Every finding on record at Apple Valley Village Health Care Center

Based on interview and document review, the facility failed to ensure a physician order was processed timely for 1 of 3 residents (R1) who was ordered scheduled tube feeding free water flushes to mitigate the risk of dehydration. This resulted in R1 not being administered these flushes for approximately 48 hours.Findings include: R1's Nutritional Assessment, dated 12/11/25, identified R1 as NPO (nothing by mouth) and dependent on tube feeding for fluid and nutritional intake in response to swallowing difficulties associated with Alzheimer's dementia and severe protein/calorie malnutrition. R1's estimated daily fluid needs averaged from 1440 to 1800ml (milliliters). Approximately 821ml of her daily fluid intake was provided via tube feeding formula, and the remaining 619ml to 979ml was from a combination of scheduled free water flushes and flushes provided in relation to medication administration. A hospital Discharge summary, dated [DATE], identified R1 returned to the facility after being treated for, but not limited to, sepsis (severe immune response to infection or injury that can lead to organ failure and death), pneumonia, and severe dehydration. R1 was ordered free water flushes 60ml every four hours. An order, dated 2/11/26, indicated a new order for 150ml free water flushes six times a day. R1's February 2026, Medication Administration Record (MAR), identified that on 2/12/26, at 8:00 a.m., R1 was administered a 150ml free water flush. A progress note, dated 2/12/26, identified R1's fluid needs were assessed by the registered dietitian (RD), and indicated R1's fluid needs would be better met with 225ml free water flushes four times a day, and to avoid flushes at night. A telephone order (TO), dated 2/12/26, ordered by physician assistant (PA)-A, and transcribed by RD-A, directed R1 to be administered 225ml free water flushes four times a day via her feeding tube and the 150ml flushes were discontinued. The order identified this was verified; however, the date, and time, of verification was not present. A General Order audit report, identified that on 2/12/26, at 12:03 p.m., RD-A created/transcribed the flush order into the electronic medical record MAR. This order directed the flushes to be administered four times a day (between 7:00 a.m. - 8:00 a.m., 10:00 a.m. - 11:00 a.m., 1:00 p.m. - 2:00 p.m., and 4:00 p.m. - 6:00 p.m.). Based on the order entry time, there was potential for R1 to receive the first flush with this order between 1:00 p.m. and 2:00 p.m. R1's February 2026 MAR, identified 2/12/26's administration time frames for 1:00 p.m. to 2:00 p.m., and 4:00 p.m. to 6:00 p.m. had an x symbol for each time frame. Additionally, 2/13/26's time frames for 7:00 a.m. - 8:00 a.m., 10:00 a.m. to 11:00 a.m., and 1:00 p.m. to 2:00 p.m., were blank. The 2/13/26, 4:00 p.m. to 6:00 p.m., time frame indicated: Reason: Not Administered: Other Comment: pm shift. The General Order audit report for the 2/12/26 flush order change, identified that on 2/13/26, at 11:16 p.m., licensed practical nurse (LPN)-A verified the order (approximately 35 hours after the order was placed). R1's February 2026 MAR, identified it was not until the following morning on 2/14/26, between 7:00 a.m. and 8:00 a.m., that R1 received a scheduled free water flush after the last administered scheduled flush on 2/12/26, at 8:00 a.m. (approximately 48 hours later). This resulted in a potential 1350ml fluid deficit for R1 in relation to the untimely order processing. When interviewed on 3/5/26, at 1:11 p.m., RD-A stated that once she assessed the resident's nutritional and fluid needs and determined, often with consultation of the primary provider, an adjustment was needed, she entered the order into the system and alerted the floor nurse so that the order could be verified, which she expected to occur the same day as the order was provided. RD-A was unaware of any order processing concerns related to R1 and was not aware that R1 potentially missed seven free water flushes after she transcribed the order. RD-A identified she alerted R1's primary nurse of the order change on 2/12/26 but was unable to remember which nurse. RD-A stated, as R1 received approximately 800ml of water from the tube feeding formula each day, and water during the medication administration process, she was not overly concerned about R1 having become dehydrated to the point of needing hospitalization. When interviewed on 3/5/26, at 1:39 p.m., the director of nursing (DON) stated that an order entered around 12:00 p.m. was expected to be verified by a nurse within a couple of hours. Once an order was transcribed into the system, i.e. MAR, the system flagged staff with an alert when the MAR was opened. The DON identified R1 for sure should have had the order verified on 2/12/26 in prep for the 4:00 p.m. to 6:00 p.m. free water flush time frame, as the facility was expected to ensure residents who require tube feeding for hydration received the fluids as ordered and were adequately hydrated. She added that R1's flushes would not have been ordered if not needed. The DON explained, after R1 was readmitted to the hospital on [DATE], hospital staff contacted her about possible feeding and flush concerns for R1. She stated her investigation into this was concern free; however, she stated she was more focused on looking for any administration refusals and that staff signed off the feeding and flushes versus reviewing order processing. When the DON was updated on the order verification timeliness, she stated this was not their process and again she expected such orders to be processed timely as expected. The DON denied a routine audit process for such concerns but identified this was completed if there was a need such as noticed trends or identified issues. She denied any recent audits, or any recent trends or identified issues. When interviewed on 3/5/26, at 1:58 p.m., LPN-B stated once she was updated by the RD that orders were adjusted, she was expected to ensure the order was verified as soon as possible, or at least for sure before the end of her shift. At times, this was unable to be accomplished, and the task was then passed on to the next nurse for verification. LPN-B indicated there was a notification in the MAR for pending orders. Once she acknowledged this after verifying the order, the order would be pushed to the MAR for administration, and the notification would go away. LPN-B stated there was a shift where RD-A updated her about changes to R1's increased fluids after R1's return on 2/11/26; however, she did not remember the date details but did not think it was right after R1 returned. LPN-B explained she double checked this order in the system and followed the expected processes. She does not recollect any concerns with the order. LPN-B stated, as R1 was NPO, missed water flushes were a concern due to the risk of dehydration but not a significant issue as she also received fluids from other sources throughout the day. When interviewed on 3/5/26, at 2:48 p.m., LPN-C stated orders were typically transcribed by the health unit coordinator (HUC) and once transcribed, nurses were expected to verify the order(s) as soon as possible, or at least by the end of their shift. This was the same if she was to see the MAR notification for pending orders. LPN-C explained there were days, about three out of the seven, where orders were left for the evening shift that she felt the day shift could have verified. LPN-C stated, if she noticed a resident did not have flushes ordered, she would look for any updated orders and if none, would update the provider immediately, as this would concern her from a resident dehydration standpoint. LPN-C was shown R1's MAR related to the missed flushes. She commented, That is very odd. I would have flushed her. I would have flushed her out of habit, as she very much knows [R1]. When interviewed on 3/6/26, at 10:24 a.m., HUC-A identified admission and readmission orders took priority over any other orders. Next, if stat order or time-sensitive orders were provided, she then processed those before the remaining orders. For dietary related orders, such as water flush adjustments, she stated the RD typically transcribed those into the system and then a nurse verified. Thus, she did not participate in those orders; however, when such orders were placed in the scanning bin after nurse verification, she double checked to see if the transcribed by and verified by sections on the order sheet were initialed. If not, she gave the sheet back to the nurse. She stated some of the dietary orders came back to her not verified and she again placed them in the to be verified bin. She did not review this bin to ensure orders were being verified once she placed the transcribed orders into it. HUC-A was unaware of what the expectations for order processing timeliness was but identified if a dietary order was transcribed by the RD at noon, there was no reason why the nurse could not verify it by 4:00 p.m. or 5:00 p.m. that same day. HUC-A stated, due to high admissions and days when visiting providers dropped off orders closer to the end of her shift, she had to pass on the orders for the evening nurses to transcribe and verify. She did not follow up on these orders to ensure they were completed. HUC-A was unaware of any order processing concerns related to R1. When interviewed on 3/6/26, at 10:45 a.m., registered nurse (RN)-A stated the nurses were expected to verify orders as soon as possible when they were placed by the HUC in the verification bin, or when they were alerted of a pending order notification in the MAR. She stated that orders should not be sitting with a pending order status for days, as staff were expected to follow any new orders. RN-A explained this happens sometimes, when orders sit for longer than expected. RN-A identified R1 was at risk of dehydration and needed to have the flush order implemented as soon as possible after it was provided. RN-A explained there was a possible concern with R1 not receiving her fluids as ordered after she was re-hospitalized ; however, when she reviewed R1's chart upon investigation, concerns were not identified. When interviewed on 3/6/26, at 11:06 a.m., RN-B stated orders were to be verified right away. She explained that any transcribed order remained unfinished until the nurse verified it. Only then did the order flow into the MAR for the nurse to follow. RN-B stated any flush orders for R1 for sure needed to be processed as expected as R1 did not receive that many medications so her water flushes at those times did not provide her with much water during the day. This, along with her feeding being scheduled for the night hours, increased R1's risk for dehydration during the day hours. When interviewed on 3/6/26, at 11:22 a.m., physician assistant (PA)-A stated she was unaware of what the facility expectations were related to order process timeliness. She stated she would expect staff to follow whatever the facility's policy is. PA-A explained she did not review when orders were processed and/or verified, and she was unaware of any recent concerns related to this process. When R1's 2/12/26 flush order was reviewed with her, PA-A stated this order should have been verified before it was: two days seems long. PA-A indicated that if R1 truly did not get these flushes as ordered, this potentially increased her risk of dehydration. When interviewed on 3/6/26, at 12:41 p.m., LPN-A stated the order process was a disaster. She explained that often she had to fix orders when she verified them or had to process orders that were not done on the day shift by the HUC. She identified she had to process and/or verify orders every day when she worked, even orders for residents that were not hers, as some of the evening staff felt it was the HUC's responsibility to process orders, not theirs. LPN-A identified there often were times when she processed/verified orders from the day prior to time frames longer than that. She indicated there was one order in January or February that was left for a week before it was taken care of. LPN-A identified the HUC always appeared to only work on admission orders and LPN-A was unsure what the priority for order processing was and orders seemed secondary to other things the nurses were required to do. LPN-A stated she had yet to talk to the DON about her concerns; however, she had spoken to a charge nurse. When updated about R1's 2/12/26 flush order, she exclaimed, Oh my god! She explained R1 was NPO and thus a risk for dehydration. She stated, she felt there were some questions around a flush order, but she could not remember the details. Additionally, she could not recollect any concerns that surrounded the timeliness of any of the orders for R1 that she may have verified, but the situation explained to her during the interview did not surprise her. A Transcription of Orders policy, dated 2/12/24, directed that after an order was transcribed, the transcriber was to write 'transcribed by, their name, title, date, and time.' The facility was to have a system that allowed communication to the nurse when orders were entered and required verification. The nurse that verified the order was to review order documentation and ensure the full transcription of the orders were completed and accurate before they updated the electronic health record with an order acknowledgement verification. Additionally, they were to make a progress note that new orders were received and direct the viewer to see the chart. The policy lacked information as to when order transcription and/or verification was to be completed.

Based on interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 5 residents (R79) reviewed for unnecessary medication use and who consumed antipsychotic medication. Findings include: A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension . [which can] lead to dizziness, syncope, falls . it should be evaluated by both history and measurement . Risk factors include systemic diseases causing autonomic instability (e.g., diabetes, alcohol dependence, Parkinson's disease), dehydration, drug-drug interactions, and age. R79's quarterly Minimum Data Set (MDS), dated [DATE], identified R79 had moderate cognitive impairment and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS recorded R79 consumed both antipsychotic and antidepressant medication(s). R79's View General Order, printed 6/25/25, identified a current nursing order which read, Complete orthostatic blood pressure and pulse d/t use of antipsychotic medication, with a frequency listed, Once a day on the 20th of Every 3rd Month. The order continued and listed instructions which read, Enter lying, sitting, and standing BPs and Pulse under vital signs separately AND put in progress note, The order had a start date recorded, 11/20/2024. R79's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 2/2025, identified R79's recorded medication administrations and treatments for the period. The MAR listed the nursing order to complete the orthostatic blood pressure and pulse, along with spacing to record data for these collected vital signs with a date of 2/20/25. However, only a single blood pressure was listed which read, 141/67, and the MAR lacked what position R79 was in when it was obtained (i.e., lying, sitting, standing). R79's corresponding Search Vital Results, dated 1/2025 to 6/2025, only recorded the same reading of, 141/67, on 2/20/25 and also lacked information on which position R79 was in when the reading was obtained. R79's MAR and TAR, dated 5/2025, identified the same nursing order and spaces to record data for the collected vital signs with a date of 5/20/25. However, again, only a single blood pressure was listed which read, 125/60, and the MAR lacked what position R79 was in when it was obtained (i.e., lying, sitting, standing). R79's corresponding Search Vital Results, dated 1/2025 to 6/2025, only recorded the same reading of, 125/60, on 5/20/25 and also lacked information on which position R79 was in when the reading was obtained. On 6/24/25 at 1:52 p.m., registered nurse (RN)-C was interviewed, and verified they had worked with R79 prior. RN-C explained R79 was not ambulatory, however, he did transfer using a stand-by assist and did bear weight for them. RN-C stated R79 had some troubles with communication and often times wouldn't converse with staff adding, He doesn't talk. RN-C stated R79 had not complained about dizziness or lightheadedness with transfers to their knowledge. RN-C explained orthostatic blood pressures were done only if ordered on the MAR or TAR, and expressed R79 did not have an order for them to their knowledge. RN-C reviewed R79's MAR in the medical record (June 2025) and stated it lacked direction to complete orthostatic blood pressures adding, We don't have an order for that. RN-C stated they obtained R79's blood pressure earlier that day, on 6/24/25, and it had been 146/66 which RN-C stated a little high for him. R79's medical record, including progress notes, was reviewed and lacked evidence R79 had a complete set of orthostatic blood pressures obtained or checked within the past several months, nor was there documented rationale for the lack of a complete set of them, despite R79 consuming antipsychotic medications. On 6/24/25 at 3:10 p.m., registered nurse unit manager (RN)-B was interviewed, and verified they had reviewed R79's medical record. RN-B stated R79 consumed Risperdal (antipsychotic) and they were unable to locate any complete sets of orthostatic blood pressures documented in the record for the past several cycles when due (i.e., [DATE], May 25) adding aloud, I did not [find any]. RN-B stated the floor nurses should be obtaining the orthostatic blood pressures and entering them into the medical record per the nursing order. RN-B reviewed R79's medical record and verified R79 transferred with a stand-by assist and expressed, He does bear weight [with them]. RN-B stated staff should document rationale for why, if applicable, they were unable to complete the orthostatic blood pressures; however, again this was not found, either. RN-B stated R79 had sustained a few falls within the past several months, including during episode of self-transfers, and it was important to obtain orthostatic blood pressures as it was in our policy to do so and for the best interest of the patient. When interviewed on 6/25/25 at 10:51 a.m., the director of nursing (DON) stated a complete set of orthostatic blood pressures should be obtained every 90 days and recorded in the medical record. DON stated they completed a house-wide audit of this process the day prior when the issue arose during survey and were working on potentially adjusting their order set to better capture the data. DON acknowledged R79 had several falls within the past few months and expressed R79 seemed to ebb and flow with mobility adding, at times, he would be more mobile and anxious. DON verified they reviewed R79's medical record, including fall reports, and were unable to locate any orthostatic blood pressures being done or attempted since November 2024. DON reiterated they should be completed every 90 days in accordance with their policy on antipsychotic medication use which was developed in collaboration with their corporate pharmacy. This was important to do as the medication can have a major effect on their blood pressure and increase the risk of falls. A facility provided Psychotropic Medication Monitoring policy, dated 4/2025, identified a section labeled, Antipsychotic, and directed, 1. Orthostatic blood pressures are checked monthly X 3 with new antipsychotic orders . then quarterly for residents on antipsychotic medications if the resident is physically able to participate in Orthostatic [sic] BP measurements.

Based on observation, interview, and document review, the facility failed to ensure activities of interest were consistently offered, provided and documented within the medical record to support ongoing engagement and continuity of care for 2 of 2 residents (R58, R321) reviewed for activities and who resided on the transitional care unit (i.e., TCU). Findings include: R58 R58's admission Minimum Data Set (MDS, dated [DATE], identified R58 admitted to the care center on 6/2/25, and she had moderate cognitive impairment but demonstrated no delusional thinking during the review period. The MDS recorded under Section F - Preferences for Customary Routine and Activities that R58 felt it was Very important to do her favorite activities and keep up with the news; and she felt it was Somewhat important to have books, newspapers, or magazines and do things with group(s) of people. On 6/23/25 at 1:59 p.m., R58 was observed lying in bed while in her room. R58's eyes opened with audible interaction, and R58 stated she had been at the care center for just about 24 hours she thought. R58 had one visible, red-colored Word Search on her bedside dresser which was placed underneath various items such as other papers and a package of disposable wipes. R58's lacked any visible activities calendar on the wall. R58 stated she was not sure what, if any, activities she had been attending and expressed she mostly rests she thought. R58 stated she didn't recall anybody offering to take her to activities but added she'd like to go to them, if offered, adding aloud, Oh, of course! R58 stated she enjoyed many activities prior to coming to the care center such as going for walks, light exercises, and reading and doing puzzles. R58's Therapeutic Activities Observation, dated 6/3/25, identified the evaluation as, Initial Activities Assessment, and recorded R58 as having an anticipated length of stay as, Less than 3 months. The evaluation recorded R58's demographic information (i.e., statistical data) and identified R58 as being Lutheran and attending services prior to admission. R58's preferred activities' program style was recorded as, Large Groups, and Independent leisure. The option reading, One to One [1:1], was left unchecked. A section labeled, Describe resident's past interests, outlined R58 enjoyed participating in her senior community, playing board games, visits with family and watching television. The evaluation continued, [R58] is interested in music entertainment, social events and attending worship services. Independent leisure interests include watching TV, reading books she has brought with her, and TP [therapeutic programming] library books, going outside with family when weather is good and family visits. The evaluation directed, Initiate care plan. R58's corresponding Therapeutic Activities progress note, dated 6/3/25, identified staff met with R58 and welcomed her to the TCU. R58 was provided a community newsletter and . TP Things To Do flyer. The staff recorded they answered questions about activities and outlined, [R58] is here for short term rehab and has interests in group and independent pursuits during his/her stay . is interested in music entertainment, social events and attending worship services . leisure interests include watching TV, reading books she has brought with her and TP library books . R58's activities care plan, initiated 6/22/25, identified R58 was at the care center for short-term rehab and, again, outlined her interests in group and independent leisure activities. The plan listed a goal which read, Resident will participate in activities of choice, along with three interventions including, Invite and remind of programs, and Offer activity schedule. When interviewed on 6/24/25 at 1:31 p.m., nursing assistant (NA)-A stated they had worked with R58 prior and explained R58 needed help with transfers and most cares. NA-A was asked what, if any, group activities R58 attends and NA-A responded, Therapy [PT/OT]. NA-A stated they had not observed R58 to attend any group activities or events while on the TCU and reiterated aloud, PT/OT. NA-A stated the TCU did have a dedicated activities staff member; however, they were unsure of their name. NA-A stated R58 had never verbally complained about being bored to them, however, when asked how R58 seemed to spend their day when not with therapy NA-A responded aloud, mostly nap and then watch the TV. R58's POC (Point of Care) History Report (3 Records), dated 6/2025 and provided by the therapeutic activities director (TAD), identified R58 had only three (3) activities recorded as being completed since admitting to the care center on 6/2/25 (over 20 days prior). These were recorded as three separate 1:1's completed on 6/4/25, 6/12/25, and 6/16/25 with their length being 15 minutes, 40 minutes, and 10 minutes, respectively. The provided report lacked any evidence of what, if any, group-based activities (i.e., music, worship services) had been offered or attended by R58 despite these being identified as activities she was interested in. Further, R58's entire electronic medical record (EMR) was reviewed and lacked evidence R58 had been consistently invited, offered or attended any additional activities (including in-room activities like puzzles) outside of the three recorded 1:1 sessions since admitting to the care center. On 6/25/25 at 9:42 a.m., the TAD was interviewed and R58's POC History Report reviewed. TAD explained there were two people who assisted with activities on the TCU, and they visited residents upon admission to do an initial interview about their interests which is then recorded on an internal checklist. The staff then review that checklist and compare it to which residents expressed interest in which type of activities to help determine who is invited to them. TAD reviewed R58's medical record and verified it outlined R58 expressed interest in music entertainment, social events, and attending worship services. However, TAD expressed only physically attended activities were recorded in the medical record (i.e., POC History Report) and there was no system to record offered and/or declined activities adding aloud, Those are things that are not documented. TAD verified R58's medical record only have three 1:1 recorded since she admitted to the care center, and expressed a majority of residents on TCU were more therapy-focused instead of activities-focused. TAD stated they had visited with their assistants on the TCU who expressed they had stopped and talked to her [R58] multiple times but, again, acknowledged these visits were not documented within the medical record. TAD stated R58 having three recorded 1:1 completed seems good, and expressed if someone, including R58 or staff who work with her, had expressed concerns about R58 need greater engagement then they would have re-visited it with R58; however, nobody had ever reported concerns to the activities department to their knowledge. TAD explained each resident on the TCU was given a community news letter which had an included activities calendar. TAD reviewed the June 2025 calendar and verified it had multiple, scheduled music programs and social events listed on it since R58 admitted , however, again, TAD acknowledged none of these were recorded in the record as being offered or attended. TAD explained documenting offers to attend and refusals for activities were something that had gone back and forth with the corporate level but their philosophy was to solely document the ones attended adding, The emphasis has not been on the refusals, [but] has been on the actual engagements. TAD stated the only 'proof' to show R58 was being offered activities was based on word of mouth, and again expressed, I don't have anything in writing. TAD acknowledged activities were important and expressed making sure residents were invited and attending them was important as it's our mission to meet their needs. TAD added, [Activities] helps their fullness of life. TAD then expressed they amended their process recently to do a routine 30-day follow-up note (i.e., progress note) on TCU residents where they review attendance and engagement; and from this they could re-[NAME] their care plan to ensure more activities involvement. TAD and the surveyor then reviewed a sample of other residents who had resided on the TCU since admission and had been present for over 30 days. A total of four (4) residents were reviewed and all of these lacked any completed 30-day note(s) in their record. TAD stated, We may have missed some of them, adding further, There's something going on with that process that doesn't seem to be happening. Later, on 6/25/25 at 12:43 p.m., TAD e-mailed the surveyor with a note, I checked with my activity assistant and found she has some additional document about inviting residents to programs. It is not part of the medical record, but she keeps a notebook. Would you be interested in seeing it? On 6/25/25 at 12:55 p.m., TAD and the activities assistant (TAA) were interviewed, and TAA explained they started keeping a notebook on their own accord as they had repeatedly had issues hooking up with residents for activities. TAA and the surveyor reviewed this notebook, which was a small, spiral top notebook that had columns written on the pages with included room number(s) along with days of the week outlined across the top. R58's room was located on these pages and identified a series of symbols (i.e., 'S' and 'O') which TAA explained in chronological order. This included: Week of 6/2/25 to 6/6/25 was reviewed. On 6/3/25 and 6/4/25, a handwritten, N/I, was written which TAA stated meant R58 was not interested in activities. On 6/5/25, nothing was recorded, and the space was left blank. On 6/6/25, a handwritten, w/ aide [NA], was written. However, this notebook did not include documentation or symbols to show the 1:1 which had been recorded in the POC History on 6/4/25; nor did the notebook outline if R58 was reproached about activities on 6/6/25. Week of 6/9/25 to 6/13/25 was reviewed. On 6/9/25 and 6/10/25, these dates each had a one symbol which looked like a circle with a line drawn through them. TAA explained these symbols meant they didn't see them at all that day, and verified they only checked once each day based on the symbols drawn. On 6/11/25, a symbol was recorded which was shaped like a checkmark; however, TAA could not recall what this meant. On 6/12/25, a handwritten, Sleepin, was recorded and TAA verified they didn't check on R58 again based on the symbols drawn. In addition, again, this notebook did not include documentation or symbols to show the 1:1 which had been recorded in the POC History on 6/12/25. Week of 6/16/25 to 6/20/25 was reviewed. On 6/16/25, the space had four symbols of the circle with a line drawn through them on which, again, TAA explained meant they didn't see R58 on that day. Then, below those symbols, was handwritten text reading, Very Confused 10 mon [sic; 1:1 per POC] visit Very Confused. On 6/17/25, the space had, N/I, written along with two circles with a line through it and text reading, Confused [and] Crabby. On 6/18/25, a circle with a line through it was drawn and, again, text reading, Still Very Confused. On 6/19/25, one circle with a line drawn through it was present; and on 6/20/25 there was handwritten text reading, Sleeping. The notebook lacked evidence R58 was reproached about activities on 6/19/25 or 6/20/25 based on the symbols drawn. Week of 6/23/25 to 6/27/25 was reviewed. On 6/23/25, the space had another checkmark drawn along with writing, [name] @ 2:00. On 6/24/25 and 6/25/25, the spaces were blank with nothing written or drawn. TAA verified the notebook didn't record any weekend activities, and stated such was because they didn't work weekends. TAA reiterated the notebook was made by themselves and had not been directed to be used. Further, TAA stated they rarely, if ever, woke people up for activities if they were found to be asleep at that time and expressed nobody from the care center (i.e., TAD or management) had ever told them to chart these attempts or refusals (i.e., N/I) in the medical record before. In total, between the POC History Report and the presented notebook, a total of only seven (7) times were recorded to prove R58 was provided an activity (i.e., 1:1) or directly offered an activity since her admission to the care center on 6/2/25 (23 days prior); and only three of these were recorded within the actual medical record. R321 R321's admission Minimum Data Set (MDS), dated [DATE], indicated R321 was cognitively intact, had no delusions or hallucinations, had no behaviors and did not refused cares. The MDS recorded under section F Preferences for Customary Routines and Activities, R321 felt it was Very important to do her favorite activities, participate in religious practices, and keep up with the news; and she felt it was Somewhat important to have books, magazines to read, to do things with group of people, and to go outside to get fresh air when the weather was good. R321 Therapeutic Activities Observation dated 6/8/25, identified the evaluation as, Initial Activities Assessment, and recorded R321 as having an anticipated length of stay as, Less than 3 months. The assessment indicated R321 had current interest in pursuing leisure/activities and indicated R321 was interested in bingo, music entertainment, social events and attending Catholic services. The evaluation continued, R321's independent leisure interests included watching TV, going outside with family when weather was good, family visits, using her personal iPhone for streaming, games, internet searches and social media. Doing group activities, doing favorite activities, getting outdoors and participating in religious services/practices were categorized as very important or somewhat important. R321's Activities Care Plan dated 6/8/25, titled Outdoor Activity included: Going outdoors is important for patient indicated, R321 will remain safe when going outdoors evidenced by no accidents or injuries in the process. Care plan also indicated R321 was instructed to inform staff when going outdoors and was warned about sloped front parking lot, and that she may safely go outside with family assistance and supervision. In addition, care plan indicated if R321 attempted or requested to go outside alone, further safety screening may be needed. During interview on 6/23/25 at 3:15 p.m., R321 was sitting on a recliner and said she had been at the facility since 6/6/25. R321 stated she was not aware if the facility had any activities, and added Nobody has mentioned anything about activities and had not been invited to go to an activity. R321 further stated, I do not have an activity schedule in my room. During interview on 6/24/25 at 12:53 p.m., R321 was sitting on her recliner chair and said she had not been invited to any recreational activities and had only left her room to work with the physical therapist. During interview on 6/24/25 at 2:22 p.m., nursing assistant (NA)-B stated the recreational aid invited and took residents to activities. NA-B stated the facility also had a pastor who made room visits and talked to residents. During interview on 6/25/25 at 9:15 a.m., R321 stated last afternoon and so far, today, she had not been invited to attend any activities. During interview on 6/25/25 at 10:06 a.m., NA-C stated the recreational aid went around every room and asked the residents if they wanted to play bingo on the second floor. R321's POC (Point of Care) History Report dated 6/2025, identified R321 had only one activity recorded as been completed since admitting to the care center on 6/6/25. This activity was recorded as a Pastor visit. During interview on 6/25/25 at 11:59 a.m., therapeutic activities director (TAD) stated his department met with all new residents to complete the Initial Activities Assessment. This assessment identified residents' hobbies and interests, and the activities department offered resources like books, magazines, coloring books, word-finding books and others. TAD stated based on the Initial Activities Assessment, the residents were included on the activities list programs. TAD verified R321 had been added to the bingo, music, social activities, and religious services list programs. TAD verified R321's POC activities report only had one activity recorded since 6/6/25. TAD stated residents' participation in recreational activities were important for the overall well-being of the person, so they were able to do things that they liked to do. On 6/25/25 at 12:55 p.m., TAA and the surveyor reviewed the spiral top notebook identified previously. R321's room was located on these pages and identified a series of symbols (i.e., 'S' and 'O') which TAA explained in chronological order. This included: Week of 6/2/25 to 6/6/25 was reviewed. On 6/6/25 (R321's date of admission), the space had a written V on it. TAA stated this meant the room was vacant. Week of 6/9/25 to 6/13/25 was reviewed. On 6/9/25, the space had writing which read, w/ aide. There were no other symbols written to show re-approach. On 6/10/25, the space had a checkmark drawn with text adjacent, back around 3. There were no other symbols drawn to show re-approach happened. On 6/11/25, the space had a single checkmark drawn. TAA stated they were unsure what that meant. On 6/12/25 and 6/13/25, the spaces were left blank. Week of 6/16/25 to 6/20/25 was reviewed. On 6/16/25, the space had text written, on phone. There were no other symbols written to show reproach. On 6/17/25, a circle with a line drawn through it was written which TAA explained meant they didn't see R321 at all that day. On 6/18/25 and 6/19/25, both spaces to draw a symbol or record writing were left blank. On 6/20/25, a handwritten, N/I, was placed which TAA stated meant R321 was not interested in the activity when offered. Week of 6/23/25 to 6/27/25 was reviewed. On 6/23/25, 6/24/25, and 6/25/25, each space had a written, S, on its which TAA stated meant R321 was sleeping. The spaces each lacked any further symbols to show re-approach. A facility Therapeutic Activities policy, dated 11/2024, identified each facility within the corporation would provide ongoing programs to support residents in their choice of activities based on their assessment and care plan. The policy outlined, Each resident will have an individualized activity plan of care addressing the four components of an activity program. There are large groups, small groups, one to one programs and self-directed activities. The policy outlined a schedule of activities would be posted one-week in advance, however, lacked information on how attempts or refusals of activities would be recorded or captured within the medical record.

