident care plans to reflect changes in resident care for 2 of 5 residents (R4, R23) reviewed for care planning.Findings include:R4:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of legal blindness as defined in the United States. R4 propelled her own wheelchair and could wheel 150 feet independently.R4's care plan dated 7/21/25, identified R4 was at risk for falls related to vision problems and included interventions to assist with mobility and transfers, assure call light was in reach, reorient her to her room, assess fall risk every quarter and with changes in condition. R4's care plan didn't identify R4 needed supervision outside.According to a Nursing Home Incident Report dated 6/3/26, R4 had a fall from her wheelchair on the facility's outdoor patio on 5/27/26. Actions to prevent recurrence included direct supervision when R4 was outside for activities.During an interview on 6/4/26 at 12:39 p.m., registered nurse (RN)-A, who identified as the nurse manager for R4, stated she hadn't seen the incident report yet and therefore hadn't made any changes to the care plan. During an interview on 6/4/26 at 2:08 p.m., the director of nursing (DON) stated they had done verbal education with activity staff about supervision on the patio for R4 but hadn't updated her care plan. R23:R23's quarterly MDS dated [DATE], identified intact cognition and diagnoses of chronic congestive heart failure (CHF, a condition whereby the heart can't pump blood efficiently to meet the body's needs and may lead to accumulation of fluids in the lungs, legs and other areas), and peripheral vascular disease (PVD, a disorder of blood vessels). R23 had impaired range of motion (ROM) on one upper extremity and both lower extremities (LE) and needed moderate assistance with putting on or taking off footwear.R23's care plan dated 2/17/26, identified the need for assistance with compression stockings, but was not updated for resident's refusals to wear them. In addition, the care plan didn't include interventions to educate and encourage R23 to wear footwear.R23's provider order dated 1/13/26, to apply TEDs or [NAME] stockings (compression socks) in the morning and remove in the evening.R23's progress notes didn't contain refusals of care. R23's TAR, identified resident refused TEDs on 6/1 and 6/3/26, but charted as wearing them on 6/2 and 6/4/26.During an interview on 6/4/26 at 12:39 p.m., RN-A stated she would expect the care plan to reflect R4's refusals of care, and for staff to offer care even when R4 would normally refuse.A policy, Person Centered Care Planning dated 4/20/23, defined its purpose was to provide guidance to care center staff on developing the residents' person-centered care plan. Person centered care planning includes identifying individualized personal strengths, needs, preferences, interests, supports, and goals. From the perspective of the resident, the heart of person-centered care planning is defined as, I plan my care with people who work together to understand me and my care partners, allow me control, and bring together services to achieve the outcomes important to me. The care plan should emphasize the residents' strengths and goals, including supporting self-determination and participation. The care plan will be reviewed every 90 days or more frequently if needed.

Based on observation, interview, and document review, the facility failed to ensure proper storage of open enteral feeding solutions and failed to date tube feeding supplies for 1 (R8) of 2 residents reviewed for tube feeding.Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact. Diagnoses included frontotemporal neurocognitive disorder, dysphagia, diabetes mellitus type 2, non-Alzheimer dementia, and anxiety disorder.R8's care plan revised 2/26/26, tube feeding care included:Bolus feeding.Change feeding solution container and syringe every 24 hours. Follow manufacturers' recommendations or per registered dietician regarding how long formula can be open.R8's provider orders dated 6/4/26, included:Change syringe and water container daily before breakfast.Please have dietician eval resident tube feeding needs and make recommendations.Jevity 1.2 Calorie Oral Liquid (Nutritional Supplements) Give 553 milliliters (mL) via gastrostomy tube (G-tube) three times a day (TID) for Bolus feeding or 2 1/3 cartons TID (can split one carton TID if cover, refrigerate & use within 24 hours).R8's treatment administration record (TAR) instructed staff to change syringe and water container daily before breakfast.During an observation on 6/2/26 at 9:29 a.m., an open and undated Jevity 1.2 calorie, 1.5-liter, bottle was on R8's bedside table, not connected to R8's G-tube. Tube feeding supplies were lying next to the Jevity bottle, including two rinsed, undated extension tubes.During an observation on 6/2/26 at 11:57 a.m., an open and undated Jevity 1.2 calorie, 1.5-liter, bottle was on R8's bedside table, not connected to R8's G-tube. Tube feeding supplies were lying next to the Jevity bottle, including a rinsed, undated 60 mL syringe.During an observation on 6/4/26 at 7:41 a.m., an open Jevity 1.2 calorie, 1.5-liter, bottle was on R8's bedside table, not connected to R8's G-tube. Tube feeding supplies were lying next to the Jevity bottle, including a rinsed, undated 60 mL syringe.During an interview on 6/4/26 at 11:04 a.m., licensed practical nurse (LPN)-A stated the Jevity nutritional supplement, graduated cylinder, and syringe was changed daily and dated. They stated a new Jevity bottle was opened each morning to administer via gravity feeding three times through the day as ordered for R8, and the open Jevity bottle could remain at room temperature for 24 hours. They were concerned about potential bacteria growth if supplies were used for more than one day.During an interview on 6/4/26 at 11:15 a.m., director of nursing (DON) stated the Jevity bottle was labeled each morning when it was opened for the first feeding, and tube feeding supplies were labeled when changed. They stated staff follow storage and refrigeration instructions on Jevity bottle. They were concerned it could potentially put the resident at risk if not dated and stored per policy. During an interview via email correspondence dated 6/4/26 at 3:50 p.m., facility-contracted dietician stated if the Jevity should be covered and refrigerated between gravity feeds to help prevent bacterial growth and dated with the date and time it was opened. Facility policy Enteral Feeding Tube Usage instructed staff to label the feeding solution container with the date, time and nurses initials, and change and date the 60 mL syringe daily. It instructed to follow manufacturer's recommendation or registered dietician instructions for use and storage.

Based on observation and interview, the facility failed to ensure safe hot water temperatures in resident bathrooms in an area where 5 of 6 residents had potential to use the bathroom sink, and 1 of 6 residents (R23) expressed concern with hot water temperatures when reviewed for environmental concerns. In addition, the facility failed to follow care plan interventions for fall prevention for 1 of 2 residents (R39) reviewed for falls. Findings include: According to the State Operations Manual (SOM), as published by the Centers for Medicare and Medicaid Services (CMS), Revision 232, page 366: Water temperature of 100 degrees Fahrenheit (F) would be deemed a safe temperature for bathing. At 120 degrees F the time required for a third-degree burn (burns penetrate the entire thickness of the skin and permanently destroy tissue) was five minutes; at 140 degrees F the time required for a third-degree burn would be five seconds. R23's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of peripheral vascular disease and diabetes mellitus (DM, a condition where the body can't properly use blood sugar leading to high blood sugar. Long term effects may include loss of nerve sensation). R23 was independent with oral, personal, and toilet hygiene, and was mobile with independent wheelchair propulsion and transfers. R23's care plan dated 1/23/26, identified she was independent with hygiene and oral care. The plan also identified on 1/15/26, R23 had DM and should avoid exposure to extreme heat or cold. Review of Facility Domestic Water Temperature Log for Aitkin Health Services supplied by MW-A and dated May 2026, identified water temperatures taken 5/14/26 for rooms 102 to 109 didn't exceed 112 degrees F. During an interview on 6/1/26 at 5:51p.m., R23 stated the water in her bathroom sink was scalding hot, she stated she had told people but wasn't sure who. During an interview on 6/3/26 at 12:59 p.m., nursing assistant (NA)-C reported she had noticed the hot water was really hot and thought it would be an issue for residents who liked to wash their own hands. During an interview on 6/3/26 at 1:13 p.m., NA-D confirmed R23 was basically independent with activities of daily living (ADLs) and she did use the bathroom sink. During an interview on 6/3/26 at 1:28 p.m., NA-E stated the whole one side of Garden Terrace got extremely hot water and that maintenance knew this. During an observation and interview on 6/3/26 at 1:41 p.m., the administrator took the temperature of the hot water at R23's bathroom sink. The temperature with a food thermometer measured 138.2 degrees Fahrenheit (F)and a temperature gun measured 139.4 degrees F. The administrator stated it should be about 115 degrees F and rushed off to find the hot water heater. During an interview on 6/4/26 at 11:15 a.m., the administrator stated he didn't want the water to be as hot as it was yesterday due to the risk of burns and added the maintenance director would have a log of hot water temperatures. During an interview on 6/4/26 at 1:42 p.m., maintenance worker (MW)-A, who identified as the maintenance director, stated he used a temperature gun to get the hot water temperature in all of the sinks in all the rooms. MW-A added he had never had a temperature up there that was that high and that the gauge on the hot water tank was not working properly. A policy, Water Temperatures dated 4/16/24, identified its purpose was to provide direction to environmental services (ES) staff in testing and recording water temperatures at faucets and fixtures. Required temperatures were identified to be maintained at 105 to 115 degrees F and should not exceed 115 degrees F. Tests shall be conducted weekly at a minimum of one (1) faucet location per area or wing being serviced by a domestic water heater. Different fixture locations should be tested each week until they are recorded at least once annually. Tests at hot water faucet locations should be conducted by turning the hot water supply control valve to the hottest setting. The faucet and/or hot water supply at the fixture should be turned on to the fully open position, allowing the water to run for at least 30 seconds before taking any water temperature recording. Nursing staff shall report to ES staff if a resident or staff member reports that a water temperature seems excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water). ES staff will test and record the water temperature at the reported fixture location. R39: R39's admission MDS dated [DATE], was in progress and ready for export. The cognition assessment indicated R39 was cognitively intact. R39's facesheet date 6/4/26, included diagnoses of diabetes, lymphedema, and muscle weakness. R39's care plan initiated 5/18/26, indicated R39 used a recliner. Goals for lift recliner implemented on 5/26/26 included: I will continue to use my lift recliner with staff assistance for the lift function. Interventions for the chair updated 5/27/26, instructed staff to unplug R39's lift chair after positioning. R39's Fall Risk assessment dated [DATE], indicated R39 was at a high risk for falls. Progress note entry made on 5/24/26, included: Family brought in recliner yesterday, resident is safe to sit in recliner and knows how to use the chair remote but because resident requires assistance with transfers, resident uses call light to get up and out of the recliner and if resident wants to go into it from w/c. Risk assessment completed. Leave remote unplugged or out of reach so residents don't accidentally put it up or down and fall from it. Resident did call all day/evening when wanting to transfer from w/c to recliner and vice versa. Uses call light appropriately, alert and oriented. Progress note entry made on 5/27/26, included: R39 is able to use remote properly, but when staff is not in room lift chair is unplugged and R39 is to call staff to use remote, reasoning is safety purposes. During an interview on 6/1/26 at 3:30 p.m., R39 was seated in a recliner chair with legs partially elevated on the footrest. The recliner chair remote was tucked along R39's left leg and the side of the chair. R39's family member (FM-A) stated R39's chair was from home and R39 had been using the chair remote at home just fine, but facility staff said the chair would have to be unplugged when staff were not in the room for safety. FM-A said occupational therapy had assessed R39 for safety, and some staff had been unplugging it, but some hadn't, and the chair was currently plugged in now, so FM-A wasn't sure how it was supposed to be. R39's chair was plugged into outlet directly behind the chair. During an observation on 6/2/26 at 2:30 p.m., R39 was seated in their recliner. The recliner remote was on the left side of R39's lap. During an observation on 6/3/26 at 8:51 a.m., R39 was seated in their recliner alone in their room. The recliner was plugged in to the outlet behind the recliner. The chair remote was on the left side of R39's lap. R39 confirmed their chair was plugged in and they could move the chair with the remote. During an observation on 6/3/26 at 1:43 p.m., R39 was seated in recliner in room. The catheter bag was attached to the chair pocket and in direct contact with the floor. During an interview on 6/3/26 at 2:19 p.m., licensed practical nurse (LPN-A) stated R39 was very cognitive with the use of their chair remote. The problem was if R39 got into a position on accident with seat raised up, R39 would not have the strength to stop themselves from falling. During an interview on 6/3/26 at 2:34 p.m., R39 was seated in their recliner with their chair remote on the left side of their lap. R39 stated their chair was plugged in. During an observation on 6/4/26 at 7:33 a.m., R39 was seated in their recliner. The recliner remote was on R39's lap and the recliner was plugged in behind the chair. During an interview on 6/4/26 at 10:39 a.m., occupational therapist (OT-A) confirmed they had done a safety assessment on R39. They found that R39 could cognitively operate the remote, but R39 did not have strength in their legs for balance and independent transfer out of the chair in a lifted position. For safety, OT-A had recommended that R39's recliner remain unplugged when staff were not present to standby assist with transfers and repositioning of the chair. During an interview on 6/4/26 at 11:36 a.m., R39 was seated in their chair and stated it was plugged in and working. R39 held up their right hand to show they had their recliner remote. The remote was lit up with a green back light. During an interview on 6/4/26 at 12:20 p.m., nursing assistant (NA-B) stated they looked at the care plan to see how to care for residents, but they also got updates in shift report. NA-B stated they believed R39's chair was supposed to be unplugged every time staff left the room. During an interview on 6/4/26 at 12:23 p.m., NA-A stated they were not certain if anything special was supposed to be done with R39's chair or if it was in the care plan. Usually if they had questions about care, they asked the nurse. They also got information about residents during report at the start of their shift. During an interview on 6/4/26 at 12:48 p.m., registered nurse (RN-B) stated R39's chair was okay to keep plugged in. From what they knew in that moment R39's chair could stay plugged in so R39 could reposition themselves for comfort and safety. If a resident was unsafe then physical therapy or OT would let nursing know that. During an interview on 6/4/26 at 1:01 p.m., LPN-A stated the assistant director of nursing (ADON) had gone over chair safety with R49. R49 had said they understood the safety risks of being ejected from the chair and had signed an agreement to have the chair unplugged. LPN-A explained cognitively R39 was able to use the remote, but assessments indicated physically R39 did not have the strength to prevent a fall should R39 accidentally put the chair too far into lift mode. R39 was care planned for the chair to be unplugged when staff were not in the room. The chair should not be left plugged in when staff were not in the room. Staff were expected to unplug the chair before they left R39's room. During an interview on 6/4/26 at 1:28 p.m., LPN-A exited R39's room and stated the chair had been unplugged. During an interview on 6/4/26 at 1:30 p.m., the occupational therapist (OT-A) stated when they went into R39's room to do R39's treatment today R39's chair had been plugged in. They had unplugged the chair and then followed up with nursing staff to let them know R39's chair needed to be unplugged for safety. During an interview on 6/4/26 at 1:36 p.m., the director of nursing DON stated in addition to shift report, staff were expected to look at the dashboard in PCC (the electronic medical record) and the kardex. The dashboard alerted staff to care changes. The DON expected nurses to follow R39's care plans. R39's chair should only be plugged in when staff were present and assisting R39 to safely use the chair remote features. Otherwise for safety staff should be making sure R39's chair was unplugged before leaving the room. The facility policy Fall Prevention and Management indicated the purpose of the policy was to assess each resident and identify interventions to assist in preventing falls. The resident signed document regarding safety and agreement to have recliner unplugged when staff were not in the room was requested but not received.

