Every finding on record at Auburn Manor

Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 4 of 4 residents (R33, R34, R14, R24) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all residents residing in the facility.On 4/30/26 at 9:33 a.m., a Resident Council meeting was held with four residents from varied areas of the facility. R24 stated mail was not delivered to residents on Saturdays. This was confirmed by R33, R34 and R14. R24 indicated mail delivered by the post office on Saturdays would be left on the receptionist's desk near the front entrance. On Monday morning the receptionist would sort and deliver the mail to residents.During interview on 4/30/26 at 1:09 p.m., Secretary (S)-A stated it was her job Monday through Friday to sort and deliver the mail. SA stated on the weekend it would be the responsibility of the nursing supervisor.During interview on 4/30/26 at 1:22 p/m., registered nurse (RN)-A stated she was unaware collecting and passing mail was part of her responsibilities on the weekends. RN-A then stated she did not have time to deliver mail when she was the only nurse in the building overseeing all staff and residents. RN-A stated she did not have any back up assistance available to her on the weekends.During interview on 4/30/26. At 1:29 p.m., Administrator stated it was the responsibility of the secretary at the front desk to deliver mail. Administrator went on to say occasionally nursing staff would deliver mail on the weekends but not on a regular basis, and mail delivered over the weekend was typically delivered Monday after the front desk staff arrived. Administrator stated it was her expectation mail would be delivered to the residents the same day it was delivered to the facility.An undated policy with no review dated titled Policy of Mail Delivery indicated residents of [facility] have the right to receive and send mail both personal and business in nature and all letters, documents and packages will be delivered 6 (six) days a week, Monday thru Saturday. It is the duty and responsibility of [facility] to see that mail delivered to [facility] is distributed to each resident in a timely fashion.

Based on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items to reduce the risk of foodborne illness. This had the potential to affect all the residents who were provided meals from the kitchen. Findings include:During initial tour and interview of kitchen on 4/27/26 at 1:03 p.m., with Dietary Director (DD) the following was observed inside the walk-in cooler: an opened box of undated chicken stock an opened box of undated turkey stock an approximately 4x4x8 inch metal dish containing sliced carrots lacked an open or use by date,an approximately 4x4x8 inch metal dish with contents identified by DD as pizza sauce lacked an open or used by date.DD stated he was unsure of what the food storage policy stated in regard to leftover food, but he believed all food was to be dated with both an opened on and use by date.During observation of refrigerator in kitchenette by north nursing station on 4/28/26 at 2:48 p.m., the following was observed in the freezer:a loaf of multigrain bread was not sealed, dated and was covered in thick white frost, a gallon bucket of [NAME] vanilla ice cream with a jack o lantern pattern on the outside approximately 1/3 full was covered with a thick layer of white frost on both the inside and outside of the bucket,a gallon bucket of Shoppers Value vanilla ice cream approximately 1/3 full with thick white frost covering the ice cream lacked an open date or use by date.Director of Nursing confirmed the above items lacked proper labeling and should have been discarded.During interview on 4/29/26 at 2:54 p.m., Administrator stated the facilities left over food policy should be followed by all dietary staff. Stated she was unaware of leftovers stored in the kitchen or anywhere else in the facility. Administrator stated dietary staff 'batch cooked' to avoid excess food being made and therefore eliminating the need to store leftovers.A policy titled [facility] Food-No Leftover Food Retention Policy indicated no left-over food was permitted to be saved, stored, cooked, or reused. Any food remaining after service must be discarded immediately.

Based on interview and document review, the facility failed to provide ongoing communication to residents about their rights (e.g., through resident groups) for 4 of 4 residents (R33, R34, R14, R24) who attended the council meetings.Findings include:R33 quarterly minimum data set (MDS) dated [DATE], indicated R33 was cognitively intactR34 quarterly MDS dated [DATE], indicated R34 was cognitively intactR14 quarterly MDS dated [DATE], indicated R14 was cognitively intactR24 quarterly MDS dated [DATE], indicated R24 was cognitively intactResident council meeting minutes dated November 2025 through April 2026, lacked evidence resident rights had been reviewed or included in meeting discussions.During a resident council meeting on 4/30/26 from 9:33 a.m. to 10:48 a.m., R33, R34, R14 and R24 stated they regularly attended resident council meetings and did not recall a time when resident rights had been discussed. All four residents stated they did not know where resident rights were posted in the facility. Resident Right poster hung in a hallway across from the beauty salon.During an interview on 4/30/26 at 1:04 p.m., life enrichment director (LED) stated she was responsible for taking minutes at resident council meetings. LED stated a typical meeting consisted of review of previous months' topics, new residents' concerns and if there were no concerns brought forward, she would go through each department and ask if they had concerns specific to each department. LED stated a representative of the state Ombudsman office had attended resident council and she believed they had discussed resident rights. LED was unable to locate any documentation in resident council notes to support resident rights were discussed. LED stated it was important for residents to understand their rights and the residents of the facility were vulnerable to having others make all decisions for them, their rights violated and were more susceptible to abuse.During an interview on 4/30/26, at 1:49 p.m., Administrator (Admin) stated resident rights were reviewed upon admission. Admin stated if social workers were in attendance for resident council, they would be responsible for reviewing resident rights. Admin stated it was something the facility was working on to standardize recently. Admin stated it was important for residents to know and understand their rights to empower them to self-advocate and went on to state many residents' rights were directly related to how the residents wanted their lives to look.

Based on record review and interview the facility failed to ensure COVID-19 vaccinations were offered to 1 of 5 residents (R6) reviewed for COVID-19 vaccination status.Findings include: R6's quarterly minimum data set (MDS) dated [DATE], indicated R6 was admitted to the facility on [DATE], and had the following diagnoses: high blood pressure, hyperlipidemia (high levels of fat in the blood), and malnutrition. R6's undated client information vaccination record indicated R6 was overdue for their COVID-19 vaccination. R6's medical record lacked any evidence a COVID-19 vaccination was offered or provided. On 4/30/26 at 10:00 a.m., the Infection preventionist (IP) stated they had just started in this role recently. R6 had been on a list of the previous infection preventionist to be completed, however, was unable to find any supportive documentation it was ever offered or completed. The IP stated they would have expected the vaccination to have been completed within a few days of R6's admission and confirmed it should have already been completed but had not been. On 4/30/26 at 11:01 a.m., the director of nursing (DON) confirmed R6 had not been offered or received the COVID-19 vaccination. Their expectation was it would have been completed within a week of admission. The DON stated importance of supporting the residents with their treatments, preventing any infections, and supporting them in their care choices. The facility COVID Immunization policy dated 4/17/23, indicated [facility] will offer the COVID-19 immunizations and/or boosters to all residents.

Based on observation, interview and document review, the facility failed to ensure mediations were administered in accordance with physician orders for 1 of 1 residents (R 24) reviewed for medications administration.Findings include: R24's quarterly minimum data set (MDS) dated [DATE] indicated R24 was cognitively intact and had the following diagnoses: Multiple Sclerosis, Hypertension, Neurogenic bladder, Chronic Obstructive Pulmonary Disease and Hyperlipidemia.During interview on 4/30/26 at 10:48 a.m., R24 stated she had not received her scheduled 7:00 a.m. medications. R24's medication administration record on 4/30/26 at 10:52 a.m., revealed blank boxes for R24's scheduled 7:00 a.m. medications indicating they had not been administered. R24 was scheduled but did not receive the following medications:Glucosamine-Chondroitin 500-400mg tablet- 1 tabLisinopril 20mg -1 tabOmeprazole 20mg -1 capsuleMultivitamin tablet -1 tabTrimethoprim 100mg -1 tabFluticasone-Salmeterol Inhalation Aerosol 250-50 MCG/ACT - 1 puffNystatin external powder 100000 u/gmOxybutynin Chloride 5mg -1 tabBaclofen 10mg -1 tabGabapentin 300mg - 3 capsulesDuring an interview on 04/30/2026 1:22 p.m., Director of Nursing (DON) stated medications were expected to be delivered within one hour before or after their scheduled time. DON reviewed R24's medication administration record and confirmed R24 had not received her scheduled medications within the allowable time frame. DON stated it was important for residents to receive medications as scheduled and physician order because the medications are prescribed by a physician to treat specific diagnoses and should be given as the prescriber orders for residents to achieve the best outcomes.Facility policy title Person-centered Medication Pass indicated [NAME] Manor will implement a person-centered medication pass while following manufacturer guidelines as well as applicable State and Federal law and regulations. The policy indicated medications will be scheduled for administration time windows unless clinical contradictions exist or prescribing directions. The policy lacked specific guidelines for medication administration times.

Based on observation, interview and document review, the facility failed to ensure residents were aware how to file grievances anonymously, for 4 of 4 residents (R33, R34, R24, and R14) reviewed for grievances. Further, the facility failed to maintain a grievance log for a minimum of 3 years. This had the potential to affect all residents residing in the facility.Findings include: During the initial entrance conference on 4/27/26 at 12:11 p.m., Director of Nursing (DON) stated there were no grievances for the previous six months. On 4/30/26 at 9:30 a.m., R33, R34, R24, and R14 stated they were unclear how to file an official grievance, or where to find a grievance form to assure anonymity. All four residents stated they could talk to the Director of Nursing (DON). DON had instructed residents all grievances or concerns were to be handled internally. During interview on 04/30/2026 at 1:22 p.m., DON stated a grievance is any report of a concern a resident feels necessary to discuss about their care or about the facility. DON stated if a resident had a concern they were to bring it to her, the social worker (SW) or any staff and then depending on the concern would determine how it was handled. DON stated a resident could fill out the form or staff could assist them if a resident brought forward a verbal grievance. DON stated residents were encouraged to bring grievances and concerns forward in real time instead of waiting until resident council. She went on to state she verbally followed up with a one-to-one meeting in the resident's room. DON stated the facility did have a process for tracking grievances which included a paper grievance form and a grievance log to be filled out for every reported grievance. DON stated although residents had verbally brought forward concerns, she did not have any copies of grievances, grievance investigations/resolutions, nor did she have a grievance log tracking resident grievance A facility policy titled Grievance, Complaint & Non-Retaliation with a last review date of 1/25/22 indicated the following: Residents are encouraged and supported in bringing their concerns and complaints forward to any [facility] and Services employee. If an informal resolution cannot be found, the resident will be offered the opportunity to file a formal grievance report form. The resident may file a grievance orally to an employee. The employee is to complete the grievance report form with the resident's oral report. The grievance will be forwarded to the grievance official for review within a reasonable expected timeframe. The grievance official will maintain a record of any formal complaints filed. Records will be kept for at least 3 years and will include the dated original complaint, the investigation, and resolution of the compliant. Records will be available for review by the commissioner of health or a designated representative.