Based on observation, interview, and document review, the facility failed to ensure non-pressure related wounds were monitored for signs and symptoms of infection and healing until resolved for 1 of 1 resident (R16) reviewed for skin concerns. Findings include: R16's significant change Minimal Data Set (MDS) dated [DATE], identified R16 had no cognitive impairment, diagnoses of arthritis, hypertension, dementia, depression, atrial fibrillation, was dependent on staff for all mobility, used a pressure reducing device for the bed and wheelchair, and was taking an anticoagulant (a medication that prevents blood clots). R16's MDS did not identify any current skin tears, abrasions or wounds. R16's skin integrity care plan (CP) dated 12/22/24, included interventions to reduce the risk for pressure ulcers including monitoring mobility, observing skin daily, and completing visual body audits weekly. R16 used a full body lift and needed two staff for transfers. R16's progress note dated 5/3/25, identified previous right shin skin tear that was covered with Tegaderm tape and had discharge, the dressing was removed, and the area was measured to be 4 cm x 4.5 cm. A request was sent to the wound nurse to see R16 and staff were to continue to monitor. R16's active provider orders included an order to complete wound care for a right shin abrasion dated 5/8/25. The orders directed staff to change the dressing every other day as needed if soiled or if it fell off, cleanse with wound cleanser and gauze and pat dry, cover with a bordered gauze dressing, and initial/date the dressing. R16's wound management report documented the following: 5/3/25, observed skin tear that was 4 cm x 4.5 cm, red with pale red to pink, thin and watery fluid, scant wound tissue was moist and had a flap tear which could be repositioned to cover the wound bed. 5/15/25, observed skin tear that was 2.5 cm x 3 cm, red with pale red to pink, thin and watery fluid, a moderate amount of the wound tissues was wet and involved 25-75% of the dressing, total flap loss, entire wound bed was exposed. 5/22/25, observed skin tear that was 2 cm x 2 cm, bloody, bright red with a moderate amount of the wound tissues were wet and involved 25-75% of the dressing, total flap loss, entire wound bed was exposed. R16's medical record lacked documentation of further assessment, measurement, and/or resolved status of the skin tear between 5/22/25 and 6/23/25. R16's Comprehensive Skin Risk with Braden dated 5/30/25, identified a pressure injury was present, however a box titled skin tear/laceration present was unchecked, and no other ulcers, wounds, or skin problems were identified. R16's Visual Body Inspections reported completed during weekly baths dated 6/2/25 through 6/23/25 lacked identification of any skin tears. R16's treatment assessment record (TAR) dated 5/27/25-6/25/25, identified wound care for right shin abrasion. Staff were to cleanse, pat dry, apply a cut to fit piece of calcium alginate to the wound bed, cover with a bordered foam dressing and initial/date. During observation and interview on 6/23/25 at 3:06 p.m., R16 stated his right shin bumped against the full body lift a while back and explained the wound took a while to heal. R16 indicated this happened on more than one occasion, but could not elaborate. R16 had a foam dressing dated '6/22' on the right shin with one additional visible small encrusted wound near the dressing the size of a dime, with no drainage or redness. During an interview on 6/24/25 at 11:28 a.m., family member (FM)-A stated the staff did the best they could and were careful with dressing changes, and explained when staff used the full body lifts with R16, R16's legs were bumped often. During an interview on 6/25/25 at 9:07 a.m., R16 stated his leg was not really good and wanted to know if there was someone he could talk to. The dressing on the right shin was still dated 6/22. During an observation and interview on 6/25/25 at 11:13 a.m., two nursing assistant (NA)-D and (NA)-F used a full body lift (Hoyer) to transfer R16 from the bed to the wheelchair. R16's right shin was observed to slide down against the battery on the pole of the lift. NA-D stated she never noticed his leg against the pole, was aware there was a bandage on the right shin, but was unaware of its origin or any interventions related to the lift, mobility, and skin monitoring, and referred questions to the nurse. During an interview on 6/25/25 at 12:09 a.m., nursing assistant (NA)-E stated she had been an aid for a long time and did not work directly with R16, but had assisted with transfers and stated his legs were stiff and needed to be loaded sideways onto the wheelchair preventing R16's legs from contacting the lift. During observation and interview on 6/25/25 at 11:20 a.m., registered nurse (RN)-D reviewed R16's medical record and was unable to determine the origin of R16's right shin skin tear, but did identify the active wound care order. RN-D confirmed the dressing changes were done on the evening shift and had not observed the wound today. RN-D then confirmed the bandage was initialed and dated 6/22. During an interview on 6/25/25 at 11:33 a.m., nurse manager (RN)-A stated an incident report would not be done for skin, the staff would care for the wound regardless or its origin, and the wound care nurse would not follow a skin abrasion/tear because it was not pressure related. RN-A stated normal practice would be to have a progress note accompany the wound assessment unless it was done on a body audit/bath day. RN-A was unaware R16 had a right shin skin tear and but then confirmed no progress note or audit was completed that mentioned a skin tear around the date the wound care order was written. RN-A reviewed the events tab for April, May, and June then confirmed the record did not specify origin or date the wound occurred. During an interview on 6/25/25 at 12:39 p.m., the director of nursing (DON) stated new skin alterations would be on the wound management platform which started the monitoring process. It was expected to track and monitor all skin tears/abrasions regardless of their origin and a progress note or a note on the wound management platform should be documented. The policy was to monitor wounds every seven days document on the visual body audit, but the audit would only identify if it was a new skin wound. The DON expected that staff would be monitoring and assessing all skin wounds in the wound management platform. The DON identified no root cause analysis or interventions in place to prevent future injury to R16 and indicated this was an area the facility could improve, and stated the facility was currently without a wound nurse at this time. A policy, Skin integrity revised 3/10/25 identified Cassia facilities will use the wound management area of MatrixCare electronic health record to document skin integrity issues. Facilities with Point Click Care (PCC) will document wounds in the skin and wound area of PCC.

Based on observation, interview and document review, the facility failed to effectively communicate with a dialysis center and failed to provide care consistent with professional standards of practice for 1 of 2 residents (R98) reviewed for dialysis. Findings include: R98's quarterly Minimum Data Set (MDS), dated [DATE], indicated R98 was admitted to the care facility on 7/10/24, was cognitively intact, and was receiving dialysis while a resident. R98 had a General Order, dated 7/11/24, indicating Remove dressing from dialysis site on the shift after they return from dialysis (unless otherwise ordered) and an order, dated 4/2/25, indicating R98 went to dialysis on Tuesdays, Thursdays and Saturdays. During observation and interview on 6/23/25 at 1:41 p.m., R98 was lying in bed without a shirt and the bedsheets pulled up over her chest. Exposed was a dialysis port, (a central venous catheter [CVC], which is a flexible, long, plastic, y-shaped tube that is threaded through the skin into a central vein in the neck.) The CVC was exposed to the air without covering. R98 stated she had received a bath earlier in the day and was waiting on the nurse to come and cover it. During follow up observation and interview on 6/25/25 at 8:40 a.m., R98 was lying in bed again, with her dialysis port uncovered and exposed to open air. R98 stated the plastic covering placed by dialysis would often itch and she would remove it or ask staff to remove it when she came back from dialysis. During an interview on 6/25/25 at 9:30 a.m., nurse manager and registered nurse (RN)-A stated she believed the staff at the dialysis center were managing R98's dialysis port for the most part. RN-A stated the port would remain covered for a short amount of time after R98's dialysis treatment and would be removed by care facility staff. RN-A stated communication between the facility and the dialysis center was done via a communication form uploaded under Consults in the electronic medical record (EMR). When reviewed with RN-A, the most recent communication form between the care center and the dialysis center was dated 4/17/25. RN-A further stated the facility did not always receive the communication forms back from the dialysis center. During an interview on 6/25/25 at 9:50 a.m., licensed practical nurse (LPN)-A stated when R98 returned from the dialysis center, the nurse at the care facility, on the next shift, would remove the clear plastic covering that kept the dialysis port from being exposed to open area and would clean R98's skin around the port with normal saline and leave it uncovered, open to air. During an interview on 6/25/25 at 10:22 a.m., the charge nurse at the dialysis center (CN) stated after R98 had a dialysis run, the staff at the dialysis center would clean the port and cover it with a clear plastic dressing to prevent infection. The CN stated staff at the care facility should not be touching the dialysis port or dressing in between dialysis runs and that the clear plastic dressing should be left in place. The CN further stated the staff at the care facility had not been communicating with the dialysis center that they were removing the clear plastic film leaving R98 vulnerable for infection, or that the clear plastic film was itching R98, stating they had other dressings they could try had they known R98 was bothered by the clear plastic dressing. During an interview on 6/25/25 at 10:53 a.m., the director of nursing (DON) stated R98's order to remove the dressing from the dialysis site was a house standing order and was not intended for a resident who had a dialysis port, but rather a fistula (a surgical connection made between an artery and a vein) which does not require a cover for infection control. The DON confirmed the dressing covering R98's dialysis port should not be removed, which put R98 at a higher risk for infection, and there was concern about collaboration with the dialysis center. A facility policy titled Dialysis, reviewed 3/10/2025, indicated residents who require dialysis will receive this service consistent with professional standards of practice and the comprehensive person-centered plan of care and the facility would have ongoing communication and collaboration with the dialysis facility.

Based on interview and document review, the facility failed to ensure a resident/ resident representative's voiced grievances, were tracked through the facility-established grievance process, and the resident representative was updated on the resolution of the grievance for 1 of 1 residents (R55) who had reported missing clothing items and care concerns. Findings include: MECHANICAL LIFT R55's quarterly Minimum Data Set (MDS) dated [DATE], indicated R55 had moderate cognitive impairment and was dependent on staff for hygiene, bathing, and transferring. R55's care plan dated 3/3/23, indicated that R55 required the total assistance of two staff members using a full body lift for transfers. An email correspondence from resident representative (RR)-B and registered nurse (RN)-D, the unit nurse manager, dated 6/21/24 at 7:43 p.m., indicated RR-B had witnessed an unknown staff member use a mechanical lift to transfer R55 to bed independently. Another email correspondence from resident representative (RR)-B and RN-D dated 6/24/24 at 10:09 p.m., indicated RR-B had witnessed an unknown staff member use a mechanical lift to transfer R55 to bed by independently. A Performance Improvement Form dated 7/2/24 at 3:10 p.m., indicated a meeting had occurred between RN-D and nursing assistant (NA)-F and confirmed NA-F had used a full-body mechanical lift to transfer R55 by themselves. The form indicated what action management had taken and mechanical lift education that had been provided. A Performance Improvement Form dated 7/5/24 at 2:31 p.m., indicated a meeting had occurred between RN-D and NA-G and confirmed NA-G had used a full-body mechanical lift to transfer R55 by themselves. The form indicated what action management had taken and mechanical lift education had been provided. A review of grievances from 1/16/24 to 7/16/24 was completed and identified nine grievances for the six-month period. The facility lacked a grievance form for R55. R55's record was reviewed and lacked evidence that R55's concerns were addressed through the facility grievance process to determine what, if any, other actions were needed to ensure all staff were aware of the care plan and, if needed, re-educated to ensure appropriate, safe transfers for R55. During an interview on 7/16/24 at 1:15 p.m., resident representatives (RR)-A and RR-B stated they visited R55 daily and had a camera in R55's room for observing when R55 needed assistance. RR-A and RR-B stated they had communicated multiple concerns with the facility they felt had not been resolved. RR-A stated she had emailed and discussed in person a concern regarding two different staff members, on two separate occasions, using the mechanical lift by themselves to transfer R55 when they thought two staff members were needed. RR-A stated she did not feel R55 was safe knowing this had occurred and not knowing what, if anything, the facility had done to correct this issue that could have caused harm to R55. RR-A stated they now felt like they had to continuously watch the camera to ensure RR-A was receiving safe care and they should not have to do this. During an interview on 7/17/24 at 8:50 a.m., RN-D, the unit nurse manager, stated she had a conversation with R55's representatives and had realized that she was not receiving emails from them due to an IT issue. RN-D stated she became aware of the representative concern regarding the one-person mechanical lift use a couple of weeks ago. RN-D stated education and final warnings were given to the two staff members involved on their next shift. RN-D stated she had informed the family that would look into this concern and complete education with the two staff members involved but did not file a formal grievance and had not followed up with R55's representatives after education and the investigation was completed. RN-D stated she talked with R55's family often and if they had continued concerns regarding this issue, they could have asked for an update. During an interview on 7/18/24 at 10:04 a.m., the director of social services (DSS), the grievance official, stated floor staff had access to grievances forms they could fill out and then bring to her so she could track the issue and make sure the concern was addressed by all of the appropriate parties. The DSS stated she babysat the concern as it goes through the grievance process to ensure it reaches resolution and then ensures that resolution is brought to the resident/ resident representative. The DSS stated she expected staff to complete a grievance form when the issue had occurred on more than one occasion or could not be fixed instantly. The DSS stated there was value in having documentation so the issues could be tracked. During an interview on 7/18/24 at 11:44 a.m., the director of nursing (DON) stated the DSS was in charge of grievances and grievance forms could be found throughout the facility form for residents and families to complete when they had a concern. The DON stated if a concern was brought to a staff member, it was up to that staff member's discretion to decide if an official grievance needed to be completed. The DON stated the facility did not have official criteria to determine when filing a grievance was necessary. The DON stated they had not filed an official grievance regarding staff using a mechanical lift to assist R55 because the issue was followed up on so quickly and taken care of right away. The DON stated that RN-D had informed R55's representative that education would be provided when the concern was brought forward. The DON stated because education had been given to staff immediately she did not think it was necessary to follow up with the representatives after the investigation and education were completed. MISSING ITEMS On 7/17/24 at 3:02 p.m., a request was made for any reports of missing items for R55 in the last six months. A reply was received on 7/17/24 at 3:21 p.m., from the Director of Social Services (DSS) indicating no missing items were reported for R55 in 2024. During an interview on 7/16/24 at 1:15 p.m., RR-A stated they had noticed multiple of R55's clothing items go missing in the last few months and they had notified facility staff however had not heard anything about it since then. During an interview on 7/17/24 at 2:13 p.m., nursing assistant (NA)-A stated she had noticed a few of R55's outfits go missing over the last few months and she had looked for the outfits however had never found them. NA-A stated she did not fill out a missing laundry form and was unsure if anyone else had. During an interview on 7/18/24 at 10:29 a.m., RN-D, the nurse manager of the unit, stated she was not aware of any of R55's personal items missing however if it had happened, she would have expected a report to have been sent to the DSS. During an interview on 7/18/24 at 12:19 p.m., the DSS stated the facility used a separate system for tracking lost items than for following grievances. The DSS stated she was in charge of tracking lost items and had a form she expected any staff member to fill out if they noticed or were notified of a resident missing a personal item. The DSS stated when she was notified of a missing item, a further investigation was completed including a facility-wide email and monthly summary that she followed. The DSS stated that if an item was not recovered, they were pretty flexible about reimbursing residents for items that had gone missing. The DSS confirmed that she had reviewed her records and had not found evidence that a form had been completed for R55. The facility Grievance policy dated 10/20/23, indicated grievances could be filed orally or in writing, and all grievances would be responded to within seven days. The policy indicated the staff person receiving the concern would initiate the grievance form and it would then be routed to the grievance official. The grievance official would ensure any necessary investigations were completed as well as corresponding documentation. The policy indicated that once the grievance investigation was completed, the form as well as the written grievance decision would be sent to the facility administrator for review. The documentation would also be sent to the facility's quality assurance person for review and tracking using a grievance tracking log.

Based on observation, interview, and document review, the facility failed to ensure routine grooming and personal hygiene care (i.e., nail care) was provided for 1 of 3 residents (R60) reviewed for activities of daily living (ADLs) and who was dependent on staff for such care. Findings include: R60's admission Minimum Data Set (MDS), dated [DATE], identified R60 had moderate cognitive impairment, demonstrated no delusional thinking, and did not have diabetes mellitus. Further, the MDS identified R60 required supervision and/or touching assistance to complete personal hygiene cares. On 7/15/24 at 2:21 p.m., R60 was observed in his wheelchair while in his room. R60 had a visible, slight finger contracture present on his left hand but had multiple long fingernails present on both hands with the edge of the nail being several millimeters (mm) long on some of them and some nails having a dark-colored debris present under the edge. R60 was interviewed and stated he was getting help with bathing once a week but needed help with his fingernail clipping adding, These [nails] are too long. R60 stated he thought he had been asked about clipping them prior but was not sure when or why they hadn't been clipped. R60 reiterated he wanted his nails clipped adding, Yea. R60's care plan, dated 6/21/24, identified R60 had multiple medical conditions including Parkinson's Disease and chronic kidney disease (CKD). The care plan outlined R60 required assistance to complete his ADLs along with various interventions including, GROOMING: Staff to provide assist with grooming. The care plan lacked any intervention or direction on nail care and/or preferred nail length, if applicable. R60's most recent Visual Body Inspection(s), dated 7/3/24 and 7/10/24, were reviewed. These identified R60 had no new skin impairments (i.e., bruises, pressure sores); however, lacked detail or evidence R60's nails had been reviewed with the completed skin check. R60's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 7/2024, identified R60's provided and recorded medications along with his completed treatments. These both lacked evidence of any nail care had been completed or offered during the month period thus far. On 7/16/24 at 1:32 p.m., nursing assistant (NA)-A was interviewed. NA-A explained they had worked with R60 a few times since he admitted to the care center and stated the NA(s) were responsible for nail care if the resident was not diabetic. NA-A stated nail care should be completed weekly adding, We do with the baths. NA-A stated R60 was typically accepting of care and, at request of the surveyor, observed R60's fingernails. NA-A verified their length and condition and expressed they were unsure when they had been last clipped or trimmed. NA-A stated nail care, either when offered or completed, was not routinely documented in their charting and expressed, Maybe the nurse [does]. NA-A verified R60 would need staff help to clip his fingernails. R60's entire medical record including progress notes was reviewed and lacked evidence what, if any, nail care had been offered or completed for R60 within the past several weeks. When interviewed on 7/16/24 at 1:40 p.m., registered nurse (RN)-C explained nail care should be completed with the weekly bathing schedules and expected the care completed adding, They should be done. RN-C stated the nurses only recorded nail care on the MAR/TAR, if applicable, to their knowledge and verified the NA(s) were able to clip or trim fingernails for non-diabetic residents. On 7/16/24 at 1:51 p.m., registered nurse unit managers (RN)-A and RN-B were interviewed. RN-A explained nail care should be done with the scheduled bathing but could also be done whenever needed. RN-A stated they expected fingernails and toenails to be checked and, if needed, attended to or clipped. RN-A stated nail care was not necessarily documented unless it was offered and refused adding nail care was more a standard of care with a bath. RN-A verified R60 likely needed help to clip his fingernails and stated it should be completed for proper hygiene. RN-A stated they would review the medical record and provide documentation of nail care if located. No further medical record information was received. A provided Nursing Assist Standard Cares policy, dated 3/2024, identified nursing staff would provide quality care to those served and listed standard cares which would be provided unless indicated on the care plan. The list of cares or services included, 8. Nail care weekly and PRN [as needed]. Nails should be short and clean.