Based on observation, interview, and record review, the facility failed to ensure infection prevention measures were followed as care planned for 1 of 2 residents (R39) who had a indwelling catheter. Findings include:R39's admission Minimum Data Set (MDS) dated [DATE], was in progress and ready for export. The cognition assessment indicated R39 was cognitively intact.R39's Facesheet dated 6/4/26, included diagnoses of diabetes, lymphedema, muscle weakness, and urinary retention.R39's care plan initiated 5/18/26, indicated R39 had an indwelling foley catheter related to urinary retention. 5/18/26, goals included R39 will show no signs or symptoms of urinary infection. Interventions for the catheter initiated 5/18/26, instructed staff to keep R39's catheter bag off the floor.During an observation on 6/1/26 at 3:30 p.m., R39 was seated in a recliner chair with legs partially elevated on the footrest. R39's catheter drainage bag was hanging off the side pocket of the chair on R39's right side facing the door. The bottom of the bag was in direct contact with the floor.During observations on 6/2/26:-at 1:30 p.m., R39 was seated in their recliner with their catheter bag hooked on the side pocket of the recliner facing the door. The catheter bag was touching the floor. A staff member was in the room applying lotion to R39's legs.-at 2:43 p.m., R39 was seated in recliner. Catheter bag remained attached to side of chair with the catheter bag resting directly on the floor.During an observation on 6/3/26 at 8:51 a.m., R39 was seated in their recliner. R39's catheter bag was hanging on the right-side pocket of R39's recliner. The bottom of the bag was resting on the floor.During an observation on 6/3/26 at 1:43 p.m., R39 was seated in recliner in room. The catheter bag was attached to the right-side chair pocket and in direct contact with the floor.During an interview on 6/3/26 at 1:45 p.m., nursing assistant (NA-A) stated they thought catheter bags should probably not touch the floor, and they knew for sure it was important for the catheter bag to be low so it could drain downhill.During an observation on 6/3/26 at 1:55 p.m., the assistant director of nursing (ADON) confirmed R39's foley bag was touching the floor. The ADON stated the bag should not be touching the floor because of the risk for contamination and infection.During interview on 6/3/26 at 2:19 p.m., licensed practical nurse LPN-A stated R39's catheter should not be hanging in a manner that allowed it to touch the floor. LPN-A entered R39's room. R39's catheter bag was hanging on the side of R39's garbage can not touch the floor. LPN-A removed the catheter bag from the garbage bag, placed a sanitized bin on the floor next to R39's recliner, and hung the bag on the side of the recliner so the bag sat in the bin instead of on the floor. After exiting the room LPN-A explained the catheter bag should not be hung on the side of the garbage can or come in contact with the floor because it created a risk for bag contamination and infection for the resident.During an observation on 6/3/26 at 4:11 p.m., R39 was seated in their recliner. Their catheter bag was hanging on the side of the recliner with the bottom of the catheter bag resting in a bin.During an observation on 6/4/26 at 7:33 a.m., R39 was seated in their recliner. R39's catheter bag was sitting inside the side pocket of R39's recliner. During an observation on 6/4/26 at 10:49 a.m., R39 was wearing shorts and was seated in their recliner. Staff was in the room. R39's foley bag was tucked inside the side pocket of their recliner.During an observation on 6/4/26 at 11:36 a.m., R39's catheter bag was tucked into the pocket of their recliner. The tubing tube was filled with clear yellow urine from the drainage bag up to the bottom edge of R39's shorts.During an interview on 6/4/26 at 12:20 p.m., NA-B stated they looked at the care plan to see how to care for residents, but they also got updates in shift report. Cather bags should be hung for good drainage and should not come in contact with the floor for infection prevention reasons.During an interview on 6/4/26 at 12:48 p.m., registered nurse (RN-B) stated catheter bags should not touch the floor for infection prevention reasons.During an interview on 6/4/26 at 1:01 p.m., LPN-A stated R39's care plan had been updated, and staff were to put R39's catheter bag into a clean bin on the floor when R39 was in their recliner to prevent contamination and promote drainage. The bag should not be hung on the side of the recliner or placed in the side pocket of the chair due to risk for back flow and contamination of the bag. Both back flow of urine and contamination of the bag could lead to an infection and or even sepsis. LPN-A stated they would follow up with some staff education. They expected staff to follow the care plan and read the system alerts that went out to staff anytime an update or change was made to the resident plan of care.On 6/4/26 at 1:28 p.m., LPN-A exited R39's room and stated they had removed R39's catheter bag from the chair pocked and hooked it on the chair so the bag sat in a clean bin.During an interview on 6/4/26 at 1:36 p.m., the director of nursing (DON) stated foley catheter drainage bags should be hung lower than the body in a manner to prevent back flow. The drainage bag and tubing should not come in contact with the floor or other potentially unclean surfaces. These measures were important to follow to help prevent infection.Policies pertaining to catheter care were requested but not received.

Based on interview and document review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) to 2 of 3 residents (R10, R37) reviewed whose Medicare Part A coverage ended and remained in the facility. Findings included: R10's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage form (SNF ABN, CMS-10055), dated 3/10/25, identified on 3/13/25, estimated a daily rate of $515,44 would be charged and not covered by Medicare-A. R10's medical record lacked indication CMS-10123 was provided to the resident at least 48 hours prior to stoppage of Medicare part A. R10's census list dated 5/15/25, identified R10 remained a resident of the facility after 3/13/25, but not on Medicare part A as payer source. R37's Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage form (SNF ABN, CMS-10055), dated 11/25/24, identified on 11/28/24, an estimated daily rate of $500.00 would be charged and not covered by Medicare-A. R37's medical record lacked indication CMS-10123 was provided to the resident at least 48 hours prior to stoppage of Medicare part A. R37's census list dated 5/15/25, identified R10 remained a resident of the facility after 11/28/24, but not on Medicare part A as payer source. During an interview on 5/14/25 at 9:36 a.m., registered nurse (RN)-A stated she was responsible for providing the resident with the NOMNC and the SNF ABN forms when Medicare part A stopped coverage. RN-A stated the NOMNC was provided to the resident when they were discharged from the facility and the SNF ABN form was provided to the resident when Medicare part A coverage stopped but the resident stayed in the facility. The NOMNC was not provided to the residents that stayed in the facility after Medicare part A coverage stopped and they still stayed in the facility. During an interview on 5/14/25 at 9:49 a.m. the administrator and the regional director of operations (RDO) stated they were not aware both CMS-10123 and CMS-10055 had to be given to the resident when they were discharged from Medicare A but remained in the facility. Facility policy Medicare Denial Procedure last reviewed 2/27/24 indicated the Medicare Denial Notice would be delivered no later than 48 hours prior to discharge from services and far enough in advance to allow the Medicare beneficiary sufficient time to consider their options and make an informed choice regarding their right to appeal the decision that Medicare will not cover specific services. If the beneficiary will continue to stay in the care center, the facility would provide CMS-10055.

Based on interview and document review the facility failed to enter and follow provider orders for 1 of 1 resident (R9) reviewed for provider orders. Findings included: R9's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R9 was cognitively intact and diagnoses included coronary artery disease, heart failure, and hypertension. Medications taken daily included a diuretic (water removing pill). R9's admission orders dated 4/17/25, indicated daily weights and to notify the provider for a 2-pound (lb.) weight gain in 24 hours or a 5 lb. weight gain in 7 days. R9's active Order Summary Report dated 5/13/25 lacked an order for daily weights or to call the provider based on weight gain parameters specified in the orders. During an interview on 5/13/25 at 1:18 p.m., nurse assistant (NA)-A stated all residents with daily weights were done by the NA and then given to the nurse to review. NA-A looked at her list and stated R9 was not a daily weight. During an interview 5/13/25 registered nurse (RN)-A stated the nurse manager entered all admission orders into R9's electronic medical record (EMR) at time of admission. The charge nurse would review that all orders were entered correctly and a third nurse would then triple check all orders were entered correctly. All three staff members would sign a form which indicated the checks were performed. During an interview on 5/15/25 at 9:34 a.m., register nurse (RN)-B confirmed admission orders were entered by the nurse manager at time of admission, the charge nurse then did a double check, and finally the next shift RN would do a triple check all orders were entered correctly. RN-B reviewed R9's medical record and confirmed there were no orders for daily weights entered or parameters to notify the provider related to weight gains. During an interview on 5/15/25 at 11:04 a.m., the director of nursing (DON) stated an expectation all orders would be entered at the time they are ordered, both completely and correctly. Facility physician order policy was requested but not provided.

Based on interview and document review the facility failed to ensure ordered as needed (PRN) antipsychotic medications were limited to a 14-day time period and a face-to-face provider visit with clinical documentation indicating the medication needed to remain was performed prior to the medication extended past the 14 day period. The facility also failed to document behaviors and non-pharmacological interventions utilized prior to usage of an antipsychotic for 1 of 5 (R39) residents reviewed for unnecessary medications. Findings include: R39's admission Minimum Data Set (MDS) assessment dated [DATE], identified R39 had significant cognitive impairment. Diagnoses included hypertension and dementia. Medications received included an antipsychotic. R39's active Order Summary Report dated 5/15/25, indicated Quetiapine Fumarate (an antipsychotic medication used for mental health behaviors) 25mg by mouth every 8 hours PRN for agitation, anxiety, or delusion was ordered on 4/17/25. The order lacked a 14 day stop date. R39's Medication Administration Report (MAR) for 4/25 and 5/25 were reviewed. R39 reviewed the antipsychotic medication was administered on 4/20/25 at 9:30 p.m., 4/23/25 at 8:45 a.m., 5/6/25 at 5:58 p.m., and 5/7/25 at 2:30 p.m. R39's nursing progress notes were reviewed for 4/25, and 5/25, and lacked documentation of any behaviors other than wandering the hallways and wandering into resident rooms. The progress notes also lacked behaviors that occurred or non-pharmacological interventions that were attempted before medication was given for each incident the antipsychotic was administered in April and May of 2025. R39's provider visit note dated 5/8/25, indicated a diagnosis of dementia and hallucinations. The record also indicated R39 did not have behavioral disturbances and had remained stable mentally. Per staff and provider assessment today R39 appeared to have adjusted well to the new environment and was pleasantly confused. During an interview on 5/15/25 at 7:41 a.m., nurse assistant/ trained medication assistant (TMA)-A stated if a resident needed any kind of as needed medication administered the nurse would need to be notified because assessments needed to be performed and documented prior to medications being given. TMA-A stated R39 never had any behaviors except for wandering in the hallways and occasionally into a different resident room. R39 was pleasant and always very easy to redirect when he wandered into a different resident room. During an interview on 5/15/25 at 9:34 a.m. registered nurse (RN)-B stated if a PRN antipsychotic medication was needed to be administered then the nurse would assess the resident to see what behaviors had occurred and what non-pharmacological interventions had been attempted prior to the request for the medication. That would be documented in the resident's nursing progress notes as well as the response to the medication after it was given. RN-B stated she had never given R39 any PRN antipsychotic because she was not aware R39 had any true behaviors that would warrant an antipsychotic. RN-B was unsure how long a PRN antipsychotic order was good for. During an interview on 5/25/25 at 11:04 a.m., the director of nursing stated a PRN antipsychotic medication order was only good for 14 days, then needed to have the provider see the resident before it could be renewed. Wandering was not a reason to give an antipsychotic medication. The DON stated an expectation that all staff would utilize a PRN antipsychotic only when necessary and only after nonpharmacological interventions were attempted first. All behaviors and interventions would need to be documented in the progress notes. Facility policy Psychotropic Medications last issued 8/20/24, indicated PRN psychotropic medications ordered would be limited to 14 days. The prescribing practitioner would evaluate and document the medications necessity, benefits, and improvement (expressions, indications of distress). If the physician deemed appropriate to extend beyond the 14-day limit, supporting rationale must be documented. The policy also indicated all nursing staff would utilize PRN psychotropic medication, following provider order, if non-pharmacological intervention(s) are unsuccessful.

Based on observation, interview and document review the facility failed to follow grievance policy and procedures involving 2 of 2 residents (R1, R2) when R1 voiced concerns about treatment received from another resident (R2) in the facility and a grievance was never filed on behalf of R1, and he was never provided resolution or follow up. Findings include: R1's admission Record indicated he admitted to the facility on [DATE]. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's care plan dated 4/10/25, indicated he was alert and oriented and was able to express his needs. R2's quarterly MDS dated [DATE], indicated a Brief Interview of Mental Status (BIMS) of 8 (moderate cognitive impairment), verbal behaviors directed toward others (threatening, screaming, cursing) 1-3 days. During interview on 4/29/25 at 4:21 p.m., R1 stated R2 intentionally antagonized him and said, I want it to stop. R1 said R2 approached him and and said things like, hit me, hit me. R1 stated he was not afraid or threatened by R2 but said he did not feel like he should have to put up with it. During observation on 4/29/25 at 4:31 p.m., R1 was seated in the dining room. R2 propelled himself into the room and stated, he's trouble, referring to R1. Staff intervened and R2 responded with loud negative vocalizations. During interview on 4/30/25 at 9:25 a.m., R1 stated he had reported his concerns to the social service designee (SSD) and registered nurse (RN)-A. R1 said they told him they would look into it but said they do not follow up with him. R1 said R2's behavior was outrageous and said, he just keeps coming at you. During interview on 4/30/25 at 9:36 a.m., nursing assistant (NA)-A said R2 would yell and swear if he did not like something. NA-A said the previous week R2 had been unhappy with R1 and had made threatening comments to him. NA-A said R1 was not fearful of R2 but R1 did not like the way R2 treated himself and others. During interview on 4/30/25 at 11:16 a.m., The SSD said R2 made rude comments to many residents. The SSD said R1 did not like R2 and had voiced his concerns to her. When asked how the facility was handling R1's concerns, the SSD said they gave R1 the option to leave the room. The SSD stated she had not followed up with R1 and said his concerns had been discussed with the interdisciplinary team but no one had ever advised her to fill out a grievance form. The SSD said she had conversations with R1 but did not document them. During interview on 4/30/25 at 11:46 a.m., RN-A said R2 was like a playground bully. RN-A said R1 seemed to be R2's primary target and said R2 taunted R1 and would curse at him. During interview on 4/30/25 at 1:07 p.m., the assistant administrator said a grievance should be filed anytime a concern was brought by a resident or family. The assistant administrator said the facility would review the concern and follow up. The assistant administrator said she had been aware of many instances involving R1 and R2. Facility policy Reporting Grievance dated 1/9/17, indicated grievances included those regarding care or treatment, the behavior of staff or other individuals receiving services and other concerns regarding a residents stay. If a grievance was voiced by an individual the facility will make prompt efforts to investigate and resolve the grievance. The grievance will be documented on the grievance for and will be investigated within 72 hours. Within 10 days of filing the grievance the findings will be provided to the complainant in writing.

