Every finding on record at Augustana Care Hastings Health and Rehabilitation

Based on interview and document review, the facility failed to ensure a safe transfer with a mechanical lift was performed to reduce the risk of serious harm, injury, impairment, or death for 1 of 3 residents (R1) reviewed for mechanical lifts. This resulted in immediate jeopardy for R1. The immediate jeopardy (IJ) began on 3/16/26 when nursing assistant (NA)-A and NA-B did not check to ensure all four straps of the sling were attached to the lift, resulting in a fall, fractured ribs and hospitalization for R1 and was identified on 3/19/26. The regional nursing consultant, the assistant director of nursing, the administrator, medical records, the director of nursing, and the nurse manager were notified of the IJ on 3/19/26 at 3:45 p.m. The IJ was removed on 3/17/26 and the deficient practice corrected 3/17/26 prior to the start of survey and was therefore past noncompliance. Findings include: R1's care plan dated 1/5/26 indicated R1 required a mechanical lift for transfer with assistance of two staff. R1's undated care sheet indicated R1 used a medium sized sling. R1's progress note dated 3/16/25 at 10:26 a.m. indicated two staff nursing assistants (NA)-A and NA-B were using the mechanical lift with the appropriately sized sling when the top left strap of the sling came loose from the mechanical lift. R1 fell from the lift and injured her left shoulder. Emergency Services were contacted and R1 was sent to the hospital for further evaluation and care. R1's incident report dated 3/17/26, indicated an interdisciplinary team meeting (IDT) meeting was held regarding R1's fall on 3/16/17. R1 had suffered acute displaced fractures of 2nd and 3rd left ribs. R1's face sheet dated 3/18/26 indicated R1 was an [AGE] year-old female who admitted to the facility on [DATE]. R1's relevant diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left side, osteoarthritis, and fibromyalgia. During an interview on 3/18/26 at 1:35 p.m., NA-F stated staff know a resident's transfer status via the care sheets provided at the nursing station. If a resident transfers using a mechanical lift, they always use two staff at a minimum. Before moving the resident, they ensure the sling is securely connected to the mechanical lift. NA-F stated the nurse educator had come and spoken with staff that morning with reeducation about using mechanical lift. The mechanical lift education provided was the same information provided to staff upon hire. During an interview on 3/18/26 at 1:51 p.m., NA-G stated to transfer a resident they will use at least two staff. One staff member will manage the resident's legs, and the other staff will control the machine. NA-G stated before they move the residents, they ensure the lift sling loops are all attached completely. During an interview on 3/18/26 at 2:05 p.m., NA-E stated to move a patient with a mechanical lift, they use two staff members. One staff member should be positioning the resident's legs, and the other person will be operating the lift. NA-E stated they should raise the residents by approximately six inches and then check for safe sling contact before moving the residents to the new surface. After the incident on 3/16/26, she completed retraining and signed a paper stating she had done the education. She reported this did not change her practice when transferring residents because she goes by the book. During an interview on 3/18/26 at 4:04 p.m., the director of nursing (DON) stated after the incident on 3/16/26, the mechanical lift and the sling involved in the incident were removed from the floor. The staff involved were interviewed and reenactments were completed to determine what had happened. The DON stated they compared this situation to their current process for using mechanical lifts and found a discrepancy when the NA did not check to ensure all sling straps were secured to the mechanical lift. The DON stated they immediately reeducated all staff on shift with the existing mechanical lift reeducation used for staff onboarding. They continued with retraining staff for all morning, evening, and night shifts since 3/16/26. During an interview on 3/18/26 at 4:15 p.m., NA-A stated she was R1's aide the morning R1 fell from the lift. She requested help from NA-B to transfer R1 from her wheelchair to her bed. They used the medium sized sling that R1 was already underneath her. Because NA-A was on R1's right side, she attached the right upper and lower loops of the sling to the mechanical lift. NA-A controlled R1's feet as NA-B lifted her into the air and moved the lift backwards. They paused between the wheelchair and the bed to obtain R1's weight using the mechanical lift's weighing feature. While they were weighing R1, the top left strap of the sling came off the mechanical lift and R1 fell onto her left shoulder. NA-A stated she stayed with R1 while NA-B ran to get more staff members. NA-A stated if she could do anything differently, she should have checked all four points of sling to the lift and checked the other NA's work. During an interview on 3/18/26 at 4:39 p.m., the nurse manager stated when using a mechanical lift to transfer a patient, staff need to ensure all four loops of the sling are attached properly. Staff should check for this by lifting the residents slightly into the air and observing the sling loops are tight and completely attached to the machine. Only after this check should staff continue with the resident transfer. The nurse manager stated she was one of the nurses who responded to the incident on 3/16/26 and assessed R1. Staff called for an ambulance while she provided care until the emergency services arrived. Immediately after the fall, the staff development nurse began reeducating all staff on shift. The reeducation consisted of their preexisting checklist used to determine lift competency upon hire. If the staff development nurse is not available, the nurse manager and the DON have been coming in early or staying late to provide education to staff outside of business hours. During an interview on 3/19/26 at 8:38 a.m., NA-C stated to transfer a resident with the mechanical lift, she would ensure the sling was attached to the mechanical lift. To do this, she would place the loops on the machine and slightly lift the patient while over a stable surface to visualize the tension and attachment. Once she verified this, she would have another aide direct the resident's legs while she controlled the lift and completed the resident's transfer. Prior to the beginning of her shift this morning, NA-C stated the staff development nurse did 1:1 reeducation with her. During an interview on 3/19/26 at 8:47 a.m., NA-D stated before transferring a resident with a mechanical lift, staff should lift the resident halfway into the air. While above the surface, check all four points of contact of the sling to the machine. If there was an issue with the sling connection, staff should lower the resident back onto the original surface and adjust the sling prior to continuing. Once the sling is properly attached to the lift, they can complete the transfer. NA-D stated he received reeducation on 3/16/26 because he was working at the time of the incident. The re-education was not new materials and was a reminder of staff expectations. During an interview on 3/19/26 at 11:14 a.m., NA-B stated she assisted with transferring R1 from her wheelchair to her bed. NA-B stated she lowered the mechanical lift over R1 and secured the sling's lower loop to the mechanical lift. NA-B stated she waited for NA-A to secure the other loops before raising R1 into the air then moved R1 away from the wheelchair when she began to use the weighing feature of the mechanical lift to obtain R1's weight. NA-B stated the upper left sling loop then disconnected from the mechanical lift and R1 fell backwards, hitting her shoulder. NA-B stated she then ran from the room to get help. NA-B stated she should have double checked and tugged on the sling loops to make sure they were in the lift. During an interview on 3/19/26 at 12:45 p.m., NA-H stated if he was using a mechanical lift to transfer a resident, he would ensure the machine is working first. After securing the resident into the sling and attaching it to the mechanical lift, he would start to lift the resident and then observe the loops to ensure they are attached. NA-H stated they do not move the resident away from the bed or chair before they verify the sling is completely and securely attached to the mechanical lift. During an interview on 3/19/26 at 12:53 p.m., RN-A stated to transfer a resident using the mechanical lift, they have to check the sling is properly attached. To ensure attachment, they will lift the residents into the air a little and visualize tension on all sling loop points. They must complete this check prior to continuing with the transfer. During an interview on 3/19/26 at 2:30 p.m., the staff development nurse stated all nursing and aide staff are educated about how to use a mechanical lift upon hire and annually. This training consists of a video, a competency checklist, and representatives from the lift company providing in-person training. Since the incident on 3/16/26, herself and other leadership staff have been using the competency checklist to provide reeducation with the staff. They conduct this education through a combination of shift huddle announcements and 1:1 with staff. During an interview on 3/19/26 at 2:50 p.m., the DON stated directly after she responded to the incident on 3/16/26, she began an investigation. She had NA-A and NA-B complete written statements and went through a demonstration with NA-A. Based on the information gathered, they believe NA-B did not attach or did not properly attach the upper left loop of R1's sling to the mechanical lift. Then, NA-A and NA-B failed to complete the pause and safety check prior to completing the transfer. Because of these preliminary findings, they suspended both NA-A and NA-B. To prevent any further incidents from occurring, they immediately began education staff with their existing competency checklist. Educational materials were discussed in shift huddles and on a 1:1 basis by herself, the nurse manager, and the staff development nurse. They also completed audits of like-residents and observed staff complete transfers using the mechanical lift. These audits were completed with the lift competency checklist. In an email sent on 3/19/26 at 10:51 a.m., the DON indicated 58 staff have been retrained on proper mechanical lift usage. All remaining staff were part-time employees, or on leave of absence. The past noncompliance immediate jeopardy began on 3/16/26. The immediate jeopardy was removed and the deficient practice corrected by 3/17/26, after the facility implemented a systemic plan that included the following actions: An observation of a mechanical lift transfer on 3/19/26 at 1:06 p.m. showed NA-C and NA-D entered R3's room and discussed transferring her from her wheelchair to her bed. NA-C brought the mechanical lift into the room and then lowered the arm directly over R1's head and lap. Using the sling R3 was already sitting on, NA-C attached the bottom loops to the mechanical lift and NA-D attached the top loops. NA-D directed NA-C to control the machine while he guided R3's legs. NA-C then lifted R3 slightly into the air and said Check while visually verifying all four sling loops were attached to the mechanical lift. NA-D also looked at the sling loops and said Okay, indicating he agreed with the check. NA-C then continued raising R1 into the air. NA-C and NA-D then successfully transferred R3 into her bed. An observation of a mechanical lift transfer was completed on 3/19/26 at 1:22 p.m. for R4. NA-C brought the mechanical lift into R4's room and discussed the plan to transfer from her wheelchair into her bed. When NA-E arrived, NA-C positioned the mechanical lift directly over R4's head and lap. Using the sling already in R4's wheelchair, NA-C attached the two left-side loops while NA-E attached the two right-sided loops. NA-C then raised R4 slightly into the air, then paused and said Check. Both NA-C and NA-E looked at the loops and verified there was tension in the loops. NA-C then continued raising R4 into the air. NA-C and NA-E then successfully transferred R4 into her bed. The facility policy and procedure titled Floor-Based Full Body Sling Lift Use, dated 2/1/26, indicated:1.Push the UP button on the hand control for the lift until there is slight tension on the sling loops. PERFORM SAFETY CHECKa. Once there is tension on the loops, double check each loop to be sure each is securely in the hook.b. Double-check the position and stability of all straps and other equipment. c. Ensure clips, latches, and bars are securely fastened and structurally sound.d. As needed, lift the resident's knee(s) and smooth out the sling under the thigh(s).e. Lift resident about 2 inches off the surface and verify that weight is evenly spread between the straps of the sling.f. Verify that residents will not slide out of the sling or tip backward or forward.