Based on observation, interview, and document review, the facility failed to ensure a developed skin condition was comprehensively assessed and, if needed, acted upon or monitored to ensure healing for 1 of 1 resident (R141) reviewed who had large areas of dry, flaking skin present on their leg. Findings include: R141's admission Minimum Data Set (MDS), dated [DATE], identified R141 had intact cognition and demonstrated no delusional thinking. Further, the MDS outlined R141 had several medical conditions including anemia; however, R141 had no current wounds, skin ulcers, or other skin-related problems. R141's Nursing Admission, dated 6/23/24, identified R141 admitted from the hospital on the same date and outlined multiple body systems to review along with areas to record what, if any, conditions or issues were identified. The completed evaluation identified no edema was present on R141's lower extremities, however, there was no recorded spaces or areas to record what, if any, skin conditions were present. R141's care plan, dated 6/24/24, identified R141 was at risk for skin integrity alteration due to multiple medical conditions and decreased mobility. The care plan listed a goal which read, Skin will remain intact through 90 days, along with interventions including encouraging him to elevate his heels in bed, pressure-relieving cushions, a licensed staff visual body inspection weekly and, [Nursing assistant] to observe skin daily during cares and notify nurse promptly of any areas of concern. On 7/15/24 at 7:02 p.m., R141 was observed lying in bed while in his room. R141 was interviewed and explained he admitted to the care center after having a fall at his home where he sustained a hematoma (a collection of blood trapped outside the vessel under the skin) on his right leg. R141 pulled up his right pant leg which showed a large, black-colored area on the swollen lateral right thigh; however, nearly the entire surface of the leg extending down to the foot had visibly dry, flaking skin present as well with some skin flaking falling off as the pant leg was re-adjusted. R141 stated the scaling just falls off lately and he was unsure what, if any, treatment or monitoring was being done adding there was no consistent cream or ointment being applied to his recall. R141 stated the skin was somewhat itchy and sore but added it's not near as bad as it was [prior]. R141 stated he believed the staff was aware of the condition. When interviewed on 7/17/24 at 9:31 a.m., nursing assistant (NA)-A stated they had worked with R141 prior and described him as very much independent with most cares. NA-A stated they had observed R141's right leg and expressed it had a black area on it along with dry skin. NA-A stated they don't know exactly how long the dry skin had been present but added, I think when he came, think so. NA-A verified the dry skin had been present for at least a week to their recall and, as a result, the NA(s) were trying to lotion it when able or if R141 asked for it. NA-A stated the nurses had not directed anything specific for it to their knowledge (i.e., lotion twice a shift) and stated the area appeared kind of the same since they had first noticed it prior. NA-A stated the nurses were aware of it to their knowledge adding, I think so. R141's most recent Comprehensive Skin Risk with Braden, dated 7/14/24, identified R141 needed assistance with activities of daily living (ADLs), had cardiovascular disease and chronic kidney disease (CKD). An attached Braden Scale (used to screen for pressure ulcer risk) identified a score of 16.0 which was labeled, At Risk. This evaluation identified R141 had bruising present which was not required to be tracked in Wound Management, however, lacked any evidence R141 had dry skin present or what, if any, treatment or monitoring of it was being done despite floor staff knowledge of it. R141's completed Visual Body Inspection(s), dated 6/23/24 to 7/13/24, identified a total of four evaluations were completed. The last completed, on 7/13/24, identified R141 had no skin issues on his heels along with no new skin issues elsewhere with dictation present, No new skin concerns. Neither of the four completed inspections had any dictation or indication of the developed dry skin condition. In addition, R141's Wound Management tracking, located in the electronic medical record (EMR), lacked any specific tracking or monitoring of the developed skin condition. R141's medical record was reviewed and lacked evidence the developed skin condition had been comprehensively assessed to determine what, if any, interventions were needed to ensure healing. The record lacked evidence of any current treatments. Further, the record lacked evidence the condition had any ongoing, routine monitoring to ensure healing and prevent complication or worsening. When interviewed on 7/17/24 at 9:38 a.m., registered nurse (RN)-C stated they had just noticed that morning R141 had dry skin on his right leg so, as a result, they made a note to contact the medical provider about it and get treatment started. RN-C stated they had noticed R141's right leg yesterday, too, however, didn't feel it was as much [as bad] as now adding it looked so dry. RN-C verified today (7/17/24) was the first time it had been reported to them from the overnight shift. RN-C explained new skin issues or conditions, such as dry skin, should be reported and assessed to determine any treatments needed adding such would be recorded in the progress notes. RN-C verified R141 had no current treatments in place for the dry skin and added, We should get some orders. On 7/17/24 at 1:59 a.m., registered nurse unit managers (RN)-A and RN-B were interviewed. RN-A verified they had reviewed R141's medical record and explained when a skin condition was identified, then the nurse should evaluate it and update the provider, if needed. RN-A and RN-B expressed if a NA finds a skin issue, they expected the nurses to be notified. RN-A stated the wound nurse had just today looked at R141's leg who applied lotion to what was described as a lot of that dry, flaky skin. RN-A stated the wound nurse had not been involved with the developed dry skin prior but had just noticed it today when in there observing his skin for other reasons. RN-A explained any evaluation or assessment of a skin condition would likely be under the assessments within the EMR, however, it lacked anything completed. RN-A stated any developed skin condition not improving after a period of treatment should also be re-evaluated and the medical provider updated. RN-A and RN-B both expressed neither of them had been updated on R141's dry skin prior to that day and explained floor staff had various means to update them, if needed, such as e-mail or verbal report. RN-A stated had someone updated them, then it would have been reviewed and evaluated by themselves or the wound nurse sooner. RN-A stated it was important to ensure skin conditions, including dry skin, were evaluated and acted upon timely as we don't want any further issues [i.e., infection, complication]. A provided Skin Integrity policy, dated 3/2024, identified skin care, the assessment of risk and treatment plans would be based on resident' goals. The policy outlined, Cassia facilities will use the Wound Management area of the MatrixCare [EMR] to document skin integrity issues. A procedure was listed which included, NAR will inspect skin daily with cares. Any skin alterations will be reported immediately to licensed nurse, and, Nurse will communicate new skin alterations to the interdisciplinary team, MD/NP/PA, and the resident representative. Further, the policy added, Nurse will follow documentation guidelines below for any new skin alterations, which included implement appropriate treatment, completion of a new skin risk assessment if pressure or mixed etiology, and update the care plan.

Based on observation, interview, and document review, the facility failed to consistently implement a restorative nursing program (RNP) to prevent a possible decrease in mobility for 1 of 1 residents (R52) reviewed for range of motion. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 had intact cognition with no rejection of care behaviors during the look-back period (LBP). The MDS indicated R52 required maximal assistance for transferring, moderate assistance with bed mobility, and walking was not attempted. The MDS indicated R52 received occupational therapy and physical therapy during the LBP but was not on an RNP. R52's care plan dated 7/3/24, indicated R52 was on a RNP and was to receive stand-by assistance (SBA) and verbal cues while ambulating 500 feet daily. R52's orders were reviewed and did not reference an RNP. R52's Point of Care History report dated 7/4/24 through 7/16/24, indicated R52 had completed his RNP twice during the period, 11 times the field was left unanswered, and on one occurrence it was documented as deferred due to condition. The report did not identify when or if R52 had refused his walking program. R52's medical record was reviewed and lacked indication that R52 had been offered or refused his RNP from 7/4/24 through 7/16/24. R52's physical therapy Discharge Summary dated 6/25/24, indicated on discharge from physical therapy, R52 was ambulating up to 500 feet with SBA and verbal cues. The summary indicated that R52 continued to require assistance with ambulation and was on an RNP. During an interview on 7/15/24 at 3:28 p.m., R52 stated when he was discharged from physical therapy in late June 2024, he was supposed to be on a walking program. R52 stated since he had been discharged from physical therapy, he did not recall anyone offering the walking program to him. During an interview on 7/17/24 at 10:05 a.m., physical therapist (PT)-A stated after reviewing R52's medical record, R52 had an RNP that included ambulating 500 feet with SBA daily. PT-A stated it was important this program was completed consistently, so R52 maintained his ability to walk as was established in physical therapy. During an interview on 7/17/24 at 10:14 a.m., nursing assistant (NA)-D stated R52 had never refused assistance from him. NA-D stated he was unsure if R52 was on an RNP however thought he might have been receiving assistance with range of motion. During an observation and interview on 7/17/24 at 12:00 p.m., NA-D stated after talking with R52 he thought aides had not been remembering to offer R52 his RNP and was observed instructing R52 to ask staff when he wanted to complete the walking program. During an interview on 7/18/24 at 10:15 a.m., registered nurse (RN)-D, the nurse manager for the unit, stated the RNP would populate as a task the aides had to complete for their documentation so the aides should have been aware of the RNP. The Point of Care History was reviewed with RN-D who confirmed the documentation indicated R52 had not received his RNP consistently and did not include an indication of refusals in the documentation. During an interview on 7/18/24 at 11:38 a.m., the director of nursing (DON) stated the instructions for the RNP could be found in the resident's care plan, and documentation of completion was found in the Point of Care History. The DON stated if the restorative nursing program was refused, this would also be documented in the Point of Care History. The facility Restorative Nursing/Functional Maintenance Program Review policy dated 3/28/24, indicated the RNP would have been entered into the care plan and scheduled in the point of care documentation for aides to complete.

Based on observation, interview and document review, the facility failed to ensure an appropriate medical justification was documented for an indwelling catheter and failed to attempt a trial discontinuation without medical justification for continued use for 1 of 1 resident (R35) reviewed for catheter use. Findings include: R35's quarterly Minimum Data Set (MDS) dated , 6/18/24, indicated R35 was cognitively intact and had an indwelling catheter. R35's Resident Face Sheet, printed 7/17/24, indicated R35 had multiple medical diagnoses including personal history of urinary (tract) infections and other specified disorder of bladder-bladder spasms. R35's physician ordered, dated 7/16/24, instructed staff to change foley catheter every two weeks and PRN [as needed] for leaking or decreased urine output with signs of bladder distension. 18 FR [French] 10CC [milliliters]. The order instructed the staff to change the foley catheter once a day on the 2nd and 17th of the month. R35's care plan, revised 7/2/24, indicated R35 required assistance with toileting due to impaired balance/gait and incontinence with a foley catheter in place for urinary output. Interventions included leaving approximately 200 milliliters (ML) of urine in the foley catheter bag when emptying per resident preference. R35's Electronic Medical Record (EMR) lacked medical necessity or justification for the use of a urinary catheter. R35's EMR indicated R35 had two urinary tract infection (UTIs) in the past 6 months. A hospitalization note, dated 1/8/24, indicated R35 was hospitalized due to nausea, vomiting, diarrhea and pain with urination in her urethra with a diagnosis of UTI due to Foley catheter and a history of Extended-spectrum beta-lactamases (ESBL) UTI. The hospitalization further indicated R35 had a previous hospitalization in October 2023 with similar presentation with a UTI due to Foley catheter. A M Health Fairview Geriatrics provider note, dated 2/16/24, indicated R35 was visited due to concerns regarding increased lethargy and paranoia. The note indicated a urine analysis and culture was collected and came back grossly abnormal in the setting of indwelling Foley catheter. The note further indicated R35's indwelling foley catheter was placed years ago due to chronic dysuria [painful urination] and that R35 historically has not struggled with urine retention. The note further indicated the provider spoke with R35 regarding trialing discontinuation of the Foley catheter and would discuss it further at her regulatory provider visit in March 2024. R35's March 2024 provider visit note lacked any evidence of discussion regarding a trial discontinuation of R35's Foley catheter and indicated, previously discussed trial without Foley catheter as it was initially placed for dysuria and not obstructive uropathy. admitted ly, did not revisit today. During an interview and observation on 7/15/24 at approximately 5:00 p.m., R35 was laying in bed with a Foley catheter bag hanging at bedside. R35 stated she had the catheter for years due to it being painful when she urinated and developing chronic UTIs. R35 did confirm she has had multiple UTIs with the catheter in place. During an interview on 7/18/24 at 11:06 a.m., the nurse manager and registered nurse (RN)-D stated she spoke with the provider who admitted ly did not discuss removal of the Foley catheter as she believed R35 would refuse, stating R35 had adamantly refused to remove the catheter in the past. RN-D further confirmed that since the catheter was placed in 2021, they had not attempted a trial removal, stating it relieved her symptoms of painful bladder spasms when it was placed. RN-D stated R35 was having some symptoms of dysuria with the catheter in place so it was discussed to potentially remove it however R35 would not allow it. During an interview on 7/18/24 at approximately 12:30 p.m., the director of nursing (DON) stated she understood the importance of having medical justification for long standing Foley catheter use and would work with the provider or R35's urologist on proper justification for keeping the Foley catheter in place. A facility policy titled Urinary Indwelling Catheter Insertion and Management, revised 6/25/24, indicated all residents with an indwelling catheter require a medical justification for the initiation and continuing need for catheter use.

Based on interview and document review, the facility failed to assess and reassess what, if any, non-pharmacological pain interventions would be helpful and accepted by 1 of 1 resident (R95) to supplement medication management of chronic pain continually rated severe and described as frequently interfering with sleep and daily activities. Findings include: R95's quarterly Minimum Data Set (MDS), dated [DATE], indicated R95 was cognitively intact with frequent pain rated as 8/10 that frequently affected his sleep and interfered with therapy and day to day activities. R95's Diagnoses list, dated 5/29/20, indicated R95 had several medical diagnoses including chronic pain syndrome and opioid dependency. R95's physician orders, indicated R95 had the following medication orders; cyclobenzaprine (a muscle relaxer) 10 milligram (mg) one tablet by mouth three times a day (TID), hydrocodone-acetaminophen (a narcotic pain medication used to treat pain) 5-325 mg one tablet by mouth twice a day and two tablets by mouth once a day, Lyrica (used to treat nerve pain) 25 mg two capsules once a day, meloxicam (a nonsteroidal anti-inflammatory drug often used to treat arthritis pain) 15 mg one tablet by mouth TID, Suboxone (contains the opioid buprenorphine, it has some pain-relieving effects and may help chronic pain patients with an opioid use disorder manage their pain as well as their withdrawal symptoms) 8-2 mg one film sublingual (under the tongue) TID. R35's physician orders further indicated an order to monitor pain: please document signs/symptoms of pain if any and the non-[NAME] [non-pharmacological] intervention that was used every shift. R95's pain assessment, dated 5/12/24, indicated R95 received scheduled and as needed pain medications and frequently had pain rated as severe that frequently interfered with sleep and daily activities. The pain assessment indicated via check box that R95 had received non-pharmacological pain interventions however lacked any documentation of what was used or accepted by R95 and what worked or did not in helping decrease R95's pain. R95's pain assessment, dated 2/18/24, indicated the same responses as the pain assessment dated [DATE], indicating no improvement or change in R95's pain. R95's medication and treatment administration record indicated R95 had pain rated as 8/10 or higher on 70 shifts (three per day) in the past 30 days. R95's progress notes, dated 4/1/24 - 7/17/24, were reviewed and lack any evidence of attempted, or offered, non-pharmacological pain interventions to supplement pain medication in an attempt to help relieve R95's chronic pain. R95's progress notes further indicated R95 had five falls on 4/26/24, 5/4/24, 7/7/24, 7/13/24, and 7/17/24. R95's care plan, dated 6/18/2020, indicated R95 had actual alteration in COMFORT r/t [related to] OA [osteo arthritis] of (L) [left] knee, morbid obesity, chronic pain. Resident takes scheduled and PRN pain interventions. History of high pain rating, provider aware. Followed by pain clinic. Interventions on R95's care plan had not been revised since 6/18/202 and included monitor level of comfort and notify provider if pain is not adequately managed with current interventions, pain medications as ordered and non-pharmacological interventions: offer positioning, warm blanket, ice pack, emotional support, toileting, drink, snack, activity, TV show, movie. R95's electronic medical record (EMR) further lacked a comprehensive assessment and reassessment of what, if any, non-pharmacological pain interventions R95 would accept or were successful in helping to relieve R95's pain despite chronic pain continually rated as severe. R95's pain clinic notes indicated R95 was seen in the pain clinic monthly since 12/6/23. The pain clinic notes indicated no changes to R95's current pain regiment on 12/6/23, 2/7/24, 4/3/24, 5/1/24, and 7/1/24, and lacked any non-pharmacological pain interventions. Medication was adjusted on 1/10/24, and 6/3/24, when Meloxicam was increased. During an interview on 7/17/24 at 8:08 a.m., nursing assistant (NA)-B stated R95 had been having more falls lately because his knees were getting weak and buckling causing him to fall. NA-D stated R95 did not complain of pain to her however she often observed him asking the nurses for pain medication. During an interview on 7/17/24 at 8:26 a.m., R95 was sitting up in his electric wheelchair and stated he continued to have severe pain despite working with the pain clinic. He stated they started him on Suboxone which was supposed to take his pain down but it doesn't despite being on it for more than six months. R95 stated his most severe pain was in his knees and tailbone and that he felt a little bit of relief when he could lay in bed to get the weight off of his tailbone. R95 stated his pain was currently a 7/10 and was usually around an eight after being up for the day. R95 further stated he understood he would not be completely pain free but would be comfortable if his pain could decrease to about 4-5/10 and indicated that nobody had assessed what is pain goal was. R95 had his computer open and was currently searching for a new cushion for his wheelchair to see if that would give him any relief. He further stated he was open to trying different non-pharmacological pain interventions such as aromatherapy or massage however staff had never asked him what made the pain better or worse or what he was willing to try, stating that staff only asked what his pain level was. R95 indicated he used to ride the stationary bike to try to keep his strength up however the pain in his knees had gotten worse and he could not do it anymore, leading to increased weakness and falls. R95 stated he was going to be starting therapy soon. During an interview on 7/17/24 at 11:04 a.m., registered nurse (RN)-G stated R95 would often report pain however he does not show pain and that staff gave him pain medication as ordered and R95 did not have any as needed pain medication to keep it black and white since he was an addict and would often seek pain medication. RN-G stated in the past, they had tried ice, a warm blanket or offered to lay R95 down however it, always had to be his pain pills. RN-G stated if a non-pharmacological pain intervention had been attempted, it would have been indicated in a progress note however there was no documentation of what had been attempted, what had worked and what had not worked. During an interview on 7/18/24 at 8:48 a.m., nurse manager and registered nurse (RN)-D stated the pain clinic manages R95's pain and pain medication, stating they got the pain clinic involved in R95's care because he never backs off of his pain scale and is always wanting more pain medication. RN-D stated she allowed the nurses to complete their own assessment of R95's pain however his facial expressions did not match his verbal description of pain. RN-D stated if a non-pharmacological intervention was used it would have been identified in a progress note or a physician order. RN-D stated R95 was his own worst enemy and was using the stationary bike however lately, had been refusing to use it, refusing to ambulate and refusing therapy. A facility policy titled Pain Management, revised 10/14/22, indicated the pain management program was based on a facility-wide commitment to resident comfort. Pain Management could include any of the following measures: assessment, root cause analysis, pharmaceutical and non-pharmaceutical interventions and follow up of effectiveness of PRN pharmaceutical interventions.