Based on observation, interview and document review the facility failed to reduce the risk of falls for 1 of 3 residents (R3) reviewed for accidents and supervisor. R3 had a high risk for falls and was observed attempting to self-transfer from a wheelchair to bed. Findings include: During continuous observation on 3/19/25, R3 was seated in the dining room with his eyes closed at 6:45 a.m., where he remained until 7:47 a.m., when he propelled himself down the hall toward his room. Staff spoke with R3 on his way down the hall. At 7:51 a.m. R3 was observed propelling from his room. At 7:47 a.m. R3 told NA-B, I want to go to sleep but they keep kicking me out. NA-B said, they kicked you out, huh. then walked away. At 8:02 a.m. a staff member moved R3 to a table in the common area where he sat with a book. At 8:25 a.m. R3 remained seated in his wheelchair with his eyes closed. At 9:12 a.m. R3 again propelled himself toward his room. At 9:18 a.m., R3 got the door to his room open, and a housekeeper moved him back into the hallway. At 9:30 a.m., the housekeeper told R3 he had to wait for the NA's and said they could not take him to the bathroom because they were a little busy. At 9:32 a.m., R3 again entered his room. Surveyor alerted trained medication aide (TMA)-A that R3 was attempting to self-transfer to his bed. TMA-A intervened and told R3 he needed to wait for a NA to come off break and one to finish charting before they could help him into bed. At 9:40 a.m. NA-B was observed in the common area. TMA-A did not report that R3 had requested help. At 9:49 a.m. NA-A returned to the unit. At 9:51 a.m. R3 was talking to TMA-A who did not acknowledge him. R3 propelled himself toward his room. TMA-A then asked NA-A and NA-B to assist R3 to lay down. NA-B stated, We aren't supposed to, are we? and NA-A said, they want him up until after dinner. At 9:56 a.m., NA-A and NA-B assisted R3 to his room. NA-A said R3 had been up since she arrived at 6:00 a.m. NA-A and NA-B assisted R3 in the mechanical stand and transferred him to his bed and covered him with blankets. When asked about toileting, NA-A said R3 would tell them if he needed to go and said, sometimes they offer. NA-A and NA-B checked R3's brief and changed it after they determined he was wet. While charting R3's brief, NA-A stated R3 did not like to roll and said, believe it or not, he is terrified of falling out of bed. NA-B stated R3's wife wanted staff to keep him up during the day because of falls. NA-B said if laid down, R3 would try to crawl out of bed. R3's Admission Record indicated he admitted to the facility on [DATE]. Diagnosis included hemiplegia (severe or complete unilateral loss of strength or paralysis) and hemiparesis (weakness in one leg, arm, or side of the face) and vascular dementia. R3's Fall Risk assessment dated [DATE], indicated he had a fall on 1/27/25. Continence and mobility indicated R3 required assistance with elimination, was confined to a chair and was only able to steady himself with assistance. R3's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R3 displayed no behaviors, was frequently incontinent of bladder and always continent of bowel. R3's MDS indicated he was dependent on staff for transfers and toileting. R3's care area assessment (CAA), dated 2/4/25, indicated he was continent of bowel, frequently incontinence of bladder and needed assistance with cares. R3 had a diagnosis of vascular dementia, peripheral vascular disease, benign prostatic hyperplasia, and hemiplegia/hemiparesis of left side. The fall CAA indicated R3 needed extensive assistance with activities of daily living, scored 16 on the fall risk assessment indicating a high risk for falls and had one fall since admission to the facility. R3's care plan dated 2/28/25, identified bladder incontinence related to confusion and impaired mobility. The care plan directed staff to change R3 as needed. The care plan identified a risk for falls related to confusion and poor communication. The care plan directed staff to assist as needed with mobility and transfers, ensure call light was within reach, appropriate footwear, and bed in lowest position with a fall mat beside the bed. The care plan indicated R3 liked to get out of bed and crawl. R3's Kardex Report dated 3/18/25, indicated Bladder/Bowel, change and PRN (as needed). Safety, ensure call light in reach, bed in low position with fall mats. I prefer to get out of bed and crawl. Facility Resident Incident Log dated 1/20/25 through 2/26/25, indicated R3 had one fall on 1/27/25. R3's Progress Notes identified the following: 1/26/25, Nursing assistant (NA) entered the tub room and found R3 had transferred himself onto the toilet. Staff assisted R3 and reminded him to call for help as he required assistance to transfer. 1/27/25, Staff heard a banging noise and found R3 on the floor in his room. R3 was laying with his feet toward the bathroom door. A correlating Incident Form dated 1/27/25, indicated interdisciplinary team (IDT) reviewed the incident and recommended R3 be placed on every two-hour toileting plan. 1/31/25, R3 self-transferred into bed from his wheelchair. R3 had two episodes of putting himself on the floor and told staff I just roll over and this is where I end up. The note indicated was a purposeful act. 2/18/25, R3 was found attempting to crawl out of bed. R3 had his body scooted down with his knees on the fall mat. 2/25/25, R3 attempted to crawl out of bed this shift. 2/26/25, R3 was found attempting to self-transfer out of bed. NA found R3 with both legs on the fall mat and the top half of his body on the bed. R3 was reminded to use the call light. 2/28/25, R3 attempted to crawl out of bed. Upper body on bed with legs on fall mat. 3/7/25 at 3:00 p.m., NA reported when passing by R3's room he was crawling out of bed a kneeling on the floor mat in front of his bed. R3's hands were on the bed when she found him. Root cause indicated, it appeared R3 was crawling out of bed. A correlating Incident Audit Report dated 3/11/25, indicated R3 stated he wanted to get out of bed. The IDT review determined R3 was care planned to be able to get out of bed to his mat and indicated the incident was intentional and not a fall. 3/7/25 at 9:00 p.m., R3 was heard yelling from his room. R3 was found sitting on his fall mat. R3 was unable to describe what he was doing at the time and had been incontinent of bladder. 3/8/25, R3 found seated on his fall mat with his back against the bed around midnight. R3 had stool on his hands, urinal, and mat. Root cause indicated, possibly needed to use the bathroom. During interview on 3/18/25 at 4:04 p.m. NA-A stated R3 liked to sneak into his room and transfer himself in and out of bed. NA-A stated R3 transferred with staff using a mechanical stand. NA-A said she had not seen R3 try to self-transfer but said she had found him on the ground. When asked about fall interventions, NA-A stated, I wouldn't know. NA-A said staff used the Kardex for a care guide. During interview on 3/19/25 at 10:06 a.m., registered nurse (RN)-A stated R3 should be checked every two hours and said it should have been in his care plan. RN-B stated she thought R3 could verbalize the need to use the toilet, but not consistently. RN-A stated they had R3 on a two-hour toileting plan to try to catch him but said on the off hours staff would find him on the mat. RN-A said R3 could not be left alone in his room because he did not use the call light. RN-A stated when R3 had been at home he would crawl to the bathroom when he needed to go. RN-A stated initially when R3 rolled out of bed they were calling it a fall and said there had been no instances of rolling out of bed in the medical record, just crawling out of bed and kneeling on the mat. RN- A was unable to explain how staff assessed whether R3 rolled out of bed or was intentionally crawling out of bed. On 3/19/25 at 11:57 a.m. R3 was interviewed with family member (FM)-A. FM-A stated R3 had fallen and broke his hip and went to a different facility for rehab. FM-A stated R3 returned home after rehab but only lasted two days because she could not care for him. FM-A stated prior to the fall with fracture, R3 did not really have falls at home. FM-A said, I guess he crawled on the floor at the previous facility and was told he did that here at the facility. FM-A said R3 did not do that at home. FM-A said she felt a big part of R3's falls was when he needed to go to the bathroom. FM-A said the staff had not really implemented a plan. FM-A said they had discussed toileting R3 at 10:30 a.m. since he always wanted to go when staff were trying to bring others to lunch but said it had not happened. During interview on 3/19/25 at 12:50 p.m., the director of nursing (DON) stated after a fall, the IDT reviewed and said they had a list of suggestions they used for fall interventions. The DON said she thought R3 was on a two-hour toileting plan and said the previous day, RN-A had discussed it with staff. At 1:07 p.m. the DON stated when R3 was seen on the floor it was not considered a fall and said it had been the nurse practitioners idea. The DON stated she was unable to provide evidence of assessment to indicate R3 was on the floor intentionally versus falling out of bed. Facility Policy Fall Prevention and Management dated 6/5/23, indicated the care center will assess each resident for risk of falls and identify interventions to assist in preventing falls and/or injuries. A falls analysis will be completed when a resident had two or more falls, to review fall trends, identify individual and systemic causes of falls, evaluate current interventions for effectiveness and if needed to determine additional interventions. All interventions that are identified through the assessment/review process will be documented in the resident's care plan using person centered language.

Based on interview and document review, the facility failed to supervise, implement, and assess fall interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a laceration to the middle of her forehead which required an emergency department (ED) visit and sutures. Findings include: R1's Face Sheet dated 4/29/24, indicated R1 had arthritis in both hips, spinal stenosis (abnormal narrowing of the spinal canal), and mild cognitive impairment. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had mild impaired cognition, had two or more falls without injury and one fall with minor injury, and needed extensive assistance with transfers, toileting and bed mobility. R1's Fall Risk assessment dated [DATE] indicated R1 had three or more falls in the last 90 days, was confined to her chair, needed assistance with elimination, and not steady on her feet without assistance. R1's score was 20 (a score of 10 or higher put the resident at risk for falls). R1's care plan dated 10/2/24, identified R1 was at risk for falls due to cognitive impairment. An intervention directed staff would not leave R1 in her wheelchair in her room alone. R1 would stay in a common area if she did not want to sit in her recliner after meals or activities. Additional interventions identified encouraging R1 to wear glasses, wear good footwear, and to use a reacher when grabbing items out of reach. R1's Emergency Department (ED) Provider Encounter note dated 11/18/24, indicated R1 had a large laceration in the middle of her forehead that needed 15 sutures to close. On 11/19/24 at 12:51 a.m., a progress note written by registered nurse (RN)-A indicated on 11/18/24 at around 6:14 p.m., R1 was found in her room on the floor in front of her closet, yelling for help. R1's wheelchair was behind her. R1 was bleeding from her forehead, she was assessed and sent to the ED. A facility communication book was located on each unit (Garden Terrace and Town Square) and in the administration office. The front of the book indicated staff were to review the book at the start of the shift, and staff were to sign after reading the new information. The Garden Terrace communication book had eleven updates from 11/4/24 to 12/11/24, with three staff signatures total. The Garden Terrace communication book lacked updates pertaining to R1 and her fall on 11/18/24. The Town Square communication book had eleven updates from 11/4/24 to 12/11/24, with two staff signatures on several pages. The Town Square communication book lacked updates pertaining to R1 and her fall on 11/18/24. The administration office communication book had ten updates from 11/4/24 to 12/11/24 with three staff signatures on one page. An update to the administration office communication book dated 11/19/24 indicated R1 could not be left alone in her room in her wheelchair. There were no other changes to R1's fall risk interventions in the administration office communication book. On 12/11/24 at 12:19 p.m., nursing assistant (NA)-A stated she was an agency staff member on 11/18/24. After dinner, she went into R1's room and asked if she wanted to go to bed and R1 declined. She left R1 in her wheelchair in her room alone. She was not aware R1 was not supposed to be left alone in her room while she was in her wheelchair until after she fell the evening of 11/18/24. She has been directed to look in the communication book for any changes in interventions for residents, but she could not recall the last time she looked in the communication book. She had access to document in R1's electronic medical record (EMR), but was not given access to review R1's care plan and interventions. On 12/12/24 at 10:54 a.m., RN-B stated the facility did not have a good way to communicate with agency staff. The facility had relied on word of mouth, but this was not working. The facility had a communication book for any changes in interventions or other updates on residents. Staff were to read and sign when they come into work. RN-B stated she was not sure who was responsible for ensuring the communication book had been read by staff, and she was not sure why the communication book was not being signed by staff. There was a hole in the process that had not been fixed. On 12/12/24 at 11:01 a.m., RN-A stated on 11/18/24 at around 6:14 p.m., she was getting report from another staff member when she heard someone yelling. She went into R1's room and saw R1 on the floor in front of her closet. R1's wheelchair was behind her, and she was bleeding from her head. R1 had been left alone in her room in her wheelchair, and shouldn't have been. She assessed R1 and sent her into the ED due to R1's forehead laceration. On 12/12/24 at 11:19 a.m., the director of nursing (DON) stated agency staff had access to document in the resident's EMRs, but were not able to review resident care plans or interventions. The EMR had a care stream section that showed activity of daily living (ADL) needs, but it would have been a hit or miss if fall interventions were in the care stream for staff to see. Staff should look in the communication book for any interventions or changes to resident care. The nurse managers were responsible for making sure staff were looking at the communication books and signing them. She was not sure why staff were not looking at the communication book. On 12/12/24 at 11:57 a.m., physician's assistant (PA)-A stated she was aware R1 had a fall, but was not aware staff were not following the care plan. It was possible if the care plan had been followed, R1 would not have fallen. R1 had been was declining prior to the fall, but after the fall on 11/18/24, R1 had a more rapid decline, and was more confused and agitated. The facility Fall Prevention and Management policy dated 2/15/24, directed there will be interventions implemented to minimize future falls.

Based on interview and document review, the facility failed to ensure treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed who did not receive the necessary care and monitoring related to multiple incorrect insertion attempts of an indwelling catheter which resulted in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, leading to a diagnosis of sepsis and admission to the Intensive Care Unit (ICU) via ambulance. This resulted in actual harm for R1. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. MDS indicated R1 had an indwelling catheter, always incontinent of bowel, and neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). MDS also indicated R1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's health conditions form dated 6/2/24, to 7/2/24, were identified as anemia, benign prostatic hyperplasia (enlargement of the prostate) (BPH) with lower urinary tract symptoms, hemiplegia and hemiparesis (weakness and/or paralysis on one side of the body) following cerebral infarction (stroke) affected left non-dominant side, neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well. As a result, the bladder may not fill or empty correctly), and dementia. R1's care plan (CP) dated 7/10/24, identified risk for bleeding due to anticoagulant (blood thinner) use, directed staff to monitor vitals and for bleeding, and contact provider with changes and update as needed. CP identified R1 was at risk for urinary tract infection (UTI) due to indwelling catheter and directed staff to observe and monitor for signs of infection and urine quality changes (change in urine color/sediment). R1 had an indwelling Foley catheter 14 F (French) 10 cc (cubic centimeters), and directed staff to document urine output at the end of every shift. R1's physician order dated 6/21/24, identified change 14 F catheter with 10 cc every 28 days at evening 2 p.m. to 10:30 p.m. once a month and change the bag at the same time. R1's physician order dated 6/21/24, identified empty catheter bag and document output three times day (morning 6:00 a.m. to 2:30 p.m., evening 2:00 p.m. to 10:30 p.m., night 10:00 p.m. to 6:30 a.m.). R1's House Standing Orders signed and dated 2/29/24, identified may irrigate catheter with 30 to 60 ml (milliliters) of sterile normal saline with signs of blockage (clots, no urine flow or bypassing around catheter). Change indwelling catheter PRN (as needed) if becomes obstructed or comes out of bladder. R1's electronic medication administration record (EMAR) from 6/29/24, through 7/2/24, identified: -6/29/34, urine output evening shift 2:00 p.m. to 10:30 p.m. 150 ml; EMAR lacked documentation for morning or night shift output. -6/30/23, urine output evening shift 2:00 p.m. to 10:30 p.m. 600 ml; EMAR lacked documentation for morning or night shift output. -7/1/24, urine output 6:00 a.m. to 2:35 p.m. 450 ml, 2:00 p.m. to 10:30 p.m. 300 ml, and 10:00 p.m. to 6:30 am. 0 ml. -7/1/24, Acetaminophen oral tablet 500 mg (milligrams) 2 tablets by mouth as needed one time per day was documented as administered at 9:30 p.m., not effective. -7/1/24, 2:00 p.m. to 10:30 p.m. blood pressure (BP) 97/57 mmHg (millimeters of mercury) and the only blood pressure documented in R1's EMAR. -7/1/24, evening shift 2:00 p.m. to 10:30 p.m. change 14 F catheter with 10 cc balloon every 28 days (once a month). R1's progress notes from 6/28/24, through 7/5/24, identified: -6/28/24, at 12:07 a.m. to 7/2/24, at 12:15 a.m. no documentation noted in R1's medical record (four days). -7/2/24, at 12:15 a.m. 14 F was inserted at 9:20 p.m. and tolerated well. Later at 11:15 p.m. resident woke up screaming ouch and in pain. Irrigation, repositioning, and massage of bladder done but no urine output and still in a lot of pain. Small amount of thick blood and clots in bag and bloody urine bypassing. On call notified and she said to call on call provider if pain increased. -7/2/24, at 12:15 p.m. From report the evening nurse changed resident catheter with a 14 F (per interview with LPN-A this was a 16 F see below) and then a 16 F with blood output. At 8:30 p.m. writer was called to R1's room, screaming in pain, and guarded his groin area whenever staff tried to reach for that area. R1 refused to have brief closed due to increased pain, bladder scanned for 216 cc. On call nurse