Based on observation, interview and document review the facility failed to assess and monitor non-pressure related skin injuries for changes until resolved for 1 of 3 (R1), reviewed for quality of care.Findings include:Findings include:R1's annual Minimum Data Set (MDS), dated [DATE], identified R1's cognition was intact and had diagnoses of multiple sclerosis (MS)- (an autoimmune disease where your immune system mistakenly attacks the protective covering of your nerves (called myelin) in the brain and spinal cord producing symptoms such as fatigue, walking difficulties, numbness, and muscle weakness), diabetes, congestive heart failure and pyoderma gangrenosum (a rare disease where a person's immune system attacks its own skin, causing extremely painful, rapidly spreading ulcers or sores, most often on the legs). Further indicated R1had open lesions other than ulcers, rashes, cuts.and Moisture Associated Skin Damage (MASD) that required applications of ointment/medications and nonsurgical dressings other than to feet.R1's care plan dated 9/30/24, identified a problem at risk for moisture due to incontinence of bladder and/or bowel, decreased activity, immobility, shear and friction. Other risk factors: recent ADL decline, MS, cardiovascular disease, depression, diabetes, polyneuropathy, pain, shortness of breath, required assist with activities of daily living (ADL)s, congestive heart failure (CHF), and Pyoderma Gangrenosum and admitted to the facility with several lesions on her body. Also has a history of MASD to her buttocks. Followed by Dermatology since 2/2024 for Pyoderma Gangrenosum lesions (neck, midback, right shin and abdomen). At times have refused treatments. Interventions dated 9/20/24 include to provide treatment per physician orders, involve and educate R1 and family in prevention/treatment methods related to skin integrity, NAR/CNA to observe daily during cares and notify nurse promptly of any areas of concern.R1's Visual Body Inspection note dated 9/17/25, identified R1 had no new skin concerns at this time.R1's Wound Management note dated 9/20/25, identified R1 had a right shin rash that measured 31 centimeters (cm) x 7 cm and left shin rash measured 2.5 cm x 13 cm. Healed discontinued information: policy updated, wound management no longer required this skin alteration, Staff will continue to monitor until resolved per updated facility policy.R1's progress note dated 9/20/25 at 1:50 p.m., identified R1 was noted to have 31 centimeters (cm) X 7 cm rash from right inner lower leg to the middle of her inner thigh. A 2.5 cm x 13 cm rash from left inner lower leg to top left inner knee. R1 complained of pain to her right foot and rated it 8 out of 10. Tylenol, 650 mg prn was given for pain. Medication seems effective. The rashes are not raised; they are flat and pink in color, no warmth to the touch. Provider updated through email and family-member (FM)-A at the facility visiting and stated R1 used to have that kind of rash. Will continue to monitor.R1's Visual Body Inspection note dated 9/24/25, identified R1 had no new skin concerns at this time.R1's progress note dated 9/27/25, identified R1 was sent to the hospital per provider orders.R1's hospital Consult notes dated 9/29/25, identified R1's initial wound assessment note described the wound etiology to be Pyoderma gangrenous:1. Wound 1 location left neck, bilateral axilla, left back, abdomen, right thigh and right leg wound base appears to be scar tissue with a few small ones on the abdomen with small amount of yellow/gold/tan drainage with mild pain present.2. Wound 2 location bilateral axilla fungal/yeast wound etiology rash with odor present.Orders to follow up weekly with wound care.R1's Hospital Discharge summary dated [DATE], identified R1 was hospitalized for congestive heart failure and had new orders for the following wounds:1. Left neck, bilateral abdomen and right thigh: cleanse wounds with normal saline and pat dry, place xeroform gauze product (non-adherent, occlusive dressing, which means it helps protect the wound, maintains a moist healing environment, and does not stick to the new tissue) over wound bed, cover with ABD pad (large, sterile, absorbent dressing used to cover large wounds or surgical incisions on the abdomen) and secure with tape, change dressings daily.2. Left back and right anterior shin: cleanse wounds with normal saline and pat dry with non-sterile 4 x 4 gauze. Right shin cover with 4 x 4 Mepilex soft, foam bandage designed to absorb fluid from a wound). Left back cover with xeroform and a 6 x 6 Mepilex.3. Bilateral axilla: do not use Cavilon advanced wand (a single-use foam applicator containing a unique, ultra-thin polymer barrier designed to protect and heal severely damaged or intact skin from caustic body fluids like liquid stool and gastric fluid) on this patient. Clean axilla with bath wipes and dry, apply a very thin layer of citric aid AF ointment and continue treatment for 2 weeks.R1's progress noted dated 10/1/25 at 9:07 p.m., identified R1 returned from hospital.no new skin concerns.R1's Visual Body Inspection note dated 10/1/25, Although the hospital discharge summary identified R1 had wounds, R1's inspection not only identified that R1's scars were visually inspected and without change, both heels intact and free of deep tissue injury (DTI) or other skin alteration. No new bruises, skin tears, moles, pressure injuries or rashes noted. R1's Physician progress note dated 10/9/25, identified R1 has Pyoderma gangrenosum, presenting with multiple open wounds, starting late 2023, currently treated with vitamin D, topical clobetasol (prescription-strength corticosteroid medication applied directly to the skin to treat severe inflammatory skin conditions) and cyclosporine (potent immunosuppressant medication that works by decreasing the activity of the immune system), follows with dermatology and the visiting wound physician. R1's wounds were not addressed on this visit. R1's Visual Body Inspection note dated 10/12/25, identified R1's scars were visually inspected and without change, both heels intact and free of deep tissue injury (DTI) or other skin alteration. No new bruises, skin tears, moles, pressure injuries or rashes noted. R1's Visual Body Inspection note dated 10/15/25, identified R1's scars were visually inspected and without change, both heels intact and free of deep tissue injury (DTI) or other skin alteration. No new bruises, skin tears, moles, pressure injuries or rashes noted. R1's Visual Body Inspection note dated 10/20/25, identified R1's scars were visually inspected and without change, both heels intact and free of deep tissue injury (DTI) or other skin alteration. No new bruises, skin tears, moles, pressure injuries or rashes noted. R1's treatment administration record (TAR) dated October 2025 identified the following:1. Bilateral armpits: DO NOT USE CAVILON ADVANCED WAND ON THIS PATIENT 1) Clean axilla with bath wipes and dry. 2) Apply a very thin layer of Critic Aid AF ointment BID and prn to red/denuded areas. Do not scrub the skin if soiled, instead cleanse gently and apply another thin layer of Critic Aid Ointment. 3) Continue this treatment for 2 weeks. This was documented as completed from 10/1/25 to 10/15/25.2. Left buttock: cleanse with ns, pat dry, apply skin prep to surrounding tissue, cover with 6x6 silicone adhesive dressing. Change every sun, wed and prn. This was documented as completed on 10/1/25, 10/5/25, 10/8/25, 10/12/25, 10/15/25 and 10/19/25.3. Left mid back and right shin: cleanse with ns, pat dry, skin prep peri wound, add xeroform to wound-base on back cover with silicone adhesive dressing. Change every Sun, Wed and prn. This was documented as completed on 10/1/25, 10/5/25, 10/8/25, 10/12/25, 10/15/25 and 10/19/25.4. Left posterior head/neck: cleanse with NS, pat dry, apply Clobetasol to wound edges as directed and Tacrolimus to center of wound as directed daily. Ensure pillowcase is clean. Replace pillowcase as needed. This was documented as completed from 10/1/25 to 10/20/25 with the exception on 10/7/25 and 10/10/25 due to resident refusal.5. Right thigh and bilateral abdomen: 1) Cleanse wound with wound cleanser or NS and pat dry. 2)Apply Tacrolimus to center of wound then cover with xeroform gauze over wound bed. 3) Cover with 4x4 gauze and secure with tape. 4) Change dressing daily. This was documented as completed from 10/1/25 to 10/20/25 with the exception on 10/7/25 and 10/10/25 due to resident refusal.R1's record was reviewed from 9/20/25 to 10/20/25, did not include any monitoring of R1's wounds nor any weekly comprehensive skin assessments to identify interventions to protect R1's skin from further injury. In addition, it did not identify the physician was notified of R1's dressing change refusals on 10/7/25 and 10/10/25. Furthermore, the record lacked wound care follow up in 2 weeks per the hospital discharge summary on 10/1/25. During an interview on 10/16/25 at 2:25 p.m., R1 was lying bed and stated she had a rare skin disorder and had sores all over her body like her arm pits, neck, abdomen and legs. R1 stated they were painful and never go away but do get better.During an interview on 10/20/25 at 11:26 a.m., nursing assistant (NA)-A stated she hasn't worked with R1 much but when does provides cares she always notices a bandage on R1's abdomen and legs. NA-A stated she had never seen what was under the bandages.During an interview on 10/20/25 at 11:36 a.m., NA-B stated R1 had a lot of bandages on her body, to include her abdomen, right and left lower legs. NA-B stated she had never seen under the bandages.During an interview on 10/20/25 at 11:46 a.m., NA-C stated R1 had dressings on