Based on interview and document review, the facility failed to ensure identified dental concerns (i.e., loose dentures, need for appointment) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 2 of 2 residents (R106, R65) reviewed who voiced dental complaints during the survey. Findings include: R106 R106's admission Minimum Data Set (MDS), dated [DATE], identified R106 had intact cognition and demonstrated no delusional thinking. Further, the MDS identified a section labeled, L0200, along with spaces to record broken/loose-fitting dentures, cavities, or mouth pain. This was answered, None of the above were present. Further, R106's Census listing, printed 7/18/24, identified R106's current payor source listed, Medicaid MN, with an effective date, 05/10/2024. On 7/16/24 at 8:33 a.m., R106 was interviewed. R106 stated she admitted to the care center a few months prior and had some unresolved concerns with her dentures. R106 explained she used an upper denture which doesn't fit along with a bottom plate which had seemingly shrunk into my gum. R106 stated the misfitting dentures had been an issue for a long, long time and, at times, caused trouble chewing for her. R106 stated nobody from the care center had asked her about her dentition or what, if any, dental services or appointments were available or wanted. R106 added the loose dentures had been really tricky to deal with lately. R106's Nursing Admission, dated 4/24/24, identified R106 admitted from the hospital on the same date along with a section labeled, Oral/Dental, which contained spaces to record what, if any, dental concerns were present. This identified R106 had her own teeth on the lower palate along with an upper denture. The assessment, again, marked None of the above were present, for the various dental conditions as outlined on the MDS. The form lacked any spacing to record what, if any, dental services were explained or offered at the time; nor was there spacing or dictation to record when R106's last dental examination had been. However, R106's progress note, dated 4/26/24, identified the following, NUTRITION: Initial Visit . Oral/Dental status: Res has upper denture and natural lower teeth. Per [R106], upper denture is poor fitting but easily adjusted w/ [with] denture glue. Res notes some difficulty w/ chewing [due to] poor dentition, however res denies pain/difficulty . offered foods cut into bite size pieces w/ extra gravy/sauce . res is agreeable to. Diet order updated accordingly. SLP notified of chewing concerns. The note lacked evidence R106 had been offered any dental appointment to have the dentures evaluated. R106's Care Conference Summary, dated 5/2/24, identified R106's initial care conference was held with R106 in attendance. A section of the summary was labeled, Ancillary Services offered (Check all that apply, which provided spaces to record what, if any, services were offered including dental. However, this was answered with, Not applicable (indicate reason) - na. A subsequent section outlined a checkmark placed adjacent to, Declined all ancillary services. The completed summary lacked evidence which of these conflicting answers (i.e., NA versus declined) was accurate; nor if R106's identified loose-fitting denture had been discussed. A subsequent progress note, dated 5/6/24, identified R106 was seen again for a nutritional review and the note outlined, Res notes some difficulty w/ chewing during initial [staff] visit, which res relates to poor dentition. No chewing/swallowing concerns noted. However, again the note lacked evidence R106 had been offered any dental appointment to have the dentures evaluated. R106's care plan, last revised 6/27/24, identified R106 required assistance with activities of daily living (ADLs) due to her past medical history and condition. The care plan identified an intervention which read, ORAL CARE: Staff to provide assist with oral care. However, the care plan lacked any further dictation or interventions for R106's dental status or condition despite R106 being identified to have poor-fitting dental appliances by the nutrition review. When interviewed on 7/16/24 at 1:27 p.m., nursing assistant (NA)-A stated they had worked with R106 a few times since she admitted to the transitional care unit (TCU). NA-A explained R106 needed some help with cares but completed oral cares on her own adding R106 had her own teeth. NA-A stated they were unaware R106 had complaints of a loose-fitting denture but expressed last week they had noticed R106 had a swollen lip which they reported to the nurse. NA-A stated they were unsure what caused the swollen lip. Further, NA-A stated any dental appointments would be scheduled through the nurse managers or the health unit coordinators (HUC). R106's medical record was reviewed and lacked evidence the loose-fitting denture had been acted upon and discussed with R106 to determine what, if any, services were wanted or needed; nor if it had been referred to a dental provider despite R106 reporting the denture caused trouble with chewing. On 7/17/24 at 10:00 a.m., registered nurse unit manager (RN)-A was interviewed and verified they had reviewed R106's medical record and spoken to the social worker (SW) about R106's dental status. RN-A explained when a resident admitted to the TCU, they were typically there for only a short time so it was difficult to get them referred to the in-house service for dental needs as they were onsite only quarterly. However, RN-A stated if concerns were expressed by the resident or identified, they could get a referral sent and arrange an outside appointment, if needed. RN-A stated the nurses who evaluated a resident's dentition could also notify them or social services if concerns were identified. RN-A stated neither them or the social worker were aware R106 had a loose-fitting denture (as identified in the progress notes) and verified the dietary staff who authored the notes had not passed the information onto them. RN-A stated if they had been told of it, then a referral would have been placed and help provided to R106 to set-up a dental appointment with an outside service. RN-A stated the author of the note had verbally reported (just prior when asked about it due to surveyor inquiry) R106 stated she did not want any action taken with it, however, RN-A acknowledged the lack of documentation in the medical record to support such adding, I would have documented that personally. RN-A verified R106's medical record lacked evidence the loose-fitting denture was acted upon to determine what, if any, services were wanted or needed adding, No, not that I see. RN-A reviewed R106's Care Conference Summary and acknowledged the recorded response of 'NA' under ancillary services. RN-A stated the social worker, to her recall, did not routinely offer dental appointments or referrals at the time of these conferences to TCU-based residents. Further, RN-A stated it was important to ensure dental issues, such as loose-fitting dentures, were acted upon timely to ensure no oral discomfort and proper nutrition was maintained. 49339 R65 R65's significant change MDS assessment, dated 5/22/24, indicated R65 had intact cognition and demonstrated no delusional thinking. Further, the MDS identified a section labeled, L0200, along with spaces to record no natural teeth or tooth fragments(s) (edentulous). This was answered, None of the above were present. Further, R65's Face Sheet, printed 7/18/24, identified R65's current payor source listed as, Medicaid MN. On 7/16/24 at 8:32 a.m., R65 was interviewed and stated, I don't have any dentures .I would like dentures. R65 explained they haven't talked to me about dentures. R65 further clarified that nursing staff or social workers at the facility have not talked to her about dentures and indicated she has not had dentures since being in the facility. R65's Chart Progress Note dental visit, dated 2/27/24, indicated R65 was seen for dental exam and expressed interest in dentures. Note indicated, We discussed the options of traditional dentures vs implant supported dentures vs no treatment She states she is interested in plant supported dentures. Note further indicated, We have referred [R65] to our Mounds View office for a consult re: [regarding] implant supported dentures. R65's Care Conference Summary, dated 3/14/24, indicated a quarterly care conference was completed and a radio-button answered yes to R65, and family invited and attended care conference. Under ancillary services section, indicate approximate date of last visit- Last dental visit date, indicated see resident documents. The document lacked any information about dentures or follow up on dental visit from 2/24. R65's Care Conference Summary, dated 6/2/24, indicated a quarterly care conference was completed and a radio-button answered yes to R65, and family invited and attended care conference. Under ancillary services section, indicate approximate date of last visit. Last dental visit date, indicated see resident documents. The document lacked any information about dentures or follow up on dental visit from 2/24. A review of R65's progress notes, dated 1/2/24 to 7/17/24, lacked evidence of reference to dental appointment in February 2024. On 7/17/24, a progress note indicated, in discussion with resident and resident's spouse, resident and spouse endorsed together that they do not wish to pursue dentures/implants at this time. This was after surveyor inquired about status of dentures and appointment follow up for R65. R65's care plan, printed 7/16/23, identified R65 required assistance with activities of daily living. The care plan identified an intervention which read, ORAL CARE: Staff to provide assist with oral care. However, the care plan lacked any further dictation or interventions for R65's dental status or condition. R65's medical record was reviewed and lacked evidence of coordination after dental appointment and R65's desire to obtain dentures. On 7/17/24 at 2:20 p.m., registered nurse unit manager (RN)-F indicated the process for getting a resident seen for dental is social services obtains the consent signed, which is then sent to the dental provider. They [dental provider] determined who they were going to see at the visits and came every couple of months. RN-F stated if there is an urgent need or concern, they can be seen sooner. After reviewing documentation, RN-F indicated that it looks like [R65] was referred to another dental clinic which they were going to follow up with. On 7/18/24 at 8:10 a.m., RN-F indicated they had a conversation with [R65] and her husband about dentures, they only want implants, and did not want to go back and forth with appointments and have decided to not proceed. RN-F stated that this was an elective procedure for R65. RN-F stated the current process for paperwork received from onsite dental visits was the paperwork was sent to the facility, given to the nurse manager on the floor who reviewed, completed follow up as indicated and then placed in the chart. RN-F indicated this has been the process since they had been there and added, I was not employed here when she was seen by the dentist. R65 verified there was no progress notes in R65 regarding follow up appointments for dental appointments. On 7/18/24 at 10:08 a.m., RN-F indicated they followed up with onsite dental provider and was informed that an appointment was made for R65 at the other clinic after the referral was made, the care coordinator (at the dental provider) was unable to provide information as to who was notified about the appointment. On 7/18/24 at 10:25 a.m., family member (FM)-C indicated that they are involved with R65's care and visit often. FM-C confirmed the facility had not talked to them until yesterday (7/17) about R65's desire for dentures. FM-C indicated R65 had talked about wanting dentures around the beginning of the year. On 7/18/24 at 11:11 a.m., director of nursing (DON) stated they had a dental provider that provided onsite services routinely. She stated social services obtained consents and the dental visit notes were uploaded into the chart. DON further indicated the facility was not notified of R65's referral appointment being made as an order would have been entered with a time and date and there was no order for it. The facility was unable to provide any documentation to support that facility was involved or aware of follow up needed from February dental appointment prior to survey. A facility policy titled Ancillary Services, reviewed 2/12/24, was provided. The document indicated social services staff or designee would meet with resident or their representative upon admission and identify needs and goals for obtaining care from Ancillary service providers and then obtain information from the last dental visit. Further indicated health information staff or designee with schedule appropriate appointment per facility procedures and social service staff or designee would document the resident's plan for ancillary health care services in resident's care conference summary form. Ancillary services were reviewed with each care conference and updated when requested by resident/resident representative.

Based on observation, interview, and document review, the facility failed to ensure symptoms of respiratory impairment and potential infection were assessed and acted upon for 1 of 1 residents (R44); failed to ensure combative behaviors with personal, intimate care (i.e., pericare) were assessed and, if able, interventions developed to provide comfort during such care for 1 of 1 resident (R77); and failed to ensure interventions to reduce or control developed edema were implemented or re-evaluated for 2 of 2 residents (R44, R31) observed with lower extremity edema. Findings include: RESPIRATORY SYMPTOMS: R44's quarterly Minimum Data Set (MDS), dated [DATE], identified R44 had intact cognition and demonstrated no delusional behaviors (i.e., misconceptions or beliefs held contrary to reality). Further, the MDS outlined R44 had no significant respiratory diagnoses present and lacked any ICD-10 coding for cough, unspecified (i.e., R05.9). R44's care plan, dated 6/16/23, identified R44 was at risk for a decline in medical condition due to schizophrenia and anxiety. A goal was listed which read, Resident will maintain current level of health through 90 days, along with various interventions to help R44 meet this goal including, Monitor for changes in condition and notify provider and resident representative as indicated. On 8/7/23 at 5:30 p.m., R44 was interviewed and expressed she felt like she had a cold. R44 expressed she had an ongoing cough which, at times, was productive with mucous and phlegm being coughed up. R44 stated she had the symptoms for awhile now but felt like they were getting worse now. R44 stated she had been tested prior for COVID-19 and it was negative. R44 added she believed staff were aware of her symptoms as they hear me cough, but was unsure what, if any, actions were taken or what, if any, monitoring of her respiratory status was being completed adding, None of that [lung sounds, SpO2 levels]. R44's progress notes, dated 6/1/23 through 8/7/23, were reviewed. On 6/21/23, a note was completed which outlined R44 had . stated that she is not feeling well . with cough episodes . minimal wheezing on the left lower lobe ., and several as-needed medications, including Tylenol and cough syrup, were given. There were no further note(s) identified to demonstrate if R44's condition had continued, improved or resolved. Further, there were no further notes outlining any further episodes of coughing being reported after 6/21/23. On 8/9/23 at 8:43 a.m., R44 was again observed laying in bed while in her room. R44 had a white-colored sheet pulled up and over her entire body including her face and had several audible, loud coughing spells which could be heard from the hallway outside her room. R44's roommate was also present in the room at the time with their eyes closed. The roommate demonstrated no coughing during the same period. When interviewed on 8/9/23 at 9:37 a.m., nursing assistant (NA)-A stated they were familiar with R44 and described her as very much with it [cognitively]. NA-A explained R44 had been coughing and making comments about having a persistent cough for a couple weeks, including R44 having asked for cough syrup and cough drops. NA-A stated they were unsure where the cough came from but believed the nurses were aware of it and going to keep an eye on it. Further, NA-A stated R44's cough was about the same since they had first noticed it. R44's medical record was reviewed and lacked evidence R44's cough had been comprehensively assessed, including for causative factors or for potential infection, or had ongoing monitoring (i.e., daily lung sounds, respiratory rates) despite direct care staff having awareness of the cough and R44 asking for medication to help reduce or improve the symptoms (i.e., cough drops). When interviewed on 8/9/23 at 1:19 p.m., licensed practical nurse (LPN)-A stated they had worked with R44 several times over the past few months and described her as pretty independent with cares. LPN-A stated they were unaware R44 had been having issues with an ongoing cough as neither R44 or the direct care staff (i.e., NAs) had reported any concerns to their knowledge. LPN-A explained R44 had a history of nausea episodes and allergies, however, reiterated a cough was never reported, historically, with those. LPN-A stated if R44 or the NA(s) had reported a cough, then they would have went and assessed R44, including for lung sounds and cough characteristics, and documented it within the medical record. On 8/10/23 at 7:47 a.m., registered nurse unit manager (RN)-A was interviewed and verified they had reviewed R44's medical record. RN-A explained R44 did have a standing as-needed (i.e., PRN) order for cough syrup due to having episodes of a cough in the past; however, verified the medical record lacked evidence R44's recently reported symptoms of cough (i.e., potential infection) were assessed or acted upon. RN-A stated they needed to follow up with the NA(s) and reiterate they need to let the nurses know of symptoms when seeing or hearing of them. RN-A recalled R44's episode of cough and general malaise back in June 2023, and expressed it had resolved to my knowledge, so reported symptoms now would be new for R44. Further, RN-A stated they had just placed a nursing order yesterday (8/9/23) to complete a respiratory assessment on R44 every shift for one week to help assess and monitor the symptoms. A facility policy on respiratory monitoring and evaluation was not provided. BEHAVIOR: R77's quarterly Minimum Data Set (MDS), dated [DATE], identified R77 had moderate cognitive impairment, demonstrated no delusional behaviors (i.e., misconceptions or beliefs held contrary to reality), and required extensive assistance of one staff member to complete toileting and toileting-related cares (i.e., cleans self after elimination). On 8/7/23 at 12:46 p.m., R77 was interviewed about her quality of life and care while at the nursing home. R77 stated the staff treat me mean, but did not explain further even when asked. R77 was asked if she had reported the concerns to the nurses or management, but she did not respond verbally rather just nodded her head up and down in an affirmative manner. R77 denied concerns with other residents on the unit and reiterated it was just staff who were 'mean' to her. Adding, she did not feel safe at the nursing home. During an interview on 8/9/23 at 9:53 a.m., nursing assistant (NA)-A stated she routinely worked with R77 and described her as a [NAME] with personal, intimate cares (i.e., pericare). NA-A stated R77 struck out when staff attempted to change her incontinent brief or cleaned her perineal area. NA-A stated she questioned if R77 had been sexually abused. NA-A stated the behavior of physically striking out only happened with changes and perineal cares. Staff explained cares prior to completing, but R77 would still strike out at them and respond aloud, Stop touching me. This behavior had been happening for several weeks. NA-A stated staff had tried female only caregivers with R77 but the behavior continued. Further, NA-A stated the nurses were aware of this behavior. On 8/9/23 at 10:49 a.m., R77's family member (FM)-D stated R77 had resided at the nursing home for some time and they were unaware of any past trauma or abuse prior to admission. FM-D stated they were unaware R77 had been striking out during personal cares and expressed R77 always seemed to like it there [nursing home]. R77's completed Social History and Psycho-social Review, dated 5/29/23, identified R77 was evaluated and had sustained no significant losses over the past quarter, and had a mental health diagnosis but felt their treatment plan was effective. These treatment options were listed as, Medication and ACP psychotherapy. A question was listed which read, Does resident have a trauma care plan in place currently?[,] which was answered, No. The completed evaluation lacked recorded evidence R77's had behavior of striking out with personal care and been assessed or evaluated for potential past trauma (i.e., sexual abuse) or potential causative factors. R77's care plan, dated 6/14/23, identified R77 required assistance with toileting due to decreased mobility, incontinence and a history of seizure disorder. The care plan outlined R77 wore a white-colored TENA brief for her incontinence and included, Requires more assist on NOCs [nights]. The care plan included a section labeled, Behavioral Symptoms, which identified R77 had a history of having difficulty with shared items, aggressive behaviors towards others, swearing and name calling, refusing medications, and a history of making false or exaggerated allegations. The care plan directed to ensure safety of R77 and others, to re-approach when physically aggressive. However, the care plan lacked any recorded problems or interventions for how to address or respond to R77 with personal, intimate cares (i.e., pericare) to help reduce her behavioral symptoms of hitting out; nor any recorded interventions for female only caregivers with such tasks. In addition, R77's medical record was reviewed and lacked evidence the identified behavior of striking out with personal cares had been comprehensively assessed, including for causative factors or if any interventions developed for staff to implement with personal cares to reduce R77's behaviors and/or anxiety with the cares performed. There was no evidence this had been evaluated despite direct care staff reporting the behavior as present and ongoing causing them (floor staff) to implement their own interventions (i.e., female only caregivers). On 8/9/23 at 11:23 a.m., the unit social worker (SW)-A was interviewed via telephone, and verified they had medical record access. SW-A explained trauma was evaluated upon admission to the nursing home using the Social History and Psycho-social Review. R77 did not have any past trauma to their knowledge. SW-A stated they were unaware R77 had been striking out with personal, intimate cares. They had never been told of that. SW-A stated R77 did have a past history of striking out, but such had not happened for some time since R77 no longer had a roommate, was physically declining, and rarely out of bed. SW-A reviewed R77's care plan and verified it lacked evidence female only caregivers had been assessed or added, and they explained it was possibly added by the unit manager but they weren't sure. SW-A reviewed R77's NA care sheet and verified it also lacked direction to use female only caregivers. SW-A stated R77 possibly did need female only caregivers, however, they don't know as the problem had never been mentioned. SW-A stated R77 was currently on caseload for psychotherapy (via ACP), however, she had not been seen since January 2023. On 8/10/23 at 7:26 a.m., registered nurse unit manager (RN)-A stated trauma and stressors were evaluated by the social service evaluations (i.e., Social History and Psycho-social Reviews). RN-A stated R77 had always denied past trauma. When trauma was voiced or identified, a corresponding trauma informed care evaluation would be completed. Pending such evaluation, certain protocols and interventions would be placed. RN-A explained behavioral conditions, were evaluated in tandem with nursing and social services to help get down to the bottom as to why they were happening. RN-A stated R77 possibly just doesn't like peri care, which was causing the behaviors. However, it had not been fully evaluated. RN-A stated any completed evaluation of behavioral symptoms or conditions would be recorded on the social services assessments. RN-A stated they were just made aware of the concern with R77's behavior during pericare the day prior, on 8/9/23, and they hadn't yet dug too much into her with an evaluation as a result. However, RN-A stated an assessment of behavioral symptoms, including striking out with personal cares, was important as staff want to provide personalized care and do their best to honor resident wishes and past experiences, if present (i.e., trauma). Further, RN-A stated they were unaware the floor staff had implemented a female only caregiver approach, and expressed if staff are seeing behaviors warranting such action then they should have reported them to the nurse to be addressed. A provided Behavioral Health Services policy, dated 10/2022, identified facility staff would identify, document, and inform the provider of specific details regarding changes in a resident's mental health status, behavior, and cognition. The policy outlined, New or changing behavioral symptoms will be evaluated by the interdisciplinary team (IDT) in order to help determine the underlying cause and to address any modifiable factors that may have contributed . could include . [Infection, Dehydration, Depression, Loneliness, Fear, etc.] EDEMA MANAGEMENT: R44's quarterly Minimum Data Set (MDS), dated [DATE], identified R44 had intact cognition, demonstrated no delusional behaviors (i.e., misconceptions or beliefs held contrary to reality), and did not have heart failure or other heart/circulation disorders present. R44's Physician Order Report, dated 5/9/23, identified R44 had several medical diagnoses including acute respiratory failure, adrenocortical insufficiency, and long term use of anticoagulants (medication to thin the blood). R44's medical and treatment regimen was listed which included an order, . continue TEDs on in AM off at HS [bedtime] . Twice a Day; 0800, 20:00 [8:00 p.m.]. R44's care plan, dated 6/2023, identified R44 was at risk for impaired nutritional status due to several medical conditions including, LE [lower extremity] edema. However, the care plan lacked any specific problem statements, goals, or subsequent interventions to address the edema what, if any, specific interventions for it were being completed. Further, the care plan outlined R44 was at risk for a medical decline due to schizophrenia and an adrenal insufficiency and directed, Monitor for changes in condition and notify provider and resident representative as indicated. On 8/7/23 at 5:33 p.m., R44 was observed laying in bed while in her room. R44's bare feet and lower portion of her legs were exposed and had visible swelling (i.e., edema) present with the left leg being slightly more swollen in appearance. R44 stated they had a history of edema and the legs had been swollen for a couple weeks now. R44 stated they used to wear TED stockings (a soft, elastic type material used to reduce swelling) on their legs but didn't anymore because they started to hurt so she refused to wear them. R44 stated nobody from the nursing home and talked with her since she stopped wearing them or offered to apply ACE wraps or re-measure her legs for better fitting TEDs. Further, R44 stated she felt the edema was getting worse since she first noticed it weeks prior. On 8/8/23 at 3:10 p.m., R44 was again laying in her bed and had no TEDs or ACE wrappings in place on her legs. R44's ankles and lower portion of her legs remained with visible swelling. R44 reiterated she stopped wearing her TEDs about a week prior as they didn't fit, and expressed she was open to wearing better fitting ones, if provided or offered. During subsequent observation, on 8/9/23 at 8:37 a.m., R44 was walking down the hallway towards her room using a walker and, again, did not have any visible TEDs or ACE wraps in place. During an interview on 8/9/23 at 9:23 a.m., nursing assistant (NA)-A stated R44 was very independent with most cares and required not too much help. NA-A stated R44 used to wear TEDs but stopped a couple weeks ago as she didn't like 'em on her feet. NA-A explained they had noticed that they [legs, ankles] swollen and felt the nurses were aware but added, It is what it is. NA-A stated they felt the swelling was about the same as when first noticed several weeks prior, and expressed the TEDs intervention had even been removed from the NA care plans which NA-A believed was likely due to R44 refusing to wear them. On 8/9/23 at 1:19 p.m. licensed practical nurse (LPN)-Astated R 44 was pretty independent with most cares. LPN-A stated R44 had physician-ordered TEDs but she didn't check to see ifR44 had them on or not. LPN-A reviewed R44's medical record and expressed the physician order for TEDs was still active and, as a result, they should be on as ordered. LPN-A stated they were aware R44 had mild edema present, and any application of the TEDs would be recorded in the Medication Administration Record (MAR). LPN-A stated she was unaware R44 had been refusing to wear the TEDs for the past weeks. She stated it was important to explain the risk of not wearing TEDs and documented it in the medical record. Further, LPN-A stated it was important to ensure TEDs or edema treatments, in general, were implemented to help remove the fluid build up in the legs. R44's MAR, dated 7/2023, identified R44 had an order in place for TEDs to be applied in the morning and removed at bedtime. The order had a listed start date of 10/31/22, and remained active and open ended. The MAR had spaces to record if they were applied, removed, and staff initials to demonstrate each application and/or removal. There were no documented refusals for the entire month, however, one day (7/7/23) had the spacing to record the application blank with no dictation or refusal recorded. R44's current MAR, dated 8/2023, identified the same order for the TEDs with the same start date listed. The MAR again provided spaced to record if they were applied, removed, and staff initials to demonstrate such for each date. The MAR identified each day of the month, including the days R44 was observed by the surveyor not wearing them, as being applied in the morning and removed at bedtime. R44's medical record was reviewed and lacked evidence R44's edema had been comprehensively reassessed for potential intervention management, including re-measurement of TEDS or the application or ACE wraps, despite R44 having a physician order to wear such devices and direct care staff having awareness R44 had refused them for several weeks time. On 8/10/23 at 7:36 a.m., registered nurse unit manager (RN)-A was interviewed. RN-A explained R44 had long-standing issues with edema and, as a result, had active orders for TEDs to be worn. RN-A stated they were not aware R44 had been refusing to wear the devices as it had not been reported to them so, as a result, they had just spoken with R44 who expressed they did want them and would be re-measured for better fitting ones. RN-A stated if a treatment, including TEDs, was refused, then the nurse should have been notified. RN-A reviewed R44's medical record, including the MAR, and verified the nurses' were still recording the treatment as administered adding, I have some work to do [education]. Further, RN-A stated it was important to ensure TEDs were applied, or other edema management interventions sought, as edema was an easily corrected thing with those interventions provided. 44658 R31's annual MDS dated [DATE], indicated R31 had mild cognitive deficits, independent with eating, limited assistance for bed mobility, total assistance for transfers, and extensive assistance for dressing and toileting. R31's diagnoses included a congenital deformity of the hip, diabetes, morbid obesity, paraplegia (lower extremity paralysis), congestive heart failure (which can cause fluid retention in the lower extremities and lungs), lymphedema (fluid retention in the lymph system causing swelling in the arms and legs), urinary incontinence, and Lupus (an autoimmune disease resulting in pain and organ damage). R31's CAA dated 7/18/22, indicated R31 triggered for communication, ADL function, falls, and pressure ulcers. R31's care plan dated 3/8/19, indicated R31 was non-ambulatory due to a congenital hip malformation and a fall resulting in a left hip fracture and used an electric wheelchair for mobility. The care plan lacked indication R31 had a history of edema or intervention for the care and management of R31's edema. R31's physician orders dated 5/18/23, indicated R31 had approval for occupational therapy (OT) for skilled maintenance for lymph (fluid retention) treatment. R31's OT discharge summary dated 6/16/23, indicated OT began treating R31 on 5/19/23, related to lower extremity edema due to R31 was not wearing TG shapes (leg wraps) that were previously issued. R31 was to wear leg wraps during the day, doubled at the foot and ankle. The leg wraps were to be removed at night, washed, and hung to dry. During an observation and interview on 8/9/23 at 1:37 p.m., R31's family member (FM)-A was visiting R31 in her room. R31 was in her wheelchair wearing ankle socks but no leg wraps. R31 stated she did not know what happened to her leg wraps but that she should have them on. FM-A touched R31's lower left leg, stating R31's leg felt cold and that R31 should have leg wraps on to help with her circulation. During an observation and interview on 8/10/23 at 7:24 a.m., nursing assistant (NA)-D assisted R31 to get dressed and perform personal hygiene. NA-D removed R31's ankle socks revealing a significant indentation around both of her ankles where the socks had been. With assistance from another NA, NA-D transferred R31 into her electric wheelchair using a Hoyer lift. R31 then wheeled herself to the dining room for breakfast. R31 did not have leg wraps on. During an interview on 8/10/23 at 9:15 a.m., NA-D stated she did not see any leg wraps in R31's room and her care sheet did not indicate she wore them. During an interview on 8/10/23 at 9:46 a.m., registered nurse (RN)-F verified there was no order to apply wraps to R31's lower extremities although RN-F recalled R31 used to wear them for lower extremity edema and because she was unable to move her legs. RN-F also stated she had not been notified by NA-F of R31's pitting edema around her ankles and would have expected to be so she could do a further assessment. During an interview on 8/10/23 at 11:54 a.m., OT-A stated when a resident was discharged from therapy services, any recommendations for continuing care were given to the nurses a few days prior to the discharge to ensure they were added to the resident's care plan and care sheet to minimize the disruption in care. OT-A stated R31 was seen by therapy for edema in her lower extremities due to limited mobility. Due to R31's intolerance of Velcro leg wraps, therapy recommended R31 wear tube grip leg wraps for long-term maintenance of her edema. OT-A further stated R31 was to have the leg wraps on during the day and removed at night. During an interview on 8/10/23 at 1:00 p.m., the director of nursing (DON) stated therapy recommendations were to be documented on a communication form and given to the nurse manager, who would include the interventions on the resident's care plan and the NA's care sheet. The DON further stated she would expect NAs to notify the nurse when they see pitting edema on a resident's extremities to ensure the resident received any necessary interventions. The facility Restorative nursing/Functional maintenance program review dated 4/13/23, indicated physical and occupational therapy would complete paperwork to instruct the nursing staff of any recommended restorative or functional maintenance programs after a resident was discharged from therapy services. The clinical manager or therapy staff would enter the recommendations into the resident's care plan for the restorative and/or nursing assistants to complete. The clinical manager and therapy staff were also to meet monthly to review the resident's progress and goals to determine the appropriateness of the program and document the findings in the resident's electronic medical record. The facility Ace bandage-Support/Compression stocking use policy dated 4/13/23, indicated residents were to have two pairs of support/compression stockings. Orders for the use of the stockings were to be indicated on the resident's NA assignment sheet and/or the resident's electronic profile. Licensed nursing staff were to verify and document the application and removal of the stockings or ace wraps. Ace wraps or stockings were also to be applied early in the morning before swelling occurred. The policy also indicated staff were to observe the resident's skin for signs of pressure prior to application. No further information regarding the care of residents with edema was provided.