was notified and suggested flush/irrigate catheter, push fluids and change catheter to 14 F. When catheter was flushed there was increased pain and no output. Removed 16 F and noted continuous gross hematuria (bleeding) with some blood clots from penis. On call was notified and she said to let him drain for 15 minutes then insert a 14 F. After 15 minutes the gross hematuria was minimum and R1 felt better with less pain. -7/2/24, at 5:09 a.m. R1 was screaming, reported a lot of pain (10 out of 10) when his brief was changed around 3:30 a.m. R1's vitals blood pressure (BP) 90/53, respirations 18, and oxygen saturation 92%. Bladder scan completed and resulted in 249 cc with no urine in output in bag. On call provider notified and gave order to send to emergency room (ER) at 4:30 a.m. -7/2/24, at 10:01 a.m. received call from local hospital, R1 had been admitted with diagnosis of sepsis. R1's family updated and placed on LOA (leave of absence). -7/4/24, at 5:53 p.m. called hospital for update. R1 was moved out of ICU (intensive care unit) and downgraded to medical unit, off drip and BP was ok, and placed on two antibiotics. Possibly be there for two more days. -7/5/24, at 2:13 p.m. was readmitted back to facility from hospital at 1:30 p.m. R1 had indwelling catheter in place that was free flowing, patent, urine was light yellow in color, without sediment, no blood no unusual odor. R1's catheter was to be changed every 28 days, if anticipated difficulty with catheter contact urology. Continued to be treated with antibiotics for UTI every 12 hours for 11 more days. R1's hospital admission notes dated 7/2/24, indicated indwelling catheter change completed at nursing home facility last evening resulted in significant bleeding and no urine output. An attempted catheter placement in ER resulted in ongoing bleeding and no urine output. CT (computerized tomography) scan was completed and showed catheter balloon inflated in the urethra. Urology was contacted and replaced the catheter over a guidewire with cystoscopy (a hollow tube equipped with a lens inserted into urethra and slowly advanced into the bladder). Principle problems identified: urinary tract infection associated to indwelling catheter, sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), with acute renal failure and septic shock, and anemia with acute blood loss from urethra resulting from Foley catheter placement. R1's lab results dated 7/2/24, urine collected at 9:14 a.m. revealed: urine was amber colored, turbid (cloudy), trace of ketones, large amount of blood, severely increased protein levels (indicates problems with the kidneys), positive nitrate (most likely indicates a bacterial infection in the bladder), and a small number of leukocytes (white blood cells). R1's Complete Blood Count (CBC) dated 7/2/24, identified hemoglobin low 10.7 g/dl (grams/Deciliter) (normal range 13.5 to 17.5. g/dl). R1's CT scan of abdomen pelvis dated 7/2/24, at 6:32 a.m. identified indication: gross hematuria and decreased urine output, sepsis. Impression: malposition Foley catheter with balloon inflated with in the penile urethra. Only mild urinary bladder distension. During an interview on 7/8/24, at 4:00 p.m. licensed practical nurse (LPN)-A stated R1 was due for a catheter change on July 1, 2024. LPN-A stated she had gathered supplies: catheter size 16 F, catheter bag, catheter change kit, and an extra syringe. LPN-A indicated pulled out R1's catheter 14 F after deflating balloon and noted urine was dark amber, cloudy, and sediment in the tubing without odor. LPN-A stated emptied 450 cc of urine from collection bag. LPN-A stated when she inserted the 16 F catheter bright red blood was seen, panicked, and pulled out the catheter. LPN-A stated talked with floor manager LPN-B and informed was normal for R1 to bleed a bit and instructed to insert another catheter. LPN-A stated went back and inserted 16 F catheter and bloody return was noted with a small amount of urine. LPN-A stated she had went to the EMAR and noted the order indicated 14 F, it was then she realized she had inserted the wrong size catheter twice. LPN-A stated she reported to LPN-B and DON and was told it was fine and instructed to let things settle down/stop bleeding before the catheter was changed again. LPN-A stated checked on R1 prior to end of shift and no pain, no urine was flowing out of the tube and offered to flush but RN-A said no it was ok and left for the day. LPN-A stated a provider should have been notified about the wrong size catheter (2 times) and blood returned with little to no urine but did not due to LPN-B and DON indicated it was normal for R1 to bleed some. LPN-A stated they did not document this and should have. During a telephone interview on 7/9/24, at 2:00 a.m. registered nurse (RN)-A stated she started her night shift at 6:00 p.m. RN-A indicted she had received report from the LPN-A regarding R1's Foley catheter change. RN-A stated LPN-A indicated she she inserted a 14 F and got blood so removed it, placed another catheter this time a 16 F and was still bleeding when she realized she had used the wrong size catheter. RN-A indicted LPN-A reported to DON and floor manager LPN-B and they both came to conclusion the urethra was already irritated, so it was ok to leave it in until morning, monitor for bleeding, and replace it the next day with a 14 F catheter. RN-A stated she had never seen blood in R1's catheter prior to this day. RN-A stated she peaked in on R1 at 6:30 p.m. prior to a medication pass that evening and there was approximately 100 cc of bloody drainage in the collection bag and in the catheter tubing and R1 reported no pain at that time. RN-A stated she had been told in the past when the catheter was not placed properly due to the BPH and neurogenic bladder a small amount of blood was normal for R1. RN-A stated when she had placed R1's catheter in the past, she had never seen any bleeding. RN-A stated later, a staff nursing assistant came and got her and indicated R1 was in pain. RN-A went to R1's room and he complained of pain and said, ouch ouch. RN-A stated she tried to close his brief, but he would not allow and yelled out. RN-A checked urinary output which had remained the same as earlier (6:30 p.m.) then called the on-call nurse (DON) and was directed to massage the bladder area, push fluids, and then flush the catheter tubing. RN-A stated a provider should have been notified when R1 started to have no urine output with bleeding but she relied on DON for direction instead. RN-A stated DON instructed her the provider did not have to be called because there was nothing he could do and would round the next day. RN-A indicated she was unable to flush the catheter tubing, R1 complained of more pain, then she contacted DON again. RN-A stated DON indicated R1's 16 F catheter should be removed and replaced with a 14 F. RN-A stated she removed the 16 F catheter and R1 had gross hematuria from the penis and replaced it with a 14 F with approximately 80 cc of bloody drainage in bag and allowed more time to see when urine would drain and what color. RN-A stated she had bladder scanned R1 prior to the insertion of the catheter and noted 216 cc. RN-A verified at 11:00 p.m. R1 complained of pain again, but was unable to give more Tylenol. RN-A texted DON and instructed to reposition R1, massage the bladder area and if in one hour still in pain call the on call provider and ask for order to use emergency kit to give a different analgesic. RN-A stated R1 indicated he was ok and then checked on him again at 3:00 a.m. bloody output had remained the same in bag at 50 ml and no urine noted and R1 had started to complain about pain again. RN-A called on call provider and informed them R1 had no urinary output and bladder pain then received order, and sent R1 into the hospital. During an interview on 7/9/24, at 11:00 a.m. hospital physician assistant (PA)-A (provided urological care to patients) verified she was notified about R1's admission to ER and asked to provide assistance with insertion of a catheter. PA-A stated R1 had a large prostate and obstructive urinary symptoms and required the use of a guide wire and cystoscopy (a hollow tube equipped with a lens to view the urethra and bladder) as she inserted the indwelling catheter. PA-A indicated was unable to see if there was a false tract (a false passage in the urethra is formation of an epithelialized tract created when the catheter was inserted aggressively against the urethral wall and/or a weak part of the urethra rather than guided through the urethra lumen, into the bladder, and may occur more often in men due to an enlarge prostate) due to excessive bleeding in the urethra. PA-A stated reinsertion of a catheter had the potential to cause more damage and/or bleeding. PA verified when staff nurse inserted the catheter, got blood return a provider should have been notified right away and not waited. PA-A stated additionally, no urine output for up to 12 hours can cause increased risk for infection due to stagnate urine and possibly go into the kidneys which can be serious. During an interview on 7/9/24, at 11:37 a.m. primary provider/physician assistant (PA)-B stated R1 had no urine output from 9 p.m. until sent to ER (7 hours). PA-B indicated when a nurse lacked skill for catheter insertion they may butt up to the inside of the urethra and felt like it was in the bladder, but no urine appeared. PA-B stated lack of urine would be the most thing to worry about but when catheter was placed incorrectly and in the wrong spot and/or a clot blocked off urine flow that would have been concerning. PA-B stated when R1 was catheterization improperly more than once that increased his risk for urethral damage and increased bleeding. PA-B stated R1's gross hematuria was caused by trauma from cauterization that was for sure and the only thing that made sense. PA-B verified it would have been a good idea to have updated provider after the second time the wrong size catheter was inserted and bleeding continued. PA-B also stated when nurse had contacted the DON 4 to 6 times in a matter of 6 hours she was in over her head, clearly struggled, and required direction from the provider especially when R1 yelled out in pain, increased bleeding, and low urine output. PA-B stated she would have not recommended to change 16 F catheter a 14 F catheter, provider should have been contacted much sooner and R1 most likely sent into hospital earlier. During an interview on 7/9/24, at 12:44 p.m. floor manager (LPN)-B stated R1 has had a history of difficult indwelling catheter attempts with scant amount of blood but would have expected that to stop within an hour. LPN-B stated on 7/1/24, LPN-A informed him she attempted to insert the wrong size catheter 16 French (F) (should have been a 14 F), larger than it should have been, and blood came through the tubing. LPN-B stated the bleeding was caused by insertion of a catheter too large and scraped his urethra (a muscular tube that conveys urine from the urinary bladder to the exterior at the end of the penis). LPN-B stated along with the director of nursing (DON) we had chosen to wait to re-insert another catheter due to urethra being raw, could have caused more damage and discomfort, and allowed that area to recover. LPN-B stated there had been some harm done here, there had been damage to the urethra and R1 bled, required medical intervention, sent to hospital, and admitted . During an interview on 7/9/24, at 2:05 p.m. floor manager registered nurse (RN)-C stated staff had difficulty with catheter placement with R1 in the past with flank blood upon insertion then subsided. RN-C indicated she would have been concerned from the word go when there was more blood than urine that would not be a typical finding after placement of a urinary catheter. RN-C also stated if there was flank blood after insertion of the catheter would have expected it to dissipate and see clean urine within in four hours with at least 50 cc an hour while fluids were pushed also. RN-C stated R1 had an extremely enlarge prostate and therefore made it a more difficult insertion and caused irritation of the urethra which caused bleeding. RN-C verified repeated insertion of a catheter risked irritation to the lining of the urethra, creased an entry of bacteria which increased risk for infection. RN-C stated it was basic nursing education/practice to not inflate balloon until you get urine back. R1's change in condition occurred when he had less than 50 cc of urine out for more than two to three hours and a provider should have been contacted especially when the bleeding should have subsided much sooner. RN-C stated LPN-A placed a larger sized catheter (16 F) rather than 14 F that was ordered and bleeding occurred. RN-C stated LPN-C would be expected to document in the progress notes what transpired from the insertion of the catheters and what was going on during shift change. RN-C stated no follow up had been completed since the incident, no root cause analysis, and had been done or education with the nurses involved. During a telephone interview on 7/10/24, at 8:45 a.m. medical director (MD) stated staff nurses attempted to insert three catheters and the trauma to the urethra most likely was started with the first insertion, when the wrong sized catheter 16 F was used. MD stated a catheter balloon should never be inflated until you get a flow of urine. MD stated would have been important with blood return and no urine a provider should have been notified right away, sent to ER so an evaluation could have been completed at another facility. MD verified when a resident had ongoing bleeding, on an anticoagulant, and bled for more than two hours, would be alarming and something else was going on. MD stated he would have expected more documentation from the nursing especially with low urine output and bleeding, in the medical record, to establish a time-line, and what interventions were tried. During a telephone interview on 7/10/24, at 12:48 p.m. ER supervisor RN-D verified R1 arrived in ER with a 16 F catheter with no urine output and blood in bag. RN-D stated the 16 F was removed and a 5:45 a.m. another catheter was placed by the ER staff with no resistance and into a suspected false tract. RN-D stated if the false tract would have not been there previously before R1 came to ER would have most likely met up with resistance due to R1's BPH but would have then inserted directly into the bladder. RN-D stated urology PA-C was contacted and a catheter was placed with a scope and guide wire into the bladder. During an interview on 7/10/24, at 1:10 p.m. DON stated she had many conversations with both staff nurses starting from 7/1/24, at approximately 4:00 p.m. through 7/5/24, at 11:32 p.m. regarding R1. DON stated last time she had heard from RN-A was at 11:32 p.m. DON stated she arrived at the facility early the next morning on 7/2/24, asked RN-A how R1 was doing and was informed she had sent him to emergency room via ambulance. DON stated she would have expected to be notified R1 was sent to hospital but was not. A vulnerable adult (VA) report was not filed with the State Agency, because the nurses did follow the facility policy, processes, and procedures, except for inserting the wrong catheter size. DON stated because of the long holiday weekend she was not aware until Monday morning (7/6/24), when R1 came back from hospital, and the cat scan (CT) (computer tomography scan) showed R1 had a catheter balloon inflated in the urethra rather than the bladder. DON stated repeated catheter insertion could have raised the risk of complications such as infection and urethral damage/bleeding. DON stated an incident report should have been filed under medication error. DON verified no incident report was filed. DON also verified no investigation was started prior to 7/8/24, when surveyor arrived at their facility and at that time she started reviewing the documents such as medical record and hospital visit notes. DON indicated she had talked to LPN-A on 7/8/24, in the morning after surveyor had already interviewed her and education was completed briefly about lack of documentation, checking doctor's orders more thoroughly prior to changing out of the catheter to ensure the correct size was used. DON stated she had not visited and /or provided RN-A with education since incident. DON also verified there was no internal investigation or root/cause analysis completed within the facility. During a telephone interview on 7/11/24, at 12:00 p.m. emergency care provider, osteopathic doctor (DO) (look at patients as a whole person consisting of a mind, body, and spirit, and tend to focus on preventative medicine) stated the facility inserted a Foley catheter more than once, no urine output and bleeding occurred, clearly it was placed in the wrong spot and not in the bladder. DO stated at that time most likely that was when they started the false tract. DO indicated no urine output was not due to a blood clot because they tried to flush the catheter at the facility, no urine output and only blood. DO stated we removed the Foley catheter once he arrived at ED and inserted a 3 -way catheter without resistance and only a small return of urine. DO stated this indicted there was a false tract prior to his arrival at ED. DO verified the CT scan confirmed the Foley balloon was in the penile urethra therefore suspected R1 had a false tract. DO indicted numerous insertions of a Foley catheter within 10 hours would have caused damage and a false tract when not inserted properly. DO stated the facility continued to re-insert catheters, with no urine out put and bleeding, caused urethra trauma, provider was not contacted right away and should have been, which delayed care and R1 became septic with bacteria in catheter. DO indicated she believed this cause R1 harm. Review of facility policy titled Foley Catheter Insertion, Male Resident dated 2001 identified the purpose of the Foley catheter was to provide for and maintain constant urinary drainage. Verification that there was a physician order was required to identify what size Foley catheter was specified. After preparation insert the catheter gently into the meatus (end of penis) approximately five to seven inches until urine began to flow from the bladder then advance the catheter another two inches and inflate balloon with 5 cc (cubic centimeters) and removed syringe. If resistance met do not force the entry, stop the procedure, and notify supervisor. The physician would be expected to be notified of any abnormalities (i.e. bleeding, obstruction). The following information should be recorded in the resident's medical record: -date and time of procedure -name, title of individual who preformed procedure -all assessment data (e.g. character, color, clarity) obtained during the procedure -the size of the Foley catheter inserted and amount of fluid used to inflate the balloon -how resident tolerated procedure -signature and title of person recording data Facility policy titled Notification of Significant Changes dated 5/2/22, identified policy provided guidance to staff when and who to notify of a significant change in a resident's status. Definition of a significant change meant a change in resident's status, a need to alter treatment, and accident results in injury, or a decision to transfer or discharge the individual receiving services from care center. The charge nurse will immediately (as indicated by the change of condition) informed the resident, consult with the physician, and notify the resident representative for the following significant change: an accident that involved the resident which results in injury and has the potential for required physician intervention, a deterioration in health, in either lift-threatening conditions or clinical complications, and decision to transfer to another provider from the care center without primary physician involvement.