her abdomen, when she cleans R1 she has to be very careful to not bump all the bandages. NA-C stated she had never seen under the bandages.During an interview on 10/20/25 at 12:13 p.m., NA-D stated R1 had wounds on her legs, abdomen and her back. NA-D stated when the nurse does her dressing changes, she will ask for help rolling R1 but had never seen R1's wounds.During an interview on 10/20/25 at 12:22 p.m., licensed practical nurse (LPN)-A stated R1 had current wounds on her left and right abdomen, side of her left head, right thigh, left mid back and right shin that she has treatment orders for. LPN-A reviewed R1's record and was unable to find R1's weekly comprehensive wound assessments for these wounds. LPN-A stated they should include measurements, wound bed and peri wound. LPN-A stated they should be monitoring for signs and symptoms of infection and it should be done weekly.During an interview on 10/20/25 at 12:32 p.m., nurse manager (NM)-A stated for non-pressure skin wounds the nurse would initially measure the wound and document it in a skin event, call and update the family and provider to get a treatment started right away. NM-A stated we no longer measure non pressure wounds weekly; our skin policy was updated about a month ago. NM-A further stated R1 used to be followed by dermatology but was unsure of the last time she saw dermatology.During an interview on 10/20/25 at 12:54 p.m., director of nursing (DON) stated they recently had their skin policy updated which directed that staff no longer had to do weekly comprehensive skin assessments on non-pressure wounds. DON reviewed R1's record and stated R1 had multiple current wounds that are not comprehensively assessed each week to include measurements, wound base, peri wound, drainage or odor. DON was unable to articulate how staff would know if there was a change in the wound to notify the doctor without the assessments. DON further stated she was unsure the last time R1 was seen by dermatology for her wounds and was not currently followed by wound rounds.Facility policy, Skin Integrity, revised 10/3/25, identified a policy that Cassia seeks to utilize an interdisciplinary approach to promote best practice in areas of skin injury prevention and promotion of healing. Skin care, risk assessment and wound care treatment plans are based on resident focused goals of pressure redistribution, improved or sustained skin integrity, mobility, comfort, infection prevention, healing and/or palliation. Cassia facilities will use the Wound Management area of the MatrixCare EHR to document pressure injuries, deep tissue injuries, arterial ulcers, diabetic ulcers, venous ulcers, surgical incisions with removable dressings. Facilities with Point Click Care (PCC) will document pressure injuries, deep tissue injuries, arterial ulcers, diabetic ulcers, venous ulcers and surgical incisions in the skin and wound area of PCC. Matrix sites and PCC sites will document all other skin integrity concerns such as bruises, skin tears, rash, MASD, and surgical incisions with a non-removable dressing (ordered by the provider not to remove), etc. in the treatment section of the EHR by entering a treatment to monitor and treat the area until it is healed. The treatment will be discontinued when healed.A skin alteration event/incident report will be completed any time there is any other type of facility acquired skin concern. Surgical incisions do not require an event/incident report. Bruises that are less than the size of a quarter and are not suspicious would not need an event/incident created but should have a progress note explaining the bruise. Updates will be given to MD/NP/PA, Dietitian and resident representative monthly, or more often if area is deteriorating or not healing as expected. The provider will be updated for wounds that worsen. The provider will be updated for wounds that are stagnant for 2 weeks and will be asked to consider a change in treatment if applicable. If a bruise, skin tear or abrasion are the result of a fall, the fall event/incident report will cover those injuries and no additional skin alteration event/incident is required.Measuring/Describing wounds: 1. Location of wound 2. Type of wound 3. Length is the greatest length head to toe 4. Width is the greatest width side to side. 5. Depth is measured by inserting a moistened sterile cotton tipped applicator into the deepest portion of the wound base to measure depth in centimeters. Grasp the fully inserted applicator with the thumb and forefinger at the skin surface. Withdraw the applicator while maintaining the grasp with the thumb and forefinger at the point of the indicating depth. Measure from the tip of the applicator to the position of the thumb with a measuring tool to determine depth. 6. Tissue types -- use percentages to describe the wound bed with the following tissue types: Epithelial, granulation, eschar, intact, discolored skin, scab, callous, slough, red/pink, etc. Percentages should equal 100%.7. Undermining/tunneling is measured by gently inserting the moistened applicator to measure undermining and/or tunneling using the applicator as described in depth measuring. Measure as if the resident were a clock and the head is 12 o'clock. Measure undermining by measuring the extent of the undermining clockwise then the deepest part of the undermining. For example: 1.5 cm from 2-7 o'clock. Measure tunneling by measuring the depth of the tunnel and give direction of the tunnel by the clock method. For example, 3 cm at 3 o'clock. If there is more than 1 tunnel, number each clockwise.9. Thickness of injury (for non-pressure related ulcers): Document if the wound is partial thickness (isolated to the skin), or full thickness (below the skin) 10. Drainage, document amount of drainage such as no drainage, scant, small, moderate, large or copious. 11. Drainage, document type of drainage such as no drainage, serous, sero-sanguinous, sanguineous, purulent, or other (Describe). 12. Document odor from wound after the dressing has been removed and the wound has been cleansed. Do not document odor from the dressing. 13. Document presence of pain at site of the wound. 14. Describe wound edges (e.g. black, calloused, denuded, erythematous, or rolled). 15. Describe the peri wound area up to 4 cm from the edge of the wound. Measure in centimeters. Describe the characteristics of the surrounding skin (e.g. intact, denuded, erythematous, indurated, macerated). 16. Document progress to healing in the past week (e.g. improved, no change, worsening) for the following: Pressure injury, deep tissue injuries, arterial ulcers, diabetic ulcers, venous ulcers, surgical incisions. If the surgical incision has a dressing that is ordered by the provider not to be removed, you will not document progress to healing.

Based on observation, interview, and document review, the facility failed to ensure food temperatures were checked or obtained in a manner to reduce the risk for cross-contamination between food items prepared in the main production kitchen. In addition, the facility failed to ensure 1 of 1 can opener was kept in a clean and sanitary manner. These findings had the potential to affect 66 of 67 residents who consumed food from the main production kitchen. Findings include: Can opener During a visit to the kitchen on 5/19/25 at 6:08 p.m., an [NAME] commercial can opener blade's tip had a dark tan dry shinny debris on the tip of the blade up to, black debris caked along most of the blade, reds spots in the upper part of the blade. During observation and interview on 5/20/25 at 8:50 a.m., the commercial can opener blade was still covered with same debris. The culinary director (CD) observed and confirmed the debris built up on the can opener's blade. CD stated the can opener was washed 3 to 4 times a week. CD stated he was not sure when was the last time it was washed. CD stated a dirty blade posed a risk for cross contamination and it should be washed daily. CD added it will add to the evening cleaning duties. Thermometer During observation and interview on 5/21/25 at 11:45 p.m., cook (Ck)-A checked the temperature of the food ready to be served to the residents. Ck-A used a commercial thermometer to check the temperature of the country fried steak. Ck-A grabbed a moist and stained washcloth next to the sink behind the steam table and proceeded to wipe the thermometer before checking the asparagus temperature. When Ck-A was stopped from checking the next food item's temperature and asked to explain the procedure to clean the thermometer, Ck-A stated he never used alcohol wipes to disinfect the thermometer after checking a food item temperature and before checking the next food item on the steam table. Ck-A stated he would get a clean washcloth to prevent cross contamination. During interview on 5/21/25 at 1:44 p.m., CD stated using a moist dirty washcloth was not the facility's procedure to disinfect the thermometer. CD stated the thermometer used to check the food temperature should be sanitized with an alcohol wipe or a sanitizing solution to prevent cross contamination. During interview on 5/22/25 at 1:07 pm., director of nursing stated a dirty can opener and failure to use proper sanitization procedure of a thermometer used to temp the food were infection control issues. Facility's policy titled Sanitation dated 1/10/25, indicated food service areas shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Facility's policy title Food Temperature Monitoring dated 1/5/22, indicated during temperature monitoring, thermometers should be sanitized prior to checking food temperatures, and between each food item. You may use an alcohol swap or sanitizing solution.