Based on observation, interview, and document review, the facility failed to ensure resident medications were ordered in a timely manner to avoid underdosing for 3 of 3 residents (R1, R89, R101) reviewed for medication administration. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, independent with eating and required extensive assistance for all other activities of daily living (ADLs). R1's diagnoses included diabetes, schizoaffective disorder/bipolar, chronic obstructive pulmonary disease (COPD-causing inflammation and narrowing of the airway and difficulty breathing), obstructive sleep apnea (OSA-causing intermittent periods of non-breathing during sleep), and unspecified allergies. R1's Care Area Assessment (CAA) dated 3/7/23, indicated R1 triggered for communication, ADL function, falls, psychotropic drug use, and pain. R1's care plan dated 7/12/23, indicated R1 had an altered respiratory status related to COPD and OSA and was at risk for medical decline. Interventions included administering medications as ordered. R1's physician orders dated 12/8/22, indicated R1 took Advair twice a day for COPD, capsaicin three times a day for shoulder, arm, and back pain, Flonase Allergy Relief nasal spray twice a day for allergies, and ipratropium bromide four times a day for rhinitis (runny nose). R1's Medication Administration Record (MAR) dated 6/7/23 to 7/7/23, indicated the following medications were unavailable for administration: -Advair: -6/7/23, AM dose. -6/8/23, AM dose. -capsaicin: -6/9/23, HS dose. -6/10/23, HS dose. -6/27/23, noon dose. -6/28/23, AM and noon dose. -Flonase nasal spray: -6/30/23, HS dose. -ipratropium bromide nasal spray: -7/3/23, PM dose. R1's MAR dated 7/8/23 to 8/7/23, indicated the following medication were unavailable for administration: -ipratropium bromide nasal spray: -8/6/23, noon, PM, HS dose. -8/7/23, AM, noon dose. During an interview on 8/7/23 at 1:21 p.m., R1 was sitting in her room; her nose appeared red. R1 stated the facility ran out of her medications sometimes and they had currently been out of a nasal spray she used to control allergy symptoms for the past few days. R1 stated her nose kept running and running and she didn't feel good. R1 further stated the facility had run out of all her medications at sometime or another. During an interview and observation on 8/10/23 at 1:33 p.m., R1 was sitting in her wheelchair in her room. R1's nose was visibly red, and she had clear mucus running out of her left nostril. R1 stated two days before her nasal spray ran out, there was hardly any medication in the bottle, and it should have been refilled then. R89's quarterly MDS dated [DATE], indicated R89 had intact cognition, required extensive assistance with dressing and was independent with all other ADLs. R89's diagnoses included seizures, diabetes, atrial fibrillation (irregular heartbeat causing an increase in clot formation), COPD, major depression, chronic pain, persistent migraine aura with status migrainosus (sensory disturbances lasting more than a week prior to a migraine headache and migraine headaches lasting longer than 72 hours). R89's CAA dated 3/21/23, indicated R89 triggered for ADL function, falls, psychotropic drug use, and pain. R89's care plan dated 6/18/23, indicated R89 had an alteration in comfort related to chronic pain and medical conditions including history of a stroke, anxiety, atrial fibrillation, COPD, OSA, tremors, seizures, and morbid obesity. Interventions included administering medications as ordered. R89's physician orders dated 7/6/22, indicated R89 took atorvastatin once a day for high cholesterol, cyclobenzaprine three times a day for back pain, Pradaxa twice a day for atrial fibrillation, and levothyroxine once a day for hypothyroidism (low thyroid). R89's MAR dated 6/9/23 to 7/9/23, indicated the following medications were unavailable for administration: -atorvastatin: 7/9/23, bedtime (HS) dose. -Pradaxa: -6/9/23, PM dose. -6/29/23, PM dose. -7/5/23, AM dose. R89's MAR dated 7/11/23 to 8/7/23, indicated the following medications were unavailable for administration: -cyclobenzaprine: -7/15/23, noon dose. -7/27/23, AM dose. -7/28/23, AM, noon, PM dose. -7/29/23, AM dose. -7/30/23, noon, PM dose. -7/31/23, AM dose. -8/1/23, AM, noon, PM dose. -levothyroxine: -7/22/23, AM dose. During an interview on 8/7/23 at 3:06 p.m., R89 stated the facility had run out of several of his medications several times and it was terrible. R89 stated the most recent occurrence was less than a week prior and they would probably run out of something else pretty soon. R89 stated he had chronic pain in his shoulders that became worse when he did not receive his medications including his cyclobenzaprine. The facility had also run out of his heart medication, Predaxa, which concerned him. R89 further stated it made it more difficult for him to sleep. During an interview on 8/9/23 at 11:35 a.m., R89 stated the facility had run out of Primadone? R89 stated the medication helped calm his tremors and he had difficulty bringing utensils to his mouth during breakfast that morning. During an interview on 8/9/23 at 2:236 p.m., RN-G stated it was difficult to tell when a nasal spray needed to be reordered because the bottle was opaque and therefore, the medication may not be refilled early enough. RN-G further stated they had run out of R89's cyclobenzaprine and she had been trying to call the provider to get a preauthorization. RN-G further stated she thought sometimes residents missed doses of their medications because staff did not know where to find the medications. RN-G also stated R89 liked to be in involved and in control of his medications. During an interview on 8/10/23 at 9:56 a.m., RN-F stated she was aware medications had not been delivered timely from the pharmacy. RN-F stated occasionally she had ordered medications prior to being off, and upon returning to work a few days later, the medications still had not been delivered. RN-F stated it was frustrating. RN-F further stated R1's Desitin was never there and although her nasal spray bottle indicated it was delivered on 8/5/23, staff may not have known where to look for it and therefore R1 did not receive it for a couple of days, causing R1 to have a runny nose. RN-F further stated she was unaware R89 had run out of medications but most of R89's concerns were regarding pain and R89 freaks out if he did not receive all his medications. During an interview on 8/10/23 at 10:50 a.m., the consulting pharmacist (CP) stated it was concerning R1 had missed her Advair inhaler because it was used to manage her COPD. The CP also stated because R89 took cyclobenzaprine for pain, missing doses would increase his pain. The CP stated although the cyclobenzaprine may require a preauthorization from the provider, because it was a scheduled medication, staff should start the process of contacting the provider to obtain refills in advance to avoid R89 missing any doses. The CP also stated it was important for R89 to receive his cardiac medications to avoid complications. During an interview on 8/10/23 at 12:35 p.m. the director of nursing (DON) stated staff should re-order medications five to seven days prior to running out to avoid a resident missing any doses. The DON stated staff should also look in the Omnicell (a medication dispensing machine) for a back-up or emergency supply, then call the pharmacy and/or provider for a STAT delivery if necessary. The facility Pain Management policy dated 7/13/21, indicated chronic pain required continual assessment of pain and pain medication regimen. No further information regarding ordering or refilling pain medications was indicated. 47495 R101's quarterly MDS dated [DATE], indicated R101 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. R101 was non ambulatory and had no locomotion on or off the unit during the look back period. The MDS further indicated R101 had several medical diagnoses including arthritis due to bacteria of the left hip, osteoarthritis of bilateral knees, depression, and stage III pressure injury to left buttock. R101's orders dated 8/2/23, indicated R101 had an order for Lidocaine 2% gel to wounds twice daily prior to wound care. R101's MAR for the month of August indicated an order for lidocaine 2% gel to wound prior to wound care. However, the lidocaine gel had not been administered since the order was received on 8/2/23. During an interview on 8/9/23 at 11:16 a.m., RN-H stated R101 received wound care daily and verified an order for lidocaine to the wound bed prior to wound care for pain. However, they have not had the lidocaine since the order so it had never been provided. RN-H stated she was unsure why the lidocaine gel was not available for use. During an interview on 8/10/23 at 8:20 a.m., RN-I stated the expectation was was to reorder medications when the bubble packs get to the red, meaning when there were approximately 7 doses of a medication left. During an interview on 8/10/23 at 8:05 a.m., RN-A stated she expected to be notified when a medication was out and she had not heard of R101's lidocaine not being available. Facility policies regarding medication administration, and ordering and/or refilling resident medications, were requested but not received.

Based on interview and record review the facility failed to provide 1 of 1 resident (R343) with timely toileting care to promote a dignified toileting experience. Findings include: A nursing progress note, dated 8/3/23, indicated R343 was alert and oriented to person, place and time and was continent of bowel and bladder. A social worker progress note, dated 8/4/23, indicated R343 was cognitively intact. R343's care plan, dated 8/3/23 indicated R343 needed staff to provide assist of two staff members with toileting. Toilet upon rising, before and after meals, at bedtime and as needed. During an interview on 8/7/23 at 6:02 p.m., R343 stated he could not maintain his bowel continence because staff could not get to him in time. R343 stated over the weekend he pushed his call light to use the bed pan but after waiting 30 or so minutes. R343 was unable to hold his bowels and had a bowel incontinence episode. R343 stated he felt embarrassed and that staff just slapped on a brief. R343 stated staff expect him to have a bowel movement in his brief. During an interview on 8/9/23 at 11:00 a.m., nursing assistant (NA)-B stated R343 was able to transfer to his wheelchair via a hoyer lift but was unsure how his toileting needs were managed. NA-B stated R343 sat independently in his wheelchair and was independent with morning cares. During an interview on 8/10/23 at 7:11 a.m., R343 stated he used his brief to have a bowel movements, would rather sit on the toilet or commode. However, since he wore briefs, staff expected him to go in the brief. It feels pretty icky telling yourself to soil your pants. During an interview on 8/10/23 at 12:20 p.m., the nurse manager (RN)-J stated the expectation for a resident who transfers via hoyer lift would be to transfer them to a commode to have a bowel movement. Staff should not put a brief on a resident who was continent and expect them to have a bowel movement in bed. RN-J stated when residents transfer using a hoyer lift, the intent was for staff to utilize a toileting sling and transfer the resident to the commode when they can tolerate sitting. During an interview on 8/10/23 at 11:58 a.m., the director of nursing (DON) confirmed it would not be facility protocol to expect a continent resident who needed assistance with transferring to have to have a bowel movement in their brief, in bed. DON stated a toileting sling and commode should have been used. A policy on toileting and dignity was requested but not received.

Based on observation, interview, and document review the facility failed to ensure call lights were accessible for 2 of 3 residents (R26, R31). In addition, the facility failed to ensure an electric wheelchair was charged each night to ensure the highest level of independence for 1 of 1 residents (R31). Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had mild cognitive deficits. R26 was independent with eating, required total assistance for toileting, and extensive assistance for all other activities of daily living (ADLs). R26's diagnoses included diabetes with neuropathy (lack of sensation in extremities), heart failure, stroke affecting dominant right side (hemiparalysis), morbid obesity, and aphasia (difficulty with communication and comprehension). R26's Care Area Assessment (CAA) dated 8/9/22, indicated R26 triggered for ADL function, urinary incontinence, falls, and pressure ulcers. R26's care plan dated 9/19/17, indicated R26 was at risk for falls related to neuropathy, hemiparalysis, impaired mobility, and urinary incontinence. The care plan also indicated R26 required assistance with wheelchair mobility and was unable to self-propel. The care plan lacked indication of R26's need to have a call light within reach. During an observation and interview on 8/7/23 at 2:15 p.m., R26 was in her wheelchair to the left of her bed. R26's call light was wrapped around the left bed rail and hanging below the bed frame, out of R26's reach. R26 stated she had a stroke that paralyzed her right side and was unable to reach her call light or maneuver her wheelchair to call for assistance if necessary. Nursing Assistant (NA)-F entered R26's room, turned on R26's light, asked how R26 was, and left the room. NA-F did not move R26's call light within her reach. During an interview and observation on 8/7/23 at 2:24 p.m., NA-G verified R26's call light was out of R26's reach and pinned it to R26's shirt. During an observation and interview on 8/9/23 at 9:55 a.m., an unknown NA was seen leaving R26's room with a bag of trash after providing continence care to R26. R26 was sitting up in bed; her call light was wrapped around the left grab bar behind R26, and hanging below the bed frame, out of R26's reach. R26 stated although her brief had just been changed, she had a bowel movement and needed to be changed again. R26 stated she was unable to reach her call light and requested staff assistance. During an interview on 8/9/23 at 10:05 a.m., NA-E verified R26's call light was not within her reach and placed it on her lap. R31's annual MDS dated [DATE], indicated R31 had mild cognitive deficits, was independent with eating, limited assistance for bed mobility, total assistance for transfers, and extensive assistance for dressing and toileting. R31's diagnoses included a congenital deformity of the hip, osteoarthritis of the right shoulder (degeneration of the bone), heart failure, diabetes, morbid obesity, paraplegia (lower extremity paralysis), urinary incontinence, and Lupus (an autoimmune disease resulting in pain and organ damage). R31's CAA dated 7/18/22, indicated R31 triggered for communication, ADL function, falls, and pressure ulcers. R31's care plan dated 3/8/19, indicated R31 enjoyed activities including bingo, social activities, and church services. R31 was also non-ambulatory due to a congenital hip malformation and a fall resulting in a left hip fracture and used an electric wheelchair for mobility. The care plan also indicated R31 had a history of mild cognitive impairment. R31 was at risk for skin impairment. Interventions included ensuring and encouraging R31 to turn and reposition every two hours. The care plan lacked interventions regarding the use and placement of a call light. During an observation and interview on 8/7/23 at 1:33 p.m., R31 was sitting in her wheelchair in her room. R31's call light was wrapped around the grab bar on her bed rail and tucked under the sheets. R31 stated she would not be able to access her call light even if she was able to wheel to the bed because her feet stick out and she couldn't get close enough to reach it. During an observation on 8/9/23 at 9:54 a.m., R31 was asleep in her bed. The call light was wrapped around the grab bar on her left side and hanging approximately 18 inches toward the floor; out of R31's reach. During an interview on 8/9/23 at 10:04 a.m., NA-E verified R31's call light was not within her reach and placed it across R31's abdomen. During an interview on 8/10/23 at 9:46 a.m., registered nurse (RN)-F stated call lights should always be accessible to residents so they can call for assistance. During an interview on 8/10/23 at 12:52 p.m., the director of nursing (DON) stated call lights should always be accessible to the residents. The DON verified if R26, and R31's call lights were hanging below their bed frames, they would not be able to reach it to call for assistance. The facility Nursing assistant standard cares policy dated 4/13/23, indicated staff were to place the call light within reach of the resident. Wheelchair During an observation and interview on 8/8/23 at 2:42 p.m., R31 was sitting in her wheelchair watching TV. R31's wheelchair was plugged into the wall, charging. R31 stated the staff forgot to plug in her wheelchair the night before and therefore she was unable to attend bingo that afternoon, her wheelchair didn't have enough battery power and she was afraid she would get stuck somewhere. During an observation and interview on 8/10/23 at 7:12 a.m., R31 was in bed and ready to get up for the day. R31's wheelchair was parked by her closet and not plugged in to charge. R31 expressed frustration and stated she had told the night staff to plug it in. She didn't want to end up sitting in the middle of the floor all day because it was boring. During an interview on 8/10/23 at 7:24 a.m., NA-D verified R31's wheelchair was not plugged in but NA-D had not worked with R31 before and therefore did not know if that would mean R31 was unable to use it or not. During an interview on 8/10/23 at 9:46 a.m., RN-F stated R31's wheelchair should have been plugged in and charged every night to ensure R31 was able to be mobile throughout the following day. During an interview on 8/10/23 at 1:08 p.m., the DON stated staff should ensure R31's wheelchair was plugged in to charge every night to ensure she had enough battery life to maintain her mobility and independence. A facility policy regarding accessibility of resident equipment and/or accommodation of resident needs was requested but not provided.

Based on observation, interview, and document review, the facility failed to provide a clean homelike environment for 1 of 1 residents (R63) whose bed linens were soiled. Findings include: R63's Admission Minimum Data Set (MDS) dated [DATE], indicated R63 was cognitively intact, did not refuse cares, required extensive assistance with activities of daily living, and occasionally incontinent of bladder and bowel. MDS also indicated R63 was at risk for skin breakdown. R63's diagnoses included pathological fracture, cancer, diabetes mellitus, benign prostatic hyperplasia (enlarged prostate), and depression. R63's ADLs (activity of daily living) care plan dated 6/16/23, indicated assistance was required with ADLs including bathing, bed mobility, transfers, dressing, grooming, and toileting. R63's care plan indicated he was at risk for alteration of skin breakdown due to incontinence of bladder and/or bowel, decreased activity, immobility, nutritionally at risk, shear, and friction. R63's Physician Order Report dated 8/11/23, identified an order dated 7/6/23 for triamcinolone acetonide lotion 0.1% to be applied to R63's chest and back, for rash and other nonspecific skin eruption. During observation on 8/7/23 at 12:57 p.m., R63 was not in his room. R63's bed was not made, and the bed linen was pushed back towards the foot of the bed. The top sheet had several dark red colored stains measuring between one to two inches in diameter. The fitted sheet had a stain area at the edge of the bed. The stain was brownish in the center, the edges were dark yellow, and it measured about 12 by 10 inches. During observation on 8/8/23 at 2:29 p.m., R63's bed was made; the top sheet was folded about 7-8 inches over the bed quilt and there were two visible dark red stains. Upon inspection, the top sheet had the same red stains identified the previous day, and the fitted sheet had the same brownish/yellowish stain at the edge of the bed. During interview on 8/8/23 at 2:36 p.m., registered nurse RN-D verified R63's bed linens were soiled. RN-D stated bed linens were changed when residents get a shower and as often as needed. During interview on 8/9/23 at 10:13 a.m., R63 stated it bothered him to sleep on dirty linens. At home, R63 changed bed linen every other day. During interview on 8/10/23 at 9:37 a.m., RN-E stated the bed linen needed to be changed on shower days and as needed. During interview on 8/10/23 at 1:36 p.m., the director of nursing (DON) stated her expectation was bed linens were changed once a week and as needed. DON stated soiled linen was a dignity and infection control issue; especially if the resident had issues with skin integrity. The facility Nursing assistant standard cares policy, reviewed on 4/13/23, indicated Nursing staff will provide quality care to those we serve. Unless otherwise indicated on the resident's care plan, the following standard cares will be provided by nursing assistants to all residents at Cassia facilities as the resident allows. The policy directed staff to change the bed linen weekly on bath day and as needed.

Based on interview and document review, the facility failed to ensure an allegation of resident-to-resident abuse was thoroughly investigated to provide continued protection for 2 of 2 residents (R61, R338) involved in a resident-to-resident altercation. Findings include: A Nursing Home Incident Report (NHIR) dated 6/22/22, indicated on 6/22/22, R338 was heard shouting and cursing at her daughter in the hallway. R61 went to the hallway and told R338 not to speak to her daughter that way. R338 shouted at R61 saying Shut up and mind your damn business. Staff intervened and assisted R61 to the dining room to get a soda. On the way back to her room, R338 saw R61 in the hallway and stated, Get out of here you witch and kicked R61's wheelchair. R61 then spilled her soda onto R338's back and wheelchair. Staff reported no injuries to either resident. A NHIR 5-day report dated 6/27/22, indicated R338 had a history of verbal abuse as reported by R338's family member and refused all psychology referrals. The report investigation summary reported after the altercation between the two residents, R61 and R338 were eating at opposite sides of the dining room when R338 began yelling at R61 from across the dining room. The report indicated a staff statement was received and the staff was a credible witness. No further interviews or statements by staff or residents were indicated. R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had severe cognitive deficits, required limited assistance with dressing, supervision with toileting and personal hygiene, and was independent with all other activities of daily living (ADLs). R61's Care Area Assessment (CAA) dated 2/7/23, indicated R61 triggered for psychotropic drug use. R61's care plan dated 6/27/22, indicated a resident-to-resident altercation had occurred between R338 and R61; however, the care plan lacked interventions related to the incident to prevent further altercations from occurring. R338's discharge MDS dated [DATE], indicated R338 had intact cognition and required extensive assistance for most ADLs. R338's care plan dated 4/26/22, indicated R338 had aggressive behaviors; however, the care plan lacked indication of the incident between her and R61 or interventions to keep the residents separated from each other. R338's CAA dated 5/15/22, indicated R338 triggered for pain. The CAA lacked evidence R338 triggered for mood or behaviors. During an interview on 8/10/23 at 1:10 p.m., the director of nursing (DON) stated investigations of alleged abuse were a collaborative effort between the DON, nurse manager, social worker, and other staff. The DON further verified there was no documentation any staff other than nursing assistant (NA)-H, who witnessed the incident in the hallway between R61 and R338, were interviewed. The DON also stated no other residents were interviewed to determine if they had witnessed the event in the dining room, how they may have been affected by the event, if they had a similar experience with R61 and/or R338, or if they felt safe in the facility. The facility Vulnerable Adult policy dated 10/14/22, indicated a resident's care plan would be revised if the physical, mental, or psychosocial needs or preferences of the resident had changed as a result of an incident of abuse. The policy indicated all suspected or alleged reports of resident abuse were to be thoroughly investigated. The investigation may include but was not limited to interviewing any potential witnesses to the incident. The staff were to analyze possible reasons for the occurrence and determine what changes were to be made to prevent further occurrences. No further interventions or procedures were indicated, including procedures related to an incident of abuse occurring between two residents.

Based on observation, interview and document review, the facility failed to provide routine bathing and hair washing to 1 of 1 residents (R101) reviewed for activities of daily living (ADLs). Findings include: R101's quarterly Minimum Data Set (MDS) dated [DATE], indicated R101 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, non ambulatory, and no locomotion on or off the unit during the look back period. The MDS further indicated diagnoses included arthritis due to bacteria of the left hip, osteoarthritis of bilateral knees, depression, and stage III pressure injury to left buttock. An order dated 7/27/23, indicated staff to encourage R101 to take a tub bath, okayed per wound nurse. R101's care plan indicated R101 required physical assistance with bathing, and a scheduled bath day of Wednesday morning. During interview and observation on 8/7/23 at 2:44 p.m., R101 was laying in bed with just a sheet over her and no clothing on with greasy, disheveled hair. R101 stated while she would like a tub bath, she cannot get a bath because of her wounds. R101 stated she was washed up now and then but not receiving full bed baths. During an interview and observation on 8/9/23 at 10:01 a.m., R101 stated she did not receive her scheduled bed bath yet this morning but that nursing assistant (NA)-C wanted to wash her hair today, but everyone always forgets. During an interview on 8/9/23 at 11:06 a.m., NA-C stated R101 was total care, meaning she needed physical assistance with all her ADLs. NA-C stated R101 was scheduled for a bath that morning. NA-C stated R101 had been in bed for a really long time. R101 does not ask to get out of bed. However, staff were not asking or encouraging her to get out of bed. During an interview on 8/9/23 at 2:25 p.m., NA-C stated she did not have time to wash her (R101) hair today. I washed her back when we changed her brief this morning. During an interview on 8/10/23 at 7:24 a.m., R101 confirmed she did not receive a bed bath, and no one washed her hair yesterday. R101 stated she wanted her head shaved so she could keep her head clean with a washcloth, stating it was just more sanitary and her hair would get tangled in everything. During an interview on 8/10/23 at 8:05 a.m., registered nurse (RN)-A stated the expectation was for residents to receive their weekly bath and for hair to be washed during baths, even bed baths. A policy on ADLs was requested but not received.