Based on interviews and document review, the facility failed to notify the resident's physician timely with a change in condition for 1 of 3 residents (R1) when staff inserted an indwelling catheter three times, resulted in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, sent to emergency room via ambulance, and developed sepsis, and admitted to intensive care unit. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. MDS indicated R1 had an indwelling catheter, always incontinent of bowel, and neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). MDS also indicated R1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's health conditions form dated 6/2/24, to 7/2/24, were identified as anemia, benign prostatic hyperplasia (enlargement of the prostate) (BPH) with lower urinary tract symptoms, hemiplegia and hemiparesis (weakness and/or paralysis on one side of the body) following cerebral infarction (stroke) affected left non-dominant side, neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well. As a result, the bladder may not fill or empty correctly), and dementia. R1's care plan (CP) dated 7/10/24, identified risk for bleeding due to anticoagulant (blood thinner) use, directed staff to monitor vitals and for bleeding, and contact provider with changes and update as needed. CP identified R1 was at risk for urinary tract infection (UTI) due to indwelling catheter and directed staff to observe and monitor for signs of infection and urine quality changes (change in urine color/sediment). R1 had an indwelling Foley catheter 14 F (French) 10 cc (cubic centimeters), and to document urine output at the end of every shift. R1's physician order dated 6/21/24, identified change 14 F catheter with 10 cc every 28 days at evening 2 p.m. to 10:30 p.m. once a month and change the bag at the same time. R1's physician order dated 6/21/24, identified empty catheter bag and document output three times day (morning 6:00 a.m. to 2:30 p.m., evening 2:00 p.m. to 10:30 p.m., night 10:00 p.m. to 6:30 a.m.). R1's House Standing Orders signed and dated 2/29/24, identified may irrigate catheter with 30 to 60 ml (milliliters) of sterile normal saline with signs of blockage (clots, no urine flow or bypassing around catheter). Change indwelling catheter PRN (as needed) if becomes obstructed or comes out of bladder. R1's progress notes from 6/28/24, through 7/5/24, identified: -6/28/24, at 12:07 a.m. to 7/2/24, at 12:15 a.m. no documentation noted in R1's medical record (over four days). -7/2/24, at 12:15 a.m. 14 F was inserted at 9:20 p.m. and tolerated well. Later at 11:15 p.m. resident woke up screaming ouch and in pain. Irrigation, repositioning, and massage of bladder done but no urine output and still in a lot of pain. Small amount of thick blood and clots in bag and bloody urine bypassing. On call notified and she said to call on call provider if pain increased. -7/2/24, at 12:15 p.m. from report the evening nurse changed resident catheter with a 14 F (per interview with LPN-A this was a 16 F, see below) and then a 16 F with blood output. At 8:30 p.m. writer was called to R1's room, screaming in pain, and guarded his groin area whenever staff tried to reach for that area. R1 refused to have brief closed due to increased pain, bladder scanned for 216 cc. On call nurse was notified and suggested flush/irrigate catheter, push fluids and change catheter to 14 F. When catheter was gushed there was increased pain and no output. Removed 16 F and noted continuous gross hematuria (bleeding) with some blood clots from penis. On call was notified and she said to let him drain for 15 minutes then insert a 14 F. After 15 minutes the gross hematuria was minimum and R1 felt better with less pain. -7/2/24, at 5:09 a.m. R1 was screaming, reported a lot of pain (10 out of 10) when his brief was changed around 3:30 a.m. R1's vitals blood pressure (BP) 90/53, respirations 18, and oxygen saturation 92%. Bladder scan completed and resulted in 249 cc with no urine in output in bag. On call provider notified and gave order to send to emergency room (ER) at 4:30 a.m. -7/2/24, at 10:01 a.m. received call from local hospital, R1 had been admitted with diagnosis of sepsis. R1's family updated and placed on LOA (leave of absence). -7/4/24, at 5:53 p.m. called hospital for update. R1 was moved out of ICU (intensive care unit) and downgraded to medical unit, off drip and BP was ok, and placed on two antibiotics. Possibly be there for two more days. -7/5/24, at 2:13 p.m. was readmitted back to facility from hospital at 1:30 p.m. R1 had indwelling catheter in place that was free flowing, patent, urine was light yellow in color, without sediment, no blood no unusual odor. R1's catheter was to be changed every 28 days, if anticipated difficulty with catheter contact urology. Continued to be treated with antibiotics for UTI every 12 hours for 11 more days. R1's hospital admission notes dated 7/2/24, indicated indwelling catheter change completed at nursing home facility last evening resulted in significant bleeding and no urine output. An attempted catheter placement in ER resulted in ongoing bleeding and no urine output. CT (computerized tomography) scan was completed and showed catheter balloon inflated in the urethra. Urology was contacted and replaced the catheter over a guidewire with cystoscopy (a hollow tube equipped with a lens inserted into urethra and slowly advanced into the bladder). Principle problems identified: urinary tract infection associated to indwelling catheter, sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), with acute renal failure and septic shock, and anemia with acute blood loss from urethra resulting from Foley catheter placement. During an interview on 7/8/24, at 4:00 p.m. licensed practical nurse (LPN)-A stated R1 was due for a catheter change on July 1, 2024. LPN-A stated she had gathered supplies: catheter size 16 F, catheter bag, catheter change kit, and an extra syringe. LPN-A indicated pulled out R1's catheter 14 F after deflating balloon and noted urine was dark amber, cloudy, and sediment in the tubing without odor. LPN-A stated emptied 450 cc of urine from collection bag. LPN-A stated when she inserted the 16 F catheter bright red blood was seen, panicked, and pulled out the catheter. LPN-A stated talked with floor manager LPN-B and informed was normal for R1 to bleed a bit and instructed to insert another catheter. LPN-A stated went back and inserted 16 F catheter and bloody return was noted with a small amount of urine. LPN-A stated she had went to the EMAR and noted the order indicated 14 F, it was then she realized she had inserted the wrong size catheter twice. LPN-A stated she reported to LPN-B and DON and was told it was fine and instructed to let things settle down/stop bleeding before the catheter was changed again. LPN-A stated checked on R1 prior to end of shift and no pain, no urine was flowing out of the tube and offered to flush but RN-A said no it was ok and left for the day. LPN-A stated a provider should have been notified about the wrong size catheter (2 times) and blood returned with little to no urine but did not due to LPN-B and DON indicated it was normal for R1 to bleed some. LPN-A stated they did not document this and should have. During a telephone interview on 7/9/24, at 2:00 a.m. registered nurse (RN)-A stated she started her night shift at 6:00 p.m. RN-A indicted she had received report from the LPN-A regarding R1's Foley catheter change. RN-A stated LPN-A indicated she she inserted a 14 F and got blood so removed it, placed another catheter this time a 16 F and was still bleeding when she realized she had used the wrong size catheter. RN-A indicted LPN-A reported to DON and floor manager LPN-B and they both came to conclusion the urethra was already irritated, so it was ok to leave it in until morning, monitor for bleeding, and replace it the next day with a 14 F catheter. RN-A stated she had never seen blood in R1's catheter prior to this day. RN-A stated she peaked in on R1 at 6:30 p.m. prior to a medication pass that evening and there was approximately 100 cc of bloody drainage in the collection bag and in the catheter tubing and R1 reported no pain at that time. RN-A stated she had been told in the past when the catheter was not placed properly due to the BPH and neurogenic bladder a small amount of blood was normal for R1. RN-A stated when she had placed R1's catheter in the past, she had never seen any bleeding. RN-A stated later, a staff nursing assistant came and got her and indicated R1 was in pain. RN-A went to R1's room and he complained of pain and said, ouch ouch. RN-A stated she tried to close his brief, but he would not allow and yelled out. RN-A checked urinary output which had remained the same as earlier (6:30 p.m.) then called the on-call nurse (DON) and was directed to massage the bladder area, push fluids, and then flush the catheter tubing. RN-A stated a provider should have been notified when R1 started to have no urine output with bleeding but she relied on DON for direction instead. RN-A stated DON instructed her the provider did not have to be called because there was nothing he could do and would round the next day. RN-A indicated she was unable to flush the catheter tubing, R1 complained of more pain, then she contacted DON again. RN-A stated DON indicated R1's 16 F catheter should be removed and replaced with a 14 F. RN-A stated she removed the 16 F catheter and R1 had gross hematuria from the penis and replaced it with a 14 F with approximately 80 cc of bloody drainage in bag and allowed more time to see when urine would drain and what color. RN-A stated she had bladder scanned R1 prior to the insertion of the catheter and noted 216 cc. RN-A verified at 11:00 p.m. R1 complained of pain again, but was unable to give more Tylenol. RN-A texted DON and instructed to reposition R1, massage the bladder area and if in one hour still in pain call the on call provider and ask for order to use emergency kit to give a different analgesic. RN-A stated R1 indicated he was ok and then checked on him again at 3:00 a.m. bloody output had remained the same in bag at 50 ml and no urine noted and R1 had started to complain about pain again. RN-A called on call provider and informed them R1 had no urinary output and bladder pain then received order, and sent R1 into the hospital. During an interview on 7/9/24, at 11:00 a.m. hospital physician assistant (PA)-A (provided urological care to patients) verified she was notified about R1's admission to ER and asked to provide assistance with insertion of a catheter. PA-A stated R1 had a large prostate and obstructive urinary symptoms and required the use of a guide wire and cystoscopy (a hollow tube equipped with a lens to view the urethra and bladder) as she inserted the indwelling catheter. PA-A indicated was unable to see if there was a false tract (a false passage in the urethra is formation of an epithelialized tract created when the catheter was inserted aggressively against the urethral wall and/or a weak part of the urethra rather than guided through the urethra lumen, into the bladder, and may occur more often in men due to an enlarge prostate) due to excessive bleeding in the urethra. PA-A stated reinsertion of a catheter had the potential to cause more damage and/or bleeding. PA verified when staff nurse inserted the catheter, got blood return a provider should have been notified right away and not waited. PA-A stated additionally, no urine output for up to 12 hours can cause increased risk for infection due to stagnate urine and possibly go into the kidneys which can be serious. During an interview on 7/9/24, at 11:37 a.m. primary provider/physician assistant (PA)-B stated R1 had no urine output from 9 p.m. until sent to ER (7 hours). PA-B verified it would have been a good idea to have updated provider after the second time the wrong size catheter was inserted and bleeding continued. PA-B also stated when nurse had contacted the DON 4 to 6 times in a matter of 6 hours she was in over her head, clearly struggled, and required direction from the provider especially when R1 yelled out in pain, increased bleeding, and low urine output. PA-B stated she would have not recommended to change 16 F catheter a 14 F catheter, provider should have been contacted much sooner and R1 most likely sent into hospital earlier. During an interview on 7/9/24, at 2:05 p.m. floor manager registered nurse (RN)-C stated repeated insertion of a catheter risked irritation to the lining of the urethra, increased an entry of bacteria which increased risk for infection. RN-C stated it was basic nursing education/practice to not inflate balloon until you get urine back. R1's change in condition occurred when he had less than 50 cc of urine out for more than two to three hours and a provider should have been contacted especially when the bleeding should have subsided much sooner. During a telephone interview on 7/10/24, at 8:45 a.m. medical director (MD) stated staff nurses attempted to insert three catheters and the trauma to the urethra most likely was started with the first insertion, when the wrong sized catheter 16 F was used. MD stated a catheter balloon should never be inflated until you get a flow of urine. MD stated would have been important with blood return and no urine a provider should have been notified right away, sent to ER so an evaluation could have been completed at another facility. MD verified when a resident had ongoing bleeding, on an anticoagulant, and bled for more than two hours, would be alarming and something else was going on. MD stated he would have expected more documentation from the nursing especially with low urine output and bleeding, in the medical record, to establish a time-line, and what interventions were tried. During a telephone interview on 7/10/24, at 12:48 p.m. ER supervisor RN-D verified R1 arrived in ER with a 16 F catheter with no urine output and blood in bag. During an interview on 7/10/24, at 1:10 p.m. DON stated she had many conversations with both staff nurses starting from 7/1/24, at approximately 4:00 p.m. through 7/5/24, at 11:32 p.m. regarding R1. DON stated last time she had heard from RN-A was at 11:32 p.m. DON stated she arrived at the facility early the next morning on 7/2/24, asked RN-A how R1 was doing and was informed she had sent him to emergency room via ambulance. DON stated she would have expected to be notified R1 was sent to hospital but was not. DON stated repeated catheter insertion could have raised the risk of complications such as infection and urethral damage/bleeding. During a telephone interview on 7/11/24, at 12:00 p.m. emergency care provider, osteopathic doctor (DO) (look at patients as a whole person consisting of a mind, body, and spirit, and tend to focus on preventative medicine) stated the facility inserted a Foley catheter more than once, no urine output and bleeding occurred, clearly it was placed in the wrong spot and not in the bladder. DO stated at that time most likely that was when they started the false tract. DO indicated no urine output was not due to a blood clot because they tried to flush the catheter at the facility, no urine output and only blood. DO stated we removed the Foley catheter once he arrived at ED and inserted a 3 -way catheter without resistance and only a small return of urine. DO stated this indicted there was a false tract prior to his arrival at ED. DO verified the CT scan confirmed the Foley balloon was in the penile urethra therefore suspected R1 had a false tract. DO indicted numerous insertions of a Foley catheter within 10 hours would have caused damage and a false tract when not inserted properly. DO stated the facility continued to re-insert catheters, with no urine out put and bleeding, caused urethra trauma, provider was not contacted right away and should have been, which delayed care and R1 became septic with bacteria in catheter. DO indicated she believed this cause R1 harm. Facility policy titled Notification of Significant Changes dated 5/2/22, identified policy provided guidance to staff when and who to notify of a significant change in a resident's status. Definition of a significant change meant a change in resident's status, a need to alter treatment, and accident results in injury, or a decision to transfer or discharge the individual receiving services from care center. The charge nurse will immediately (as indicated by the change of condition) informed the resident, consult with the physician, and notify the resident representative for the following significant change: an accident that involved the resident which results in injury and has the potential for required physician intervention, a deterioration in health, in either lift-threatening conditions or clinical complications, and decision to transfer to another provider from the care center without primary physician involvement. Review of facility policy titled Foley Catheter Insertion, Male Resident dated 2001 identified the purpose of the Foley catheter was to provide for and maintain constant urinary drainage. Verification that there was a physician order was required to identify what size Foley catheter was specified. After preparation insert the catheter gently into the meatus (end of penis) approximately five to seven inches until urine began to flow from the bladder then advance the catheter another two inches and inflate balloon with 5 cc (cubic centimeters) and removed syringe. If resistance met do not force the entry, stop the procedure, and notify supervisor. The physician would be expected to be notified of any abnormalities (i.e. bleeding, obstruction).