Based on interview and record review, the facility failed to ensure 2 of 2 (R33, R34) residents reviewed for dignity, received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide toileting assistance resulting in episodes of incontinence.Findings include:R33's admission minimum data set (MDS) dated [DATE], indicated R33 was cognitively intact and had the following diagnoses: history of urinary tract infections (UTI's), depression, generalized weakness and lymphedema (swelling caused by an accumulation of fluid in the tissues).During interview on 4/27/26 at 3:13 p.m., R33 stated she frequently waited for assistance to use the bathroom and at times it could be over an hour. R33 stated it had caused her to become incontinent of both bowel and bladder. She went on to state it doesn't make me feel good. Its degrading. No one wants to sit in their pee or poop.Review of R33's call light logs from 3/29/26 through 4/28/26 indicate R33 had call lights greater than 30 minutes on 26 occasions.R34's admission MDS dated [DATE], indicated R34 was cognitively intact and had the following diagnoses: non-traumatic spinal cord disfunction, peripheral vascular disease (a condition leading to low blood flow to limbs), and personal history of UTI's.During interview on 4/29/26 at 11:51 a.m., R34 stated she needed to use a mechanical lift (a machine to assist in transferring a person from a bed or chair to another location) which required two staff to operate. R34 stated staff frequently had to wait for additional staff assistance and had become incontinent on more than one occasion while waiting. She went on to state she was embarrassed by this and felt like she was being forgotten because she was old.Review of R34's call light logs from 3/29/26 through 4/26/26, indicated R34 had call lights greater than 30 minutes on 14 occasions. During interview on 4/30/26 at 1:22 p.m., Director of Nursing (DON) stated she expected staff to answer call lights as quickly as possible and ideally under 15 minutes. DON confirmed call light logs revealed call lights extending beyond 30, 45 and 60 minutes. DON could not offer an explanation as to why call lights were not being answered faster. DON stated if a resident had to wait an extended amount of time and became incontinent it could have a negative impact on the residents. DON went on to state residents lived at the facility to receive assistance and care. Waiting for a long period of time could result in a resident not receiving the care they needed and could harm them emotionally, holistically and physically. DON stated it was never acceptable if a resident felt embarrassed or humiliated after becoming incontinent because of waiting an extended period for a call light to be answered. A call light policy was requested but not received.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) physician orders were followed for parameters set by the physician. This resulted in actual harm for R1 who became unresponsive and required emergency transport and hospitalization after receiving insulin that should have been held. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of diabetes mellitus, dementia, and mild cognitive impairment. R1's care plan, dated 9/13/24, directed administer insulin as ordered, monitor for side effects/effectiveness of medication and update provider as needed. Monitor for signs and symptoms of hypoglycemia, follow standing house orders, and update nurse practitioner (NP) as needed. R1's provider orders, dated 3/12/25, directed decrease insulin aspart (rapid-acting insulin used to manage blood sugar in people with diabetes) to 6 units before meals related to Type 2 Diabetes Mellitus with diabetic neuropathy. Hold if blood sugar less than 100 milligrams per deciliter (mg/dl). R1's provider orders, dated 3/20/25, directed hold Novolog (another name for insulin aspart) if blood sugar less than 150 mg/dl. R1's medication administration record (MAR) directed to administer insulin aspart 100 units/milliliter (ml). Inject 6 units subcutaneously before meals. Hold if blood sugar is less than 150 mg/dl. The MAR indicated: On 3/23/25, R1's BS was 137 mg/dl at 7:00 a.m., insulin was administered by RN-A. On 3/28/25, R1's BS was 97 mg/dl at 7:00 a.m., insulin was administered by RN-B and 144 mg/dl at 12:00 p.m., insulin was administered by RN-B. On 3/28/25, R1's BS was 82 mg/dl at 5:00 p.m., and insulin was administered by RN-C. A progress note, on 3/26/25 at 10:43 p.m., indicated R 1 was found to have sluggish response upon checking his BS which was found to be 32 mg/dl. R1 was administered glucagon (medication to increase blood sugar levels) 1 milligram (mg) IM (intramuscular) per house standing orders. After 10 minutes, BS was 33 mg/dl, so 9-1-1 was called. R1 was not responsive. Paramedics got BS up to 468 mg/dl, but R1 was still not responsive so he was transferred to the hospital. R1's hospital discharge summary indicated R1 was admitted on [DATE] for generalized weakness, decreased consciousness, hypoglycemia (low blood sugar), bradycardia (slow heart rate), hypokalemia (low potassium), and hypomagnesemia (low magnesium). Hypoglycemia was corrected on 3/28/25 with D50 (dextrose 50% intravenous solution used to restore blood sugar levels). Urinary tract infection (UTI) was diagnosed and treated with antibiotics during hospitalization . R1 was discharged to the facility on [DATE]. On 4/2/25, at 12:33 p.m., RN-A stated R1 had a recent order change to hold the insulin if his BS was under 150 mg/dl. RN-A stated she should not have given R1's insulin on 3/23/25 when his BS was 137 mg/dl. On 4/2/25, at 1:15 p.m., RN-B stated he was not informed R1's orders had been recently changed. RN-B stated he should have read the order. RN-B stated he administered 6 units of insulin aspart to R1 for BS readings of 97 and 144 on 3/28/25. RN-B stated he was provided education after the incident, including the need to open another window within the medical chart for additional instructions. RN-B stated the window titled more held the parameters for withholding the insulin and he was unaware of the need to open this section prior to the incident. On 4/2/25, at 1:48 p.m., RN-D stated she was working on 3/28/25, when she was called to help R1 whose BS was 33 mg/dl. RN-D stated she administered glucagon. RN-D stated R1's BS was still 33 mg/dl five minutes after the administration of the medication. She stated she administered another dose of glucagon and glucose gel in his lower lip per the facility's standing orders. RN-D stated R1's BS was 32 mg/dl after five minutes, so 9-1-1 was called. RN-D stated it was important to read the entire medication order and follow it. On 4/2/25, at 3:10 p.m., the director of nursing (DON) stated nurses were expected to read the full medication order. The DON stated the facility was still adjusting to a new electronic medical record system that was implemented 8/2024. The DON stated the system required the nurse to click on more to see scheduling details and parameters. On 4/2/25, at 4:00 p.m., the pharmacist stated if R1 ended up in the hospital with hypoglycemia, after receiving insulin that was ordered to be held for a BS of 82, it should be considered a significant medication error. On 4/2/25, at 4:44 p.m., RN-C (an agency nurse) stated this was his second shift at the facility on 3/28/25. RN-C stated R1's BS was 82 mg/dl and he administered R1's insulin at 5:00 p.m. RN-C stated he did not see the instructions to hold the insulin for a BS less than 150 mg/dl as that was in another section that required him to click on it, labeled more. RN-C stated he was unaware he was expected to click on the section titled more. On 4/2/25, at 4:59 p.m., the NP stated R1's insulin should have been held for a BS of 82. The NP stated the hypoglycemia led to R1 being hospitalized and should be considered a significant medication error. A facility document, Standard Diabetes Mellitus Protocol, undated, directed administer medications as directed. A facility policy, Medications Administered through Certain Routes of Administration, dated 11/15/24, directed subcutaneous injection medications to verify medication order on the MAR; check against physician order.