Based on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was removed and hand hygiene completed prior to room exit for 2 of 2 residents (R6 and R28) observed for enhanced barrier precautions (EBP). In addition, the facility failed to ensure housekeeping staff changed their gloves and performed hand hygiene between cleaning of two resident (R2 and R27) rooms. As well, the facility failed to follow infection control practices while assisting with resident eating to reduce the risk for the spread of infection for 3 of 8 residents (R3, R28, R32) reviewed who required staff assistance with dining. Findings include: ENHANCED BARRIER PRECAUTIONS R6's annual Minimum Data Set (MDS) dated [DATE], indicated R6 had intact cognition and a diagnosis of diabetes mellitus. In addition, R6 had a stage four pressure ulcer and required substantial and/or maximal assistance to roll left and right and was dependent on staff for transfers. R6's physician order dated 4/3/25, indicated treatment orders for R6's sacral wound once daily. R6's EBP care plan revised 3/28/25, indicated R6 required EBP for impaired skin integrity and directed staff to follow EBP per policy. R28's quarterly MDS dated [DATE], indicated R28 had moderately impaired cognition, and diagnoses of heart failure, other fracture, anxiety disorder and depression. In addition, R28 had an indwelling catheter and was dependent on staff for activities of daily living. R28's physician orders dated 1/30/25, indicated Catheter type: Coude Fr. (French) 16; Balloon size: 10 cc (cubic centimeters); Frequency catheter changes every 4 hours PRN (as needed) for by passing or if clogged/falls out. R28's EBP care plan revised 4/16/25, indicated R28 required EBP related to an indwelling catheter and directed staff to follow EBP per policy. During observation on 5/20/25 at 2:04 p.m., NA-C exited R28's room and wore a gown and gloves. NA-C pushed a mechanical lift down the hallway to a section where another mechanical transfer device was stored. NA-C cleaned the lift and still wore the same gown and gloves. NA-C removed their PPE, threw the PPE in a soiled utility room, and completed hand hygiene. During interview on 5/20/25 at 2:07 p.m., NA-C stated they assisted another staff member to transfer R28 into bed. NA-C stated they should have removed their PPE upon exiting R28's room, but kept the PPE on because the wipes to clean the lifts had bleach in them. During observation on 5/21/25 at 9:35 a.m., NA-D wore a gown and gloves and took R6's toothbrush and basin from her and rinsed them in the bathroom. NA-D removed gloves, performed hand hygiene (HH), and assisted R6 to turn side to side to get a sling underneath her. NA-D removed the gown as exiting R6's room and held the gown in their hand as they went to the full mechanical lift, which was more than four feet away from the resident's room and across the hallway. Licensed practical nurse (LPN)-B nurse directed NA-D to place the gown in the hamper in R6's room. NA-D returned to R6's room with the lift and previously worn gown in hand and placed the gown in the hamper in R6's room. NA-D placed on a new gown, completed hand hygiene, and applied gloves. During interview on 5/21/25 at 10:04 a.m., NA-D stated they were supposed to remove PPE inside R6's room and prior to room exit. During interview on 5/21/25 at 2:03 p.m., LPN-B verified they gave NA-D correction in the moment and stated staff should remove PPE prior to room exit and not carry PPE down the hallway. During interview on 5/22/25 at 11:57 a.m., registered nurse (RN)-B stated staff needed to remove their gown and gloves and complete hand hygiene before leaving a room with enhanced barrier precautions for infection control purposes. During interview on 5/22/25 at 1:34 p.m. with the director of nursing (DON) present, the infection preventionist (IP) stated staff needed to remove their gowns and gloves before they left a resident room under enhanced barrier precautions. IP stated there was a risk of spreading infection when PPE was not removed prior to room exit. The facility policy Transmission-based precautions, enhanced barrier precautions and empiric precautions dated 5/13/25, directed staff to don gown and gloves prior to high-contact care activity and change PPE before caring for another resident for a resident under enhanced barrier precautions. The policy directed staff to doff gown and gloves before room exit for a resident under contact precautions and did not specific PPE removal for a resident under enhanced barrier precautions. HOUSEKEEPING R2's quarterly MDS dated [DATE], indicated R2 had intact cognition and diagnoses of seizure disorder or epilepsy, depression, and psychotic disorder. In addition, R2 was independent with most activities of daily living. R27's significant change MDS dated [DATE], indicated R27 had intact cognition and their activities of daily living needs varied from independent to substantial and/or maximal assistance. During observation on 5/21/25 at 9:57 a.m., housekeeping aid (HA)-A wore gloves, exited R27's room, took a mop head off the mop handle, and placed the mop head in a plastic bag. HA-A wore the same gloves, removed the broom and dustpan from the housekeeping cart, and swept near the entrance of R27's room. HA-A wore the same gloves, placed the broom and dustpan back on the cart, and placed a wet floor sign in R27's room. HA-A wore the same gloves, knocked on R2's door, entered R2's room, and turned on the bathroom sink. Another housekeeping aid came to clean the bathroom. HA-A wore the same gloves and wiped furniture surfaces near the window in R2's room. HA-A wore the same gloves, mopped R2's floor, and used the broom and dustpan near R2's room entrance. During interview on 5/21/25 at 10:09 a.m., HA-A verified they did not change their gloves or complete hand hygiene between R2 and R27's room. HA-A stated they should change their gloves and complete hand hygiene after every room and before cleaning the bedroom if they cleaned the bathroom first. During interview on 5/21/25 at 11:21 a.m., the director of environmental services (ESD) expected staff to change their gloves and perform hand hygiene between resident rooms to prevent cross contamination. During interview on 5/22/25 at 1:34 p.m. with the director of nursing (DON) present, IP expected housekeeping staff to change their gloves and complete hand hygiene between residents' rooms and upon exit of room to go to the housekeeping cart. IP stated staff were at risk of spreading germs. The facility policy Hand Hygiene dated 7/3/24, directed staff to perform hand hygiene after touching environmental surfaces. 49034 DINING R3's Resident Profile dated 5/21/25, indicated R3 required extensive assistance from staff while eating. R28's Resident Profile dated 5/20/25, indicated R28 required extensive assistance from staff while eating. During an observation on 5/21/25 at 8:15 a.m., nursing assistant (NA)-A was observed sitting with R28 to her left and R3 to her right. NA-A was observed to use her right hand to take a spoon of food to R28's mouth, put the spoon down, and then use R28's clothing protector to wipe R28's mouth. NA-A then used her right hand to take a spoon of food to R3's mouth and used R3's clothing protector to wipe her mouth. NA-A then used her right hand to adjust the top of R3's straw to assist R3 with drinking. NA-A then began assisting R28 with eating with her right hand and continued the same process as outlined above. At 8:33 a.m., NA-A was observed to take a pen out of her pocket and write something down. NA-A then put the pen back in her pocket, grabbed R3's straw with her right hand, and adjusted it to give R3 another drink before removing her clothing protector. NA-A was observed to then leave the table. During this observation, hand hygiene was not observed to be completed by NA-A. During an interview on 5/21/25 at 11:07 a.m., NA-A stated she had received training on how to assist residents with eating from the facility. NA-A stated she was supposed to complete hand hygiene before and after assisting residents with eating and make sure each hand was only used to assist one resident. During observation on 5/21/25 at 12:41 p.m., NA-C assisted R3 and R28 with dining. NA-C primarily used one hand to alternate between R3 and R28 with meal assistance and did not perform hand hygiene between the residents. NA-C wiped R28's mouth with a clothing protector and continued with meal assistance for both residents without hand hygiene between the residents. During interview on 5/21/25 at 2:17 p.m., NA-C stated they completed hand hygiene before meal assistance and verified they did not complete hand hygiene between resident assistance. NA-C stated they were right-handed and was not sure if they should use both hands to assist two residents at the same time with their meals. During interview on 5/22/25 at 11:57 a.m., RN-B stated staff needed to complete hand hygiene between residents during meal assistance or should designate one hand to each resident. During interview on 5/22/25 at 1:34 p.m. with the director of nursing (DON) present, IP stated staff needed to perform hand hygiene between assistance of residents in the dining area due to infection risk. 48065 R32 R32's annual Minimal Data Set (MDS) dated [DATE], indicated was cognitively impaired, needed maximal assistance with eating, oral hygiene, showers, upper body dressing, personal hygiene and was dependent on staff with lower body dressing, toileting hygiene and transfers. R32 also included diagnoses of dementia, non-traumatic brain dysfunction, diabetes mellitus, arthritis and anxiety disorder. R32's eating care plan printed 5/22/25, indicated R32 required extensive assistance of one staff to eat meals due to weakness and dementia. During observation on 5/19/25 at 6:00 p.m., dinner was served in the second-floor dining room. The dinner consisted of a pulled pork sandwich, tater tots, mixed greens salad and mandarin oranges gelatin. Some of the residents did not require any assistance, some needed help to set up their meals, and others required maximal assistance to eat their meals. During observation on 5/19/25 at 6:21 p.m., R32 was sitting with 5 other residents who required moderate to maximal assistance to eat. Nursing assistant (NA)-F was sitting between R32 and another resident who required maximal assistance to eat. At 6:38 p.m. NA-F held R32's sandwich in his hand, talked to her, and brought the sandwich to 32's mouth and she took a bite. NA-F used a fork to give a bite to the resident sitting on his right side without hand hygiene. A couple minutes later, NA-F grabbed a tater tot with his hand but R32 didn't eat it. NA-F held R32's sandwich in his hand and offered to R32 but she turned her head away. During interview on 5/21/25 at 1:53 p.m., NA-F stated on 5/19/25, as usual, he used hand sanitizer before he started to help R32 and another resident to eat their dinner. NA-F stated both residents needed maximal assistance and R32 used special silverware. NA-F said sometimes R32 had trouble holding the silverware and needed maximal assistance to eat, and sometimes R32 could not focus and it was easier to for NA-F to hold the food with his hand to bring the food very close to R32's mouth. NA-F stated sometimes R32 needed to take a first bite and appeared to remember she was eating. NA-F acknowledged he was helping R32 and another resident to eat dinner, and acknowledged he held a tater tot and the sandwich with his hands. NA-F stated it was wrong to hold R32's food with his hands because it was a break of the infection control practice. During interview on 05/22/25 at 01:07 p.m., director of nursing stated using one's bare hands to help R32 to eat was an infection control issue. The facility's Feeding of Residents by Staff policy dated 3/10/25, indicated staff were to perform hand hygiene before and after assisting residents with eating but did not outline the procedure when staff were assisting more than one resident at a time to eat. In addition, the policy indicated residents unable to feed themselves will be provided with assistance per their care plan. The policy indicated to offer small bite-sized portions on the fork or spoon at a regular rate.