Based on observation, interview and record review the facility failed to comprehensively reassess a resident for a bowel program while bed bound to ensure continence status was maintained for 1 of 1 residents (R101) reviewed for bowel and bladder status. Findings include: R101's quarterly Minimum Data Set (MDS) dated [DATE], indicated R101 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. R101 was non ambulatory and had no locomotion on or off the unit during the look back period. Further, R101 had a foley catheter in place and was frequently incontinent of bowel. The MDS further indicated R101's diagnoses included arthritis due to bacteria of the left hip, osteoarthritis of bilateral knees, depression, and stage III pressure injury to left buttock. R101'a admission MDS, dated [DATE], indicated R101 was always continent of bowel and bladder. R101's orders dated 8/2/23, indicated Lidocaine 2% gel to wounds twice daily prior to wound care. An order dated 8/4/23 indicated R101 could not use a commode due to wounds. R101's wound assessment dated [DATE], indicated in chair for no longer than 1 hour but lacked direction for use of/non-use of commode. R101's careplan dated 6/14/23, indicated R101 required staff assist of 1-2 with toileting and was incontinent of bowel with a foley catheter. The care plan directed staff to check and change R101 upon rising, before and after meals, at bedtime and as needed. During an interview on 8/7/23 at 2:46 p.m., R101 stated she did not get out of bed due to a pressure injury on her bottom (left buttocks). R101 stated she had not been out of bed in nine months and prior to her being bed bound due to the pressure injury she was continent of bowel and bladder and did not have a catheter. During an interview on 8/9/23 at 10:01 a.m., R101 stated she was able to sense when she had to have a bowel movement and would have to have a bowel movement (BM) in bed on a pad. She was not able to hold it in as long as she used to. R101 stated she wanted things back the way they were prior to being bed bound. How much less dignity can they give me. During an interview on 8/9/23 at 11:06 a.m., nursing assistant (NA)-C stated about 9 months ago R101 was able to use an easy stand and have a BM on the toilet but she had to just do it in bed on her back stating R101 did not use a bed pan or commode. During an interview on 8/10/23 at 7:24 a.m., R101 stated staff had not educated her on the risk of loosing her bowel continence further if she did not attempt a toileting plan or using a bed pan or bedside commode. During an interview on 8/10/23 at 8:05 a.m., registered nurse (RN)-A stated the order for no commode was actually a recommendation and they could look into getting a bedside commode for R101. RN-A stated R101 refused a bed pan, it was a frustrating case. During an interview on 8/10/23 at approximately 11:30 a.m., the director of nursing (DON) and assistant director of nursing (ADON) stated the facility was working on incorporating more bowel programs with the residents and confirmed R101 was not on a current bowel program to help maintain her bowel continence while bed bound. The DON stated R101 was able to make her own decisions and was making poor decisions regarding her health. The ADON and DON confirmed the facility had toileting slings to use with their hoyer lifts to allow a transfer from bed to a toilet or commode and were in the process of ordering more. The DON confirmed R101's electronic medical record lacked a comprehensive reassessment or R101's bowel habits since becoming bed bound to ensure continence status was maintained. A policy on toileting/toileting programs was requested but not received.

Based on interview and document review, the facility failed to identify and report a significant change of condition to the resident's medical provider, and the resident's representative in a timely manner for 1 of 3 residents (R1) reviewed for a change in condition. This resulted in an immediate jeopardy (IJ). The IJ began on [DATE], at 7:45 a.m. when nursing assistant (NA)-A found R1 unresponsive. NA-A reported this to registered nurse (RN)-A, who stated it could be a stroke. RN-A did not conduct a thorough assessment of R1, and did not contact R1's nurse practitioner (NP)-A to report R1 was unresponsive until 10:14 a.m., and at that time did not give full report that R1 was not responding. In addition, RN-A failed to notify R1's family on the change in condition. R1 was transported to the hospital at 3:20 p.m. at the request of R1's family. R1 died on [DATE]. The administrator and the director of nursing (DON) were notified of the IJ on [DATE], at 2:25 p.m The IJ was removed on [DATE], at 2:59 p.m. but non-compliance remained at the lower scope and severity of a D, potential for more than minimal harm. Findings include: R1's Face Sheet printed [DATE], indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, utilized a wheelchair, and required extensive assistance with most activities of daily living (ADLs). R1's care plan dated [DATE], indicated R1 made herself understood and understood others. R1's care plan further directed staff to monitor for changes in condition, and notify provider and resident representative as indicated. On [DATE], at 3:25 p.m. a progress note indicated R1 had been lethargic and unresponsive throughout the shift. RN-A had checked on R1 several times throughout the shift. R1's vitals were taken and were normal. NP-A had been notified and requested a blood sugar check. If the check was normal, call back later in the shift if R1 continued to be lethargic. R1's blood sugar was 120. R1's family member (FM)-A arrived sometime after noon and were concerned about R1. RN-A called NP-A again, noting R1 had not improved, and family was concerned. While awaiting return call from NP-A, FM-A requested R1 be sent in to the emergency department (ED). 911 was called to transfer R1, who left the facility at 3:20 p.m R1's medical record lacked any indication of a change in condition prior to the progress note entered at 3:25 p.m. on [DATE]. On [DATE], at 11:36 p.m. a progress note indicated FM-A was called and R1's condition was discussed. FM-A stated R1 had a major stroke, had a poor prognosis, and FM-A had been told R1's condition was terminal. R1's United Hospital emergency room Notes dated [DATE], indicated R1 was unresponsive to physical or verbal stimulation. R1 had difficulty clearing secretions in the back of her oropharynx (throat) and had acute right-sided [CONDITION(S)] (weakness on one side of the body). R1 was found to have a very large left-sided ACA (anterior cerebral artery) and MCA (middle cerebral artery) stroke, not recoverable. [NAME] Triage Call Log (log indicating when NP-A had been contacted) indicated two calls were received from RN-A to NP-A regarding R1. The first call was on [DATE], at 10:14 a.m. and the second call was on [DATE], at 2:13 p.m On [DATE], at 11:10 a.m. FM-A was interviewed and stated he went to visit R1 at approximately 2:00 p.m. on [DATE]. FM-A stated R1 was lying in bed, with her lunch tray unopened on the bedside table which was unusual as R1 was always up. FM-A stated he attempted to waken R1 and could not. FM-A stated he went to the nurse's station and spoke with RN-A, who told him he had previously checked R1's vital signs, and R1 had been tired all day. FM-A returned to R1's room and attempted to awaken her again and could not. FM-A stated he returned to RN-A asked if NP-A had been called. FM-A stated he attempted to find another staff member to assess R1 and could not. FM-A stated he again went to RN-A and asked for a nurse manager. FM-A stated RN-A told him the RN managers were in care conferences. FM-A went to the first floor and with the assistance of social service worker (SS)-A found RN-C in the hallway. RN-C and the DON went to speak with RN-A, and directed RN-A to conduct additional assessments. FM-A stated RN-A began taking R1's vital signs and assessing R1, and shortly after emergency medical services (EMS) arrived. FM-A stated when EMS arrived, they asked RN-A how R1 had been that morning and RN-A had stated just like this. EMS stated to FM-A that R1 appeared to have had a stroke sometime in the night. When at the hospital, the ED staff told FM-A that R1 had a major stroke, most likely a terminal event. R1 passed away in the hospital on [DATE]. On [DATE], at 2:02 p.m. RN-A was interviewed and stated on [DATE], NA-A approached him around 8:00 a.m. and stated R1 was still sleeping, and was not reactive to being changed. RN-A stated he worked with R1 the day before and she was up for breakfast. RN-A stated he had assessed R1 and she appeared to be just sleeping but was not responsive to verbal or physical stimulation. RN-A stated at approximately 9:00 a.m. he checked on R1 again, and she was still unresponsive. RN-A stated he took R1's vital signs, and attempted a pain stimulus check with no response. RN-A stated he called NP-A at approximately 9:30 a.m. and left a message with the triage line. RN-A stated about 30 minutes later the triage line called with instructions to take R1's blood sugar, attempt to get R1 up into her wheelchair, continue to monitor her, and call back if she did not become responsive. RN-A stated he felt that transferring R1 was unsafe and R1 would have just slid out of the chair. RN-A stated he was unable to awaken R2 for lunch, which was abnormal as R1 would usually go to the dining room for meals. RN-A stated FM-A arrived, and was concerned. RN-A explained he had called NP-A, went to check on her R1 again and she was still in the same position that she was in throughout the day. RN-A again called NP-A at approximately 1:30 p.m. and left a message that R1's condition had not changed. RN-A stated FM-A called the DON who came and instructed RN-A to conduct neuro-checks (used to assess an individual's neurological functions and level of consciousness to determine whether the individual is functioning properly and reacting appropriately to the tests) on R1. RN-A stated this was the first time anyone mentioned a neuro-check. RN-A stated he completed the assessments and noted R1 was unresponsive to pain and unable to participate in neuro-checks. RN-A stated before receiving a return call from NP-A, FM-A requested R1 be sent to the hospital. RN-A stated he did not feel he could call 911 without doctors' or NP orders unless a resident was in dire, urgent need. RN-A stated he wanted assistance from a nurse manager but could not find them as they were in care conferences and in the past I have been told not to bother them during care conferences. RN-A further stated, Looking back, I should have called 911. On [DATE], at 2:33 p.m. NA-B was interviewed and stated she had worked with R1 on the evening of [DATE]. NA-B stated she had provided R1 with an evening snack, assisted her in night cares, and got R1 into bed around 9:00 p.m. NA-B stated she checked on R1 around 9:30 p.m. before the end of her shift, and R1 indicated to NA-B that everything was fine. On [DATE], at 2:39 p.m. NA-A was interviewed and stated on [DATE], at about 7:30 a.m. she observed R1 to have her eyes closed and was snoring. NA-A stated she attempted to awaken R1, but she was not responding. NA-A stated she attempted to reposition R1 onto her side to change her incontinent brief, but R1 was unable to participate in repositioning or gripping the side rail on her bed. NA-A stated she reported this to RN-A, who came to check R1's vital signs. When NA-A asked RN-A what was wrong with R1, RN-A stated he did not know and thought it could be a stroke, or she could be super sleepy. NA-A stated shortly after this she brought R1's breakfast tray in, and attempted to awaken R1 by shaking her and calling her name, but R1 was not responsive. NA-A stated she had not seen R1 like this in previous days. NA-A stated she continued to check on R1 and attempt to awaken her throughout the shift and she was still like that. NA-A stated she asked RN-A how R1 was doing several times and RN-A told her he did not know yet. NA-A stated R1's condition had not improved throughout her shift. On [DATE], 10:19 a.m. RN-C was interviewed and stated she was in care conferences from about 1:00 p.m. until 2:30 p.m. on [DATE]. RN-C stated SS-A approached her and stated there was a problem on the unit with R1. RN-C stated she went to R1's room and observed R1 lying in bed with her head slightly elevated, and eyes closed. RN-C stated RN-A was in the room attempting to take R1's vital signs. FM-A stated this was not R1's normal behavior, and RN-C immediately noticed a change in condition for R1 and stated, I thought it was a stroke. RN-C stated RN-A told her he had called 911 per FM-A's request. RN-C was present when EMS arrived, and she heard EMS staff say R1 appeared to have had a stroke. RN-C stated EMS asked RN-A how long R1 had been in that condition, and RN-A stated all shift. RN-C stated would have expected RN-A to inform her of a change in condition, and the family and medical provider also be informed right way. RN-C further stated she would expect staff to call 911 if concerns with a resident did not resolve and there was always someone who is available for nursing staff to consult with about resident concerns. On [DATE], at 10:36 a.m. the DON was interviewed. The DON stated on [DATE], at around 2:45 p.m. she was approached by SS-A and FM-A who informed her R1 was not waking up. The DON stated she went to speak with RN-A, who verified R1 was unresponsive, and also informed her he had contacted NP-A twice. The DON stated she instructed RN-A to conduct a neuro-assessment, check lung sounds, and vital signs. The DON stated she informed FM-A they could request for R1 to be sent into the hospital if they wanted treatment, which FM-A was in agreement with. The DON stated RN-A should have conducted a neurological assessment on R1 sooner. The DON stated while it was the common practice to get orders to call 911, staff could call 911 without orders, especially if family is requesting. The DON stated nurses have education on what to do if a resident has a change in condition. On [DATE], at 12:47 p.m. NP-A was interviewed and stated she received a message from R1 that staff was unable to awaken R1, and R1 was sleepy but comfortable. NP-A reviewed R1's medications and directed RN-A to take R1's blood sugar and vital signs. NP-A stated she did not recommend RN-A do neuro-checks on R1 as she assumed RN-A had conducted neuro-checks as part of his initial assessment, and would have reported any abnormalities. NP-A stated she was not aware R1 was unresponsive, only that she was sleepy. NP-A stated it would have been helpful to have a more thorough assessment from RN-A to determine R1's needs. NP-A verified signs and symptoms of stoke include a change in mental status, weakness, impairment in walking or talking, total paralysis or weakness on one side, drooling, and drooping in the face. The facility policy Transfer of Resident to Hospital reviewed [DATE], directed: For life threatening emergencies: Check the resident's Code Status form/POLST/MOST, call 911, if indicated. Then notify physician and primary contact of the emergency and transfer. The facility policy Notification of Physician and Resident Representative revised [DATE], directed primary physicians, residents, and the resident representative, consistent with their authority, will be updated with all resident condition changes as soon as possible. The names of those contacted will be documented in the progress notes. The policy further directed If a physician is unavailable or does not respond in a timely manner, nurse will contact 911 if indicated. In the event of an emergency licensed staff have the discretion to transfer via 911 emergency services to the hospital. If the facility staff feel additional consultation is required concerning a resident's condition, a call would be placed to the director of nursing (or designee) and to the medical director. Additional notifications to home office staff would be made as indicated. The facility policy Change in Condition revised [DATE], directed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition; Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status; Facility staff will also notify the RN in charge or the RN on call as indicated when changes in resident condition occur. The IJ was removed on [DATE], at 2:59 p.m. after it was verified through interview and document review the facility implemented a systemic plan of reeducation and policy change regarding change in condition.

Based on interview and document review, the facility failed to ensure the sling was properly applied to the full body mechanical lift for 1 of 3 residents (R1) who used a mechanical lift. R1 suffered a fractured knee and subdural hemorrhage requiring hospitalization when the loop of the sling come out of the mechanical lift causing R1 to fall to the ground. The facility immediately implemented interventions and corrected the deficient practice on 1/5/21. As a result of the immediate interventions this is being issued as past noncompliance at Immediate Jeopardy (IJ). The immediate jeopardy began on 1/4/21, when R1 fell out of the sling during a transfer from bed to wheelchair was corrected on 1/5/21, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the past noncompliance immediate jeopardy at 5:30 p.m. on 1/7/21, as a result of the immediate corrective action taken by the facility. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact and required two plus person physical assist for transfers. R1's care plan dated 10/28/20, indicated R1's ambulation and transfers were impaired due to obesity, weakness, depression and required a mechanical lift with transfers. The care plan directed staff to provide total assist of two for transfers using Hoyer. R1's progress note dated 1/4/21, at 8:30 a.m. indicated, Resident called daughter to update on resident's change in condition and laceration on back of head. Facility to send to emergency room [ER] to have laceration looked at due to increased bleeding. R1's progress noted dated 1/4/21, at 10:25 a.m. indicated, Resident laying on flour [sic] on her back side. Aid [sic] reported resident fell from the lift while the aid [sic] was transferring her from the bed to wheelchair, hit her head on the dresser and landed on her back. When interviewed on 1/7/21, at 11:00 a.m. nursing assistant (NA)-C stated staff were supposed to attach the sling loop to the lift bar and always double check to ensure everything was properly in place prior to moving the resident. When interviewed on 1/7/21, at 11:24 a.m. NA-B stated he and another aide (NA-A) were in the room when R1 fell from the lift. NA-B stated R1 was an assist of two for transfers and required a large sling. NA-B stated he placed the sling under R1, brought the lift into the room and attached the sling loops to the lift bar. NA-B stated NA-A was in the room when he started to move the resident. NA-B stated, I started lifting the lift using the remote control and then looked to make sure the sling was secure. NA-B further stated he started moving the resident off the bed while NA-A assisted with R1's legs. NA-A then turned to position by the wheelchair. Just before [R1] fell it sounded like something snapped off. The clasps were both still on. The loops on the sling were not torn or anything. NA-B further stated his process was to hook the loops on and then pull down and shake them to make sure they were hooked up correctly. NA-B further stated he did that this time and every time and that both staff were supposed to verify the sling was secure. When interviewed on 1/7/21, at 12:03 p.m. DON stated the director of environmental services inspected the lift following the accident on 1/4/21, and did not find anything wrong with the lift. DON further stated, If there was a part of the sling caught in the clasp [safety clip] it could pull out. DON further stated it was okay for one NA to set up the sling and connect it to the lift alone as long as the second NA was in the room for the transfer and had verified everything was hooked up correctly. When interviewed on 1/7/21, at 12:26 p.m. NA-A stated she was assisting with R1's roommate on 1/4/21, when NA-B requested assistance to transfer R1 from the bed to the wheelchair. [NA-B] got R1 ready for transfer and got her all hooked up while I was emptying the trash. NA-A stated she was directing R1's feet but as she turned to position herself by the wheelchair she heard a pop, turned back around and R1 was falling to the ground. NA-A stated the process was that one staff would move the lift while the other staff would direct the resident's feet. NA-A further stated that she worked with NA-B a lot and he would normally pull on the sling [loops] prior to lifting to make sure they are secure, but could not recall seeing him do that this time. Honestly, I should have walked over and looked closer, but I trust [NA-B]. I did visualize the loops; I am 98 percent sure they were in there correctly. NA-A further stated the silver [safety] clips were in place and both secure after the incident and the sling was not ripped. NA-A further stated, It is possible the sling was under the clasp [safety clip]. It is possible it was under the clasp and I just did not see it. I should have gone over physically myself to make sure, but knowing [NA-B], I had no doubt he did anything wrong. It [double checking] is something that should absolutely be done. NA-A further stated they were short staffed that day with only five NAs when they normally have eight. When we are short staffed, we hurry. NA-A further stated she had a competency on the lifts at her prior facility and transferred to this facility December of 2019. NA-A further stated she did not receive another competency on this lift at this facility and did not receive a normal orientation due to being a transfer. NA-A stated, The machines here [this facility] are different than the ones there [previous facility]. When interviewed on 1/7/21, at 1:37 p.m. in-service educator (ISE) stated NAs were trained on the lifts during orientation which included a video and return demonstration and then received a yearly skill check off competency. ISE could not confirm NA-A completed a competency during orientation or prior to her first shift at this facility and that lift competencies were supposed to be done every year per policy. ISE further stated, the second staff present during transfers did not have to be present while the sling was being attached to the lift, but the second person still had full responsibility to ensure everything was properly connected. When interviewed on 1/7/21, at 1:54 p.m. maintenance director (MD) stated there was a work order on 1/4/21, following the accident requesting him to inspect the lift. MD confirmed the lift involved was Viking M Liko lift number three. The lift was clearly marked out of service. I looked it over completely did not find any [NAME] with it. M-A further stated he did not consider it [the accident] a lift malfunction. When interviewed on 1/7/21, at 2:55 p.m. maintenance technician (M)-A stated the lifts were inspected monthly. M-B stated most common issue found on monthly inspection was missing safety clips. When interviewed on 1/7/21, at 3:10 p.m. MD stated the lifts were inspected monthly and it was rare to find a mechanical problem with the lifts. MD stated the most common issue was missing the safety clip. When interviewed on 1/7/21, at 3:28 p.m. tech support specialist from the mechanical lift company (TSS)-A stated the recommended maintenance schedule for the Liko Viking M lift was yearly and could be done by a Liko representative or the facility. TSS-A further stated to operate the lift properly they are supposed to inspect the lift and all clips prior to raising. TSS-A further stated under normal use the safety clips should not come off. I have noticed when staff are in a hurry staff yank it [the sling] off and not slide it off the way it should. TSS-A further stated, The only way it [sling loop coming out of the sling bar] could happen if the sling loop was not on properly. It would have to go past that [safety] clip. It would have to go past that [safety clip] it will not come out once you put weight in the sling and properly lift. It will not come off. Review of the facility investigation file indicated an email from MD to DON on 1/5/21, indicating Monday morning I was informed through our maintenance program that I needed to repair a lift. There were no specifics as to what was wrong with it so I looked it over the best I could and found nothing wrong that would cause an accident. Review of the facility Event Report dated 1/4/21, at 1:36 p.m. indicated R1 experienced a witnessed fall during a transfer from bed to wheelchair using a mechanical lift, resulting in a major injury requiring R1 to be sent to the ER. The report further indicated factors leading to fall included machine malfunction and that the Hoyer machine was taken away to be inspected by maintenance. Review of NA-A's education transcript indicated NA-A completed and met expectation on the EZ Lift on 6/19/19. The transcript further indicated NA-A completed the LIKO mechanical lift competency skills checklist on 1/5/21, after the incident occurred. Review of the undated Viking M Mobile Lift instructions for use indicated, The equipment should only be used by trained personnel. Exercise care and caution during use. As a caregiver, you are always responsible for the patient's safety. The instructions direct users to always make sure that before lifting, the sling's strap loops are correctly connected to the sling bar hooks when the sling straps are stretched up but before the patient is lifted from the underlying surface. Review of the facility policy Floor-Based, Full Body Sling Lift Use dated 1/14/19, indicated full body lifts were to be used for the transfer of resident per resident's care plan. The use of a full body lift required two staff members present to assist in the transfer. The policy further indicated the lift and sling must be checked to ensure all parts were in place prior to using. The policy directed staff to ensure all clips or loops were secure then lift resident until there is slight tension on the sling loops. Perform safety check: Once there is tension on the loops, double check each loop to be sure each is securely in the hook. Double-check the position and stability of all straps and other equipment. Ensure clips, latches, and bars are securely fastened and structurally sound. Lift resident about 2 inches off the surface and verify that weight is evenly spread between the straps of the sling. The past noncompliance immediate jeopardy began on 1/4/21. The immediate jeopardy was removed, and the deficient practice corrected by 1/5/21, after the facility implemented a systemic plan that included the following actions: The facility immediately decommissioned the lift on 1/4/21, and sent it to maintenance for inspection. On 1/4/21, the facility initiated an investigation to include a step-by-step reenactment with the staff members (NA-A and NA-B) involved as well as lift competency testing for both the NA's and return lift demonstration. On 1/5/21 and 1/6/21, the facility provided in-service lift review and re-education training to all staff who assist with lift transfers. Also, NA-A and NA-B were retrained and required to demonstrate competency on mechanical lift transfers on 1/5/21 and 1/7/21 respectively. Staff interviews confirmed the facility implemented corrective action and therefore this will be cited at past noncompliance.