Based on observation, interview, and document review, the facility failed to ensure sufficient nursing staff and leadership to meet assessed resident needs and facility processes for 2 of 2 residents (R5, R37) reviewed for pressure ulcer prevention, for R7, R42 reviewed for activities of daily living who were dependent on staff for their care, for R1 who was left exposed and nude on the toilet, and R18 who utilized an indwelling catheter reviewed for dignity. In addition, the facility failed to reassess and implement proactive interventions to reduce the risk of falls and injuries for R26 and R44 who sustained falls at the facility. Additionally, the facility failed to address ongoing staffing and long call light concerns identified during resident council meeting minutes. Also, during survey, one family (FM-A) and four residents (R4, R5, R14, and R33) expressed ongoing concerns with not enough staff and significant wait times for cares. These findings contributed to several associated deficiencies and the lack of sufficient and/or competent staff had the potential to affect all 45 residents within the care center. Findings include: Refer to F550. Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet facing window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter. Refer to F656. Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs. Refer to F677. Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care. Refer to F686. Based on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care, consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries. Refer to F689. Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop proactive interventions to reduce the risk of falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center. R1 R1's quarterly Minimum Data Set (MDS), dated [DATE] identified R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. In addition, R1 medical diagnoses include spinal stenosis (narrowed space around the spinal cord causing irritation and compression of the spinal cord), heart failure, and arthritis. R4 R4's admission MDS assessment, dated 1/6/25, indicated R4 had moderately impaired cognition. R4 required maximal staff assistance for dressing, bathing, toileting and bed mobility. R4 required moderate staff assistance for transfers and personal hygiene. In addition, R4's medical diagnoses include osteoporosis, seizures, muscle weakness, and history of breast cancer. R5 R5's quarterly Minimum Data Set (MDS) dated [DATE] identified R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, R5 identified as a risk of developing a pressure ulcer/pressure injury. R5's medical diagnoses include bipolar, anxiety, depression, and chronic pain. R7 R7's quarterly MDS, dated [DATE], identified R7 with severe cognitive impairment, was dependent on staff for personal hygiene care and did not reject care. R7's medical diagnoses include stroke, peripheral vascular disease, diabetes, arthritis, aphasia (impairment in speaking), hemiplegia (paralysis on one side of body), and depression. R14 R14's quarterly MDS dated [DATE], identified R14's with intact cognition, was dependent on staff for all toileting and dressing and required substantial assistance with personal hygiene and bathing. In addition, R14 did not reject cares. In addition, R14 medical diagnoses include spinal cord compression, neurogenic bladder, diabetes, arthritis, paraplegia (paralysis on one side of the body), and depression. R18 R18's quarterly MDS dated [DATE] identified R18 with moderate cognitive impairment, was dependent on staff for toileting hygiene and lower body dressing, and did not reject care. In addition, R18 with indwelling catheter (tube to drain urine from bladder to a bag outside of the body). In addition, R18 medical diagnoses include diabetes, peripheral vascular disease, arthritis, and depression. R26 R26's quarterly MDS dated [DATE], identified R26 had severely impaired cognition and required assistance for nearly all ADLs. In addition, R26 did not reject cares. In addition, R26 medical diagnoses include dementia, heart failure, kidney disease, diabetes, aphasia (difficulty speaking), seizures, anxiety and depression. R33 R33's admission MDS dated [DATE] identified R33 with intact cognition, required substantial assistance with dressing, bathing, and mobility such as rolling from side to side in bed, lying to sitting, sitting to stand and transferring from bed to chair. In addition, R33 did not reject cares. R33's medical diagnoses include hip fracture, and Parkinson's Disease. R37 R37's quarterly MDS dated [DATE] identified R37 with significant impairment to cognition, impairment to lower extremities, was dependent on staff for all efforts of self-care. Also, R37 identified as a risk of developing a pressure ulcer/pressure injury. In addition, R37's medical diagnoses include Alzheimer's, dementia, depression, and bipolar and did not reject care. R42 R42's Significant change in status MDS dated [DATE] identified intact cognition, no impairment in upper and lower extremity range of movements, was dependent on staff for mobility, toileting, and lower body dressing and required assistance with personal hygiene. R42's medical diagnoses include hip fracture, coronary artery disease, heart failure, urinary tract infection, and Parkinson's disease. R44 R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). In addition, R44's medical diagnoses include dementia, hypertension, kidney disease, anxiety and depression. Resident and family interview: During interview with family member (FM)-A of R44 on 2/3/25 at 3:51 p.m., FM-A stated R44 had sustained a few falls since she admitted to the care center from her prior assisted-living setting, and the falls led him to believe the facility did not have enough staff to provide R44 with adequate supervision. During interview with R4 on 2/3/25 at 5:12 p.m., R4 stated she, feels the facility [sic] understaffed and it takes a long time and sometimes they don't come. R4 expressed frustration as when she admitted to the facility she needed more assistance from staff and wasn't receiving it. During interview with R33 on 2/3/25 at 2:22 p.m., R33 stated she got very frustrated when she put her call light on for staff assistance as it just takes forever. R33 stated she used her call light for staff assistance to get in and out of bed, any transfers, and to go to the bathroom. R33 stated the time of day did not impact how fast the call lights were answered. R33 stated it could take up to an hour for her call light to be answered. R33 stated facility's lack of call light response has caused her to have an accident [incontinent of urine] and added, what if I fall and no one comes for how long? During interview with R5 on 2/3/25 at 2:44 p.m., R5 stated, not enough help to answer call lights. Staff interviews: During interview with trained medication aide (TMA)-A on 2/4/25 at 7:31 a.m., TMA-A stated I don't feel there is enough staff to meet the needs of the residents. I have twenty-five residents. If aides show up it is four to five aides per morning shift. They recently reduced staffing to 'cut costs' apparently and people have missed showers and answering call lights has been delayed. During interview with licensed practical nurse (LPN)-A on 2/4/25 at 7:46 a.m., LPN-A stated, I have twenty-one residents. They need help today. Normally I have more than that. Some days I don't have time to get my work done. Range of motion exercises (ROM's), sometimes I don't get to it. LPN-A stated they were not surprised if showers weren't done due to staffing. During interview with licensed practical nurse (LPN)-B who was also the facility infection control/wound nurse, stated she was responsible to complete weekly wound assessments and document results in the resident electronic medical record (EMR). LPN-B stated an initial Weekly Wound Tool assessment had been completed for R42's wound on 12/16/24, and should have been completed weekly thereafter until healed. LPN-B stated she was out sick for thirteen days in December (2024) and it fell off my radar. Furthermore, LPN-B stated, I get pulled to the floor a lot. During interview with registered nurse (RN)-B on 2/5/25 at 12:36 p.m., RN-B stated, Staffing is always a concern here. If we have five aides working on a shift and three are agency aides, then the two facility aides have to chart on all of the residents because we don't allow the agency aides to document. It is too much. Also, RN-B stated, due to staffing, the range of motion exercises and other personal cares won't be done. RN-B stated she had seen aides in the past have a tendency to leave residents in their beds to eat meals instead of assisting them up out of bed and transporting them to the dining room. During interview with RN-B on 2/5/25 at 10:31 a.m., (RN)-B reviewed R44's fall reports dated 12/23/24, and 1/2/25, and stated, I am just going to be honest with you, and stated she was not sure if all of R44's fall reports had been brought to IDT for review. RN-B reviewed R44's fall on 12/23/24, and verified it lacked any new interventions being recorded or outlined. RN-B stated the lack of completion with the report could possibly be related to being pulled to the floor so much due to staff call-ins adding, Often, I don't [get them done]. RN-B stated it was a chore and a struggle to get all assigned things such as fall reports and admissions done timely, adding they felt, at times, new interventions had been done but just not been documented. During interview with staffing coordinator (SC) on 2/5/25 at 10:09 a.m., SC stated she worked in the position for ten to eleven years. SC stated she directed staff concerns regarding low staffing to the DON. SC stated call lights should be answered within ten to fifteen minutes. No more than fifteen minutes. SC stated she was expected to follow guidance from management to staff nursing assistants with one aide per 10 residents and, it used to be one aide per 8 residents. SC stated she recently was informed that she was responsible for staffing both the skilled nursing facility and the assisted living facility portion of the building. During interview with director of nursing (DON) on 2/5/25 at 10:45 a.m., DON stated expectation of, Call lights are to be answered as soon as the staff are able to answer them. Everybody should answer call lights. Not just one role. Time range acceptable ideally within half an hour to forty-five minutes. Half an hour is common. Things happen and we want to answer them right away. Sometimes we cannot. It is frustrating. DON stated staffing for 2/5/25, was impacted due to a call in from a nurse so the DON had to fill in for the empty shift and administer morning medications and treatments until a nurse from the evening shift agreed to come in early to relieve her. DON stated the facility did not have access to call light logs and did not do call light audits to determine length of time call lights were on. Call lights: During continuous observation and interview on 2/5/25 starting at 9:20 a.m., the call light was illuminated outside room of R14. -At 9:39 a.m., registered nurse (RN)-D stood outside of room and did not answer it. RN-D entered another resident room. -At 9:40 a.m., RN-C walked past the room and entered another resident room. -At 9:41 a.m., Another staff member walked past the room. -At 9:43 a.m., RN-C walked to medication cart outside of R14's room and typed into computer and walked away. -At 9:44 a.m., RN-D obtained hand sanitizer from outside R14's room and walked across the hall to another resident room. -At 9:46 a.m., RN-D obtained surgical gloves from medication cart outside R14's room and walked back across the hall to another room. -At 9:46 a.m., a laundry staff person knocked on the door and brought in clean clothes to R14 room and said, Oh I don't do that. Did you get your light on? Staff walked outside of R14 room and saw the illuminated call light on above R14's door. Staff walked back into the room and spoke a few words and walked down the hall toward the nursing station. -At 9:48 a.m., laundry staff entered room again and brought in more clothes. Call light was still illuminated. At this time an activities staff member walked past R14's room. -At 9:50 a.m., RN-D walked past R14's room and entered another resident room. -At 9:51 a.m. nursing assistant (NA)-G walked out of another resident room and obtained an EZ stand from the hall and entered R14's room. NA-G stated, Sorry I didn't know your light was on. During interview with NA-G on 2/5/25 at 10:00 a.m., NA-G stated, I don't know how long it was on. I help with answering call lights. NA-G stated R14 had choir practice in activities. Since we are short staffed, I am working on another unit and part of this one. I have an agency aide with me so this is slowing things down and we can't answer all the lights when we should. There is no one to help us. NA-G stated, I have to prioritize. That was unacceptable for her to wait that long. We are responsible for answering call lights. The nurses can answer but don't really. During interview with R14 on 2/5/25 at 10:02 a.m., R14 stated, my light was on for almost an hour. I need them [staff] to get me up. I can't do it by myself. It is frustrating for me. I am late for my activity and am mad about it. They need more help here to get us all up and ready. During interview with NA-D on 2/5/25 at 10:04 a.m., NA-D stated, we don't have enough to help with this floor so we have to ask for help from other units which takes a long time. The call light times are very long. Resident Council: Review of facility's Resident Council meeting minutes for January 2025, December 2024, October 2024, August 2024 and June 2024 identified concerns were verbalized from residents about inadequate staffing. During interview with resident council member attendees (R1, R13, R20 and R25) on 2/4/25 at 1:12 p.m., R1 stated, on a lane (hall) with only one aide, [we are] bound to wait. It is like Christmas out here when the lights are going. R13 stated, Mornings are bad. Facility has not been responding real well. Nothing has really changed. R1 stated, facility staff[sic] their hands are tied. Management are the ones who call the shots. Facility Assessment: The Facility Assessment (FA) reviewed 10/29/2024, identifies the facility is licensed for 60 beds with an average census of 48. The FA identified 80% of residents are totally dependent on staff for mobility needs and receive skilled nursing level care such as range of motion exercises, transfers, ambulation, dressing, feeding, including bed mobility assistance. The staffing plan includes direct care staff ratios of: -Day Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse -Evening Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse -Night shift: 3 nursing assistants with one RN or LPN Charge nurse. No other information was provided. 49034

Based on observation and interview and policy review, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in 3 of 5 medication carts affecting 3 of 4 units of the facility. Findings include: During observation on 2/03/25 at 7:36 p.m., an unattended and unlocked medication cart was observed outside in the hallway of the unit named, Eagle Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. At 7:40 p.m., registered nurse (RN)-E returned to medication cart. RN-E indicated they left the medication cart unlocked and unattended. RN-E stated a resident was hollering and they went to help them. RN-E stated it unattended medication carts should always be locked so residents couldn't get into it. During a continual observation on 2/05/25 at 11:08 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Bluejay Lane. The cart was placed between the doors of resident rooms. During observation, numerous residents and family members walked past the unattended and unlocked medication cart. At 11:39 a.m., licensed practical nurse (LPN)-B verified the medication cart was unlocked and unattended. LPN-B locked the medication cart. LPN-B state medication carts should be locked at all times when not in use, so resident's do not get in there and overdose and staff don't steal medications. 44656 During observation on 2/5/25 at 9:35 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Cardinal Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. During interview with registered nurse (RN)-C on 2/5/25 at 9:37 a.m., RN-C stated, it is unlocked because I forgot to lock it when I walked away. [It is] important to be locked and we have important medications that are deadly in there and we don't want anyone to get into there and take whatever they want. During an interview on 2/05/25 at 12:30 p.m., director of nursing (DON) stated all unattended medications carts should be kept locked at all times, to prevent people from getting into them that shouldn't as it could have ill effects. A facility policy titled Storage and Expiration Dating of Medications and Biologicals, revision date 8/1/24, section 5.3 indicates Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet while facing a window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE] identified R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. In addition, R1 had diagnoses of spinal stenosis (narrowed space around the spinal cord causing irritation and compression of the spinal cord), heart failure, and arthritis. During observation on 2/4/25 at 8:08 a.m., R1 was sitting on the toilet naked. R1 was left alone by nursing assistant (NA)-C while NA-C left room to obtain supplies. The bathroom had a shower curtain as a separator between the bathroom and resident's bedroom which was left opened. The window of bedroom faced facility courtyard, and the window blinds were not closed for privacy. R1 faced the courtyard and shrugged, reaching for a small towel to cover her breasts. Trained medication aide (TMA)-A walked into room and saw R1 on the toilet, walked to the window, and closed the blinds to the courtyard. I closed the curtains[blinds] because [R1] was being exposed. I would be super embarrassed. TMA-A stated, I could tell [R1] was uncomfortable. During interview with NA-C on 2/4/25 at 8:13 a.m., NA-C stated she had worked for an agency and that I left the window shade open. I left to get wipes. Yes, I left her on the toilet naked. Also, the window blinds were open enough for anyone outside the window to see inside the room. During interview with R1 on 2/4/25 at 8:20 a.m., R1 stated, there was a curtain. I usually ask to have the blinds closed. It is not a pleasant thing being left alone on the toilet naked and feeling exposed here. R1 stated NA-C was new and was not prepared to assist with bathing. R1 stated, I have given up a lot of my dignity while being here. It does bother me when I am left exposed but don't say anything because it doesn't change. During interview with DON on 2/4/25 at 12:41 p.m., DON stated, That is unacceptable. We want [R1] to be comfortable. I would offer a drape or something to cover her body before leaving the room. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated, I would not leave anyone naked on the toilet and leave the room. I would cover them and shut the blinds for privacy and dignity. I would be very upset if someone did that to me. R18 R18's quarterly (MDS) dated [DATE], identified R18 had moderate cognitive impairment, was dependent on staff for toileting and lower body dressing and had an indwelling catheter (tube to drain urine from the bladder into a collection bag). During observation and interview on 2/3/25 at 6:03 p.m., R26 was in wheelchair while nursing assistant (NA)-A transported him to his room. NA-A wheeled R26 down the hall past another resident and staff member into R26's room. A large urine drainage bag was visible from under R26's wheelchair and was uncovered. NA-A stated he had been assigned to assist R26 from facility's dining room to his bedroom. NA-A stated the drainage bag should be covered and was unable to locate a privacy cover in the residents' room. NA-A stated importance of covering the bag was privacy. During interview with director of nursing (DON) on 2/4/25 at 12:47 p.m., DON stated urine drainage bags, should always be covered. We have dignity covers and pillowcases to cover up the urine drainage bags. Undated facility policy titled Quality of Life-Dignity stated, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. And Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R44) reviewed for unnecessary medication use. Findings include: R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment but demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care). Further, the MDS identified R44 had depression, anxiety disorder, but consumed only anti-depressant medication (i.e., high-risk medication) during the review period. On 2/5/25 at 8:54 a.m., R44 was observed seated in a standard wheelchair in the television room by the central nursing station. R44 appeared calm and responded aloud, Good, when asked about her day so far. R44 was unsure how long she had lived at the care center and responded again aloud, Pretty good. R44 had no obvious physical symptoms of anxiety at this time (i.e., crying, worried expression). R44's Ridgeview Home Health Hospice Orders For Facility, dated 1/13/25, identified R44's name and listed an admitting diagnosis of senile degeneration of the brain. R44 was listed as being admitted to hospice the same day (1/13/25), and included a section labeled, Above orders per hospice, with two orders written below this. These included an order for morphine as needed and, 2 [circled] Ativan [an anti-anxiety medication . every 4 hours as needed for anxiety. Update hospice if ineffective. However, the completed order lacked any identified stop date for the medication. R44's Medication Administration Record (MAR), dated 1/2025 and 2/2025, respectively, were reviewed and identified the transcribed order for the PRN Ativan (ordered 1/13/25). R44 was recorded as receiving the medication two (2) times with doses recorded on 1/13/25 at 3:24 p.m., and the other on 1/17/25 at 12:03 p.m. For both administrations, the results were recorded as effective. R44's corresponding progress note, dated 1/13/25 at 3:24 p.m., identified the medication was provided and listed rationale, Crying and very agitated. The note lacked what, if any, non-pharmacological interventions had been attempted prior to the medication being give. R44's other corresponding progress note, dated 1/17/25 at 12:03 p.m., identified the medication was provided and listed no rationale or record information on why the medication was provided; nor any information on what, if any, non-pharmacological interventions were attempted prior. R44's care plan, dated 1/31/25, identified R44 consumed anti-anxiety medication and wrote out, NURSING: The resident uses anti-anxiety medications (lorazepam [Ativan] PRN per hospice order) r/t [related to] Anxiety. The care plan directed to administer the medication as ordered, monitor for effectiveness or side effects, and monitor and record occurrence for target behaviors and document per protocol. On 2/5/25 at 8:59 a.m., registered nurse (RN)-F was interviewed and reviewed R44's medical record. RN-F explained R44 had most cares completed by the nursing assistant (NA) staff and needed help with most activities of daily living (ADLs). RN-F verified R44 was on hospice care and explained R44 used to cry a lot and, as a result, they had recently increased her anti-depressant medication and she seems to be better. RN-F denied ever seeing physical or verbal behaviors from R44 and reiterated she just used to have just like sad statements. RN-F verified R44 had an active order for PRN Ativan and expressed many people on hospice have the same order. RN-F stated the ordered PRN Ativan typically had a date listed when it drops off [stop date] and then it should be renewed by the provider. However, RN-F verified R44's current order for PRN Ativan lacked a stop date and remained active. RN-F reviewed R44's signed hospice order (dated 1/13/25) and verified they had co-signed it but did not request a stop date adding, I should have probably checked for an end-date. RN-F reviewed R44's medical record and verified it lacked evidence of a stop-date being identified, nor evidence the provider had reviewed it since the medication had been ordered on 1/13/25 (over 14 days prior). When interviewed on 2/5/25 at 10:01 a.m., the consulting pharmacist (CP) verified they had reviewed R44's medical record and it had lacked a stop-date until that day when they obtained a six month extension of the medication. CP stated they were working with hospice providers to ensure stop-dates get listed and verified the medication needed a 14-day re-evaluation without a stop-date established. CP stated the order for the PRN Ativan happened between their reviews of R44's medications so they were not aware of it. On 2/5/25 at 10:55 a.m., registered nurse manager (RN)-B was interviewed. RN-B stated the hospice agency should be ensuring a stop-date is listed, however, there had been some examples where it didn't happen and then they (hospice) wanted the care center's provider to write out a stop date which RN-B stated their provider doesn't like that. RN-B verified the PRN Ativan should have had a two week stop date or been re-evaluated. RN-B stated it was important to ensure this happened as we don't want a gap in their medications and patient could suffer if the re-evaluation wasn't completed timely. A facility' policy on PRN psychotropic medication use was not provided.