Based on interview and record review, the facility failed to assess and/or re-assess and review for risks and benefits of the use of assistive devices including bed rails resulting in risk of potential serious harm, injury, impairment, or death for 1 of 4 (R1) residents who had a bed rail in place despite being at risk and was found with head between the mattress and bed rail. This resulted in an Immediate Jeopardy for R1. Additionally, the facility failed to assess and/or re-assess and review for risks and benefits of the use of assistive devices including bed rails for 3 of 4 residents (R2, R3, R4) reviewed for safety. The immediate jeopardy began on 10/12/22, when bed rails were placed on R1's bed prior to an assessment being completed to determine safe for use. On 12/18/22, R1 was found on the floor after sliding from her bed, which resulted in R1's head being entrapped between the bed rail and mattress. The administrator, director of quality, nurse manager, and health unit coordinator were notified of the immediate jeopardy at 1:30 p.m. on 12/29/22. The immediate jeopardy was removed and the deficient practice corrected on 12/19/22, prior to the start of the survey and was therefore was issued at Past Noncompliance. Findings include: R1 was admitted to the facility on [DATE]. R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of multiple sclerosis and had severely impaired cognition. R1 was dependent on staff for all activities of daily living (ADLS). Job Work Order dated 10/12/22, indicated attach bed rails to R1's bed. Review of Fall Scene Investigation dated 12/18/22, at approximately 6:50 p.m. indicated R1 was found by nursing staff on the floor on the left side of her bed. R1's body was observed to be laying on the fall mat next to bed, which was in the lowest position, and R1's head was on the bed in between the bed rail and mattress. R1 was assessed with no injury noted. R1's Mobility Rail Results dated 12/19/22, following the incident, revealed R1 was not appropriate for bed rails due to risk of strangulation, suffocation, bodily injury, or death if the resident or body parts were caught between the bed rail and mattress. Further, assessment determined R1 was at risk for serious injury if attempted to climb over or around the bed rails, and bed rails were determined dangerous due to R1 being considered a fall risk from bed. R1's bed rails were removed from bed on 12/19/22. In addition, R1's initial Mobility Rail Result assessment was requested but was not completed by the facility prior to installing bed rails on R1's bed on 10/12/22. On 12/27/22, at 1:49 a.m. trained medication assistant (TMA)-A indicated R1 had bed rails on her bed prior to incident on 12/18/22. TMA-A stated they had not witnessed R1 utilize the bed rails for mobility purposes and stated R1 wouldn't grab onto anything as she was fully dependent on staff for all ADLs. TMA-A indicated she found R1 on the floor beside her bed on the evening of 12/18/22. TMA-A indicated she observed R1's head stuck between the mattress and bed rail. On 12/27/22, at 2:08 p.m. family member (FM)-A indicated R1 was determined to be a high risk for falls and had fallen out of bed a few times. Further, FM-A indicated prior to R1's incident on 12/18/22, the facility had not notified them of the risks of utilizing the bed rails and no consent was obtained prior to installing R1's bed rails on 10/12/22. FM-A stated R1 would not be able to grab onto the bed rails to utilize them for mobility as R1 did not have the strength in her arms. On 12/27/22, at 2:17 p.m. nursing assistant (NA)- B indicated she observed R1 to have bed rails on her bed prior to the incident on 12/18/22. NA-B stated she had not witnessed R1 utilizing the bed rails for mobility or aiding in turning or repositioning while in bed as R1 was dependent on staff for all ADLs including bed mobility. In addition, NA-B indicated she had heard about R1's incident regarding being stuck in between the bed rails and mattress, and NA-B stated, I could see that happening as she can move around a lot while in bed. On 12/28/22, at 11:19 a.m. licensed practical nurse (LPN)-B stated on the evening of 12/18/22, LPN-B was working on the other unit and was notified to assist staff with R1. LPN-B entered R1's room and R1 was already back onto her bed. In addition, LPN-B stated R1 was assessed for injuries with no concerns identified however, R1 did report pain in her forehead and LPN-B stated, I guess if you were stuck the way she was, that would be a normal spot for pain. On 12/28/22, at 11:31 NA-D stated on the evening of 12/18/22, NA-D and another staff assisted R1 with p.m. cares and placed R1 in her bed at approximately 6:00 p.m. NA-D stated at approximately 7:00 p.m. she was notified by another staff member she needed assistance due to R1 being found lying on the floor. Further, NA-D stated when she walked into R1's room, R1 was observed with her body on the floor mat next to bed and R1's head was face down between the bed rail and mattress and R1 was heard moaning. NA-D stated she assisted R1 back onto her bed and observed R1's face to be red from her breathe being taken away, but no injuries were noted. On 12/28/22, at 2:50 p.m. nurse manager (NM)-A indicated R1 rolled out of bed on 12/18/22, and had got stuck between the bed rail and the mattress. NM-A indicated a bed rail assessment had not been completed prior to incident due to therapy staff initiating a work order for the bed rails and had not notified the nursing department prior to the bed rail being installed. On 12/28/22, at 12:37 a.m. physical therapy assistant (PTA) had been seen by therapy for bed mobility, seated balance, and core strengthening for a few months and then discharged off therapy services due to no further progression. PTA confirmed she filled out the work order for R1's bed rails on 10/12/22 to aid in therapy services working on reaching and bed mobility. Further, PTA confirmed she did not complete a bed rail assessment prior to R1's bed rails being installed and was not aware of the facility policy on bed rail assessments at that time. In addition, PTA stated she had received education on policies and procedures of requesting bed rails following R1's incident on 12/18/22. On 12/28/22, at 4:00 p.m. interim Director of Nursing (DON) indicated therapy staff initiated a work order for bed rails for R1 prior to notifying the nursing staff. Since the nursing staff were unaware R1 had bed rails, an assessment was not completed prior to bed rails being installed. DON stated a consent form with the risks and benefits related to the use of bedrails was not obtained and completed by resident's representative until after the incident. DON indicated licensed nursing staff were expected to complete a bed rail assessment and obtain a consent form acknowledging the risks and benefits of bed rails prior to installing the bed rails on a resident's bed. Further, DON indicated education was provided following the incident to the nurse managers to ensure bed rail policy and procedure were being followed and the expectation to complete bed rail assessments prior to installing the bed rails and re-assessed quarterly, as this was not being completed per facility policy. On 12/29/22, at 12:30 p.m. Interview with maintenance director confirmed bed rails were installed on R1's bed on 10/12/22, when the work order was received. The past noncompliance immediate jeopardy began on 10/12/22. The immediate jeopardy was removed and the deficient practice corrected by 12/19/22, after the facility implemented a systemic plan that included the following actions: R1's bed rails were removed, R1's care plan was updated to include two-hour safety checks, all residents currently residing in facility, who had bed rails, were re-assessed for appropriateness and safety, and education provided to nursing staff and therapy department on bed rail policy and procedures. R2 was admitted to the facility on [DATE]. R2's quarterly MDS dated [DATE], indicated R2 had a diagnosis of dementia and had severely impaired cognition. R2 required extensive assist by staff for ADLs such as bed mobility and transfers. R2 General Nurse's Observation dated 9/17/19, indicated R2 utilized 1/4 side rail on right side of bed to assist in transfers and R2 was able to utilize the bed rail appropriately. On 12/18/22, following R1's incident, R2 was re-assessed, and her bed rails were removed due to determining R2 was not appropriate for bed rails. In addition, quarterly bed rail assessments (to be completed per facility policy), for R2 were requested but facility was unable to provide. R3 was admitted to the facility on [DATE]. R3's quarterly MDS dated [DATE], indicated R3 had a diagnosis of hemiparesis to left side and had moderate cognitive impairments. R3 required extensive staff assist for ADLs such as bed mobility and transfers. R3's Admissions Observation dated 5/11/20, indicated a mobility rail assessment was completed and determined R3 was appropriate for 1/4 bed rails to aid in bed mobility. Further, Mobility Rail Results assessment dated [DATE], indicated bed rails were appropriate for R3 to utilize for mobility and transfers. In addition, quarterly bed rail assessments (to be completed per facility policy), prior to 12/19/22, were requested for R3 but facility was unable to provide. R4 was admitted to the facility on [DATE]. R4's annual MDS dated [DATE], indicated R4 had a diagnosis of hyperlipidemia and was cognitively intact. R4 required extensive staff assist for ADLs such as bed mobility and transfers. R4's Mobility Rail Results assessment dated [DATE], indicated bed rails were appropriate for R4 to utilize to promote independence and aid in turning and repositioning in bed. In addition, initial and quarterly bed rail assessments (to be completed per facility policy), prior to 12/21/22, were requested but facility was unable to provide. On 12/28/22, at 2:08 p.m. Administrator confirmed quarterly bed rail assessments for R3 and R4 could not be located. On 1/3/22, at 12:12 p.m. administrator confirmed staff had not completed any mobility rail assessments for R4 prior to 12/21/22, as the nursing department was not aware of implementation and could not verify when the bed rails were installed. Review of facility policy titled Mobility Rail Policy dated 9/21/16, indicated facility will ensure each resident with bed side rail placement has an individual assessment to determine safety based upon the resident needs as consistent with state and federal rules and regulations. Further, policy indicated the procedure to ensure safe environment of each resident included the interdisciplinary team will reassess a resident for necessity of mobility rails quarterly, annually or with a significant change in condition.

Based on observation, interview and document review, the facility failed to implement the Centers for Disease Controls (CDC) guidance for individualized transmission-based precautions including appropriate personal protective equipment (PPE) and isolation precautions to prevent the spread of COVID-19 for 1 of 1 resident (R3) who displayed symptoms of COVID-19. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death In addition, the facility failed to ensure proper hand hygiene was performed during dining for 2 of 5 (R9, R34) residents reviewed for dining; failed to ensure shared equipment was cleaned and disinfected for 2 of 3 (R9, R39) residents reviewed for shared equipment use; and failed to ensure soiled laundry was carried in a manner to prevent potential contamination for 2 of 2 residents (R9 and R21) reviewed for infection control . Finally, the facility failed to ensure proper eye protection was used to prevent the spread of COVID-19 for 1 of 1 resident (R33) who was reviewed for transmission based precautions. The IJ began on 10/2/21, when it was determined the facility failed to implement quarantine procedures for R3 after exhibiting potential COVID-19 symptoms and failed to ensure proper personal protective equipment (PPE) use. The administrator, director of nursing (DON) and nurse consultant were notified of the IJ at 5:30 p.m. on 10/14/21. The IJ was removed at 5:45 p.m. on 10/15/21, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: The CDC guidance People with Certain Medical Conditions dated 10/14/21, identified older adults were more likely to get seriously ill from COVID-19. More than 81% of COVID-19 deaths have occurred in people over the age of 65, and the number of COVID-19 deaths among people over 65 is 80 times higher than the number of deaths among people aged 18-29. Further, the risk of severe COVID-19 increases as teh number of underlying medical conditions increases in a person. Severe illness means a person with COVID-19: may require hospitalization , need intensive care, require a ventilator to help them breathe, or die. The CDC guidance Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 9/10/21, directed residents symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by healthcare personnel (HCP) using a N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for [CONDITION(S)]-CoV-2 infection. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan revised 9/24/21, identified R3 was at risk for shortness of breath related to history of pneumonia as exhibited by decreased oxygen saturations. Staff were directed to monitor for changes in respiratory function and to update R3's physician or nurse practitioner. Additionally, staff were directed to provide oxygen as ordered by the physician in order to remain above 88%. R3's nursing progress notes included the following: - On 10/2/21, at 12:19 a.m. the nurse was called to R3's room by the nursing assistant. R3 was diaphoretic (sweating heavily) and R3's breathing was noted to be a little labored. When R3 was asked how she was feeling she replied fine. R3's temperature was 100.3 degrees Fahrenheit (F) with oxygen saturations 76-80% on room air. Oxygen was applied at two liters per nasal cannula and R3's oxygen saturations rapidly rose to 90% while the head of R3's bed was elevated. - On 10/2/21, at 4:08 a.m. R3 was administered Tylenol (a [MEDICATION(S)] medication) for a temperature of 100.3. R3's temperature decreased to 98.3 following use of Tylenol. R3 stated she felt fine and kept removing her oxygen tubing. R3 had remained at 87-98% on room air throughout the night which was normal for R3. However, R3 had come into contact with a medical provider who had tested positive for COVID-19. A rapid COVID-19 test was collected on R3 on 10/2/21, and was negative. - On 10/3/21, at 4:14 a.m. the progress note indicated R3 was really tired at about 7:30 p.m. the evening prior. R3 stated tired and wanted to go to bed. R3's vital signs were documented as all within normal limits and R3 had remained afebrile through the night. R3's oxygen saturations remained 89-92% on room air. R3 had no complaints of shortness of breath and slept well all night. Although R3 progress notes indicated she had symptoms of COVID-19 including fever, labored breathing and low oxygen levels, the documentation lacked indication whether R3 had a confirmatory COVID-19 test and lacked indication of whether R3 was placed into transmission-based precautions. On 10/11/21, at 5:25 p.m. R3 was observed sitting at a table in the dining room with one other resident while waiting for her supper meal. R3 was not wearing a mask and no social distancing was observed while traveling to and from the dining room nor while R3 sat at the table. The other resident at R3's table was not masked, nor were the other residents in the dining room. On 10/11/21, at 6:49 p.m. R3 was seated in her wheelchair in her room with her room door open. There was no signage for transmission-based precautions on her door nor a cart containing personal protective equipment (PPE) for staff usage. During an observation on 10/12/21, at 2:06 p.m. nursing assistant (NA)-C and NA-D entered R3's room to provide direct care for R3. NA-C and NA-D wore surgical mask and goggles, but did not don gloves or gown. After R3 was assisted to her wheelchair, staff wheeled R3 to the dining room. R3 was not offered or encouraged to wear a mask. During an interview on 10/13/21, at 2:11 p.m. licensed practical nurse (LPN)-A stated she was unaware R3 had exhibited COVID-19 symptoms on 10/2/21, because that was her normal week off. LPN-A stated if a resident had a fever and wasn't feeling well, the first thing the nurse should do was a head-to-toe assessment, and interview the nursing assistants to ask them about the resident's symptoms. LPN-A then stated the nurse would talk to the unit manager to determine if a rapid COVID-19 test was warranted, and a rapid test would be collected. LPN-A stated afterwards, a tracking form would be filled out for the director of nursing (DON). LPN-A further stated a symptomatic resident would be placed in transmission-based precautions (TBP) even if the rapid test was negative. The resident would need to continue to be in TBP for 14 days or, if he/she tested positive, for 10 days. LPN-A also verified since the rapid test was negative, a confirmatory PCR test should have been collected. LPN-A stated R3 should have been in transmission-based precautions until 10/12/21, but verified R3 had not been put on precautions after symptoms were first observed 10/2/21, nor was R3 in precautions when observed on 10/12/21. On 10/13/21, at 2:15 p.m. R3's COVID-19 test results were requested from the DON and R3's Rapid Test Report Form dated 10/2/21 indicated the test was negative. R3's confirmatory PCR results were requested but no results were received. During an interview with the DON and the nurse consultant on 10/13/21, at 3:19 p.m. the DON indicated R3's last COVID-19 test was collected more than three months ago. R3's test collected on 10/2/21, was a rapid [MEDICATION(S)] test and was negative. Because of this, the DON stated she would need to review the facility policy regarding confirmatory testing to determine whether R3 should have had a PCR collected. - At 3:21 p.m. on 10/13/21, the DON stated they did suspect COVID-19 on 10/2/21, and collected a COVID-19 test which was negative. According to facility policy, after that, measures would be put into place and that included possible quarantine however, since R3 was fully vaccinated, no quarantine was needed, and the were to monitor the resident. The DON verified R3 had spiked a temperature, but it went down and R3 had no other symptoms. At that time the nurse consultant stated, It really was not much of a temperature. The DON stated there were no notes in the paper chart, in the electronic medical record or the communication binder that documented R3 was evaluated by the doctor or that the doctor determined R3 did not need a confirmatory test nor TBP. The DON confirmed R3 was not placed into TBP over the weekend. At that time, the DON stated she expected nursing staff to call and speak with an on-call doctor during weekend hours for next steps when a resident was symptomatic but had a negative rapid [MEDICATION(S)] COVID-19 test. During an interview on 10/14/21, at 8:13 a.m. the DON stated R3 had been exposed to a nurse practitioner (NP)-A who was at the facility on 9/28/21, who later tested positive for COVID-19. The DON said NP-A had sent her a text on 9/30/21, stating she had tested positive. The DON stated NP-A had her pull the billing statements to determine which residents had been exposed. The DON said on 10/1/21, all residents who were exposed to NP-A who were unvaccinated were given PCR tests for COVID-19. However, R3 was not in that sample due to being fully vaccinated. According to the DON, an [MEDICATION(S)] test was collected on R3 10/2/21, and she expected staff to contact the resident's medical provider for next steps such as determination of whether to collect a PCR, or for isolation. The DON stated there was not documentation to show these next steps happened. The DON indicated the facility policy directed for discontinuation of isolation precautions if a resident had signs/symptoms of COVID-19, they would need to be 72 hours without a fever without medication, and 24 hours of