Based on observation, interview, and document review, the facility failed to ensure 1 of 5 residents (R129) reviewed for dementia care was free of significant medication error when order for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and challenging behaviors) was not transcribed into the electronic medical record (EMR) according to the physician's orders [REDACTED]. Findings include: During an observation on 10/15/18, at 6:28 p.m. R129 was observed in his room with a distressed look on his face, shaking and waving his hands, standing over his wife who was sitting in a wheelchair next to him. He stated, her pants are too tight. The call light was on, but no staff were observed present in the hall. The surveyor alerted staff to R129's distress and an unidentified staff person attended to R129. R129's quarterly minimum data set (MDS) assessment dated [DATE], included a [DIAGNOSES REDACTED]. The MDS indicated R129 had long and short term memory deficits, exhibited inattentive behaviors including difficulty focusing attention, being easily distractible, and had difficulty keeping track of what was being said. According to the MDS, behavioral symptoms included both physical and verbal behaviors occurring during 1-3 days of the 7 day look back period. A review of R129's progress notes identified the following behavior documentation: Progress note dated 6/13/18, at 2:23 p.m., indicated R129 was agitated during the morning. R129 continued to state, the police should be here!. After lunch R129 became frustrated waiting for his wife and he aggressively grabbed her purse 'nearly pulling her out of her seat.' - Progress note dated 6/21/18, at 11:02 a.m., indicated R129 appeared agitated and verbally aggressive with staff What are you doing? Leave her alone! Just get the hell out of here!. R129 was banging on his nightstand and made a fist as if he was going to hit staff. - physician progress notes [REDACTED]. The plan was to increase [MEDICATION NAME] strength from 250 mg (milligrams) at bedtime to 125 mg in the morning and 250 mg at bedtime for mood stabilization. A Medication Error Report dated 9/20/18, identified the following medication error: R129 had an order for [REDACTED]. The order specified the nurse practitioner (NP) was to be updated on R129's distress and behaviors in 2 weeks. However, the order was transcribed to indicate an end date in two weeks, and following the 7/17/18 doses, the [MEDICATION NAME] had been discontinued. In addition, there was no indication the NP or physician had ever received an update regarding the impact the additional [MEDICATION NAME] had on R129's behaviors. Following the discontinuation of the [MEDICATION NAME], the nursing progress notes revealed an increase in behaviors: - Progress note dated 7/24/18, 2:03 p.m., indicated R129 punched staff members arm causing medications to spill on the floor as the staff approached wife. R129 stated, leave her alone she is fine. - Progress note dated 8/3/18, at 9:54 p.m., indicated R129 became agitated while wife was receiving cares. - Progress note dated 8/5/18, at 1:39 p.m., identified R129 as agitated, pulling the dressings off his legs and refusing to allow the nurse to assist. - Progress note dated 8/17/18, at 6:54 a.m., indicated R129 did not sleep, using call light most of the night, trying to prevent care givers from entering his side of the room and hitting staff. - Progress note dated 8/19/18 at 1:09 a.m., R129 was holding wife, preventing care givers from providing care, hitting and biting staff. R129 was swearing at staff. - Progress note dated 8/20/18, at 2:25 p.m., R129 or wife would not go to dining room for breakfast, R129 constantly pressing call light, yelled, they stole all our stuff.; combative and protective over wife. Nursing assistant (NA) stated R129 was pounding his wheelchair on the floor in his room. - Progress note dated 8/22/2018, at 6:21 a.m., R129 difficult to redirect, continues to pound on wall and push assist light. R129 angry that wife does not have pants on. Multiple attempts to help spouse. R129 continues to swing walker at staff, charge at staff. - Progress note dated 9/4/1,8 at 11:23 a.m., R129 displayed 'major behaviors' today; pounding on wall, yelling, hitting several staff, aggressive when staff tried to assist wife. They were an hour late for breakfast. Refused medications. - Progress note dated 9/5/18 at 2:25 p.m., R129 refused dressing change to his legs. - Progress note dated 9/7/18, at 1:44 a.m., 129 did not want staff to help wife, kicking them out, wanting the police called. Calmed down a little, still up trying to help wife. - Progress note dated 9/7/18, at 6:28 a.m., R129 on call light all night. - Progress note dated 9/8/18, at 5:27 p.m., R 129 refused bath. - Progress note dated 9/10/18 2:18 p.m., R129 pressing call light multiple times, even after assist offered, bang on the wall with his fist and stand in the door waiting for help. Trying to get wife out of her chair. - Progress note dated 9/11/18, 10:25 p.m., NA stated R129 trying to get wife into bed. Wife is a 2 person/standing lift assist for transfers. When NAs approached to assist, R129 became agitated, grabbed spouse and staff by arms and would not let go. NA eventually got wife to bed. R129 still angry, pacing in room and pushing emergency call light. R129 believes family and police are on their way. - The Nurse Practitioner (NP) progress note dated 9/11/18, listed R129's medications, but did not include [MEDICATION NAME]. Under assessment and plan NP indicated a [DIAGNOSES REDACTED]. Certainly, also continue mood stabilizer. - A progress note dated 9/15/18 at 11:10 a.m., indicated the NA was present with wife and R129. R129 became combative when NA was attempting to provide care to wife. R129 began to try to hit and push NA and lost balance, body weight pushed back and he went backwards, hitting his head on the floor. Contusion noted with bleeding on the back of the head. R129 sent to the emergency room and received three staples to close the wound. The medication error with the [MEDICATION NAME] was discovered on 9/20/18, by registered nurse (RN)-C while investigating R129's fall. The evaluation portion of the Medication Error Report dated 9/20/18, indicated an increase in R129's behaviors since the time of the discontinuation. During an interview on 10/17/18, at 10:53 a.m. with nursing assistant (NA)-H , NA-H verified R129 was very agitated at the time of the fall. NA-H stated he had turned his back on R129 because the resident was coming at him and NA-H knew if he turned, R129 would only hit his back. NA-H said he'd then heard a noise and when he turned around he saw R129 on the floor. NA-H further explained R129 was agitated because I was trying to help his wife and he does not understand we are helping her even if we try to explain. During interview on 10/17/18 at 2:02 p.m., registered nurse (RN)-C verified R129 had not received his [MEDICATION NAME] for 63 days due to the order having been incorrectly entered into the EMR. RN-C stated the NP had identified the medication error while in the facility on 9/18/18, and had reinstated the medication. RN-C stated R129 had his first dose of [MEDICATION NAME] again on 9/19/18 at 8:00 a.m RN-C further explained that although the transcribing nurse stated in retrospect she should have clarified the order, the nurse received education. However, the nurse who double checked the order transcription had not received further education. Efforts to interview the NP were unsuccessful. During an interview on 10/18/2018, at 11:39 a.m., with the interim director of nursing (IDON), she acknowledged she had only recently became aware of the medication error as she was not present in the facility during the occurrence. She verified the medication error should have been recognized sooner and the physician should have been updated regarding R129's increase in behaviors. The facility's 10/2018, Transcription of Orders policy indicated the nurse that verifies the order will review order documentation and ensure a full transcription of orders has been signed and is accurate.

Based on observation, interview and document review, the facility failed to implement fall interventions for 2 of 4 residents (R238, R20) reviewed for accidents. This resulted in harm for R238 who experienced frequent falls and sustained fractures of the left wrist. Findings include: R238 was observed on 11/28/17, at 7:55 p.m. lying on his bed with his left arm in a cast and sling. On 11/30/17, at 3:44 p.m. R238 was observed lying on top of his bed watching television (tv) with the head of the bed slightly elevated, call light wrapped around grab bar on the exit side of the bed, and a wheelchair (w/c) with a dycem (non-slip material) observed on the seat approximately three to four feet from the bed. There was no floor matt observed near R238's bed. On 12/1/17, at 7:30 a.m. R238 was observed lying on the top of his bed with the head of the bed slightly elevated. The call light cord was observed to be wrapped around the grab bar of the bed, and the w/c with dycem cushion was again approximately three to four feet away from the bed. There was no floor matt observed near R238's bed. On 12/1/17, at 1:52 p.m. R238 was observed lying on top of his bed with the tv on until 2:17 p.m. During the observation a 30-minute check by staff was observed to be completed. However, during the observation R238 was not offered or assisted to the bathroom. On 12/1/17, at 2:37 p.m. R238 was observed lying on top of his bed wearing grippy socks. A concave mattress was observed on the bed, and the w/c with dycem in place was observed to be three to four feet from the bed. No floor mat was observed on the floor by R238's bed, but was instead observed between the bathroom door and dresser. An Incident Report for R238 dated 11/24/17, indicated R238 had fallen on 11/24/17, at approximately 1040 (10:40 a.m.) The report indicated R238 had been found on the floor by the bathroom after having transferred himself without use of the call light. The notes indicate a call light had been activated by R238's roommate. Upon staff assessment of the resident, R238's wrist appeared to be out of alignment and he complained of pain. The facility staff sent R238 to the emergency room (ER), and he returned with a [DIAGNOSES REDACTED]. The facility's Fall Scene Investigation Report dated 11/24/17, indicated R238 was found on the floor by the bathroom door on 11/24/17, at 10:45 a.m. and had been last toileted at 0930 (9:30 a.m.) Same report indicated to assess R238's toileting schedule. A Progress Note dated 11/24/17, indicated R238 had fallen on 11/24/17, at approximately 10:40 a.m. and the PN noted R238 had hit his head at the scene and noted R238's left wrist to be dislocated with swelling and pain to the site. Same PN indicated R238 had previous fracture to the left wrist and patella (knee) from falls at the facility and also indicated toileting schedule would be assessed and urinal offered at bedside (the assessment was not completed). Following this fall, an intervention was identified to institute a three day toileting diary. On 11/29/17, at 10:52 a.m. registered nurse (RN)-B stated R238 routinely attempted self-transfers, and had been found on the floor in his room on 11/24/17, when he had refractured his wrist form a previous break in August of 2017. On 11/30/17, at 1:40 p.m. nursing assistant (NA)-A stated R238 had transferred to the unit from the transitional care unit about four to five months ago and that he required one staff transfer assist. NA-A stated R238 had fallen and broken his arm at the facility. NA-A stated R238 was a fall risk and his balance was not stable. The NA further stated R238 required frequent checks and staff needed to respond to R238 right away when he put his call light on. NA-A stated R238 puts on his call light but gets impatient and cannot wait and takes himself to the bathroom. Upon review of the incident information from 8/5/17, the following was noted: An Event Report dated 8/6/17, indicated R238 had fallen on 8/5/17 at 1:30 p.m. and had been sent to the ER for evaluation. The report does not indicate any injury identified as a result of the 1:30 p.m. fall. However, the report also indicated the resident had fallen at 8:00 p.m. due to continued attempts to self-ambulate to the bathroom. As a result of the 8:00 p.m. fall, the resident had complaints of pain in his left wrist and had limited range of motion in the wrist. An x-ray obtained the following morning, revealed a fracture to the wrist. The facility's Fall Scene Investigation Report following the fracture, indicated staff were to implement every 30-minute safety checks with an offer to toilet the resident when awake. Additional interventions included to keep personal items within reach and to initiate a toilet diary in order to determine an individualized pattern of elimination. R238's care plan dated 8/8/17, had been updated to include the need for 30-minute safety checks with offer to toilet when awake. However, this revision hadn't been transferred to the NA Assignment Sheet. R238's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R238's cognition was moderately impaired, with poor decision making with cues/supervision required, and one staff limited assistance required with transfers and toileting. Same MDS also indicated R238 was not steady, was only able to stabilize with human assistance when moving from seated to standing, walking, turning, and moving on and off the toilet. The MDS indicated R238 was not on a toileting program and did not reject cares. R238's same MDS had fractures and pain present at time of assessment with the pain scale placed at '7' of '10' (10 being the highest level of pain) on the pain scale, frequent pain with pain limiting daily activities, and requiring pain medication regimen and prn (as needed) pain medications. (R238's 14-day MDS dated [DATE], indicated R238 had no pain.) Review of progress notes and Event Reports indicated R238 had 7 additional falls between 8/5 and 11/24/17. Although numerous interventions had been identified, the resident did not have a bladder diary conducted to determine an individualized toileting plan. On 12/1/17, at 2:39 p.m. RN-B stated most of R238's falls were about R238 having to go to the toilet. RN-B stated R238 walks, thinks he can make it to the bathroom, wants to be independent, but needs to continue to be reinforced by staff to ask for assistance. RN-B stated R238 had impaired cognition and recently a psychology assessment ordered. On 12/1/17, at 4:05 p.m. NA-C stated R238 had therapy and stated a week before Thanksgiving she had seen R238 walking in his room and had reminded him he needed staff assistance. NA-C stated R238 had replied back to her, This is what I am supposed to be doing and stated the next day he fell and re-fractured his wrist. NA-C stated she checked on R238 all the time, watched him, reminded him to use his call light. NA-C stated after R238 falls he remembers for a while to use his call light and then goes back to walking on his own. NA-C stated R238 had dycem on his w/c, concave mattress, call light in reach and safety checks. NA-C stated R238 did not want his floor mat on the floor. NA-C stated she checked on R238 every 30-minutes safety checks. NA-C stated she did not ask R238 if he wanted to go to the bathroom during the safety checks because staff knew R238 would ask staff and would call for help. NA-C showed surveyor documentation on R238 on the kiosk and verified the care plan on the wall stated to offer bathroom (to R238) while awake during 30-minute safety checks. NA-C stated she had not noticed this before nor known R238 was care planned for offer to toilet every 30 minutes while awake and stated she thought it would be good to put that fall intervention on the NA assignment sheets to ask R238 if he wanted to use the bathroom during the safety check stating because the NA assignment sheets was what the NAs followed for R238's plan of care. NA-C stated R238 was very private and she would step out of the bathroom into R238's room while R238 voided and then would assist R238 with his clothing. On 12/1/17, at 4:23 p.m. NA-D stated she was taking care of R238 today and stated she followed the NA assignment sheets, that R238 had 30-minute safety checks and she would document at end of shift on the kiosk. NA-D stated R238 did not want the floor mat and stated R238 needed one staff assistance to the toilet and that she would step out of the bathroom and stay in room to give R238 privacy and go back and help with his clothes. NA-D stated R238 was dry most of the time. NA-D stated during safety check she did not ask R238 if he wanted to go to the bathroom but stated R238 called for help. On 12/1/17, at 4:42 p.m. RN-B stated the interdisciplinary team (IDT) met every day Monday through Friday except Tuesdays when just nursing staff would meet to discuss falls. RN-B stated the nurse managers will put first intervention in place and then talk to team and possibly add more fall interventions. RN-B stated the 8/8/17, safety checks with toilet every 30 minutes and three-day diary for toileting pattern was an older intervention from before R238 came to second floor from third floor. RN-B stated anti roll backs had not been placed on R238's w/c as the falls were really not about R238's w/c but about the toilet. Five minutes later assistant DON (ADON) came up to RN-B's office and stated the fall intervention for the incident on 8/5/17, was care planned under topic Falls for 30-minute safety checks with offer of toileting when awake. RN-B sitting near stated she had not realized it was a toileting intervention as it was listed under falls in the care plan and not under toileting. RN-B stated that was why she had not included offer to toilet every 30 minutes when awake in the NA assignment sheets when she updated them 9/5/17. The ADON stated she would re-educate the staff to correct the process. The ADON stated R238 had been given the urinal as a fall intervention but R238 really did not want the urinal. RN-B stated she had not completed any three-day toileting diary since R238 came to third floor and the first day of the three-day toileting diary had been put out a couple of days ago (had not been completed by staff). On 12/4/17, at 9:42 a.m. RN-B explained again she had not seen the offer to toilet when awake safety checks that had been care planned in 8/17, as it had been care planned under falls and not toileting and just had not clicked with her when reading the fall intervention. RN-B explained R238 had come to 2nd floor on 8/23/17, after the offer to toilet every 30 minutes had been implemented. RN-B explained the safety checks staff were to have eyes on him, anticipate his needs as R238 was impulsive and gets out of his bed and chair himself. On 12/4/17, at 10:55 a.m. the director of nursing (DON) stated when a resident fell the nurse working looked to see if there was an immediate intervention that was needed to be put in place. The nurse would initiate the incident, begin documenting in Matrix (electronic health record) in the computer, and the physician would be notified. Falls are reviewed each morning in the IDT stand up and the team would discuss how it happened, what the resident is trying to tell us, and how we can prevent it (falls) in the future. The DON stated, the IDT would try to do an alternative, figure out was the resident trying to go to the toilet, and then would care plan the intervention. The DON stated the fall intervention should be put in place the same day. The DON remarked the nurse managers, ADONs (assistant director of nursing), social workers, therapeutic recreation staff, or whoever was owning the incident, should care plan and follow up with it. The DON expected staff to follow the residents' care plans and the NA Assignment Sheets so when an NA is in the resident's room, the NAs know what cares are to be provided for the resident. The DON commented the NA Assignment Sheets should be consistent with the resident care plan available at the kiosks. The DON stated a toileting pattern for R238 was used as a fall intervention and the summary of the three-day toileting diary should be in his Progress Notes. DON stated with focus charting she would expect staff to know where to look. On 12/4/17, at 11:24 a.m. DON stated 30 minute checks were safety checks because a resident had fallen. She stated staff are to visually look at the resident to see if the resident is safe and intervene if necessary. The facility failed to adequately communicate fall interventions to staff to ensure implementation of planned interventions for R20. R20's most current annual MDS assessment dated [DATE], identified R20 had moderately impaired cognition, required limited assistance of one with bed mobility, transfers, walking, dressing, toilet use and personal hygiene and had no falls since prior MDS or admission. R20's CAA for falls, dated 9/4/17, identified R20 had risk factors for falls including impaired mobility, balance, incontinence, cognitive impairment, anxiety, and depression, proceed to care plan. R20's care plan dated 10/6/17, indicated R20 was at risk for falls r/t weakness, dementia, [MEDICAL CONDITION], [MEDICAL CONDITIONS], arthritis, systolic (congestive) heart failure, hypertension, and major [MEDICAL CONDITION]. Interventions included; Floor mat on left side of bed, keep walker in room beside resident as she will permit, If resident refuses to have the blankets taken off of the floor, fold them and keep them beside the chair away from her walking path, Encourage the resident to keep her blankets around her chair off of the floor-resident gets cold and uses multiple blankets to keep warm, Keep phone within reach while in bed, Cue resident during all baths/showers. Remind resident to wait to stand transfer until she has her shoes/gripper socks back on, Resident does transfer and ambulate independently, Gripper socks or appropriate non-skid foot wear at all times, Keep call-light in reach when resident in room. Remind res how and when to use call-light, Remind to ask for assistance. R20's face sheet, not dated identified current [DIAGNOSES REDACTED]. R20's Scene Investigation Report, indicated three falls had occurred in the last month: 1. On 11/3/17, at 2310 (11:10 p.m.)- Resident was found on the floor. Husband came to nurses' station to report resident was on the floor. Resident was sitting on floor leaning backwards with blankets under her head. The immediate intervention include gripper socks. The fall team meeting notes dated 11/8/17, indicated the NAR assignment sheet and Profile were updated with these change(s) on 11/8/17 and indicated: If resident refuses to have blankets taken off of floor, fold them and keep them beside the chair, away form walking path. 2. On 11/24/17, at 1745 (5:45 p.m.)- Resident found sitting on floor next to bed, floor mat in place, bed in low position. Attempted to get self out of bed for supper. No immediate interventions following the fall had been added. The fall team meeting notes dated 11/30/17, revealed no new recommendations. 3. On 11/28/17, at 8 a.m. the resident had been found on bottom in doorway with shoes on. Incident not reviewed by fall committee. On 12/1/17, recommendation for toileting diary was noted. During observation on 11/30/17, at 12:56 p.m. R20 was observed in the dining room, eating lunch independently. During observation on 11/30/17, at 2:03 p.m. R20 was was observed in bed asleep, under the covers, covers off the floor, with floor mat on left side of bed, walker by bed, and call-light in reach. During observation on 12/1/17, at 12:36 p.m. R20's husband was observed to minimally assist R20 from wheelchair to stationary chair in dining room. During interview on 12/1/17, at 10:58 a.m. NA-C stated she does not consistently work on this floor but is familiar with R20. NA-C reported she was unaware R20 had experienced falls recently, or any fall interventions in place for the resident. NA-C stated R20 fluctuates in the level of assistance she needs with transferring, dressing and toileting, sometimes not feeling good, confused or mood may not be good and needs more help and sometimes is more independent. NA-C reports need to routinely check on R20. During interview on 12/1/17, at 11:09 a.m. NA-H indicated resident prefers female aides and will ask her husband to help her with things; husband pushes resident to the dining room. NA-H is uncertain but thinks resident dresses self and needs limited assist with toileting. Not aware of resident having falls. During interview on 12/4/17, at 9:46 a.m. NA-I indicated she consistently works with R20. NA-I reports R20 has had falls recently and has mat on floor, gripper socks, and call-light in reach. NA-J took an ADL sheet out of her pocket , reviewed with NA-I, R20 had no Fall Management interventions listed on sheet which was verified by NA-I. During interview on 12/4/17, at approximately 11 a.m. RN-J indicated she was not sure who was responsible for updating the ADL sheets if changes occurred. During interview on 12/4/17, at approximately 3 p.m. the DON indicated the nurse mangers on the floors were responsible for updating the ADL sheets. Policy provided by the facility Fall and injury reduction program dated Review Date: 6/16 indicated, .Recognition and management of risk factors for falling can prevent falls and minimize injuries to enable residents in maintaining maximum mobility and quality of life . Each fall is investigated as soon as possible to determine what the resident was doing when the fall occurred . A plan is then implemented based on the findings of the investigation . All Interventions for fall and injury reduction are noted on the resident's plan of care, care card and/or profile .

Based on interview and document review, the facility failed to ensure staff operated equipment safely to minimize the risk of injury for 1 of 3 residents (R1) who refused the leg straps on the standing lift. This resulted in actual harm when (R1) sustained a right femur fracture when being lowered to the floor from a standing lift. Findings include: The manufacturer's instructions for the standing lift dated ,[DATE], indicated the standing lift was used for transfers which position the resident's feet on a platform and use a harness to hold the upper body. The lower leg straps were an accessory used to ensure that the lower parts of the resident's legs stayed close to the knee support. They pass around the knee supports, then around the patient's lower calves. The facility's undated policy for the Sara 3000 sit to stand lift indicated to keep the resident's feet on the footplate and secure the shin straps around the resident's legs and calf area. R1's medical record was reviewed. R1's face sheet indicated R1 was admitted ,[DATE] with [DIAGNOSES REDACTED]. R1's physical therapy (PT) discharge progress summary dated [DATE] indicated R1 was not able to stand without the use of the standing lift. R1's nurse practitioner ordered a PT evaluation on [DATE], due to R1's non-compliance with the proper use abdominal strap of the standing lift because it made it difficult for R1 to breath. R1's PT evaluation dated [DATE], indicated R1 was assessed for the appropriate size of abdominal strap because R1 was refusing to buckle the straps related to difficulty breathing. R1 felt more secure with the smaller strap. PT-D educated R1 that each time the abdominal strap was used all the buckles were to be secure. R1 agreed to do this and continue with the standing lift. R1's cognitive assessment dated [DATE], indicated R1 was cognitively intact and required the assistance of one staff and the standing lift for all transfers. R1's care plan review date of [DATE], indicated R1 transferred with the assist on one staff and the standing lift. The facility's event report dated [DATE], documented by licensed practical nurse (LPN)-A indicated R1 was being transferred in the standing lift when her right foot slipped off the platform of the standing lift resulting in nursing assistant (NA)-H lowering R1 to the floor. R1 complained of pain in her right hip and femur. Tylenol was administered. Nurse practitioner (NP)-K was notified and ordered an X-ray of R1's right hip and femur. R1's X-ray report dated [DATE], indicated an incomplete fracture of the mid right femur. R1's nursing progress notes dated [DATE], at 8:00 p.m. indicated after R1's x-ray was completed, NP-K ordered to transfer R1 to the hospital for evaluation. R1's hospital progress note dated [DATE], indicated R1 was hospitalized from [DATE], through [DATE], thirteen days for right hip surgery. R1 experienced a complicated hospital course including respiratory failure and required the bi-level positive airway pressure (BiPAP) machine that helps keep the upper airways of the lungs open to support breathing. On [DATE], R1 was discharged from the hospital back to the facility and then transferred back to the facility and was readmitted to the hospital that same evening for respiratory depression. On [DATE], four days later R1 was discharged to the facility on hospice. R1's nursing progress note date [DATE] indicated R1 died . R1's death certificate indicated R1 died on [DATE], the immediate cause of death was complications of immobility due to the right hip fracture from the fall. PT-D was interviewed on [DATE], at 4:30 p.m. PT-D stated the standing lift had straps that went around the waist and legs for safety. PT-D stated during the [DATE], evaluation R1 did not want to use the leg straps. PT-D stated he educated R1 on the need to use all the straps and felt she was going to agree. PT-D stated he may not have documented that information in the evaluation. PT-D stated he would not have done the transfer without using the leg straps. PT-D stated per the manufacturer directions the leg straps need to be applied. The assistant director of nursing (ADON) was interviewed on [DATE], at 10:21 a.m. The ADON stated NA-H had been trained on the use of the standing lift and mechanical lifts. The ADON stated during orientation the staff are told if a resident would refuse the leg straps, they should educate the resident, notify the nurse and use a full body lift if there is a continued refusal. The ADON stated it should be a standard of care to use the equipment properly and felt the fall could potentially be preventable as the equipment was not used as intended. NA-H was interviewed on [DATE], at 7:35 a.m. NA-H stated she had been trained on the use of the standing lift. NA-H said on the day of the fall R1 had her call light on as she needed to use the toilet and she had never transferred R1 before. She stated she looked at R1's care plan and found out she transferred with the assist of one staff and the standing lift. NA-H was going to apply the leg straps and R1 told her not to use them as they were not needed. She instructed R1 the leg straps needed to be used. NA-H used her walkie talkie and asked for assistance with R1 as she did not feel comfortable transferring her. NA-H tried to get a hold of the nurse and waited for assistance for five minutes. NA-H then went ahead and transferred R1 due to the urgent need to use the toilet. She brought R1 in the standing lift from the bathroom to the wheelchair, when R1 started slipping from the top downwards even though the abdominal strap was tightened. NA-H stated she didn't feel the leg straps would of prevented the fall. NA-H lowered R1 to about one foot off the floor. NA-H along with another staff member used a full mechanical lift to transfer R1 off the floor. NA-H stated she was retrained on the standing lift after the incident. R1's primary medical doctor (MD)-J was interviewed on [DATE], at 4:49 p.m. MD-J stated R1 was at high risk for death and the fall was a triggering event for the surgery, anesthesia and a worsened R1's respiratory condition.