Based on observation, interview, and document review, the facility failed to comprehensively assess for entrapment risk and attempt alternatives before installation of grab bars for 1 of 3 residents (R15) reviewed who were observed to have grab bars affixed to their beds. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R15 had moderately impaired cognition and required substantial assistance with transferring out of bed. The MDS indicated in section, P0100. Physical Restraints, that R15 had bed rails that were used as restraints daily. R15's Grab Bar assessment dated [DATE], indicated the assessment was done on the resident's admission to the facility, and bilateral grab bars were used to assist the resident with moving side to side. The assessment included a section Identify alternative methods/products attempted prior to the use of grab bars which was left blank. The assessment indicated the risks and benefits of grab bar use had been explained to R15/her representative and consent was received. R15's order summary dated 8/5/24, included an order for bilateral mobility bars on the bed for turning, repositioning, and bed mobility. The medical record was reviewed and did not indicate appropriate alternatives to grab bars had been attempted before installation and how these alternatives failed to meet the R15's needs. The medical record also did not indicate R15 had been reviewed for risk factors for possible entrapment such as medical diagnosis, medications, cognition, or fall risk when considering grab bar use. During an interview and observation on 2/4/25 at 9:59 a.m., R15 stated she used the grab bars to pull herself out of bed and confirmed she didn't feel they were restrictive or stopped her from moving in any way. Bilateral grab bars were observed affixed to R15's bed. During an interview on 2/4/25 at 1:55 p.m., registered nurse (RN)-B, the unit manager, stated grab bars had been applied to R15's bed on admission and they had not attempted alternatives due to the resident's weight and R15 requiring two staff members to turn in bed. At 2:54 p.m., RN-B stated she had reviewed R15's medical record and found that the risk for entrapment associated with grab bar use had been reviewed with R15 when consent was received but she did not find that individualized entrapment risk factors had been reviewed for R15's grab bar use. RN-B stated that R15's history of right-sided weakness and being at risk for falls could make her a greater risk for entrapment but did not see that these had been assessed as entrapment risks. During an interview on 2/05/25 at 12:28 p.m., director of nursing (DON) stated a nursing assessment was completed to determine if a bedrail was appropriate for a resident prior to be applied along with a reviewing a pamphlet that reviews risks involved with the resident and/or family. DON stated the resident was assessed annually and if there was a significant change with the resident. The Bed Rail Use policy dated 4/24, indicated upon admission, readmission, or change of condition, residents will be screened to determine the need for special equipment or accessories (side rails, for example.) Staff will assess the resident to identify appropriate alternatives and assess for risk of entrapment, review the risks and benefits with the resident and representative, obtain informed consent, and obtain a physician order, before installing bed rails. 49339

Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed, develop proactive interventions to reduce the risk of further falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center. Findings include: R44 R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). Further, the MDS outlined R44 had sustained a fall within the month prior to admission, however, sustained no falls since she admitted to the care center. R44's care plan, revised 12/20/24, identified R44 was at risk for falls with dictation, NURSING: The resident is at risk for falls [related to] weakness, impaired mobility . [as evidenced by] H/O [history of] fall prior to admission. The plan listed a goal which read, The resident will be free of falls through the review date, along with several interventions including anticipating/meeting R44's needs, ensure the call light is within reach, encouraging participation is activities which promote exercise, and ambulating R44 twice daily. The care plan interventions each listed a date implemented and, if applicable, revision. This identified only one revision to a single intervention on 12/20/24, the remainder of interventions being listed as having the same start-date as the problem statement. On 2/3/25 at 3:53 p.m., R44's family member (FM)-A was interviewed. FM-A stated R44 had sustained a few falls since she admitted to the care center from her prior assisted-living setting. FM-A stated they were not sure exactly what, if any, new interventions were being done between the falls. Later, on 2/5/25 at 8:54 a.m., R44 was observed seated in a standard wheelchair which had metallic anti-roll brakes installed. R44 was in the television room by the central nursing station and she appeared calm and responded aloud, Good, when asked about her day so far. R44 was unsure how long she had lived at the care center and responded again aloud, Pretty good. R44's medical record was reviewed which identified R44 had sustained multiple falls since the care plan had last been revised (12/20/24), and these included: R44's progress note, dated 12/23/24 at 11:44 p.m., identified R44 had been found on the floor at 11:20 p.m. when R44 turned on their call light to alert staff. The note outlined, Resident found on floor sitting on buttocks next to her bed. Gripper sock on right foot, left foot bare. R44 denied pain and had confusion per baseline. The note continued, First[,] resident stated she was getting up to use the toilet, then stated she was getting up to get a drink of water. The note identified R44 was assisted to the restroom and provided water, along with a voicemail left for R44's family member and the provider adding, Will continue to monitor. The note lacked any further information on what, if any, future interventions would be done to reduce R44's risk of falls. R44's corresponding incident report titled, #20 Unwitnessed Fall, dated 12/23/24, identified text from the completed progress note and outlined R44 was oriented to person only. The report listed multiple sections to record various data points including pre-disposing factors, environmental factors, and statements from staff about the event. The report included spacing to record what, if any, actions (i.e., interventions) were assessed or implemented after the event; however, this was left blank with no new interventions being listed or rationale for the lack thereof. A subsequent Fall Risk Evaluation, dated 12/26/24, identified R44 scored 19.0 which was labeled, At Risk. The evaluation identified a total of nine (9) questions to be answered by the evaluator including level of consciousness, history of falls, vision status, and medication (changes). However, the completed evaluation lacked information on what, if any, proactive interventions had been assessed or implemented to reduce R44's risk of continued falls. R44's progress note, dated 1/2/25 at 10:30 p.m., identified R44 was again found sitting on the floor. The note outlined, Noted to be sitting on floor next to wheel chair near locked exit door in hallway. No injury noted. Later stated that she wanted to go outside. The note identified R44's family member and provider were contacted. However, again, the note lacked information to identify what, if any, additional interventions were determined or assessed to reduce R44's risk of continued falls and injury. R44's corresponding incident report titled, #23 Unwitnessed Fall, dated 1/2/24, identified text from the completed progress note and the space to record R44's mental status was left blank and not completed. The report placed a checkmark next to a pre-disposing environmental factor of, Other (Describe). However, the report lacked further information on what this factor had been or was. The report, again, listed multiple sections to record various data points but, again, lacked information on what, if any, actions (i.e., interventions) were assessed or implemented after the event. A subsequent Fall Risk Evaluation, dated 1/8/24, identified R44 scored 18.0 which was labeled, At Risk. The evaluation, again, identified nine (9) questions to be answered by the evaluator including level of consciousness, history of falls, vision status, and medication (changes). However, the completed evaluation lacked information on what, if any, proactive interventions had been assessed or implemented to reduce R44's risk of continued falls. On 2/5/25 at 10:31 a.m., registered nurse manager (RN)-B was interviewed, and they explained when a fall happens, the floor staff respond and assess them for pain or injury then help them back to a surface. The staff ask the resident several questions, such as what happened, and then document them on the incident reports located in the system's risk management section. The report then is uploaded to the system for others, including management and leadership, to see and update. RN-B stated a Fall Risk Evaluation is also triggered and completed by the floor staff in the record. RN-B stated the report should then be reviewed by the interdisciplinary team (IDT) as soon as possible to help determine what, if any, new ideas or interventions are needed. RN-B then reviewed R44's reports in the system (dated 12/23/24, and 1/2/25), and verified the section labeled, Action, would be where new interventions or rationale would be recorded. RN-B then expressed aloud, I am just going to be honest with you, and stated they were not sure if all R44's fall reports had been brought to IDT for review. RN-B reviewed R44's fall on 12/23/24, and verified it lacked any new interventions being recorded or outlined. RN-B stated the lack of completion with the report could possibly be related to being pulled to the floor so much due to staff call-ins, adding aloud, Often, I don't [get them done]. RN-B stated it was a chore and a struggle to get all assigned things, such as fall reports and admissions, done timely, adding they felt at times new interventions had been done but just not been documented. RN-B verified both of R44's reviewed falls, dated 12/23/24, and 1/2/25, did not have the report completed and lacked documentation to support what, if any, new interventions had been assessed or implemented but reiterated they felt things were discussed but not formally in IDT. RN-B verified they didn't recall reviewing R44's falls with IDT but expressed they recalled adding the wheelchair brakes at some point. RN-B reviewed R44's fall care plan and verified it had not been revised since 12/20/24, despite R44 having two falls since then. RN-B again attributed the lack of updated care plan to being pulled repeatedly to the floor but verified it should be updated with any new interventions adding, We're supposed to review that on a regular basis and update it. RN-B stated it was important to ensure falls were assessed and new interventions developed and recorded as, We want to keep our residents safe. 44656 49034 R26 R26's quarterly MDS dated [DATE], indicated R26 had severely impaired cognition and required assistance for nearly all ADLs. The MDS indicated R26 had no falls since the prior MDS assessment. R26's progress note dated 8/11/24 at 1:00 p.m., indicated R26 was found lying on the floor next to his bed and could not communicate to staff what had happened. R26's quarterly fall risk assessment dated [DATE], indicated R26 was at a high risk for falls based on an assessment of factors such as mental state, history of past falls, ambulation status, medications, and predisposing diseases. R26's care plan dated 12/12/24, indicated R26 was at risk for falls related to dementia, heart failure, and a previous stroke. The care plan included multiple fall interventions such as Anti-rollback breaks and a dropped wheelchair seat, encouraging proper footwear, keeping the wheelchair by the bed/recliner when R26 was not using it, encouraging R26 to use a call light to call for assistance, etc. The care plan did not indicate any fall interventions had been added or revised since 9/11/24. R26's Fall Scene Investigation Form dated 1/16/25 at 11:50 p.m., indicated R26 had an unwitnessed fall from his bed. The form included possible environmental factors or causes that staff had assessed such as R26's call light was in reach, bed wheels were locked, glasses were off, and R26 was wearing gripper socks. The form indicated that R26 was unable to account for his fall. The form indicated R26's new/immediate fall interventions that were implemented were a wheelchair placed close to the bed, doing safety checks, and reminding R26 to call for help. The form included a section for IDT Team Review Notes which was left blank. R26's progress note dated 1/17/25 at 12:23 a.m., indicated R26 was found lying on the floor of his room with his bedding partially on the floor. The note indicated that R26 was unable to account for his fall. During an interview on 2/4/25 at 1:12 p.m., RN-F stated she was R26's and R44's nurse today. RN-F stated she was unsure if either resident had fallen recently but if they had she would expect these new fall interventions to be put on their care plan as that is how they communicate changes from shift to shift. During an interview on 2/5/25 at 12:33 p.m., RN-B stated she thought a fall investigation form had been filled out for R26's fall on 8/11/24, and given to the director of nursing (DON) but was unsure if the fall had been reviewed by IDT. The 8/11/24, fall scene investigation form was requested and not received. RN-B stated after reviewing the 1/17/25, Fall Scene Investigation Form, she did not think IDT had reviewed the fall as that part of the form was left blank. RN-B stated the expectation was that R26's care plan and nursing assistant care sheet be updated to reflect each fall and new interventions and that was not completed for R26. A facility' provided Accident: Managing Resident Falls policy, reviewed 4/2024, identified the center would evaluate and analyze hazards and/or risks for potential resident' falls on admission, quarterly and as needed. The policy outlined, The IDT will monitor for accidents and recommend modifications to improve accident interventions. A section labeled, Resident Fall Guideline, listed a procedure for a fall including providing first aid (if needed) and documenting it within the medical record. The policy directed, IDT will review all falls including the fall scene investigation form and immediate interventions implemented. Interventions may be changed or added to further reduce the risk of additional falls.