Based on observation, interview, and document review, the facility failed to appropriately monitor and comprehensively assess complaints of pain for 1 of 5 residents (R2) reviewed for pain. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition, no hallucinations, delusions, behaviors, or rejection of care. R2 was independent with most activities of daily living and had diagnoses which include seizure disorder, depression, and psychotic disorder. The MDS indicated R2 received scheduled pain medication, as needed pain medication, and non-medication interventions for pain. The MDS indicated R2 had frequent pain and rated pain at a four. The MDS indicated R2's pain frequently affected sleep and occasionally interfered with day-to-day activities. R2's pain care plan reviewed and/or revised 3/19/25, indicated R2 had a history of pain related to fibromyalgia (long-term condition which involves widespread body pain), chronic pain, diabetes, neuropathy, restless leg syndrome (nearly irresistible urge to move the legs; may experience pain), depression, and gastroesophageal reflux disease. R2 was able to verbalize pain and pain relief. Interventions included to follow PRN (as needed) analgesic house orders for pain, provide non-medication pain relief, such as rest and position changes, notify provider of any new or unrelieved pain, monitor for non-verbal signs and symptoms of pain, complete pain assessment on admission, quarterly, and as needed, give pain medication as ordered, monitor for pain medication side effects and notify provided if noted. R2's mood state care plan reviewed/revised 3/31/25, indicated pain was a situation which caused mood difficulty. The care plan indicated R2 became excessively focused on pain and health condition which became a barrier to having a quality of life. R2's pain focus may cause irritability, accusations towards staff and care, and belief R2 was not receiving proper care and services. R2's behavioral symptoms care plan reviewed/revised 3/31/25, indicated R2 had history of inappropriate use of over-the-counter analgesic medication due to a fear of being in pain. R2's associated clinic of psychology care plan reviewed/revised 3/31/25, indicated pain may affect mood and spending time out of bed doing previous hobbies. R2's cognition care plan reviewed/revised 3/31/25, indicated pain may affect cognition. R2's sleep care plan reviewed/revised 5/20/25, indicated R2 slept through the night without difficulties and was able to report alterations in sleeping patterns. Interventions included to offer pain medications as needed. R2's Pain-Comprehensive Observation dated 3/27/25, indicated R2 had moderate aching pain in her head caused by migraines and was not feeling well with the stomach flu. The assessment indicated rest and medication helped R2's pain, and movement made R2's pain worse. The assessment indicated anxiety and verbal expressions of pain was how resident expressed pain. The assessment indicated R2 had chronic pain and pain goals included sleep comfortably, comfort with movement, comfort at rest, and prefers to stay alert rather than increasing amount of pain medications or other sedating medications taken. R2's physician orders included the following scheduled medications: -10/6/20, pregabalin 100 mg (milligrams) by orally three times a day for fibromyalgia. -1/12/21, voltaren gel 1% 2 grams topically to right shoulder and bilateral knees four times a day for pain. -4/22/22, acetaminophen (pain reliever and fever reducer) 1,000 mg orally three times a day. -12/27/22, ropinirole 0.125 mg once a day one hour before bed for restless leg syndrome. -2/21/25, hydromorphone 1 mg orally twice a day and 2 mg orally twice a day for pain. -3/6/25, Topamax (anticonvulsant and nerve pain medication) 50 mg twice a day. R2's physician orders included the following PRN medications: -7/12/22, acetaminophen 1,000 mg orally for pain 1 to 3 out of 10. Non-pharmacological interventions: 1= Warm blanket, 2= re-position, 3= Ice pack, 4= Warm pack, 5= Aromatherapy. Once a day PRN. -2/21/25, hydromorphone 2 mg orally for pain 4-10 out of 10. Non-pharmacological interventions: 1= Warm blanket, 2= re-position, 3= Ice pack, 4= Warm pack, 5= Aromatherapy. Every four hours PRN. -3/25/25, Topamax 25 mg for headache. Non-pharmacological interventions: 1= Warm blanket, 2= re-position, 3= Ice pack, 4= Warm pack, 5= Aromatherapy. Once a day PRN. R2's vitals reviewed from 2/1/25 to 5/22/25, lacked evidence of R2's pain rating or scale. R2's progress note dated 4/27/25 at 10:26 p.m., indicated [R2] was steaming mad tonight. (Her words). She doesn't understand why she can't have enough pain meds for her back pain. [R2] never asked for any additional pain medication all shift. No follow-up was noted in R2's electronic health record. R2's medication administration record and progress notes during the time of medication administration were reviewed from 4/27/25 to 5/20/25 and indicated the following: -acetaminophen 1,000 mg PRN was administered during the night shift 19 out of 24 days. Five of the 19 days did not have a pain rating (verbal rating or use of non-verbal pain scale) or location documented. Three of the 19 days lacked a pain rating (verbal rating or use of non-verbal pain scale). One of the 19 days did not describe pain location. Non-pharmacological interventions were documented, and treatment was marked as effective. -hydromorphone 2 mg PRN was administered during the night shift 20 out of 24 days. Six of the 20 days did not have a pain rating (verbal rating or use of non-verbal pain scale) or location documented. Three of the 19 days lacked a pain rating (verbal rating or use of non-verbal pain scale). One of the 19 days did not describe pain location. Non-pharmacological interventions were documented, and treatment was marked as effective. A further review of R2's progress notes dated 4/27/25 to 5/20/25, indicated the following related to pain: -On 5/1/25 at 3:32 p.m., a note indicated R2 complained of headache and back pain during the shift and was not able to rate pain. R2 was given scheduled pain medications and was somewhat effective. Warm blanket given. Nurse encouraged R2 to get up as R2 was in room and in bed for the past two days, and R2 stated she did not want to get up due to headache. Vital signs were within normal limits. The note indicated staff would continue to monitor and update oncoming shift. During observation and interview on 5/19/25 at 1:10 p.m., R2 laid in bed and stated she had pain in her lower back and migraines. R2 stated she has experienced very bad pain for a long time now, and the pain medications did not help. R2 stated her pain was at an eight or nine out of ten most of the time. During observation and interview on 5/20/25 at 1:44 p.m., R2 stated the nurse gave her pain medication which would start to work soon. R2 laid in bed and stated she was tired. R2 stated she was not prescribed enough pain pills. During observation and interview on 5/22/25 at 12:09 p.m., R2 laid in bed and stated she was in pain and just received pain medication. R2 rated her pain at an eight and nine and stated her pain was in her lower back, right leg, and had a migraine. R2 stated nurses did not come back to check on her pain after pain medications given. During interview on 5/22/25 at 12:18 p.m., (LPN)-F stated R2 had a lot of different pain medications and had general pain such as back pain. LPN-F stated R2's pain was stable and relieved with current pain interventions, and R2 knew to inform the nurse when she had pain. LPN-F stated they gave scheduled pain medications and then PRN pain medications if resident continued to complain of pain. LPN-F called the provider if PRN pain medications were not effective. LPN-F stated a question popped up in the electronic health record when giving PRN pain medications where nurses indicated assessment of resident's pain, which included pain location and rating, and if the intervention was effective or not. During interview on 5/23/25 at 9:23 a.m., registered nurse (RN)-B stated staff monitored residents' pain every day in their first 100 days of admission and then assessed pain as needed with visual or verbal complaints of pain. RN-B stated R2 did not always give staff a pain rating and would say she hurts. RN-B stated R2 had chronic back pain, and R2's pain was typically described as well managed. RN-B reviewed the nursing note from 4/27/25, and stated staff should have followed-up on the comment made by R2 and stated they did not see any follow-up documented. RN-B stated it was important to manage pain for resident's quality of life. During interview on 5/23/25 at 10:00 a.m., the director of nursing (DON) reviewed R2's progress notes and stated staff assessed R2's pain daily. The DON reviewed R2's nursing note from 4/27/25, acknowledged R2's comment, and stated the nurse indicated R2 did not ask for as needed pain medications during the shift. The DON stated R2 and the pharmacist were involved in recent changes of pain medication. The facility provided progress note from 2/21/25 at 9:39 p.m., indicated Increase med dose: Res [R2] was upset about her Hydromorphone dose. Res stated that she talked to [nurse practitioner; (NP)] yesterday and NP stated that she would increase her Hydromorphone to 2 mg but NP didn't give an order. Res kept requesting to call NP to fix her Hydromorphone dose. Writer called [provider line] and updated about res complaints and NP ordered to change Hydromorphone to 1 mg PO, BID at 0800 and 1600 and Hydromorphone, 2 mg at noon and at 2000 and Hydromorphone, 2 mg, PO, Q4H [every 4 hours], prn. The note indicated R2 was told that her Hydromorphone dose increased and R2 was happy, she received her Hydromorphone 2 mg at bed time, and staff would update the oncoming shift. The facility provided Regulatory Visit note dated 4/11/25, indicated [R2] continues to [complain of] pain which is a behavioral pattern for her; subjective descriptions of pain do not really change or improve--even when she sometimes states that previous pain control was better, at that previous time her statements reflected significant pain/not well-controlled; and this pattern repeats. Therefore using more objective measures of pain - she has had less non-verbal pain behaviors with the most recent increase. The facility's Pain Management policy dated 4/28/25, indicated pain management included identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The policy indicated nursing staff assessed pain on an ongoing basis and completed pain assessments on admission, quarterly, with change in pain and with change of condition. Reports of pain were handled as high priority and nurses determined which pain scale to use based on many factors. The policy indicated staff followed parameters for as needed pain medication use when more than one as needed pain medication was ordered.