resolution of other symptoms. During a phone interview on 10/14/21, at 11:10 a.m. NP-A stated she contacted the facility via text on 9/30/21, to inform them of her positive COVID-19 test. She verified she had worked in the facility on 9/28/21, and 9/29/21 and became symptomatic the evening of 9/29/21. NP-A said because 10/2/21, was a weekend, the facility should have contacted the on-call provider for a PCR test for R3. Additionally, a note should have been placed in the provider book for the provider to review during rounds on the following Monday (10/4/21). NP-A said, at a minimum, R3 should have been placed into isolation when she became symptomatic until the provider was at the facility on Monday. The facility policy Suspected (or Confirmed) Coronavirus (COVID-19) Outbreak reviewed/revised 9/17/21, indicated Coronavirus symptoms included (but were not limited to) cough, shortness of breath or difficulty breathing, fever, chills, muscle pain (new), sore throat, and new loss of taste or smell. Residents with suspected or confirmed COVID-19 disease, immediate infection control measures would be put into place, including possible quarantine. The resident's provider would be contacted for management of care. The IJ which began on 10/14/21, was removed on 10/15/21, at 5:45 p.m. when it could be verified through observation, interview and document review the facility: - Reviewed its COVID-19 protocols for isolating symptomatic residents - On 10/14/21, education began for all staff on the topic of Transmission Based Precautions and droplet precautions. Staff were required to review each policy prior to the start of their shift and signed confirming their understanding of the policy. - On 10/14/21, education began for all nursing staff on the topics of suspected or confirmed COVID-19 outbreak, COVID-19 prevention, screening, an identification and COVID-19 testing. Staff were required to review each policy prior to the start of their shift and signed confirming their understanding of the policy. - A bright arrow message was sent to the staff to inform them of the required education as well as one on one conversations with various staff throughout the building. - In addition a bright yellow message, one on one communication, and an email was sent to staff to inform them that side shields would no longer be an acceptable form of eye protection - All other staff that did not routinely work at the care cent would be educated by the DON or designee prior to their return to work via telephone and given the appropriate policies in their employee folder for confirmation signature. - Audits on proper isolation precautions and appropriate PPE use would be conducted to ensure the policies noted above were abided by. - Risk assessments were conducted on 10/14/21 for those that were potentially exposed to R3. No high risk exposures were identified. R3 had not been symptomatic since 10/2/21 and was back to baseline. Therefore quarantine was no longer deemed to be necessary at that time. HAND HYGIENE IN DINING ROOM R9's Face Sheet printed 10/14/21, indicated R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's significant change MDS dated [DATE], indicated R9 required extensive assistance with activities of daily living (ADL)s , and limited assistance with eating. R9's care plan dated 2/13/19, indicated R9 required assistance with dressing, grooming, personal hygiene, required the EZ stand with the assist of staff for transferring, and directed staff to encourage self feeding. R9's NAR Assignment sheet revised 10/1/21, indicated R9 was non-ambulatory, sometimes required total assistance with eating, required assistance with grooming, dressing and R9 transferred with the assist of one and an EZ stand. R34's Face Sheet printed 10/14/21, indicated R34's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R34's NAR Assignment sheet revised 10/1/21, indicated R34 required set up and supervision with eating. R34's quarterly MDS dated [DATE], indicated R34 required supervision for eating. On 10/13/21, at 8:36 a.m. activity aide (AA)-B got up from assisting R9 to eat breakfast and without performing hand hygiene, AA-B went over to R34 and picked up R34's spoon and started to assist R34 with breakfast. On 10/13/21, at 9:50 a.m. AA-B stated she should have performed hand hygiene or used hand sanitizer in between assisting R9 and R34 with breakfast DISINFECTING EQUIPMENT R39's Face Sheet printed 10/22/21, indicated R39 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's five day MDS dated [DATE], indicated R39 had a moderate cognitive impairment, and required extensive assistance of two staff with transfers. On 10/13/21, at 7:14 a.m. after an observation of staff assisting R39 transfer from R39's bed to R39's wheelchair with the use of the EZ stand. Nursing assistant (NA)-E brought the EZ stand into R39's room without disinfecting the EZ stand to assist R39 transfer to the bathroom. NA-E stated she should have disinfected the EZ stand before she brought the EZ stand into R39's room. SOILED LINENS R9's Face Sheet printed 10/14/21, indicated R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's care plan dated 2/13/19, indicated R9 required assistance with dressing, grooming, personal hygiene, required the EZ stand with the assist of staff for transferring, and directed staff to encourage self feeding. R21's Face Sheet printed 10/14/21, indicated R21 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R21's care plan dated 7/10/18, indicated R21 required assistance with dressing, grooming, eating, and extensive assist with transfers On 10/13/21, at 7:13 a.m. NA-E was observed exiting R9's room carrying unbagged soiled linens, not wearing gloves and carrying the soiled linens through the resident room hallway into the soiled utility room. On 10/13/21, at 8:43 a.m. NA-G was observed exiting R21's room with unbagged soiled linens walking through the resident room hallway to the soiled utility room. NA-G stated soiled linens did not have to be bagged when bringing to the soiled utility room unless the linens were visibly soiled. LACK OF APPROPRIATE EYE PROTECTION R33's Face Sheet printed 10/14/21, indicated R33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's quarterly MDS dated [DATE], indicated R33 had mild impaired cognition, and was independent with activities of daily living (ADLs). On 10/13/21, at 7:30 a.m. housekeeper (H)-A was observed wearing a pair of prescription glasses with wing shields on the sides of the glasses and was told her eye wear was acceptable eye protection and the eye wing shields were provided by the facility. On 10/14/21, at 8:21 a.m. H-B was observed exiting R33's room who was on droplet precaution, wearing a pair of prescription glasses with wing shields on the side of the arms of the glasses. H-B stated the wing shields on the side of her prescription glasses were provided by the facility and were approved eye wear. H-B stated she did not put on another form of eye protection when entering R33's room who was on droplet precautions. On 10/14/21, at 12:18 p.m. the DON stated the policy for handling linens directed staff to place soiled linens into a plastic bag and bring directly to the soiled utility room. The DON further stated if there was no plastic bag available in the residents room, staff should be wearing gloves and carry the soiled linens away from their uniform and brought directly to the soiled utility room. The DON further sated the importance of bagging soiled linens was to prevent the risk of contaminating the uniform or the environment while caring the linens through the resident hallways. The DON further stated staff should be washing their hands in between assisting residents with eating. The DON stated the EZ stand should be disinfected after use and before the equipment was brought into another's residents room to prevent the spread of infection. The DON also ensured that staff were educated that side shields for prescription glasses were no longer allowed as an acceptable form of eye protection. The facility policy was updated on 10/14/21, to specifically address side shields. The facility policy Cleaning/Disinfecting Resident Care Equipment dated 6/5/21, indicated reusable resident care equipment would be decontaminated between residents. The policy further indicated durable medical equipment (DME) would be cleaned and disinfected before reuse by another resident. The facility policy Linen Handling dated 1/8/18, directed all soiled linen must be placed into a predetermined plastic bad and /or directly into a covered soiled linen cart. The facility policy Hand Hygiene dated 5/8/17, directed hand hygiene was to be performed before and after contact with environmental surfaces or equipment in the immediate vicinity of the resident, after removing gloves, prior to preparing or handling foods. The policy further directed the use of hand sanitizers before and after assisting a resident when not in contact with bodily fluids, before and after contact with environmental surfaces or equipment in the immediate vicinity of the resident.

Based on observation, interview and document review, the facility failed to conduct comprehensive fall assessment to determine a root cause analysis, identify patterns of falls, effective interventions and routinely implement interventions for 1 of 4 residents (R37) who had repeated falls with injury. This deficient practice resulted in an immediate jeopardy for R37 who sustained repeated head injuries after falls, and was hospitalized for [REDACTED].). The immediate jeopardy began on 6/27/19, when R37 had not been comprehensively assessed for the root cause of repeated falls with major head injury and appropriate interventions implemented and was identified on 9/12/19. The facility administrator was notified of the immediate jeopardy at 12:15 p.m. on 9/12/19. The immediate jeopardy was removed at on 9/13/19, at 5:52 p.m., but non-compliance remained at a G scope and severity level, which indicated actual harm that is not immediate jeopardy. R37's quarterly Minimum Data Set ((MDS) dated [DATE], identified R37 had [DIAGNOSES REDACTED]. The MDS identified R37 had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers and toileting. The MDS revealed R37 was unable to maintain her balance during transition without physical assistance and was frequently incontinent of both bowel and bladder. The MDS identified R37 had no falls since the last assessment on 7/2/19. R37's 5-day Perspective Payment System (PPS) MDS dated [DATE], identified R37 had [DIAGNOSES REDACTED]. The MDS revealed R37 had severe cognitive impairment and required extensive assistance of two staff with ADL's which included bed mobility, transfers and toileting. The MDS identified R37 was frequently incontinent of both bowel and bladder, was not on a toileting program and a trial toileting program had not been attempted. The MDS identified R37 was unable to maintain her balance during transition without physical assistance. The MDS revealed R37 had one fall with no injury, one fall with injury and one fall with a major injury since the last MDS assessment on 5/7/19. R37's admission Care Area assessment dated [DATE], identified R37 was alert, disoriented and had moderate cognitive impairment. The CAA indicated R37 was at risk for falls and had a history of [REDACTED]. The CAA identified R37 had one fall since her admission, on 1/29/19, and had no injuries. The CAA listed fall prevention interventions which included; staff to ensure R37 wore proper footwear and her call light within reach. The CAA revealed R37 required assistance with toileting, was unable to to express her need to use the bathroom and staff were to anticipate her needs. The CAA identified R37 was incontinent of both bowel and bladder and had a history of [REDACTED]. R37's care plan revised, 8/21/19, identified R37 was at risk for falls related to cognitive deficits. The care plan listed various interventions for fall prevention which included; call light within reach, no foot pedals on wheelchair, body pillow to outside edge of bed for positioning, keep bathroom and bedroom door open at night and have a night light on. The care plan revealed R37 was impulsive, would not use her call light and self-transferred. R37's care plan identified R37 was frequently incontinent of bowel, with loose stools and bladder. The care plan directed staff to assist R37 with toileting every three hours, at midnight and at 4:00 a.m. R37's nursing assistant care guide dated 9/9/19, revealed R37 required assistance with transfers, assist of one with toileting every three hours and offer toileting at midnight and 4:00 a.m. R37's nursing assistant care guide revealed the following safety interventions: no foot pedals on wheelchair, body pillow outside edge of bed, wheelchair and walker next to bed. Further, R37's nursing assistant care guide revealed R37 had chronic loose stools and her bathroom and bedroom door were to be kept open at night with a night light by her bed. R37's Fall Risk assessment dated [DATE], indicated R37 was at risk for falls and had fallen one to two times within the last 90 days, last fall on 1/28/19. The assessment identified R37 had several fall risk factors which included the following; history of one to two falls, change in cognitive status and behavioral changes. The assessment identified R37 ambulated with problems and with devices, required assistance with mobility, maintaining balance and with elimination needs. The risk assessment lacked an analysis of R37's risk factors, patterns of falls, injury with falls or current and attempted interventions. R37's Fall Risk assessment dated [DATE], identified R37 was at risk for falls and had fallen one to two times in the last 90 days, last fall on 2/11/19. The assessment identified R37 had several fall risk factors, which included the following; history of one to two falls, was confined to a chair, was unable to maintain her balance without assistance and required assistance with elimination. The risk assessment lacked an analysis of R37's risk factors, patterns of falls, injury with falls or current and tried interventions. R37's Fall Risk assessment dated [DATE], revealed R37 was at risk for falls and had fallen one to two times in the last 90 days, last fall on 6/20/19. The assessment identified several fall risk factors, which included change in cognitive status/behavioral indicators, ambulated with problems and with devices. The assessment identified R37 was unsteady, though was able to maintain her balance without assistance and required assistance with elimination. The risk assessment lacked an analysis of R37's risk factors, patterns of falls, injury with falls or current and tried interventions. R37's quarterly Fall Assessment Summary dated 8/6/19, identified R37 was at risk for falls, had a history of [REDACTED]. The fall assessment revealed R37's had a fall on 6/20/19, which required R37 to be hospitalized with a subarachnoid hemorrhage. The assessment identified R37 had last fallen 7/31/19. The assessment identified R37 did not verbalize her needs and indicated staff were to anticipate her needs and assist R37 with mobility. Further, the assessment identified fall interventions which included; R37's call light was to be in reach and staff were to remove the foot pedals of her wheelchair and keep R37's room free from clutter. The risk assessment lacked an analysis of R37's risk factors, patterns of falls, injury with falls or current and tried interventions. R37's Fall Risk assessment dated [DATE], identified R37 was at risk for falls and had three or more falls within the last 90 days, last fall on 5/1/19. The assessment identified several fall risk factors, which included R37 ambulated with problems and with devices, was unsteady, though was able to maintain her balance without assistance and required assistance with elimination. The risk assessment lacked an analysis of R37's risk factors, patterns of falls, injury with falls or current and tried interventions. R37's quarterly ADL Assessment Summary dated 8/6/19, identified R37 had dementia with confusion and would not always make her needs known. The assessment identified R37 did not use her call light and frequently self-transferred. The assessment revealed staff were to anticipate R37's needs. R37's medical record lacked any comprehensive assessments of R37's falls. On 9/9/19, at 6:06 p.m. during a telephone interview, R37's family member (FM)-A stated R37 had a long history of falling prior to her admission. FM-A stated R37 had fallen multiple times in the facility since her admission and had been hospitalized from the injuries she had sustained. FM-A stated R37 had been hospitalized at the end (MONTH) 2019, after falling and hitting her head, which had caused a subarachnoid hemorrhage. FM-A indicated R37 had returned to the facility and within a few days had fallen again, hit her head and had a closed head injury (concussion,) which required her to be seen in the emergency room . FM-A stated R37 had received multiple lacerations that required sutures, with the above falls. She indicated R37 had recently fallen again, hit her head and had to be sent to the emergency room for a laceration over the area she had previously injured. FM-A stated she was very concerned for R37's safety and indicated she felt devastated by R37's injuries and felt each time she hit her head, she felt she lost a little more of her mother. FM-A indicated she had requested the facility leave a nightlight on in R37's room at night and to have a sign posted to remind R37 to use her call light for help. FM-A stated the facility had placed a night light by R37's bed and kept her bathroom door open at night. She indicated she felt R37's falls were related to her attempting to use the bathroom and felt R37 was unable to remember to use her call light. FM-A indicated R37 had a long history of loose stools, was frequently incontinent of both bowel and bladder and indicated the staff offered R37 toileting every few hours. However, FM-A indicated she felt staff 's approach of asking R37 if she needed to was not an appropriate approach and felt staff should remind R37 it was time to use the bathroom. On 9/11/19, at 8:14 a.m. R37 was seated in a wheelchair in the dining room. R37 bent over to pick something off of the floor, with her chest to her legs. At that time, another resident seated at her table stated to R37, she needed to sit up before she fell , R37 then sat back in an upright position. -at 8:32 a.m. R37 remained seated in a wheelchair in the dining room, at that time, nursing assistant (NA)-B approached R37, and wheeled her out of the dining room and into her bedroom. NA-B proceeded to assist R37 with toileting needs, R37 walked back to her bed with a walker while NA-B held onto a gait belt. R37 took small measured steps towards her bed and required verbal cues from NA-B to ambulate to the bed. NA-B assisted R37 into her bed, turned on her right side, applied a body pillow to the edge of her bed on the left side, placed her call light within reach and covered R37 with a blanket. NA-B placed R37's walker and her wheelchair next to her bed, a night light was on, and plugged into an outlet towards the end of R37's bed. On 9/11/19, at 9:17 a.m. NA-C stated R37 currently required extensive assistance with ADL's, was very forgetful and self-transferred on a daily basis. NA-C stated R37 was able to follow simple directions and felt R37 would not be able to remember to use her call light. She stated R37 had several falls within the last few months and had recently fallen within the last few weeks in which she had a laceration above her right eye. NA-C stated she felt each time R37 had fallen and hit her head, she was a little bit different, declined and worsened memory. NA-C stated R37 was assisted to toilet every three hours and was unaware of any changes in R37's toileting plan. On 9/11/19, at 1:57 p.m. licensed practical nurse (LPN)-A stated R37 was at high risk for falling, routinely self transferred and felt R37 had poor safety awareness and was impulsive. LPN-A stated R37 had severe cognitive impairment and felt R37 was unable