Based on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries. Findings include: R5 R5's annual Minimum Data Set (MDS) dated [DATE] identified R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, R5 was identified as at risk of developing a pressure ulcer/pressure injury. R5's electronic medical record (EMR) nursing assistant task form titled TRANSFER: SELF PERFORMANCE-How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and documented from 1/22/25, to 2/4/25, identified R5 as requiring, TOTAL DEPENDENCE-Full staff performance. R5's EMR nursing assistant task for titled, BED MOBILITY: SUPPORT PROVIDED-How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and documented from 1/22/25, to 2/4/25, identified R5 as requiring One person physical assist. R5's nursing assistant care sheet identified R5 as requiring Repo[repositioning]: Q 2 hours and PRN-AVOID lying on RT side. During observation on 2/3/25 at 2:47 p.m., R5 lying in bed on her back watching television. During observation and interview with R5 on 2/3/25 at 5:44 p.m., R5 laying in bed on her back watching television. R5 stated, I don't recall when they asked me to turn or get off my back. It hasn't been since lunch time today. I am pretty stiff. During observation and interview with R5 on 2/3/25 at 7:20 p.m., R5 lying on bed on her back. They don't move or turn me. Haven't done it all day. They don't even ask me. During interview with nursing assistant (NA)-A on 2/3/25 at 7:26 p.m., NA-A stated he was R5's nursing assistant for the evening shift from 2:30 p.m. to 11:00 p.m., I don't know when [R5] was last turned. NA-A stated [R5] can get pressure sores so she needs to turn. NA-A stated expectation of nursing assistants to follow the nursing assistant care sheet to inform them of what the residents require with cares including turning and repositioning. NA-A stated expectation of nursing assistants to document cares and refusals in the EMR under Tasks. During interview with licensed practical nurse (LPN)-A on 2/4/25 at 8:27 a.m., LPN-A stated she was familiar with R5. LPN-A stated, [R5] moves a little in the bed but not completely. LPN-A stated expectation of nursing assistants to follow the nursing assistant care sheet to inform them of what the residents requires with cares including turning and repositioning. LPN-A stated R5 required assistance to turn and reposition at least every 2-3 hours. LPN-A stated she was not aware of when R5 was turned or repositioned last. R37 R37's quarterly MDS dated [DATE] identified R37 with significant impairment to cognition, impairment to lower extremities, was dependent on staff for all efforts of self-care, had diagnoses of Alzheimer's, dementia, depression, and bipolar and did not reject care. In addition, R37 identified as a risk of developing a pressure ulcer/pressure injury. R5's nursing assistant care sheet identified R37 as requiring Repo: Q 2 hours and PRN. Offer/enc to lay down in bed for at least short period of time after breakfast & lunch bathroom. During observation on 2/3/25 at 1:38 p.m., 2:13 p.m., 2:20 p.m., R37 sleeping on recliner lying on her back. At 5:42 p.m., R37 still sitting in recliner sleeping lying on her back but the lights to the room were turned off. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated expectation of nursing assistants to use the nursing assistant care sheet to inform them of what the residents requires with cares including turning and repositioning. NA-E stated R37 is not on turning repositioning program. Usually, we wait about 2 hours to try to get them [residents] to shift weight because if they are in the same spot too long the skin can break down. Also, we [aides] don't document it anywhere. During interview with registered nurse (RN)-B on 2/5/25 at 12:36 p.m., RN-B stated expectation of staff to reposition residents per care sheet. RN-B stated progress note from nurses should reflect refusals. RN-B verified EMR lacked documentation for both R5 and R37 were turned, repositioned, or provided range of motion exercises. If it is not documented then we cannot be sure that the ROM or turning or repositioning was done. In addition, RN-B stated both R5 and R37 were high risk for skin breakdown if not turned or repositioned regularly. During interview with director of nursing (DON) on 2/4/25 at 10:03 a.m., DON stated expectation of nursing assistants to document in the Task section of EMR on what they do for the resident like turning, toileting, etcetera. During interview with DON on 2/5/25 at 1:57 p.m., DON stated, expectation is we should still be offering to offload[sic] should be documented in progress note for refusals. DON stated, [residents] are dependent on staff for turning and repositioning and transfers. We do not have a system in place to actually see if [residents] are being turned and repositioned every 2-3 hours. DON stated R5 and R37 were considered high risk for pressure ulcers and their EMRs lacked documentation of refusals. Facility policy requested for pressure ulcer prevention and not received.

Based on interview and document review, the facility failed to assess potential signs of constipation to determine what, if any, proactive interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R41) who reported being constipated. Findings include: R41's admission Minimum Data Set (MDS), dated [DATE], identified R41 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS identified R41 did not have constipation. On 2/3/25 at 1:51 p.m., R41 was interviewed and stated she had recently moved into the care center from the hospital. R41 stated her bowels were not too good and complained of feeling constipated adding, I get stuffed up a lot. R41 stated staff were aware of this and, when she'd ask, they would give her medication to have a bowel movement. R41 stated she didn't recall anyone ever talking with her about what proactive interventions could be done such as prune juice or fiber supplements. R41 stated she'd be willing to hear what options she had as her usual pattern for a movement was every-other-day. R41's most recent Continence Evaluation, dated 1/9/25, identified a section labeled, Bowel Continence Evaluation, which outlined R41 had no history of bowel incontinence or fecal impaction, and she was able to sense the urge to defecate. The evaluation a subsection labeled, Elimination Assist, had spaces to mark what, if any, assist item (i.e., laxatives, prune juice/fiber) was used. These were all left unchecked and only a single check was placed next to the option, f. None. The evaluation continued and identified R41 remained on antibiotics and had evidence of diverticulitis (inflammation of small pouches [diverticula] that form in the wall of the large intestine). The evaluation concluded with a section labeled, Plan, which placed a checkmark next to the option, h. Other, and outlined R41 was able to participate in a bowel and bladder program with dictation, Usually continent, toilet per her request and PRN [as needed]. R41's elimination care plan, dated 1/15/25, identified R41 had urge incontinence of bladder. The care plan listed multiple interventions including barrier cream as ordered, encourage fluids during the day, laxatives as ordered, and monitor bowel pattern/consistency. The listed interventions were all last implemented or revised on 1/15/25. When interviewed on 2/4/25 at 9:41 a.m., nursing assistant (NA)-D stated they had worked with R41 only a few times but recalled the overnight nurse reporting R41 had been asking for a suppository. NA-D stated they last heard this about a week and a half ago adding they had last helped R41 to the toilet with a bowel movement the same morning the suppository was given. NA-D stated R41's stool then was putty consistency. NA-D stated R41 would, at times, still toilet herself so staff always asked her if she had a bowel movement, too. Further, NA-D stated all bowel movements were charted in the electronic system (i.e., Point Of Care). R41's POC (Point Of Care) Response History, dated 2/4/25, identified a 20-day look back period and listed the consistency staff had recorded for each bowel movement R41 had on their respective shift including: On 1/20/25, R41 had a recorded formed bowel movement. On 1/24/25 (four days later), R41 had two recorded bowel movements with one being labeled, Loose/Diarrhea. On 1/26/25, R41 had two recorded formed bowel movements. On 1/29/25 (three days later), R41 had a formed bowel movement. R41's Medication Administration Record (MAR), dated 1/2025, identified R41's provided and recorded medications for the period. This identified R41 received the following: On 1/23/25, R41 received Biscolax suppository (used for constipation) at 6:08 a.m. and the results were recorded, I [ineffective]. Later, on 1/23/25, R41 was given a dose of Sorbitol (can be used as a laxative) which was recorded, E [effective]. On 1/30/25, R41 received another Biscolax suppository with results listed, E. The MAR lacked any ongoing medications to promote regualar bowel movements (i.e., Senna). Further, R41's medical record was reviewed and lacked evidence R41 had been reassessed to determine what, if any, proactive interventions were needed (i.e., medication, prune juice, fiber) to promote more regular bowel movements and reduce the need for ongoing PRN use despite multiple as-needed laxatives being given over the past few weeks. On 2/4/25 at 2:37 p.m., registered nurse manager (RN)-A was interviewed and verified they had reviewed R41's medical record. RN-A explained R41 was mostly independent within her room and could, if she wanted, take herself to the bathroom. RN-A acknowledged R41's charted bowel movements (via POC) had some periods with multiple days between and R41 had been given as-needed laxatives. RN-A stated a comprehensive assessment of R41's bowel patterns and needs would be done initially [by] the floor nurse. RN-A stated they had just spoke with the nurse prior who was going to be looking into that [R41's bowels]. RN-A stated any re-assessment would be in the progress notes or on a subsequently completed Continence Evaluation, however, expressed the new charting system was more limited on spacing to record items such as interventions or dictation. RN-A stated nobody had reported any concerns to them about R41's bowels or potential constipation and expressed it was important to ensure it was evaluated as constipation could cause a lot of health issues. A facility' provided Protocol For Bowel Management, undated, listed a purpose to ensure each resident had a bowel movement at least every 72 hours (three days). A procedure was listed which outlined how as-needed medications would be provided and listed, Should the same resident require nursing intervention for bowel evacuation 3 or more times in one month, the nurse will inform the resident's primary physician. However, the policy lacked direction on how a comprehensive bowel management program would be assessed or documented.

Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had severe cognitive impairment but demonstrated no delusional or rejection of care behaviors. Further, the MDS identified R7 was dependent on staff for personal hygiene care. On 2/3/25 at 5:31 p.m., R7 was asked about her baths at the care center. R7 stated aloud, I'm missing those, while making a back and forth motion using her hands. R7 struggled with word-finding but reiterated, when pointedly asked, she was not getting her baths every week adding aloud, Yea [affirm]. R7's care plan, dated 9/16/24, identified R7 had a self-care deficit and needed assistance with ADLs due to weakness and other past medical history or conditions. The plan listed a goal which read, Will be clean and neatly dressed with assistance, along with multiple interventions including, Bathing: Assist X1. The care plan lacked information on how often bathing was scheduled or preferred. On 2/4/25 at 9:41 a.m., nursing assistant (NA)-D was interviewed. NA-D explained they had worked with R7 prior, including for bathing, and stated the staff followed a shower list which was on their internal computer system. NA-D stated R7 was scheduled for a twice-a-week shower and preferred only female caregivers with it. NA-D verified R7 was supposed to be getting a twice weekly shower and stated she (R7) had been scheduled with that for many months now. NA-D stated they always strived to get R7's shower done but added doing so could be more challenging in the Summer months with staffing. NA-D stated all showers or baths would be charted in the medical record and the nurse's do a corresponding skin check but only one of the two days. NA-D stated the care center had recently adjusted to only five NA working on the morning shift and, as a result, there were times when they'd be on the unit by myself and residents would then get only quick bed baths and no showers. NA-D stated if baths or showers weren't completed, they could try to re-schedule them but with the workload, it would be tough adding aloud, We don't have time to do an additional shower. NA-D stated they felt R7 was consistently getting her second evening-shift shower but then expressed aloud, I don't always know if they do it. R7's POC (Point of Care) Response History, dated 2/4/25, identified a 14-day look-back period. The data provided space to record what level of bathing assistance R7 needed (i.e., independent, supervision, dependent) along with a date and time for each episode. The data had two recorded data points, on 1/22/25 and 1/29/25, however, both of these were recorded as, Not applicable. R7's progress notes, dated 1/1/25 to 2/3/25, identified the following note(s) recorded under a label, Nurse's Note. On 1/13/25, R7 was recorded as having received a shower and skin check. R7 was recorded as having 1+ edema to her foot. On 1/20/25, R7 was recorded as having received a shower and skin check. On 1/27/25, R7 was recorded as not having a shower. The note had dictation which read, Shower not completed today. The note lacked any rationale or reason why the shower was not done. The completed progress note(s) and medical record both lacked any further evidence R7 was receiving a twice weekly shower and/or bath as was scheduled per the direct care staff. On 2/4/25 at 2:32 p.m., registered nurse manager (RN)-A was interviewed. RN-A reviewed R7's medical record and verified R7 was scheduled to receive a twice weekly shower. RN-A stated they were unsure why the nurse' charted the shower was not completed on 1/27/25, and verified the NA should be charting all completed showers or baths in the record (i.e., POC). RN-A acknowledged the lack of charting or documentation to show the second shower was being completed and expressed staff typically didn't chart a second skin check note when multiple baths are scheduled. RN-A stated staff had not consistently reported issues with getting showers or baths completed but expressed some days were very challenged with workload and call-ins. RN-A stated they were not personally checking or auditing charting to ensure it was completed but expressed showers and baths should be done and recorded as the lack of them can cause all kinds of skin problems. A provided Standard ADL Protocol, undated, identified a procedure for each respective discipline to complete ADLs. This included for the NA, Offer weekly bath or shower per individual preferences, [NA] to be present during tub bath or shower. The policy lacked information on how completed baths or showers would be recorded or tracked.

Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs. Findings include: R42's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had intact cognition. R42 required moderate staff assistance with personal hygiene and oral hygiene, maximum assistance from staff for upper body dressing, and was dependent on staff for bed mobility, sit to lying, lying to sitting on side of bed, footwear, lower body dressing and toileting. MDS indicated no behaviors present or rejection of care exhibited. R42's pertinent diagnoses included: displaced intertrochanteric fracture of right femur (a broken hip bone that has shifted or separated), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the heart), Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance and coordination) and weakness. Section M Skin Conditions indicated R42 was at risk for developing pressure ulcers and had one or more unstaged pressure ulcer at Stage 1 or higher. Furthermore, M0300 Current Number of Unhealed Pressure ulcers at Each Stage under section G; Unstageable-Deep tissues: suspected deep tissue injury in evolution, indicated one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission/entry or reentry. R42's care plan, printed 2/3/25, indicated the following: - NURSING: The resident has potential for pressure ulcer development r/t [related to] advanced age, pain, weakness, immobility, use of anticoagulant, Foley catheter. Braden = 15 with the following interventions - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Obtain and monitor lab/diagnostic work as ordered. Report results to MD [medical doctor] and follow up as indicated. - Staff to assist with routine toileting and skincare for incontinence. - Treat pain as per orders prior to treatment/turning etc. to ensure The resident's comfort. - NURSING: The resident has indwelling Foley [urinary] catheter R/T urinary retention. Foley catheter to be removed on 11/22/24 for voiding trial, he F/U [follow up] with Urology on 12/4/24. - CATHETER: Catheter - Change catheter bag, and cath kit (syringe & basin) once weekly, initial and date new supplies Q [every] Friday. - CATHETER: last changed: (SPECIFY Date). Change catheter (FREQ). (SPECIFY Size) (SPECIFY Type) -CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. - Check tubing for kinks [# TIMES] each shift. -NURSING: The resident has an ADL selfcare and mobility deficits r/t R hip FX S/P IM nailing [right hip fracture after surgical repair], weakness, difficulty in walking, pain, Parkinson's disease, orthostatic hypotension, Foley catheter, precaution for WBAT RLE (weight bearing as tolerated right lower extremity). -TOILET USE: The resident requires is dependent on mechanical stand lift Ax2 [assist of 2] to transfer on/off toilet and dependent on staff to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. He has Foley Catheter, that will be removed on 11/22/24 for voiding trial. He F/U with Urology on 12/4/24. -TRANSFER: The resident requires Mechanical Lift Ax2 with 3rd staff on standby assistance for transfers. R42's care plan lacked identification of history of pressure injury, resident specific interventions for prevention of pressure ulcers, removal of catheter and possible fluctuating ability to transfer. R42's care sheet, printed 2/5/25, identified the following: -Repo[reposition]: Q 2 hours from side to side-encourage [R42] to stay off back, has open area to coccyx -Toilet: Toilet upon waking, after meals, before bed and NOC [night] as tolerated. Wheelchair to Bathroom assist of 2 with walker to toilet -Transfer Method: Assist of 1 with [NAME] for all transfers. R42's care sheet lacked need for air mattress, cushion in wheelchair or other interventions to prevent reoccurrence of deep tissue injury or pressure ulcer. Furthermore, lacked evidence that R42's deep tissue injury/pressure ulcer had healed on coccyx. On 2/03/25 at 2:11 p.m., R42 was observed seated in his wheelchair with a cushion on the chair. R42 stated he had a sore on his bottom, and was unsure when it started but knew he had it at the hospital. R42 indicated the staff were doing wound care on it. R42 stated he was unsure of if it was getting better or worse as he was unable to see it. R42's Order Recap Report, printed 2/4/25, indicated the following order: -1. Cleanse with NS (nasal saline), pat dry 2. Apply skin prep to surrounding tissue and allow to dry. 3. Cover with a foam dressing 4. Change 3x week and PRN (as needed), D/C (discontinue) when healed as needed for DTI [deep tissue injury] sacrum and in the morning every Mon, Wed, Fri with a start stated of 12/16/24 with and end date of 1/14/25. R42's February's Medication Administration and Treatment Record (MAR/TAR), printed 2/5/25, indicated the following: -Complete weekly skin check and bath (according to shower schedule) every day shift every Friday with a progress note with findings R42's January 2025 MAR/TAR, printed 2/5/25, indicated the following: -Complete weekly skin check and bath (according to shower schedule) every day shift every Friday with a progress note with findings -On 1/3/25, 1/17/25, 1/31/25 indicated it was completed by a check mark. -On 1/10/25, the box was left blank -On 1//24/25, the box was marked with a 9 which indicates other/see progress notes R42's January MAR/TAR lacked evidence of wound care order for listed above which was started on 12/16/14, and discontinued on 1/14/25. R42's progress notes, dated 12/16/24 to 2/5/25, revealed the following: -1/31/25 at 11:04 a.m.: skin check completed with no new skin issues. -1/29/25 at 1:03 p.m.: uses the urinal and tolerates well -1/25/25 at 11:05 p.m.: continent of bowel and bladder -1/24/25 at 1:48 p.m.: shower was not done today. -1/23/25 at 9:11 a.m., [R42] scored 22 on Braden, which is not at risk for skin impairment. His appetite is improved and he is much stronger moving more and is able to lift himself off the bed and up off the wheelchair. His continence is improved, though he does wear a brief for dribbling or possible accidents. His skin is intact, incision to rt [right] upper chest healed and steri strips are peeling off. His RT hip incision is healed and no redness noted. His bottom is pink and he still is having barrier cream applied. -1/20/25 at 1:12 p.m.: is voiding well following removal of Foley catheter. -1/19/25 at 12:13 p.m.: continent of bowel and bladder -1/17/25 at 12:29 a.m.: : shower not given today .shower to be done tomorrow. -1/9/25 at 11:02 a.m.: Resident has appointment with Urology today regarding his urinary retention and Foley catheter use. Catheter removed at 0940 [9:40 a.m.,] per order. -12/30/24: [R42] scored 15 on Braden he is at risk for skin breakdown related to his inability to independently move in bed or reposition himself without sliding in bed is not able to lift clear of mattress and chair surfaces. Has redness to bottom/coccyx area and redness to groin which is treated with nystatin powder and Barrier cream to bottom. -12/20/24 at 2:25 p.m.: Coccyx/perineal area MASD [moisture associated skin damage], 1 x 0.5 cm slough appearing area to right gluteal cleft. Foam dressing applied and barrier cream applied. -12/16/24 at 8:02 p.m.: He has an open area to sacrum/coccyx are[a] .he is chairfast and non ambulatory at this time and moves feebly on his own, he will root around in the bed to get off his side to his bed and to move around in bed with friction possible, He scored 12 on his Braden which he is high risk for Skin impairment. At this time there are orders for wound care daily and 3 times weekly .Care Plan updated. R42's progress notes lacked ongoing assessment of pressure ulcer and interventions placed to prevent further development of pressure ulcers. R42's Weekly Wound Tool, dated 12/16/24, identified a suspected deep tissue injury (SDTI) located on sacrum with slough tissue present which was described as 100% thin white slough with a serous scan amount of drainage with no odor measuring at 25 millimeter (mm) in length by 8 mm in width with no tunneling or undermining. The peri-wound (tissue surrounding the wound) was described as red but blanching with defined edges with the treatment (listed above) being started. R42's electronic medical record (EMR) lacked any further weekly wound tool assessment completed. On 2/04/25 at 10:17 a.m., licensed practical nurse (LPN)-B stated she was responsible for the wound assessments. LPN-B stated skin checks are to be completed weekly by nurses on the floor and a progress note entered in the EMR. LPN-B stated if a skin issue was identified, they put it on the 24-hour sheet, let her know along with the clinical coordinators for follow up. LPN-B stated she does a Weekly Wound Tool assessment weekly on residents with wounds which is the expectation. LPN-B stated she does not update the care plan as the care coordinators update the care plan. On 2/05/25 at 10:35 a.m., registered nurse (RN)-C stated if a wound was identified during a skin check, the wound nurse, family and provider would be notified. Furthermore, they would initiate interventions needed. RN-C stated floor nurses did not update the care plan. On 2/05/25 at 10:41 a.m., RN-F stated they did not remember doing any wound cares with R42 since he had returned from the hospital and stated they worked with RN-F numerous times. RN-F stated the only wound that they had known of was a healed incision on his hip. RN-F stated, I was not aware of that one, when asked about a wound on his coccyx when returning from the hospital. RN-F indicated R42 did have some moisture related issues in his groin area but not his coccyx of sacrum. R42 was assessed by RN-F at 10:53 a.m., and did not have a pressure sore on his coccyx. On 2/05/25 at 11:01 a.m., nursing assistant (NA)-F stated nursing assistants got their information from the care plan. NA-F stated they pulled up a document on the computer that pulls resident information from the care plan for their care guide/sheet. NA-F reviewed R42's sheet and stated R42 care sheet indicated that R42 did not have a cushion in wheelchair or air mattress. Furthermore, indicated had an open area to coccyx. On 2/04/25 at 9:28 a.m., LPN-A indicated when any skin issue was noted on a skin assessment, the wound nurse was notified after documenting anything found in a progress note. LPN-A stated they (clinical coordinators) updated the care plan. During a follow up interview on 2/05/25 at 9:55 a.m., LPN-B she was able to review R42's EMR and stated R42's care plan had not been updated to reflect identification of DTSI on 12/16/24. LPN-B stated no wound assessments had been completed except for the initial assessment on 12/16/24, and no progress notes indicated the sacrum wound was monitored. LPN-B stated the progress notes lacked documentation of details of skin assessments the MAR indicated were completed. LPN-B stated the clinical care coordinators updated the care plans. On 2/05/25 at 12:20 p.m., director of nursing (DON) stated she would expect care plans to reflect residents' care. DON reviewed R42's care plan and stated R42's care plan lacked specific interventions for pressure ulcer prevention such as turning and repositioning, type of mattress, history of pressure injury, etc. A facility policy titled Person-centered Care Planning, dated 4/2024, indicated person-centered care plan will be sued by al personnel involved in the care of the resident. Furthermore, comprehensive care plans must be reviewed and revised quarterly and as needed by the interdisciplinary team.