Based on observation, interview, and document review, the facility failed to ensure a resident with known heart failure was routinely assessed for new or worse symptoms as directed by the discharging hospital physician for 1 of 1 resident (R15). In addition, the facility failed to comprehensively assess a non-pressure skin condition, to ensure wound change could be adequately monitored and acted upon promptly to promote healing and reduce the risk of complication (i.e., infection, worsening) for 1 of 2 residents (R51) reviewed who had skin impairments. Finding include: R15 R15's admission Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted to the care facility on 5/5/25, had mild cognitive impairment, and an active diagnosis of peripheral vascular (or arterial) disease (a condition where narrowed arteries reduce blood flow to the arms and legs). R15's Hospital discharge note, dated 4/24/25 - 5/5/25, directed the care facility staff to monitor for signs of heart failure daily and more frequently as condition warrants including; assessing lung sounds daily, assessing for peripheral edema daily, measuring oxygen saturations daily at rest and with activity, and to notify the physician with any change in patient condition or worsening heart failure symptoms. R15's electronic medical record (EMR), including the Care Plan, Active Orders, and Progress Notes, all printed 5/22/25, lacked any direction for nursing staff to monitor R15 for signs and symptoms of worsening heart failure. The EMR lacked documentation of R15's edema and lung sounds. The EMR indicated R15's oxygen saturations were checked daily but did not indicate if the measurement was at rest or with activity. During observation on 5/29/25 at 1:54 p.m., R15 was sitting in his recliner chair in his room with a family member present. R51's bilateral hands appeared edematous. R15's family member stated she believed R15 was wearing some compression sleeves at the hospital but not any since being admitted to the care facility. During an interview on 5/21/25 at 12:16 p.m., registered nurse (RN)-C stated R15 did not have any routine orders for daily assessment, stating some residents would have ordered routine assessments, otherwise assessments would only be completed and charted on if there was a noted concern. During an interview on 5/22/25 at 8:00 a.m., nurse manager and assistant director of nursing (ADON) stated every resident in the transitional care unit had daily weights completed, however many times a resident would have specific orders regarding monitor shortness of breath, edema, lung sounds, etc. The ADON confirmed R15 left the hospital with directions to monitor R15 for signs of heart failure daily, stating she would expect to see the documentation in a progress note or medication administration record, confirming it was not there. The ADON stated the care community had good continuity of care but agreed it would be difficult to determine if R15 had worsening heart failure if his daily status was not being assessed and documented. 49034 R51 R51's admission Minimum Data Set (MDS) dated [DATE], indicated R51 had moderately impaired cognition and was diagnosed with heart failure, liver cirrhosis (chronic liver disease causing scarring, and decreased liver function), and polyneuropathy (a condition causing weakness, numbness, and pain in the feet and hands). The MDS indicated R51 had no ulcers or other open lesions of the foot. R51's care plan dated 4/17/25, indicated R51 was at risk for an alteration of skin integrity related to heart failure, liver disease, and edema in her legs. The care plan indicated that licensed staff were to complete a visual body observation weekly, implement appropriate interventions for any areas of concern, and notify the provider and family of these new areas. The care plan indicated the nursing assistants (NA) were to observe skin daily during cares and notify the nurse promptly of any areas of concern. R51's Comprehensive Skin Risk and Braden assessment dated [DATE], indicated R51 was at risk for skin breakdown (with a score of 17) related to decreased activity, nutrition level, and shear/friction risk. The assessment indicated R51 had bruises present but had no infections, ulcers, or open lesions of the foot, no burns, skin tears, rash/abrasion, skin tear/laceration, or moisture-associated skin damage (MASD). The assessment did not include documentation of any other skin injuries to the foot. The document indicated the NAs were to complete a daily skin assessment and the licensed nurse would complete an assessment weekly. The Comprehensive Skin Risk and Braden assessment was completed on: - 4/23/25 and indicated R51 had bruising with none of the other skin alterations as outlined above. - 4/30/25 and indicated R51 had none of the skin alterations as outlined above, and bruising was not present. - 5/7/25 and indicated R51 had none of the skin alterations as outlined above and R51 continued with no bruising. - 5/14/25 and indicated R51 had an open lesion(s) on the foot but did not include a further description of this lesion. R51 continued to have bruising. R51's Visual Body Observation dated 4/16/25, did not indicate R51 had a wound to her right great toe. The Visual Body Observation was also completed on 4/23/25, and 5/7/25, and did not indicate that R51 had a wound to her right great toe. The observation dated 5/14/25, included a section titled Describe any additional new alterations in the skin from above or otherwise noted and the section did not include a description of any wound to R51's right great toe, nor did the rest of the documentation. R51's Medication Administration Record (MAR) dated 5/1/25 to 5/19/25, included an order starting on 5/14/25, to apply a thin layer of bacitracin to R51's right great toe and cover daily until the wound was healed. The order was completed daily from 5/14/25 to 5/19/25. R51's progress note dated 5/8/25 at 9:46 p.m., indicated R51 had requested the registered nurse (RN) to check her right great toe because it feels tender and noted an old scab and dry skin from a healed blister that was partially falling off. The note indicated that R51 requested the dry skin be removed entirely and the RN applied bacitracin (an antibiotic ointment) to the area. R51's progress note dated 5/12/25 at 10:28 p.m., indicated R51's entire tip of right big toe has a sore on it. The note indicated R51's right big toe had a dressing covering it, that the resident said had not been changed in approximately five days. R51 complained of soreness and asked for her dressing to be changed. The note indicated RN-A had cleansed the sore with saline, applied bacitracin, and covered the wound with gauze and tape. The note did not include a physical description of this sore or measurements. R51's progress notes dated 5/17/25 at 11:49 p.m., and 5/18/25 at 11:00 p.m., indicated that R51's dressing to the right big toe was changed as ordered. The notes did not include a physical description of this sore or measurements. R51's progress notes dated 5/8/25, through 5/19/25, were reviewed and did not include any further description of R51's wound to her right great toe. R51's Wound Management tab printed on 5/20/25 at 8:56 a.m., indicated no active, healed, or discontinued wounds had been documented under this tab since admission on 4/16/25. R51's Wound Details dated 5/20/25 at 2:52 p.m., indicated R51 had a wound to her right big toe with a specific wound type of trauma from bumping it? that measured .5 cm by .5 cm. The wound was described as a small dry area and R51 had thought she bumped it. The note indicated R51 had no pressure forces and wore socks and slippers. R51's medical record was reviewed and no further descriptions of R51's wound to her right great toe were found. During an interview on 5/20/25 at 1:12 p.m., R51 stated she didn't have a wound on her toe when she was admitted . R51 stated she thought her sock was too tight about a month ago and had rubbed on her toe and caused a wound to open up. R51 stated It [the wound] was ugly and someone had applied a dressing to her toe when they had first found it. During an interview and observation on 5/20/25 at 1:20 p.m., licensed practical nurse (LPN)-A confirmed she was R51's nurse. LPN-A stated that R51 had no skin issues at the moment and if she did, she could find it under the observations tab. LPN-A stated they would put in on the visual body observations and it should be documented there, and all she saw documented were a scattering of bruises. LPN-A stated the skin was assessed every week on bath day or if something was reported by the aides. LPN-A stated if they had found something new they would open up an event, get an order for wound care, and then should open up something so they would continue to monitor it. On request, LPN-A examined R51's right foot, and a small pink wound was noted to the end of R51's right great toe and R51 stated the wound hurts very much so. During an interview on 5/21/25 at 7:56 a.m., the assistant director of nursing (ADON) stated she followed residents with chronic wounds, or wounds that were more challenging or having a hard time healing. The ADON stated she was not following any residents in R51's unit. At 10:30 a.m., the ADON stated she would expect a full head-to-toe skin assessment to be completed on admission and then if there were any abnormalities, she would expect them to add a record to wound management if any new wounds were found so they wounds could be tracked. The ADON confirmed that she had reviewed R51's record but did not see a wound management note, that would include measurements or a description from when the wound was found/before survey entrance. During an interview on 5/21/25 at 11:12 a.m., nurse practitioner (NP)-A stated she had been notified of the wound to R51's right toe so she had assessed it on 5/14/25 on her visit but had not documented this. NP-A stated the wound was pink in color and she wanted a daily dressing change for it, so she had put in the order for the bacitracin and gauze. NP-A stated she did not feel that the wound was caused by pressure but was possible the wound was caused by R51 bumping her toe and not noticing related to her polyneuropathy. During an interview on 5/21/25 at 2:01 p.m., registered nurse (RN)-A stated she remembered the day of 5/14/25, when R51 had told her that her toe was hurting, and she had a dressing on it but the dressing didn't have a date on it so she was unsure how long it had been on there. RN-A stated the tape was very stuck to R51's skin and she had to use saline to get the dressing off. RN-A stated when she did get the dressing off of R51's big toe, a scab came off with it and a wound was present underneath. RN-A stated there was a small open wound underneath the scab but was unable to describe it in further detail. During an interview on 5/22/25 at 10:06 a.m., the director of nursing (DON) stated that she would expect nursing staff to open a wound management assessment if a new wound was discovered so the wound could be tracked. The facility Skin Integrity policy dated 3/10/25, indicated the facility staff would use the Wound Management area to document skin integrity issues. The policy indicated if, on a daily skin check by the NA, an alteration was noted, the nurse would follow the documentation guidelines below for any new skin alterations. The policy indicated staff were to document the skin alteration's specific location, physical description, and measurements. The policy included a section titled Measuring/Describing Wounds and included 14 items including the location of the wound, type of wound, measurements (length, width, depth), tissue types (epithelial, granulation, slough, eschar/slough, red/pink, etc), if drainage is present (and description if so), odor, pain, wound edge description, etc.

Based on observation, interview and document review, the facility failed to ensure a routine dental referral for a missing front tooth was followed up on along with a recommendation for an over-the-counter fluoride rinse to maintain oral health for 1 of 2 residents (R18) reviewed for dental services. Findings include: R18's quarterly Minimum Data Set (MDS), dated [DATE], indicated R18 was admitted to the care facility on 9/20/17, was cognitively intact and required supervision or touching assistance with oral hygiene. R18's most recent dental assessment form by Apple Tree Dental, dated 12/16/24, indicated R18 had obvious broken natural teeth and inflamed and bleeding gums. The note indicated R18 required direct staff supervision and if capable, could maintain oral care independently recommending oral care twice daily and to swish twice daily with an over-the-counter fluoride rinse. The Notes to Nursing Staff for follow up section indicated R18 was self-conscious of missing teeth and would like a dental assessment to repair/replace front teeth. R18's Care Conference Summary, dated 4/29/25, indicated ancillary services, including dental services, were offered to and accepted by R18. The note indicated R18's last dental visit was 4/6/23. R18's care plan, dated 9/21/17, indicated staff were to provide R18 with set up and supervision for cues for dental care. The care planned lacked any interventions related to R18 using an over-the-counter fluoride rinse. R18's Active Orders, printed 5/22/25, lacked any indication R18 was using an over-the-counter fluoride rinse. R18's electronic medical record (EMR) further lacked any indication that the dental referral to repair or replace her front teeth was followed up on. During an interview on 5/19/25 at 2:10 p.m., R18 stated her front tooth had fallen out, and while she did not have pain, she kept her mouth shut a little more due to feeling self-conscious of missing a front tooth. During an interview on 5/21/25 at 12:58 p.m., the social services designee (SSD) stated Apple Tree Dental came to the facility approximately every 4-6 months and the Health Information Director (HID) kept a running list of residents who were to be seen at the next dental visit. The SSD reviewed R18 most recent assessment from Apple Tree Dental and confirmed there was a referral for a follow up appointment related to her missing front tooth but was unaware of whether R18 had seen the dentist or had a future referral for dentistry, stating the HID would know that information. During an interview on 5/21/25 at 1:13 p.m., the HID stated R18 had refused dental care in the past so they would only make an appointment for her if she asked. The HID stated he was unaware of any dental issues for R18 and that she was not on his list to be seen by the dentist. During a follow up interview at 1:22 p.m., the HID referred to a dental visit for R18, dated 6/27/22 and two dental refusals dated 1/19/23, 4/6/23, and 10/9/23. The HID reviewed R18's chart, confirming R18 was seen by Apple Tree Dental on 12/16/24, stating he is responsible for reviewing the forms and following up on any recommendations, stating the referral should have been followed up on but was not. During an interview on 5/22/25 at 8:28 a.m., the long-term care manager and registered nurse (RN)-B stated the HID was responsible for referring the dental visits/assessments from Apple Tree Dental and passing on any recommendations as needed. RN-B stated she was unaware of the recommendation for R18 to have an over-the-counter fluoride rinse and to have follow up regarding her missing tooth. A facility policy titled Dental Services, reviewed 11/15/24, indicated it was the facility policy to assist residents in obtaining routine and 24-hour emergency dental care.