Based on observation, interview and document review, the facility failed to ensure supervision was provided, and assistive devices utilized, to minimize the risk of injury for 1 of 1 resident (R234) reviewed for allegations of rough treatment. The failure to utilize appropriate transfer techniques for R234 resulted in actual harm due to pain requiring treatment with a narcotic pain reliever. Findings include: R234 was interviewed on 12/1/15, at 1:52 p.m. and stated, A couple of weeks ago a male aide (NA)-H grabbed me under my arms, lifted me up quick and jerked me. R234 stated she had been sitting on the edge of the bed when nursing assistant (NA)-H landed her into her wheelchair (w/c). R234 stated she had told the aide, Hey! You are hurting me! The resident stated she had X-rays which showed she had sustained a cracked vertebrae and that she had experienced a lot of pain. R234's Minimum Data Set (MDS) quarterly assessment dated [DATE], identified the resident as cognitively intact (15 of possible 15) with no behavioral issues. An Incident Report dated 11/9/15 included: Incident description: (R234) came up to me this morning and stated her right low back hurt from a NA/R (nursing assistant/registered) who jerked her out of bed yesterday. NP (nurse practitioner) in building and going to check her out. The NP's progress note dated 11/9/15, at 11:05 a.m. included: Today's concern is: Right-sided low back pain without sciatica .Patient seen today at request of nursing due to acute back pain. Patient reports the pain started on Saturday morning when her aid (sic) was helping her get out of bed. She reports the aid seemed in a hurry and quickly turned her to her side while getting her out of bed, this is when the pain started. Pain is to her right lower back, constant, and described as aching, rates pain 8/10, worse when she moves, better when she is lying in bed. Pain does not radiate, no other associated symptoms reported. She denies numbness/tingling to either lower extremities, denies changes in bowel habits, denies recent falls or injuries. Patient unaware of any previous lower back injuries. She is currently on scheduled tylenol, has not been helping with the pain .Assessment/Plan: (M54.5) (diagnostic code) Right-sided low back pain without sciatica (primary encounter diagnoses); Comment: Acute; Plan: X-ray of low back--Apply warm blankets to low back--Continue scheduled tylenol--Start oxycodone 5 mg Q6hrs prn (narcotic pain medication every six hours as needed) for pain The X-ray report dated 11/9/15, was reviewed and included: Impression: 1. There is a severe compression fracture of L1 (due to compression of the lower mid-spine) and suspected mild loss of vertebral loss of body height at L5 (lower spine), age indeterminate. 2. Bilateral degenerative sacrolititis (causes include traumatic injury such as a fall, or arthritis that affects the spine). 3. Multilevel lower thoracic and lumbar spondylosis (degeneration exists between multiple vertebrae along the spine). The X-ray report also noted previous back pain and a comparison X-ray dated 2/4/15. R234's care plan dated 1/12/15, (in place on day of incident) indicated: Transfers with use of standing lift and 1 staff. Is able to transfer with assist of 1 but behavior/refusals make it dangerous for her and staff at this time. Inform resident of all actions before doing anything. Approaches included: Transfer with 1 and standing lift. Inform resident of all actions before doing anything. During an interview on 12/2/15, at 8:10 a.m. RN-A confirmed R234's X-rays had revealed a compression fracture. RN-A said they were unable to tell when the fracture had occurred, as degeneration had also been identified on previous X-rays taken in February 2015. During follow up investigation related to the incident, additional documentation from 11/9/15 indicated RN-A had spoken to the nursing assistant (NA)-H who had cared for R234. NA-H verified he had helped R234 the morning of 11/8/15, to get her brief, pants, socks and shoes on. NA-H said R234 had turned herself to the left side quickly. He said he had assisted R234 to a sitting position by putting his right arm behind her upper back and had guided her legs with his left and had held the w/c in place while she stood, pivoted, and sat down. According to the documentation, R234's care plan directed staff to use the standing lift for transfers. Although following the incident, RN-A determined the resident would have been capable of safe pivot transfer with assistance, R234 complained of pain following the transfer. Documentation also indicated NA-H had been counseled following the incident that if a resident was demonstrating change, he was to alert the nurse or manager right away so the care plan and resident Profile could be updated to reflect the changes. He was also counseled to review each resident's Profile prior to providing care. Review of the resident's Nursing Notes verified R234 experienced significant pain as a result of the incident: 1) A licensed practical nurse (LPN) note dated 11/9/15, at 2:41 p.m. resident stated a night aide had pulled her R (right) arm while getting her out of bed and her lower R quadrant back hurts .Hx (history) of Low back pain. 2) On 11/9/15, at 11:18 a.m., an LPN documented the resident's pain was rated at 7/10, (10 being excruciating pain). The note further indicated the resident had PRN Oxycodone administered and had gone to bed early. The note indicated the Oxycodone was effective. 3) The following morning a RN documented that at 7:00 a.m. R234 rated her pain as 10 out of 10 and Oxycodone was administered and was effective. 4) A LPN documented on 11/10/15, that the resident did not get out of bed for dinner her back hurts when she gets out of bed. 5) On 11/11/15, a LPN documented the resident had pain at an 8/10 and Oxycodone was administered with pain then rated at 3/10. On 12/2/15, at 8:37 a.m. LPN-A reported R234 was cognitively intact, was a reliable reporter and could be believed. On 12/2/15, at 9:04 a.m. the director of nursing (DON) stated some discipline, and some progressive education had been completed with NA-H related to the resident's concerns. In a follow-up interview on 12/3/15, at 7:58 a.m. R234 reported she had felt pain when NA-H had transferred her that day to her w/c, and was still feeling some pain following the transfer. R234 explained NA-H had not used a transfer belt when she was hurt. On 12/3/15, at 11:42 a.m. NA-C was asked how R234 was supposed to be transferred. NA-C replied, We use the E-Z stand lift .I do not know for sure. On 12/3/15, at 1:22 p.m. RN-A stated following the incident she'd observed the resident during transfer. RN-A said she had counseled NA-H and told him he needed to check the Resident Profile and care plan (which had included instruction related to care of residents, and had indicated staff were to transfer R234 using an E-Z Stand lift) before providing care for residents.

Based on observation, interview, and document review, the facility failed to ensure interventions were consistently implemented and re-assessed to minimize the risk of development and promote healing of pressure ulcers for 1 of 2 residents in the sample (R30) who were reviewed for pressure ulcers. This resulted in actual harm when the risk of development of pressure ulcers was not minimized and an additional PU with complications developed. Findings include: R30 developed a pressure ulcer (PU) over the left lateral knee, however, appropriate care and treatment was not provided timely and consistently which resulted in the PU progressing to a Stage 4. In addition, interventions were not provided to prevent PU to the heels and promote healing to the ankles. Standardized PU staging is as follows: o Stage 1 Observable, pressure-related alteration of intact skin, where adjacent may include changes in skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin. o Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. o Stage 3 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. o Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. R30's Minimum Data Set (MDS) assessments revealed [DIAGNOSES REDACTED]. In addition, the following information regarding PUs was documented: 1) 1/25/12 one Stage 2 and healed PUs, 2) 4/19/12 two Stage 3, 3) 7/11/12 one Stage 4, 4) 10/3/12 one Stage 3 and one Stage 4, and 5) 12/26/12 two Stage 3 (1 Stage 3 that worsened) and one Stage 4 PU. The annual MDS dated [DATE], triggered for PUs and the Care Area Assessment (CAA) was completed on 10/8/12. Risk factors included the need for extensive assistance of two staff to move sufficiently to relieve pressure, confinement to a bed or chair all or most of the time, the need for a special mattress or seat cushion to reduce or relieve pressure, and the need for a regular turning schedule. The CAA also noted R30 was immobile, incontinent of bowel and bladder, malnourished, and a history of healed PUs, as well as PUs on the inner ankles that were being treated. R30 had an additional risk factor of long term steroid use with [MEDICATION NAME] 5 mgs since 1/24/10. Nursing notes and wound clinic notes revealed the progression of R30's left lateral knee PU was as follows: 1) On 3/22/12, a nursing note revealed the discover of a PU over the left lateral knee described as purple, not open, and measuring 1.3 x 0.8 centimeters (cm). The cause was identified from the knee "digging into metal leg rest" of the wheelchair (w/c). The plan was to pad the w/c. The resident was going to be sent to a wound clinic due to "no improvement with wounds bilateral ankles." The nurse practitioner (NP) then ordered a foam dressing to the left lateral leg that was to be changed every two days and as needed. A pillow was to be kept below the outer knee for protection when the resident was on her left side. 2) On 3/23/12, R30 had an initial consult at the local wound clinic, however, documentation did not show the new PU on the left lateral knee was addressed at that time. The clinical record lacked as assessment of the newly developed PU. 3) On 3/26/12 and 4/5/12, the NP saw the resident, but did not address the knee PU. 4) On 4/9/12 Weekly Wound Status Documentation noted numerous open areas on the resident's ankle, but there was no mention of the knee PU. 5) On 4/12/12, R30 was again seen by the NP. A progress note dated 4/12/12, indicated licensed nursing staff requested the NP to check the left lateral knee area which had been rubbing on the w/c side while R30 was in the w/c and during transfers. The note revealed the w/c had been padded now and staff were using a Hoyer (mechanical) lift for transfers. 6) There was no Weekly Wound Status Documentation for the week of 4/16/12. Two weeks later on 4/23/12, the Weekly Wound Status Documentation included, "She also has a new open area on the outer left knee. It appears to be from the hardware of her wheelchair and is unstageable and measures 2.5 cm's x 1.8 cm's x 0.2 cm's." 7) On 4/23/12, the NP wrote "She also has a new open area on the outer left knee. It appears to be from the hardware on her wheelchair. This area is unstageable and measures 2.5 x 1.8 x 0.2 cm. Occupational therapy was ordered for offloading 100% pressure to left knee from the w/c." Clinical evidence shows if a PU fails to show progression in healing within the first two to four weeks, the PU (including potential complications) and the resident's overall clinical condition should be reassessed, including determining whether to continue or modify interventions. Possible avoidable negative outcomes may include permanent tissue damage increasing the potential for serious complications, with the tissue closest to the bone potentially undergoing necrosis (death). R30 had risk factors due to impaired circulation to the tissue from the use of medical devices, as well as pressure on legs due to contractures, with the need for special attention to effectively reduce pressure on a bony prominence. 8) On 4/30/12, the staff notified the NP of increased redness, warmth, and odor around the knee wound. The NP diagnosed [MEDICAL CONDITION] (infection) of the left leg and the NP ordered antibiotic therapy. The NP directed the resident's left knee be positioned off the bed with a pillow above and below the knee. 9) On 5/7/12, R30 was again seen at the wound clinic, and the NP noted the PU was "unstageable" (could not be visualized in order to stage from necrotic tissue), and measured 4 x 3 x 0.4 cm. (the latter measurement indicating tunneling, or a passageway of tissue destruction under the skin surface) and the surrounding skin that was purple was now an open area and part of the wound itself. 10) On 5/18/12, the NP ordered an air mattress. 11) On 5/21/12, the wound clinic nurse documented the PU remained unstageable measuring 4.5 cm by 4.3 cm by 0.8 cm. Although it had been two months since the PU was first discovered, the staff continued with the same intervention and the wound became progressively worse. The wound nurse directed staff to, "KEEP PRESSURE OFF KNEE AT ALL TIMES" that included the bed and hardware of the w/c. "Please do not just pad the hardware of the wheel chair as this does not provide pressure relief." 12) On 6/6/12, the NP progress note indicated R30 had an air mattress and was seeing an occupational therapist for positioning. 13) On 6/4/12, wound clinic consult documentation indicated the left lateral knee was debrided (removal of dead tissue to facilitate the healing process) to a stage 4 PU. The wound was cleaned down to the muscle, and measured 5.3 x 3.3 x 0.8 cm. 14) On 8/10/12, another order was written for an air mattress. 15) On 8/14/12, the NP saw the resident and ordered a Z-Flo positioning pillow for left lateral knee when in bed. The NP also wanted staff to check on status of air mattress and notified the nurses. 16) On 9/10/12, the wound clinic noted the wound knee measured 6.3 x 3.7 x 0.5, which had increased in size. 17) On 11/15/12, the wound clinic noted the wound was 8.3 x 3.3 x 0.5 and the superior edge was brown in color with moderate serous drainage, and was essentially unchanged in 12/12. 18) On 1/10/13 the wound was noted as "slightly smaller than last month. 19) R30's record showed she was utilizing an air mattress as noted on treatment records for the month of 2/13, progress notes, and in the most recent comprehensive assessment dated [DATE]. 20) R30's care plan (CP) with a review date of 2/4/13, indicated the resident had one Stage 3 PU on the left medial malleous, one Stage 3 on the right medial malleolus, and one Stage 4 on left lateral knee. Interventions directed staff to write progress notes regarding the wounds, update the physician and family monthly, provide the nutritional supplement [MEDICATION NAME] twice daily to promote wound healing, and pressure relief cushion for wheelchair (w/c). "OFFER CHANCE TO LAY DOWN BETWEEN MEALS, KEEP RT (right) FOOT/LEFT FOOT OFF LOADED W/ (with) NO PRESSURE, USING FOAM BOOTS, BLANKET OR PILLOWS. PRESSURE REDUCTION FOAM BOOT TO RIGHT FOOT EVERY NIGHT, CONTINUE TO OFF LOAD LEFT FOOT WHEN IN BED hs (bedtime). POSITION (L) KNEE OFF BED WITH PILLOWS (ABOVE & BELOW KNEE) DX: (diagnosis) INFECTED (L) KNEE WOUND, KEEP PRESSURE OFF KNEE AT ALL TIMES, INCLUDES IN BED & HARDWARE OF W/C. DON'T JUST PAD HARDWARE OF W/C, AS THIS DOES NOT PROVIDE PRESSURE RELIEF. AIR MATTRESS, LAMBS WOOL BETWEEN TOES PM." Staff were also directed to follow the turning/repositioning schedule, and "Heel Float Boots, Air Flow mattress. Wound Care--Measure wounds on Right and Left Medial Malleous AND wound on Left lateral knee." 21) R30's tissue tolerance assessments (testing to determine the skin's ability to withstand pressure) documented 2/14/13, was a sitting evaluation and was completed by a registered nurse (RN) noted the resident's skin was able to withstand 1.5 hours of pressure. Although the RN did not proceed to the next interval of testing, the documentation noted R30 tolerated repositioning every two hours. For lying, the licensed practical nurse (LPN) who completed the assessment, did not document the purpose of the testing to determine how R30's body responded to pressure. The LPN instead documented observations of wound dressings and noted that the rest of R30's skin was clean and intact. 22) On 2/7/13, the wound clinic nurse described the left lateral knee wound as Stage 4 and measured 8.0 x 2.5 x 0.2 cm and tapering to 1 cm with serous drainage and the left medial malleous measuring 1.9 x 2.2 cm with a small amount of serous drainage. It was also noted as "slightly smaller than the previous month--uses Z-Flo positioning pillow." The wounds to the ankles were described as Stage 3 with the medial malloelar ulcer described as clean and red, "unchanged" measuring 2.2 x 2.3 x 3.0 cm. On 2/13/13, at 2:00 p.m. observations were conducted of scheduled treatments to R30's PUs by LPN-B. The left lateral knee wound was open, however, the wound did appear clean. Orders were for wound care to the ankles daily, and three times weekly to the knee. Wound care specific to the knee read that the left knee was to be positioned off the bed every shift, with wound care including: Cleanse with wound cleanser, pat dry, cover wound base with [MEDICATION NAME] AG (wound dressing) and secure with 5 x 5 Allevyn adhesive ("ok to change to Algicell AG until [MEDICATION NAME] comes in"), apply [MEDICATION NAME] (ointment) to wound daily and cover with non-stick dressing, Z-Flo positioning pillow (to support vulnerable areas of the body) to left lateral knee. During the observation, however, the LPN placed the Z-Flo positioning pillow under R30's feet, and the Posie boots (specialized footwear) which were to be applied to the resident's feet were on the floor under the resident's dresser. The resident was leaning to the left, and her knees were contracted to a 90 degree angle and were approximately an inch from touching the standard mattress, with a pillow placed under the left side of the resident's trunk. During subsequent observations the resident was not positioned to minimize the risk of pressure to vulnerable areas. For example, on 2/14/13, at 9:30 a.m. R30's feet were wrapped with gauze and her heels were exposed and resting on the foot rest. At 10:15 the resident was wearing the Posie boots, however, her toes were exposed and the right foot was sliding off the foot pedal toward the front wheel of the chair. At 10:25 a nursing assistant (NA)-A was assisted to transfer R30 from the wheelchair to the bed, and the Z-Flo pillow was again incorrectly positioned under both feet (with Posie boots) with the top of the pillow approximately one inch below the wound dressing to the left lateral knee. The following day at 9:00 a.m. the resident was not wearing the Posie boots and both heels were exposed with the right foot resting against the front right wheel of wheelchair. At 10:00 a.m. R30 was in bed and again the Z-Flo positioning pillow was under both feet approximately two inches below dressing on left lateral leg. A standard pillow had been placed under the resident's left knee and another under the resident's right side. On 2/14/13 at 10:50 a.m. RN-A explained R30 had a pressure reduction mattress on the bed ordered 5/8/12, and the resident wore Posie boots on both feet. In addition, the resident was turned and repositioned every two hours according to her tissue tolerance assessment. Because a standard mattress was observed on the bed, the RN and surveyor visualized the mattress, and the RN confirmed it was not the air mattress that had been ordered on two different occasions by the NP. NA-A was interviewed on 2/15/13, at 9:05 a.m. The NA stated R30 needed a special pillow under both legs in bed, and was repositioned every two hours. The NAs were to notify the nurse if the resident's wounds were uncovered or leaking. RN-A was interviewed on 2/15/13, at 10:50 a.m. and explained that R30 had a pressure reduction mattress on the bed ordered 5/8/12, (not an air mattress) and wore Posie boots on both feet. RN-A stated R30 was turned and repositioned every two hours according to the tissue tolerance assessment. RN-A confirmed care was not consistently provided for R30 in order to minimize the risk of further development and to promote healing of the PUs. The facility's Skin Care Program policy (dated 12/12) directed staff as follows: residents who had pressure sores would receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. For residents at risk with skin alterations, staff was to immediately develop a plan of care, request physical and/or occupational therapy assessment/evaluation as needed. Staff was to also assess, measure and document PUs on a weekly basis utilizing the Weekly Wound Flow Sheet scheduled on the care path.

Based on observation, interview and medical record review, the facility failed to ensure the environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents when 1 of 1 resident (#1) had a fall during a mechanical lift transfer. Findings include: Medical record review revealed Resident #1 has [DIAGNOSES REDACTED]. Nursing Summary dated 8/22/10 noted she has severely impaired cognition and is totally dependent on staff for all activities of daily living. She is transferred with two assistance and the use of a mechanical lift. Medical record documentation notes from September 8, 2010 noted caregivers were assisting Resident #1 to transfer from bed to chair with a mechanical lift when she slipped through the lift sling. She fell to the floor and hit her head. Caregivers called Employee (E)/ nurse who responded to Resident #1's room where she was found lying on the floor, having difficulty breathing and sweating. She had her eyes closed and had a very weak pulse. Resident #1 received supplemental oxygen initially at 6 liters per nasal cannula. Resident #1's blood pressure was 149/95 and her pulse was 96. Her respirations were 22 after supplemental oxygen was started. Employee (E) transferred Resident #1's care to Employee (F)/ nurse who had returned to the unit. The physician and family decided not to hospitalize Resident #1 that evening due to her end stage condition and DNR/DNI code status. Resident #1 continued to decline over the next six days with changes in condition including an elevated temperature, increased lethargy and decreased response. She was subsequently sent to the hospital where tests revealed she had a subdural and intraparenchymal bleed on the left side of her head with a possible right occipital fracture and a positive urinalysis. She was transferred back to the facility and placed on bedrest. During the onsite visit on 9/30/10 at 10:00 a.m., an observation of Resident #1 up in her reclining wheelchair revealed no eye contact, teeth clenching, head leaned to the right. Employee (G)/nurse was interviewed on 9/30/10 at 10:09 a.m. and she stated that this was the first time Resident #1 had been up since being on bedrest since she was at the hospital. She also stated Resident #1 used to make eye contact but that has decreased now since her fall. Also, Resident #1 tended to lean her head to the right prior to the fall but now she keeps it in that position. She used to move her head more on her own than she does now. Employee (D)/nursing assistant (NA) was interviewed on 10/1/10 at 12:07 p.m. and he stated that on 9/8/10 when transferring Resident #1 with a Liko mechanical lift from the bed to chair he used a dark green lift sling which was on the resident's chair. He stated that he was not familiar with the use of that particular sling. During the transfer, Resident #1 slipped through the lift sling, fell to the floor, hitting her head. Interview with Employees H, I, J, K, L, M, N, and O/ Nursing Assistants (NA) on 10/1/10 revealed none of them were familiar with the new dark green Hoyer universal sling. This sling was new to them, was a different style and size than the Liko lime green slings staff were used to using with the Liko mechanical lift. Facility internal investigation at the time of the incident demonstrated that the sling had not been properly placed during the transfer. In addition, the facility indicated a loop from the sling had come free from the lift during the transfer. Facility staff indicated this contributed to the fall. Facility staff further indicated that a hoyer universal sling was used during the transfer. Facility policy indicated they would use a Liko sing with the Liko lift. Interview with Employee (H), one of the nurses responsible for staff training, on 10/1/10 at 1:00 p.m. revealed she was not aware of that a new Hoyer universal dark green sling had been put into use.

Based on medical record review, and interviews, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the care plan when 1 of 1 resident (#1) was transferred by staff who had no training on the use of a mechanical lift sling and the resident sustained [REDACTED]. Interviews with Employees H, I, J, K, L, M ,N and O/Nursing Assistants (NAs) during the onsite visit on 10/1/10 in the afternoon revealed none of them had training on the use of the new dark green sling. The new dark green sling was smaller and narrower with the need for different placement on the body. This sling was new to them, was a different style and size than the Liko lime green slings staff were used to using with the Liko mechanical lift. When a resident needs a sling, staff take the one in the resident's room to use. If there is not one in there, the employee will get one from the laundry to use for that resident. Interview with Employee (H), one of the nurses responsible for staff training, on 10/1/10 at 1:00 p.m. revealed she was not aware the new smaller Hoyer universal dark green sling had been put into use. Therefore staff were not trained on the use. Staff was trained regarding how to fit and use the lime green Liko sling for the Liko lift. Because clinical leadership was not aware a new style of sling was put into place, they could not make an informed decision regarding the training. An interview was conducted with Employee (D)/nursing assistant (NA) on 10/1/10 at 12:07 p.m. He stated that on 9/8/10 when transferring Resident #1 with the Liko mechanical lift from the bed to chair he used the smaller dark green sling which was on her chair. During the transfer, she slipped through the lift sling, hit her head on the floor and landed on the floor. He indicated he was not familiar with the smaller dark green lift sling and had no training regarding use of that particular sling. Medical record review revealed Resident #1's has [DIAGNOSES REDACTED]. Nursing Summary dated 8/22/10 noted she has severely impaired cognition and is totally dependent on staff for all activities of daily living. Resident #1 transfers with two assistance of staff and a mechanical lift. Progress notes dated 9/8/10 noted caregivers were assisting Resident #1 to transfer from bed to chair with a mechanical lift when she slipped through the lift sling. She fell to the floor and hit her head on the floor. After she was sent to the hospital, test revealed she had a subdural and intraparenchymal bleed on the left side of her head with a possible right occipital fracture.