During observation and interview, the facility failed to ensure 3 of 3 (R14, R19, R149) resident records that contained private, medical, and personal information were not accessible to unauthorized personnel. Findings include: During observation on 2/3/25 at 7:25 p.m., an unattended laptop identified three residents and their care sheet information. The care sheet information contained their names, diagnoses, assistance needs for dressing and showering, oxygen status, diet, toileting, repositioning, and special instructions such as preferences. Two staff walked past the unattended laptop. During interview with nursing assistant (NA)-B on 2/3/25 at 7:29 a.m., NA-B stated, that should not be open for anyone to see. Privacy is why. During interview with NA-A on 2/3/25 at 7:33 p.m., NA-A stated he was responsible for the unattended laptop. NA-A stated unattended laptop contained visible, patient confidentiality [information] and it should not be left open for everyone to see. During interview with Trained Medication Aide (TMA)-A on 2/4/25 at 7:55 a.m., TMA-A pointed to laptop and stated, It has their [resident] information on the screen and people can walk by and look at the information. We always must close the screen for privacy. During interview with director of nursing (DON) on 2/4/25 at 12:39 p.m., DON stated, that should not occur due to a HIPPA (Health Insurance Portability and Accountability Act) violation. Someone could walk by and see the private information. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated, patient information should not be visible to stop [others] from being nosey. Undated facility policy titled HIPAA Privacy Policies and Procedures state all staff and associates act in an appropriate and compliant manner to protect patient information under the HIPAA privacy regulations.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R30) reviewed whose Medicare Part A coverage ended and they remained in the facility. Findings include: R30's Notice of Medicare Non-Coverage (CMS-10123) dated 10/22/24, indicated R30's last covered day of Medicare A would be 10/22/24, and was signed by family member (FM)-B on 10/17/24. R30's SNF Beneficiary Protection Notification Review form dated 10/22/24, indicated R30 had not been provided a SNFABN as resident won appeal. R30's Notice of Medicare Non-Coverage (CMS-10123) dated 11/7/24, identified R30's last covered day of Medicare A would be 11/7/24, and was signed by family member (FM)-B on 11/4/24. R30's Census record dated 2/1/25, indicated R30's primary payer source switched from Medicare A to private pay on 11/8/24, and they stayed in the facility until current. R30's medical record was reviewed and did not indicate a SNFABN had been given prior to R30's Medicare Part A coverage ending. During an interview on 2/4/25 at 11:38 a.m., licensed social worker (LSW)-A confirmed she had reviewed R30's medical record and found that a SNFABN had not been given to R30 prior to his Medicare Part A coverage ending. LSW-A stated she oversaw giving SNFABNs to residents and thought it had been missed for R30. A policy regarding SNFABNs was not received.