Based on observation and interview, the facility failed to ensure oxygen administration was administered according to physician orders for 1 of 1 resident (R11) observed for respiratory services. Findings include: R11's face sheet printed 5/22/25, indicated R11 had a diagnosis of chronic respiratory failure with hypoxia (a condition where the lungs struggle to provide enough oxygen to the blood, leading to low oxygen levels in the body). R11's significant change Minimum Data Set (MDS) dated [DATE], indicated R11 was on hospice, had moderate cognitive impairment, received maximal assistance with oral hygiene, eating, showers, upper body dressing, personal hygiene and was dependent with bed mobility, transfers, toileting hygiene and lower body dressing. R11's MDS indicated resident received oxygen therapy and identified diagnoses of dementia, chronic obstructive pulmonary disease, and respiratory failure. R11's orders printed 5/22/25, indicated orders for 2 to 4 liters of oxygen, continuous via nasal cannula to maintain SAO2 (arterial oxygen saturation) over 90%. R11's care plan printed 5/22/25, indicated I require oxygen therapy related to restrictive lung disease/chronic respiratory failure. R11's care plan goal indicated I will not exhibit signs of hypoxia (cyanosis, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse). The care plan interventions indicated the administration of oxygen at 2 liters per minute (Lpm) via nasal cannula (NC). R11's Medication administration record (MAR) printed 5/22/25, indicated oxygen 2 Lpm to 4 Lpm via NC, continuous to maintain SAO2 (oxygen level in blood) at 90% for a diagnosis of respiratory failure with hypoxia. During observation on 5/19/25 at 2:00 p.m., R11 was sleeping in bed in supine position she had an oxygen nasal cannula on her nares, and the oxygen tank was not on. R11 appeared to be resting comfortably with no signs of respiratory distress. During observation on 5/19/25 at 4:35 p.m., R11 was in bed awake, restless, and her respirations were rapid and labored. R11's oxygen nasal cannula was under her chin and the oxygen tank was not on. During observation on 5/19/25 at 4:38 p.m., surveyor left the room to obtain staff assistance, while licensed practical nurse (LPN)-C and a nursing assistant (NA) entered R11's room. Staff exited R11's room within two minutes. During observation on 5/19/25 at 4:40 p.m., surveyor returned to the room to check on R11 and R11 was in bed laying on her left side with the oxygen cannula on her nares but the oxygen tank was not on. Surveyor left the room again to obtain staff assistance. LPN-C returned to the room with surveyor. During observation and interview on 5/19/25 at 4:41 p.m., LPN-C stated R11 had an order for continuous oxygen to keep her SAO2 above 90%. LPN-C stated R11 removed her nasal cannula but now it's on her nares. LPN-C was interviewed at R11's bedside, and confirmed the oxygen tank was not on. LPN-C stated It's always on. Maybe when they laid her [R11] down in bed after lunch, they [nursing assistants] didn't start the oxygen. LPN-C verified R11's breathing was rapid and appeared to be short of breath. LPN-C turned oxygen on at 2 liters, checked R11's O2Sats (oxygen saturation) and it was 69%. LPN-C instructed R11 to take deep breaths, O2Sats increased to 74%. LPN-C increased the oxygen to 4 Lpm and after a couple minutes, R11's O2Sats were 93%. R11's electronic medical record (EMR) lacked documentation regarding R11 being without oxygen on 5/19/25, and her SAO2 dropping below 90%. R11's Safety event described as a Medication Incident dated 5/20/25, indicated no vitals were recorded and there were no associated progress notes or additional details included for the event. During observation and interview on 5/21/25 at 7:21 a.m., nursing assistant (NA-E) switched R11's oxygen tank cannula with the portable oxygen tank's cannula and turned on the portable tank to 2 Lpm. NA-E stated he asked the nurse what R11's oxygen liter flow should be before he switched the cannula. During interview on 5/21/25 at 10:03 a.m., LPN-D stated this morning R11's O2Sats were 96% at 2 Lpm via her portable oxygen tank. During interview on 5/22/25 at 8:48 a.m., LPN-E stated the nurses monitored O2Sats and respiratory status of residents receiving oxygen. LPN-E stated the NAs were allowed to switch residents from a portable to a stationary oxygen unit, keeping the same oxygen liter. LPN-E stated if a resident O2Sats dropped under 90%, the nurse needed to make a progress note and report to the next nurse. During interview on 5/22/25 at 9:30 a.m., nurse manager/register nurse (RN)-B stated NAs were responsible for placing and switching between the portable and stationary oxygen tank. RN-B stated the nurses were responsible to monitor O2Sats levels, oxygen liter flow, replacing the oxygen tubing, and oxygen bubbler. RN-B stated when a resident had an incident like R11's, the expectation was for nurses to document and update the providers. RN-B verified there was not documentation about R11's oxygen incident. During interview on 5/22/25 at 12:55 p.m., director of nursing DON stated R11's oxygen incident was brought to her attention on 5/19/25. DON stated the nurse practitioner and guardian were updated about incident as a medication error. DON stated she has been monitoring R11's O2Sats and as soon as they learned about this incident, the staff was re-educated. DON indicated the staff was very aware of the need to ensure residents were receiving oxygen as ordered. Facility's policy titled Oxygen: Liquid Stationary dated 3/10/25, indicated oxygen will be administered per order.

Based on observation, interview, and document review, the facility failed to ensure resident's needs were addressed in a respectful and dignified manner when a resident (R12) requested incontinence assistance. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had intact cognition and diagnoses of cancer, anemia, hypertension, diabetes mellitus, psychotic disorder, and chronic obstructive pulmonary disease. R12 had hallucinations, verbal behaviors towards others, and did not reject cares. R12 was always incontinent of bowel and bladder. R12's bowel toileting program care plan revised 4/21/25, directed staff to offer bed pan after breakfast between 9:30 a.m. and 11:00 a.m. R12's activities of daily living (ADL) care plan related to toileting revised 4/21/25, indicated R12 was incontinent of bowel and bladder and required extensive assist of one staff for toileting. The care plan directed staff to check and change and/or offer bed pan upon arising, after meals, before bed and as needed. R12's ADL care plan related to transfers revised 4/21/25, indicated R12 required total assistance of two staff for transfers using a full body mechanical lift. R12's progress note dated 4/21/25 at 3:37 p.m., indicated: BOWEL TOILETING PROGRAM: An individualized, resident specific toileting program was developed on 4/3/25, based on the assessment of the resident's unique bowel pattern in which the resident is to be offered the bed pan after breakfast between [9:30 a.m. and 11:00 a.m.]. She is at risk for impaired elimination related to diagnoses of COPD, rectal cancer, and Delirium aeb [as evidenced by] weakness and immobility. She is not always able to effectively communicate needs and request toileting. She requires total assist for check and change. She has a history of being frequently incontinent of bowel, but more recently bowel incontinence has increased to always incontinent. Most of her incontinent episodes occur following breakfast between 0930-1100, [9:30 a.m. - 11:00 a.m.) per staff. Resident would benefit from increased continence. During the reference period week of 4/11/25-4/17/25, the program was followed one day. Resident did not have a continent [bowel movement] during that time the program was carried out During interview on 5/19/25 at 2:21 p.m., R12 stated she was incontinent pooping and peeing on herself and waited for staff assistance with cares for extended periods of time. During observation on 5/21/25 at 8:30 a.m., nursing assistant (NA)-G assisted R12's roommate with cares. At 8:44 a.m., NA-C wheeled R12 into the room after breakfast, and R12 stated I just did it again and needed a change. NA-C ensured R12 had call light within reach and left the room. At 8:48 a.m., NA-D entered the room to assist NA-G and R12's roommate. Shortly after, NA-D left the room and there was no mention R12 needed assistance. LPN-D entered the room to give R12's roommate medication and left. There was no mention R12 needed assistance. At 9:02 a.m., unknown nursing assistant entered the room to assist NA-G and R12's roommate. R12 expressed she needed assistance and unknown nursing assistant assured R12 she would be assisted soon. LPN-D and unknown nurse entered the room to assist R12's roommate and brought a full mechanical lift into the room. During observation on 5/21/25 at 10:14 a.m., NA-G was in R12's room and finished cares with R12. R12 laid in bed, and R12 stated staff finally assisted her. During interview on 5/21/25 at 10:27 a.m., NA-G stated R12 was assistance of one with most cares and needed assistance of two staff for transfers with the full mechanical lift. NA-G stated R12 had a small incontinent bowel movement and offered R12 the bed pan, and R12 refused. NA-G stated R12 verbalized she wanted to use the toilet, and R12 was not able to since she transferred with a full mechanical lift. NA-G stated she would redirect R12 and told R12 staff would help her with incontinent cares. During interview on 5/21/25 at 1:09 p.m., R12 was in bed and stated she did not use the toilet and was able to tell when she needed to use the bathroom. R12 stated she used a full mechanical lift to transfer so was not able to get to the toilet. R12 stated she did not like to use the bed pan, because the bed pan was hard and uncomfortable. R12 stated use of a commode was brought up in conversation before but had not used a commode. R12 stated it was important for her to stay dry and was hurt, with a tear down her face, when asked about incontinence cares. During interview on 5/21/25 at 1:52 p.m., NA-G stated R12 called when she needed a change in incontinence product and/or checked R12 every couple of hours. NA-G stated R12 needed more incontinence assistance than usual today. During interview on 5/22/25 at 11:18 a.m., licensed practical nurse (LPN)-E stated a staff member should respond to a resident's request after they finished assistance with the current resident. LPN-E stated R12 was incontinent and used a full mechanical lift. LPN-E stated residents who used a mechanical lift could use a commode and did not believe R12 tried a commode. LPN-E did not know if R12 was able to sense when she needed to use the restroom or wanted to use the toilet and stated the nursing assistants knew more about R12. During interview on 5/22/25 at 11:42 a.m., registered nurse (RN)-B staff should assist a resident within five to 10 minutes when resident asked for incontinence assistance. RN-B stated RN-D assessed bowel and bladder programs on a quarterly basis. RN-B stated R12 had a