to recall any education provided to her to use her call light. LPN-A stated R37 had several fall interventions in place, which included leaving walker by bedside, proper footwear and a night light. She stated R37 had been hospitalized for [REDACTED]. LPN-A indicated due to R37's self -transfers, they were at a loss of what to do. LPN-A indicated R37 was frequently incontinent of bowel and bladder and was assisted to toilet every three hours, midnight and 4:00 a.m. She stated she was unaware of any changes in R37's toileting program. On 9/11/19 at 6:30 p.m. R37's bedroom door was closed, surveyor knocked, opened the door, which revealed R37 was lying in bed fully dressed on her back. R37's eyes were open, and she had the body pillow placed on her chest with both arms wrapped around the pillow. R37's walker was across the room towards the wall, approximately six feet from her bed, and her wheelchair was approximately three feet from her bed towards the bathroom door. R37's door was partially closed but not latched. At that time, continuous observations were started. -at 6:53 p.m. R37 remained lying on her back, her eyes were open, she continued to hold the body pillow on her chest with both of her arms wrapped around. R37 made no attempt to get out of bed. R37's body pillow was not at the edge of her bed and her door was not open. -at 7:10 p.m. R37 remained lying on her back, her eyes were open, she continued to hold the body pillow on her chest with both of her arms wrapped around. At that time, NA-D entered R37's room, moved R37's walker and wheelchair next to her bed, walked back out of R37's room and left R37's door open. On 9/11/19, at 6:33 p.m. registered nurse (RN)-A stated R37 routinely attempted to self-transfer in the evening and early night shift. She indicated R37 was at high risk for falls, had severely impaired cognition and did not use her call light. RN-A stated R37 had several fall interventions in place which included; positioning pillow, low bed, call light, night light. RN-A stated R37 was on a routine toileting plan every three hours while awake, 12:00 a.m. and 4:00 a.m. RN-A stated during the later evening, early night shift staff would stay close to R37's room in an attempt to catch her self-transferring. However, RN-A indicated staff were not always able to do so. On 9/11/19, at 6:40 p.m. NA-A stated R37 required extensive assistance with ADL's of transfers, bed mobility, ambulation and toileting. NA-A stated R37 self-transferred on a daily basis and as recently as that afternoon. She indicated R37 would frequently try to get to the bathroom when she self-transferred and was occasionally incontinent of bowel and bladder. She indicated R37 preferred to go to bed between 6:00 and 6:30 p.m. and would often get up a few hours later and try to use the bathroom. NA-A confirmed R37's bedroom door had been closed upon entering the unit and indicated R37's bedroom door was kept open, once the hallway lights were turned off. Further, NA-A stated R37 would often shut her bedroom door when she self-transferred. On 9/11/19, at 6:33 p.m. NA-D confirmed R37's door had been closed and latched and indicated R37's door was to remain open during nighttime hours. She indicated R37 would routinely shut her door when she self-transferred and stated if she walked past R37's room and saw the door shut, she would open it. NA-D stated she had witnessed R37 had self-transferred the night prior, at approximately 2:00 a.m. and indicated it was not unusual for R37 to self-transfer to the bathroom. NA-D stated R37 would not use her call light to go to the bathroom, but would put on her call light to get up from the toilet. NA-D indicated R37 had various fall prevention interventions in place which included; keeping her door open, body pillow to edge of bed, night light, gripper socks and toileting at midnight and 4:00 a.m. On 9/11/19, at 8:38 p.m. NA-B stated R37 currently required extensive assistance with ADL's of transfers, bed mobility, ambulation and toileting. NA-B stated R37 had several falls since her admission and had been hospitalized for [REDACTED]. NA-B stated R37 was unable to remember to use her call light and staff needed to anticipate her needs. NA-B indicated R37 was on an every three hour toileting plan, where she was offered to use the bathroom. She indicated R37 attempted to transfer herself on a daily basis, most recently the prior day. NA-B stated she liked to peek in on her every few hours to make sure R37 had not self-transferred. Further, NA-B indicated the following fall interventions were to be in place for R37; body pillow, night light, call light, wheelchair and walker next to her bed and proper footwear. Review of R37's Incident Details reports from 1/29/19, to 8/31/19, revealed the following: -1/29/19, at 5:00 a.m. found on the floor of her room, calling out for help and was incontinent, though report lacked type of incontinence. The report revealed R37 was disoriented and was unable to state what she had been attempting to do at the time of the fall. The report revealed R37 required limited assistance with ambulation at the time of the fall and had sustained no injuries. The report revealed and interdisciplinary team (IDT) review of R37 's fall identified the following; R37 had presumably self-transferred to use the bathroom and would be toileted every three hours. -2/9/19, at 7:00 p.m. found on the floor of her room on lying on her back and was disoriented. The report revealed R37 had no injuries, and had been watching television in the dayroom prior to the fall. The report revealed an IDT review of R37's fall identified the following; R37 needed to have a bowel movement, had a history of [REDACTED]. The report indicated the facility R37 would try Activia yogurt twice daily for two weeks to increase normal flora. The report lacked a comprehensive analysis of R37's fall to determine a root cause analysis, such as environmental factors, incontinence at the time of the fall, and identify a potential pattern of falls. -2/11/19, at 5:45 p.m. found seated on the floor of her room in front of her bed with the lights off. The report revealed R37 had been calling out for help and had her right foot caught between the foot pedal and the front of her wheelchair. The report revealed R37 appeared to have self-transferred and became entangled in the foot pedal and indicated R37 had no injuries. IDT review of R37's fall identified R37 had attempted to stand and her foot was caught in the foot pedal and revealed R37's care plan had been followed at the time of the fall and would be updated to remove R37's wheelchair foot pedals. Further, the IDT review revealed R37's wheelchair would be lowered so her feet could touch the floor. -6/20/19, at 1:21 p.m. found on lying face down on the floor of her room in a puddle of blood. The report identified R37 had a laceration over her right eye and had been incontinent of bowel. The report revealed R37 had been toileted 30 minutes prior to the fall. IDT review of R37's fall identified she had been attempting to self-transfer to the bathroom for a bowel movement and had been sent to the emergency room for evaluation. The report revealed R37's care plan had been followed at the time of the fall and R37 would be reassessed upon return from the hospital. The incident detail report lacked comprehensive analysis of R37's fall to determine a root cause analysis and identify a potential pattern of falls. -6/27/19, at 9:00 p.m. found lying on her left side on the floor of her room and had a laceration above her left eye. The report revealed R37 was alert though unable to explain what had happened and revealed R37 had been sent to the hospital for evaluation. The report revealed an IDT review of R37's fall had been completed on 7/1/19, and identified R37 had self ambulated to use the bathroom. The IDT review revealed staff would assess and modify R37's toileting plan. The report lacked comprehensive analysis of R37's fall to determine a root cause analysis, such as environmental factors, incontinence at the time of the fall, and identify a potential pattern of falls. -7/17/19, at 9:15 p.m. found on the floor of her room lying on her right side next to her bed. The report revealed R37 had been calling out for help, attempted to get off of the floor independently, was alert and oriented. The report revealed R37 had apologized and indicated she had wanted to get up. The report indicated R37 had no injuries, was taken out of her room in a wheelchair, given a snack and assisted back to bed after one to two hours. The report revealed R37 was reminded to ask for assistance with transfers and R37 had stated, sometimes people forget that they can't walk anymore. IDT review of R37's report dated 7/19/19, identified R37 had returned to her baseline with ambulation, transfers, had dementia and did not call for assistance. The report revealed R37's walker and wheelchair would be kept next to her bed. The incident detail report lacked comprehensive analysis of R37's fall to determine a root cause analysis, such as environmental factors, incontinence at the time of the fall, and identify a potential pattern of falls. -8/31/19, at 3:45 a.m. found on the floor of her room on her right side next to her bed, had a laceration above her right eye and had indicated she needed to use the bathroom when asked. The report revealed it appeared R37 had self-transferred to go to the bathroom and rolled over her body pillow and fell on the floor. The report revealed R37 had been sent to the hospital for evaluation. IDT review of R37's fall dated 9/3/19, identified R37 had attempted to go to the bathroom. The IDT review revealed R37 would be offered to toilet at midnight and 4:00 a.m. and indicated R37's toileting plan would be reviewed. The incident detail report lacked comprehensive analysis of R37's fall to determine a root cause analysis, such as environmental factors, incontinence at the time of the fall, and identify a potential pattern of falls. R37's medical record lacked a comprehensive assessment of any of the seven aforementioned falls which included root cause analysis, determination of any patterns of the falls, review of current interventions for appropriateness and routinely implementing fall interventions. R37's admission Bowel and Bladder assessment dated [DATE], identified R37 was frequently incontinent of both bowel and bladder and had a current urinary tract infection and history of loose stools. The assessment identified R37 had dementia and was unable to express her need to toilet. The assessment revealed R37 was to be toileted per schedule. The assessment did not identify R37's toileting schedule at the time of the assessment. R37's Bowel and Bladder assessment dated [DATE], identified R37 was frequently incontinent of both bowel and bladder and had a current urinary tract infection and history of loose stools. The assessment identified R37 had dementia and was unable to express her need to toilet. The assessment revealed R37 was assisted with toileting. The assessment did not identify R37's toileting schedule at the time of the assessment. R37's Bladder assessment dated [DATE], identified R37 was frequently incontinent of both bowel and bladder and had a current urinary tract infection and history of loose stools. The assessment identified R37 had dementia and was unable to express her need to toilet. The assessment revealed R37 was assisted with toileting every three hours. R37's quarterly Bladder Assessment Summary dated 8/6/19, identified R37 was frequently incontinent of urine. The assessment revealed R37 had been hosptalized on [DATE], and had been found to have a urinary tract infection. The assessment identified R37 had dementia and was unable to express her need to toilet and staff were to assist R37 with toileting every three hours, at midnight and at 4:00 a.m. Further, the bladder assessment identified staff were to anticipate R37's toileting needs. R37's Bowel assessment dated [DATE], identified R37 had frequent loose stools, received scheduled [MEDICATION NAME] (stool bulking agent,) and was assisted to toilet every three hours, midnight and 4:00 a.m. R37's quarterly Bowel Assessment Summary dated 8/6/19, identified R37 was frequently incontinent of bowel, with loose stool, had dementia and was unable to express her needs. The assessment revealed R37 was assisted to toilet by staff every three hours. R37's medical record lacked any further comprehensive assessments of R37's bowel and bladder incontinence and did address any possible correlation with R37's bowel and bladder incontinence and her repeated falls. Review of R37's progress notes from 2/9/19, to 9/3/19, identified the following: -2/9/19, self -transferred and ambulated several times throughout the day. The notes revealed R37 was reminded to call for assistance. -2/10/19, self-transferred and ambulated independently throughout the day. The notes revealed R37 was reminded to call for assistance. -2/12/19, R37's family member voiced concerns to nurse manager regarding R37's falls at the facility. R37's family member revealed R37 had multiple falls at home and indicated she had provided 24 hour supervision of R37 for fall prevention. The note revealed R37's family member requested to have a sign posted in R37's room to call for help. -2/13/19, self transferred to the bathroom several times throughout the day. A later note revealed R37 was restless and was in and out of bed several times throughout the evening. -2/15/19, found up out of bed in her room by herself, was assisted to the bathroom and reminded to use her call light. -2/19/19, restless, attempted to transfer herself to bed, chair and toilet several times throughout the day. -2/23/19, restless, up and down numerous times throughout the night. The note revealed R37 had been found seated at the edge of her bed four times, was up walking around twice and was caught self-transferring twice. Further, the note revealed R37 had denied the need to use the bathroom. A later note revealed R37 continued to be found walking around and self-transferring numerous times throughout the shift. -2/27/19, up several times self-transferring and ambulating throughout the night. The note revealed staff re-educated R37 on the use of her call light and indicated R37 was unable to remember to use her call light. -3/17/19, routinely self-transferred from her wheelchair to her bed after meals. -3/19/19, routinely wheeled herself back to her room, would self-transfer herself into bed without staff assistance or knowledge. -6/19/19, R37's family member was offered to have R37 move to different room with a single bathroom. R37's family member agreed. -6/24/19, a fall on 6/20/19, her slippers were found to not have a grip on the bottoms. The note indicated R37's slippers were removed from her room. -6/26/19, found attempting to self transfer from her wheelchair to her bed following the evening meal. -7/7/29, continued to attempt to self-transfer. -8/2/19, found up in out of bed in her wheelchair, wheeling around in the hallway independently and was assisted back to bed. -8/3/19, found up five times since going to bed, was easily redirected and slept for three hours at a time. -8/22/19, up three times throughout the night, had removed her body pillow, brief and self-transferred to the bathroom. -8/26/19, found by staff self-transferring into the bathroom. The note revealed R37 had indicated she was following the voices, was assisted to toilet and back to bed. -8/28/19, up self-transferring at least four times throughout the night, staff had caught her four times, assisted with toileting and back to bed. On 9/12/19, at 8:02 a.m. R37's medical record was reviewed with nurse manager (NM)-[NAME] She confirmed R37's falls had not routinely been comprehensively assessed to include information such as R37's toileting needs, incontinence, safety awareness and cognition. NM-A confirmed six out of seven of R37's appeared to be related to toileting needs and incontinence. NM-A indicated the following fall interventions had been attempted for R37; staff to toilet every 3 hours, at midnight and 4:00 a.m., body pillow at the edge of the bed, night light, walker and wheelchair at bedside and frequent checks and leaving her bedroom door open at night. She indicated R37 had chronic loose stools and they had been attempting to get her bowels under control. NM-A confirmed R37's falls assessments had not routinely had a root cause analysis completed, nor had a pattern been identified, such as toileting, time of day, pain, thirst, hunger and need to ambulate. NM-A confirmed R37's falls had a pattern related to toileting, evening, after meals and at night. R37's hospital History and Physical dated 6/20/19, identified R37 had been air lifted to the hospital for trauma care as a result of a fall. The history and physical identified R37 had a CT scan which revealed a subarachnoid hemorrhage, and a laceration above her right eye which had been sutured. The history and physical revealed R37 was admitted to the hospital, would be consulted by neurology, started on [MEDICAL CONDITION] precautions as a result of her injury. R37's emergency room After Visit Summary dated 6/27/19, identified R37 had been seen in the emergency department due to a fall with a laceration. The summary revealed R37 had a closed head injury, concussion and had CT imaging completed. On 9/12/19, at 8:29 a.m. during a joint interview with the director of nursing (DON) and NM-B, NM-B stated R37 was very impulsive and routinely self-transferred. NM-B indicated she was unsure if there was any type of pattern to R37's falls and indicated she would have to review with NM-[NAME] The DON indicated she was not familiar with any of R37's falls. At that time, R37's incident detail reports were reviewed with the DON, the DON stated R37's falls appeared to have a pattern related to toileting and indicated she would expect R37's toileting to be reviewed. She indicated she felt facility staff had attempted to determine a root cause of R37's aforementioned six falls. On 9/12/19, at 9:25 a.m. R37's primary nurse practitioner (NP)-A stated she was unsure of how many falls R37 had had since her admission, though she indicated R37 routinely self-transferred. She indicated she had been in the facility in (MONTH) when R37 had fallen in her room and sustained a subarachnoid hemorrhage. NP-A indicated she would expect facility staff to complete comprehensive fall assessments which included determining root cause, any patterns and identify appropriate interventions. NP-A she expected R37's falls to be reviewed and the following potential impacting conditions; toileting needs, bowel pattern, medication review. Review of a facility policy titled, Fall Prevention and Management, reviewed 4/12/17, identified the facility would assess each resident for their fall risk on admission, quarterly and with any significant changes in condition and will identify interventions to help prevent falls, and/or to prevent injuries from falls. The policy identified if a fall occurred, staff would conduct a root cause analysis to identify interventions to prevent subsequent falls and/or injury from further falls. The policy identified the the facility would complete a fall risk assessment on admission, quarterly and with any significant change MDS. The policy indicated a post fall assessment would be completed following resident fall. The immediate jeopardy that began on 6/27/19, was removed on 9/13/19, when the facility completed a comprehensive fall risk assessment for R37 which included a root cause and patterns with R37's falls. The facility completed a comprehensive bowel and bladder assessment for R37, identified a pattern of incontinence and implemented an updated toileting plan. The facility assessed current fall interventions for appropriateness, and implemented the following fall interventions; 30 minute safety checks, a video monitoring system with motion sensor, pressure sensitive call light button would be placed next to R37 while she was in bed. The facility ensured interventions were in place and licensed nursing staff were educated on (TRUNCATED)