Based on observation, interview, and record review the facility failed to assess interventions to provide safe mechanical lift transfers resulting in fracture of distal radius and failed to follow the revised care plan to prevent impaired healing and further injury for 1 of 4 residents (R1) reviewed for accidents. Findings include: R1's care plan dated 1/26/23 indicated R1 required the assistance of one staff member with transfers, gait belt and railings. Mechanical standing lift with assistance of one staff member as needed (PRN). The care plan did not indicate any interventions for staff to monitor R1's left arm, R1's week side following CVA), with the use of the EZ-stand R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had moderate cognitive impairment. R1's diagnoses included congestive heart failure, cerebral vascular accident (stroke) anxiety, depression, and chronic kidney disease. R1 required one staff member for physical assistance with transfers, and extensive assistance of one for activities of daily living. R1's progress note dated 5/9/23 at 1:11 p.m. indicated R1 and staff reported that R1's left elbow was bumped on the doorframe when R1 was being pushed out of her room by staff to the bathroom on the EZ-stand (mechanical standing lift). R1 complained of significant pain to her left elbow with slight swelling, no bruising or skin tears noted. The area was extremely tender to touch. R1's progress note dated 5/9/23 at 10:22 p.m. indicated R1 reported pain to her left elbow, but stated her elbow was not as painful as her left wrist was with movement.There was bruising to her left wrist, but no excessive swelling. A Minnesota Adult Abuse Report Center report dated 5/10/23 at 2:20 p.m. indicated a nursing assistant (NA) was transferring R1 with an EZ stand machine (standing mechanical lift). R1's left elbow always is positioned further out than the right arm and NA steered the machine into R1's bathroom and inadvertently made contact with the doorway frame. R1's X-ray report dated 5/10/23 indicated R1's left forearm demonstrated a cortical offset at the very distal radius which might represent a fracture. R1's progress note dated 5/10/23 at 1:59 p.m. indicated R1's x-ray results returned with very subtle distal fracture. The Nurse Practitioner (NP) was updated, and ace bandage applied pending further orders. R1's progress note dated 5/10/23 at 3:43 p.m. indicated per physician, R1 was to wear a left wrist splint with a 2-3-inch ACE wrap over it up to mid forearm, keep in place at all times. Non-weight bearing to left arm for 4-6 weeks. PT to evaluate to assess for transfers. R1's progress note dated 5/11/23 at 10:44 a.m. indicated Physical Therapy (PT) evaluation was completed following the injury to the left wrist and orders for non-weight bearing of the left wrist. R1 needed moderate assistance with bed mobility and maximum assistance with pivot transfer from her bed to her wheelchair. PT recommended mobility bars on bed to allow her to assist more with transfers and bed mobility. Resident transfers from wheelchair to toilet with grabbers with minimum assistance of one staff member. Staff to use assistance of two staff for in her room from wheelchair to and from bed or recliner. Ambulation program on hold at this time. R1's care plan dated 5/15/23 indicated R1 required assistance of one staff member with a gait belt and grab bars in the bathroom for toileting. R1's wheelchair was to be at a 90-degree angle (face the wall) and ask R1 to count to 30 when she stands up, so staff can remove pants before pivoting. R1 required the assistance of two staff members when transferring from wheelchair to bed or recliner in her room. R1's nurse aide daily sheet dated 5/17/23 under the column titled Special Instructions R1 was non-weight bearing with her left hand and had changes in transfers. During an interview on 5/17/23 at 9:20 a.m. R1 stated she was being transferred in the lift to the bathroom and her elbow hit the doorway. R1 stated My arm just hung out too far. She stated the staff were still using that lift and her arm hurts as she must hold on to the bars on the lift during the transfer. During an interview on 5/17/23 at 11:42 a.m. NA-C (a student in training), stated she assisted NA-B with transferring R1 earlier in the day from her bed to the bathroom with the EZ-Stand. NA-C could not recall how R1's left arm was placed during the transfers. NA-C stated there was no discussion about R1's arm during the cares. During an interview on 5/17/23 at 11:53 a.m. NA-D stated the staff have been using the EZ-Stand. NA-D stated R1 held onto the grab bars of the EZ-Stand with both hands, but was tolerating well. During an observation on 5/17/23 at 12:02 p.m. R1 put on her call light to use the bathroom. R1 needed to be transferred out of her recliner. NA-B told R1 she was going to get the EZ-Stand. 1. NA-B used the remote to get R1's recliner in the most upright position. 2. NA-B placed the harness around R1's back and secured R1's feet on the platform with the leg straps. 3. R1 had her right arm on the EZ-Stand grab bar. 4. NA-B used the lift and lifted R1 about 2 inches. 5. NA-B noticed R1 was not hanging onto the lift grab bar with her left hand and told R1 to hold on with her left arm. R1 attempted, but winced in pain. 6. The surveyor stopped the transfer. 7. R1 was seated back into the recliner. The social worker (SW)-A witnessed the transfer. During an interview on 5/17/23 at 12:08 p.m. NA-B stated it was o.k. to use the lift with R1 stating Nursing assistants can always go up on transfer at their digression, but never down. She stated using a lift had always been the practice at the facility if the NA's feel it was appropriate and R1 was weak or did not feel well. NA-B stated she was aware R1 was currently an assistance of two members and denied seeing on the care plan that it was o.k. to use an EZ-Stand following R1's fracture her wrist. During an interview on 5/17/23 at 2:30 p.m. Physical Therapist (PT)-A stated she assessed R1 on 5/11/23 and the transfer orders were assistance of two staff members and a gait belt with standing and pivoting. PT-A stated R1 was not to use the EZ-stand because R1 was unable to stand still and would need to use both hands to provide stability during the transfer. Prior to the injury R1 was assist of one staff member and a gait belt with the use of the EZ-stand as needed for extreme weakness. PT-A stated she was not aware staff were not using the least restrictive technique for transfers. If staff were going to use the lift in an emergency then nursing should be notified as to why the resident needed the lift so a re-assessment could be done. PT-A stated the staff were trained and should always use caution with arms, legs, and cords. During an interview on 5/17/23 at 2:47 p.m. registered nurse (RN)-A stated prior to the wrist fracture R1 was assist of 1, but staff could use the EZ-Stand as needed depending on the condition of the resident. As a general rule at the facility, staff can go up on transfers, but now down. RN-A stated if staff change a transfer they must report to nursing. RN-A stated following the wrist fracture R1 was supposed to pivot transfer with two staff. The EZ-Stand was not to be used. RN-A was not aware staff were using the stand. RN-A stated the reason R1's left arm stuck out more during the EZ-stand transfers was because R1 had left sided weakness from her previous stroke. RN-A indicated an assessment had not been completed or care plan interventions to reduce the risk of injury to R1's left arm while using the standing lift. During an interview on 5/17/23 at 3:00 p.m. NA-E stated prior to the fractured wrist she would transfer R1 by herself with a gait belt. NA-E stated it would depend on how she thought R1's condition was at the time of the transfers if she used the EZ-stand. NA-E was aware that R1's transfer had changed and was now assist of two and no EZ-stand. During an interview on 5/17/23 at 3:18 p.m. the director of nursing (DON) stated she was unaware that R1's left arm stuck out of the EZ-stand further than the other, until she was interviewing staff as part of the investigation following the broken wrist. The DON indicated there were no interventions to prevent injury to R1's weak arm during lift transfers. The DON stated the staff were to follow the care plan and if they had questions they were to reach out to the nurse. During an interview on 5/18/23 at 3:24 p.m. NA-A stated when R1 moved to the unit in 1/2023 she was an assist of one pivot transfer, shortly thereafter R1 became difficult for one person, so the NA's changed her to a pivot transfer with two staff members. NA-A stated probably in 3/2023 the staff used the EZ-stand for all transfer because R1 was resistive with staff upon transfers. NA-A stated R1 had never been able to hold on firmly to the EZ-Stand as her elbow pops out from the stroke and she is not able to fully straighten her left arm out and it sticks out more. NA-A stated there were not interventions for R1's left arm on the care plan, stating the staff were just aware of this with R1. NA-A stated she never reported any concerns with R1 to the nursing staff. NA-A stated the staff must always follow the care plan. A facility process titled, Nursing Services Process: Mechanical Stand and Left Procedure undated indicated employees must follow the residents plan of care. The resident's hands are to be placed on the outside of the harness and ask residents to hold onto the handlebars. A facility training skills checklist dated 8/17 indicated for the mechanical stand the staff is to verify the care and obtain assistance from another team member if indicated. When using the stand, the staff is carefully guide the lift to chair/bed/wheelchair. Watch that all arms, legs, and tubing are safe. A facility policy titled Person-centered Care Planning, indicated the care will include services that are furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and document review, the facility failed to ensure the necessary supervision and assistive devices, for 1 of 5 residents reviewed (R1). This resulted in harm to R1, who fell and sustained a fracture when being ambulated by staff, when staff did not use a transfer belt and stationary walker to support R1's safe ambulation. Findings include: R1's past medical history, dated 04/30/14 - 05/05/14, indicated that R1 was admitted to the facility after falling at a former residence and breaking her right arm and right leg. R1 needed rehabilitative therapies. R1 had considerable pain from the fractures as well as chronic pain caused by rheumatoid arthritis. R1's admission physician order's, dated 05/05/14, indicated that R1's rheumatoid arthritis (RA) was managed with scheduled doses of daily Methotrexate and Prednisone and R1 could have Dilaudid as needed for acute pain. R1's therapy notes indicated that R1 participated in rehabilitative therapies five days a week for nine weeks during May and June 2014. R1's right-sided fractures healed and R1 progressed to the point that R1 could use her right arm and leg to propel a two-wheeled rolling walker, providing R1 had staff assistance during ambulation. R1's progress notes, dated 12/02/14, indicated that R1 began complaining of increased right arm pain that R1 rated an 8, on a scale of 1 - 10. The physician's orders [REDACTED]., in addition to R1's long-term use of Methotrexate and Prednisone to treat RA. R1's progress notes on 12/15/14 and 12/24/14 indicated that R1 was having to rest more often when being ambulated. R1 typically rested once during the ambulation program, which had recently increased to three or four rest periods when walking. Staff observed that R1 had increased difficulty walking and was more tired. R1 was unsteady at times and occasionally bumped into things, such as the bed frame. R1 told the staff she thought the medication (Dilaudid) made her more tired. On 12/26/14, R1's physician changed the dose of Dilaudid and decreased it to half of what R1 had been receiving.On 01/09/15, the progress notes indicated that R1 was re-evaluated by therapy staff during ambulation because R1 had difficulty maneuvering when walking.Therapy notes, dated 01/09/15, indicated that R1 needed a stationary walker (without wheels), instead of a wheeled walker. R1 could still ambulate up to 50 feet with the stationary walker, as tolerated, providing R1 had staff assistance during ambulation. R1's care plan, dated 01/10/15, indicated that R1 could ambulate up to 50 feet with the stationary "silver" walker and the assistance of one staff, as tolerated. Staff were to use a transfer belt for all transfers and be slow and gentle with care, due to R1's joint pain. The care plan indicated that R1 was at high risk for falls due to R1's history of falls and recent history of syncope after narcotic use. The care plan specified that R1 was not to use the "blue" two-wheeled walker.An incident report, dated 01/17/15 at 4:15 p.m., indicated that R1 fell on her right side and rolled onto her back, while being ambulated by staff in the hallway. LPN/(D) responded immediately to assess R1. R1 was lying on the hallway floor without a transfer/gait belt on. The blue two-wheeled walker was beside R1. R1 was complaining of pain in the back of her head, right hip, and bilateral arms and shoulders. The progress notes on 01/17/15 indicated that LPN/(D) gave R1 Dilaudid for pain and contacted the on-call physician regarding the incident. The on-call physician ordered x-rays of R1's right hip and pelvis, which were completed that evening and negative for fractures. At 9:17 p.m., R1 complained of increased right arm and shoulder pain and numbness in her right hand. R1's blood pressure was 190/94. LPN/(D) noted that the Dilaudid had little effect to relieve R1's pain. LPN/(D) contacted the on-call physician again, who ordered an x-ray of R1's right shoulder and a one-time dose of Norvasc to decrease R1's blood pressure. X-ray results at 11:08 p.m. indicated that R1 had sustained a moderately impacted fracture at the head neck junction of the right humerus (broken shoulder). The on-call physician directed staff to immobilize R1's right arm with a sling and to continue Dilaudid and ice packs to control R1's pain. PT/(C) was interviewed on 02/10/15 at 10:59 a.m. PT/(C) stated that PT/OT services were previously provided to R1 in connection with right-sided arm and leg fractures that R1 had on admission to the facility. R1, who is alert and oriented, expressed a strong desire to walk and be as independent as possible so she could return home. R1 worked hard in therapy. R1 recovered from the injuries sustained prior to admission and was able to use a two-wheeled rolling walker for ambulation, which R1 owned. R1 did not progress enough that she could return home. R1 had poor safety awareness and continued to need the assistance of one staff for transfers and ambulation with the two-wheeled walker. R1 needed long-term care. After formal therapy services ended, R1 had a restorative ambulation program that was performed by nursing. R1 could ambulate 50 feet with the two-wheeled walker as tolerated, providing R1 had assistance from one staff while she ambulated or transferred. On 01/09/15, PT/(C) reassessed R1, in response to nursing concerns that R1 was having difficulty when walking. During PT/(C)'s assessment on 01/09/15, PT/(C) observed that R1 had impaired balance when standing. R1 tended to lean backwards at times and would lose her balance. R1 was unable to independently correct any loss of balance and R1 didn't possess the coordination to keep up with the two-wheeled walker. PT/(C) changed R1's restorative ambulation program on 01/09/15 and initiated the use of a stationary walker, which had the two front wheels covered with tennis balls to decrease propulsion speed of the walker. The therapy department provided the stationary walker to R1, which would increase R1's safety during ambulation. The stationary walker was a basic model (without hand brakes or a seat) that was silver in color. One staff needed to continue to assist R1 with transfers and ambulation and hold onto the gait belt to correct any loss of balance that might occur. R1 was interviewed on 01/29/15 at 8:40 a.m. R1 is alert and oriented and accurately articulated the history of her injuries, dating back to the time of facility admission. R1 stated she needs more help from the staff now with tasks like dressing and grooming, that she was able to perform independently prior to the 01/17/15 fall. R1 stated that the staff had always placed a transfer belt around her waist and hung onto to it whenever staff helped her into the bathroom or walk down the hall. On the day of the 01/17/15 fall, the aide didn't put the transfer belt on R1 and the aide had no transfer belt with her. The aide walked alongside R1 all the way to the end of the hall, without any direct contact with R1. When R1 got to the end of the hall and started to turn around to go back to her room, R1 lost her balance and fell on the floor. R1 had considerable pain after the fall, which is presently controlled. R1 started therapy exercises yesterday (01/28/15) to re-gain function of her right arm. R1 had two walkers in her room, a blue two-wheeled walker and a silver stationary walker. R1 did not know which walker was used at the time of the 01/17/15 fall. R1 stated she owned the blue walker and wants her possessions kept in her room. The therapy department gave her the silver walker a few weeks ago and told her she needed to use the silver walker for all walking instead of her blue walker.Observations in R1's room on 01/29/15 at 8:40 a.m. indicated that a blue two-wheeled walker was positioned in the far corner of R1's room, away from R1's reach. A silver stationary walker was positioned next to R1's recliner, where R1 sat during the interview. LPN/(D) was interviewed on 02/10/15 at 8:23 a.m. LPN/(D) was the nurse assigned to R1's care unit on 01/17/15. LPN/(D) was in the nurse's room around 4:00 p.m. on 01/17/15 when she was notified that R1 had fallen. LPN/(D) left the nurses's room immediately and could see R1 laying on the floor at the end of the hallway. Nursing Assistant (NA)/(L) was standing next to R1. R1's blue two-wheeled walker was off to the side of where R1 was laying on the floor. R1 had no gait belt on. LPN/(D) questioned NA/(L) about why NA/(L) was not using a gait belt and not following R1's plan of care. NA/(L) was very quiet and replied "I don't know." After LPN/(D) assessed R1, LPN/(D) reviewed R1's care plan with NA/(L) and instructed NA/(L) to use a gait belt when assisting any resident with mobility. R1 was complaining of hip and head pain. LPN/(D) conducted a complete head-to-toe assessment of R1, notified the on-call physician of the findings, and medicated R1 for pain control. The on-call physician ordered x-rays of R1's right hip, which were completed and negative for fracture. Several hours later, R1 began complaining of pain and tingling in her right arm. LPN/(D) notified the on-call physician again and x-rays of R1's right arm were ordered and completed. The right arm x-ray results were not back yet when LPN/(D)'s shift ended. NA/(L) was interviewed on 01/29/15 at 10:35 a.m. NA/(L) stated she works on all four of the facility's care units. On 01/17/15, she was assigned to R1's care unit. Around 4:00 p.m., she answered R1's call light. R1 was in the recliner in her room and requested help to go to the bathroom. She assisted R1 out of the recliner, without using a transfer/gait belt. NA/(L) stated she knows it's facility policy for the aides to have a gait belt on their person at all times and to use the gait belt when assisting residents with any mobility. She didn't have a gait belt with her on 01/17/15 when she responded to R1's call light. She "just didn't use one" when she assisted R1 on 01/17/15, even though there are extra gait belts at the nurse's desk. When R1 got up from the recliner, R1 grabbed her blue two-wheeled walker and headed toward the bathroom while NA/(L) followed behind R1. NA/(L) stayed in R1's room while R1 was in the bathroom. Afterward, R1 told NA/(L) she wanted to go for a walk. R1 used the blue two-wheeled walker to walk all the way to the end of the hallway, while NA/(L) walked beside R1. NA/(L) didn't have a gait belt on R1 and made no physical contact with R1 while R1 walked. When R1 got to the end of the hallway, R1 fell . NA/(L) stated she didn't know R1 wasn't supposed to use the blue two-wheeled walker. NA/(L) stated she wasn't aware the therapy department had given R1 a different walker to use. NA/(L) stated she didn't check R1's care plan on 01/17/15, prior to assisting R1 with care. NA/(L) stated she was trained by the facility to read the resident care plans at the beginning of the shift and she "just didn't do it" on 01/17/15, even though she stated she had sufficient time to do so. After R1 fell , NA/(L) checked R1's care plan and found that the care plan indicated that R1 was supposed to use the silver walker provided by the therapy department, not the blue two-wheeled walker owned by R1. After R1's fall, NA/(L) stated she was formally coached by nurses to follow the resident care plans and to use a gait belt when assisting residents. Observations on 01/29/15 at 9:30 a.m. indicated that the distance from R1's room to the area in the hallway where R1 fell on [DATE] was approximately 25 feet. The facility's policy on Transfer Belts (undated) indicated that "All nursing employees directly working with residents will have a transfer belt with them at all times. A transfer belt will be used for all residents requiring stand-by assist, assist of one, and assist of two, for transfers and ambulation." The procedure outlined in the policy indicated that staff were to position the gait belt around the resident's waist, grasp the gait belt from underneath when assisting the resident to stand, and maintain a firm grasp on the belt while walking alongside the resident.NA/(L)'s training records indicated that NA/(L) had met a competency exam for the use of transfer/gait belts, as recently as 11/05/14.