bowel program and followed the standard urinary incontinence cares of assistance upon rising, between meals, at bedtime and as needed. RN-B was not aware of any trial of a commode and stated the interdisciplinary team usually discussed commode use when bowel and bladder programs were reviewed. RN-B was not aware R12 requested toilet use. During interview on 5/22/25 at 2:51 p.m., RN-D stated they reviewed residents' bowel and bladder programs during their MDS assessment period. RN-D stated they reviewed residents' chart and interviewed staff and residents to assess bowel and bladder programs. RN-D stated R12 recently started a bowel program when staff stated R12 had the urge to have a bowel movement after breakfast. RN-D did not know how to answer that one when asked about a bladder program. RN-D was not aware of any bowel and bladder concerns for R12. During follow-up interview on 5/23/25 at 8:46 a.m., NA-G stated they were with R12's roommate from approximately 8:00 a.m. and 9:00 a.m NA-G stated they answered a couple other call lights before they assisted R12, while they waited for assistance to transfer R12 into bed. During interview on 5/23/25 at 9:45 a.m., the director of nursing (DON) stated R12 was not always able to request toileting assistance before an incontinence episode. DON expected staff to communicate with nurses or nurse managers about bowel and bladder concerns to assess if there could be gains of continence for residents. The DON expected staff to prioritize to meet residents' needs. The facility's Resident Rights policy dated 11/15/24, indicated Cassia facilities recognize that they must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of the resident's quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R4, R32, R34, R44) over [AGE] years old whose vaccinations histories were reviewed. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R4's face sheet, dated 4/10/24, indicated she was [AGE] years old and resided in long-term care. The face sheet indicated diagnoses which included type 2 diabetes mellitus. R4's facility immunization record and MIIC (Minnesota Immunization Report) report, both dated 4/10/24, indicated she received the received PPSV23 on 10/20/1999, and again on 3/29/2006 followed by the PCV13 on 9/21/15. R4's facility immunization record lacked evidence that R4 was offered or received education regarding PCV20 vaccine. The electronic medical record (EMR) lacked evidence of shared clinical decision making with the physician regarding the PCV20. The EMR lacked evidence R4 was offered or received PCV20. R32's face sheet, dated 4/10/24, indicated she was [AGE] years old and resided in long-term care. The face sheet indicated diagnoses included emphysema (condition in which the air sacs of the lungs are damaged and enlarged causing breathing issues), and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe). R32's facility immunization record and MIIC (Minnesota Immunization Report) report, both dated 4/10/24, indicated she received the received PPSV23 on 7/19/2007, the Prevnar 7 (PCV7) on 7/19/2007 followed by the PCV13 on 9/16/15. R32's facility immunization record lacked evidence that R32 was offered or received education regarding PCV20 vaccine. The electronic medical record (EMR) lacked evidence of shared clinical decision making with the physician for PCV20. The EMR lacked evidence R32 was offered or received PCV20. R34's face sheet, dated 4/10/24, indicated he was [AGE] years old and resided in long-term care. The document indicated diagnoses included hypertension (high blood pressure), acute respiratory distress (condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen), and unspecified diastolic (congestive) heart failure (happens when the heart muscles do not relax properly between beats). R34's facility immunization record and MIIC (Minnesota Immunization Report) report, both dated 4/10/24, indicated he received the received PCV13 on 10/22/15, the PPSV23 and PCV13 on 9/15/16, followed by the PPSV23 on 9/12/17. R34's facility immunization record lacked evidence that R34 was offered or received education regarding PCV20 vaccine. The electronic medical record (EMR) lacked evidence of shared clinical decision making with the physician for PCV20. The EMR lacked evidence R34 was offered or received PCV20. R44's face sheet, dated 4/10/24, indicated he was [AGE] years old and resided in long-term care. The document indicated diagnoses included hypertension, unspecified atrial fibrillation (abnormal heart rhythm), and chronic kidney disease (kidneys no filtering waste properly). R44's facility immunization record and MIIC (Minnesota Immunization Report) report, both dated 4/10/24, indicated he received the received PPSV23 on 3/13/2011, followed by the PCV13 on 3/13/15. R44's facility immunization record lacked evidence that R44 was offered or received education regarding PCV20 vaccine. The electronic medical record (EMR) lacked evidence of shared clinical decision making with the physician for PCV20. The EMR lacked evidence R32 was offered or received PCV20. A TCU admission packet was provided on 4/10/24 to surveyor. The admission packet includes three separate pages of information on RSV, COVID, and pneumococcal vaccines that provided to TCU residents. The document prompts a conversation regarding each immunization. The document is signed by provider with a note under additional comments, advise pt. discuss with PCP. During interview on 4/10/24, at 10:43 a.m., infection preventionist (IP)-A verified she was the infection preventionist. IP verified it falls in her responsibility to ensure residents are up to date on all immunizations. She stated that immunizations are verified through MIIC (Minnesota Immunization Information Connection). IP-A indicated she used the current Centers for Disease Control and Prevention (CDC) recommendations for immunization guidelines and verified using the table from CDC from March 2023 for pneumococcal vaccines. IP stated that TCU residents are not given COVID, RSV (respiratory syncytial virus), or pneumococcal vaccines as the provider feels they are too sick while they are here to receive it. IP stated that LTC residents are offered the COVID, flu, tetanus and pneumococcal (PPSV23 or PCV13) vaccines. On 4/10/24, at 12:15 p.m., IP-A verified after she reviewed the EMR, R4, R32, R34, and R44's pneumococcal immunizations as listed above. On 4/10/24, at 1:23 p.m., IP-A verified that R4, R32, R34, and R44 where not offered the PCV20. IP-A stated no residents have been offered the PCV20 in the facility. IP-A verified that when checking the pneumococcal immunizations that she was verifying the completion of the series (PPSV23 and PCV13) and the facility was not doing any shared clinical decision making for the PCV20. IP-A verified that no education or conversations have been had with not only the residents listed above but any residents in the long-term care. IP-A stated that any TCU residents are referred to the primary care provider to obtain the pneumococcal immunizations as the provider overseeing their care (while in TCU), won't give orders for the immunizations as it is felt they are to sick while they are there. IP-A verified the documents listed above in the admission packet for TCU residents. IP-A stated the LTC admission packet is different and does not include these documents. On 4/11/24, at 10:12 a.m., IP-A reviewed immunization consent forms with surveyor. IP-A stated they administer COVID vaccines the beginning of April and obtained consent to do this. The same form is used for all immunization consents, titled Immunization Consent. IP-A stated in the short description, she puts in what immunization is being discussed; for example, covid vaccine. IP-A stated that if all the radio buttons are not answered on the form, it cannot be locked and signed. IP-A verified that the consents signed for the covid vaccine (described in the short description), the only vaccine that was discussed was the covid vaccine. IP-A verified that for the pneumococcal vaccine section of the form, she marked on the radio-button no-I do not wish to receive the pneumococcal vaccinations that are recommended according to the CDC/ACIP and no discussion about the pneumococcal vaccine was had. IP-A verified the Immunization Consent forms for R4, R32, R34, and R44 did not indicate there was a discussion or education provided about PCV20 despite the radio-button having indicated it had been refused. During interview on 4/11/24, at 10:52 a.m., administrator verified that immunizations are given upon admission, and she referred to infection preventionist and director of nursing for their expertise. A facility policy titled Pneumococcal Vaccine with a review date of 7/24/23 was provided. Policy indicated to offer our residents immunization again pneumococcal disease in accordance with current CDC or state guidelines and recommendations. The document included the CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023.

Based on observation, and interview, the facility failed to ensure appropriate infection control measures were followed related to ensuring clean personal was transported intrafacility in a method that ensured cleanliness and protected the clean laundry . This had the potential to affect all 41 residents on the long-term care floor (LTC) along with an unspecified number of residents whose laundry is done by the facility in the transitional care unit (TCU). Findings include: On 4/8/24 at 2:06 p.m., a four-tiered metal open and uncovered laundry cart with personal clothing items was observed to be on 2nd floor uncovered. Along the top rack, personal items (short sleeve shirts, sweatshirt, etc.) hanging from hangers were hung from the metal bars along the sides and on the shelves were folded personal items (pants, etc.). On 4/08/2024, at 2:13 p.m., laundry aide (L)-A verified that they were delivering resident's personal laundry to their rooms. L-A verified this is the cart that is used to deliver all resident laundry on the second floor and a similar cart is used for the TCU. L-A verified that the cart is a metal four-tiered open cart. L-A stated that all the resident names are along the top of the cart and that is where the items that require hangers are hung (in correlation to their names). L-A verified that shelves are used for resident items that go in their drawers. L-A verified that cart is not covered. L-A stated the laundry cart for downstairs is smaller as we don't do everyone's laundry downstairs, like we do up here, as it is a temporary stay. L-A was not able to identify how many residents' laundry on the TCU was being done currently as it always is changing. On 4/10/24, 8:14 a.m., during a laundry tour both laundry carts for LTC and TCU were observed. Neither laundry carts had covers or a means to protect the clean laundry from dust or soil attached to them. The laundry cart used to deliver the personal items for TCU was similar to the cart used for LTC, just smaller in size. The carts used for linens were covered with attached plastic covers. L-A stated, the only reason I can think of why they aren't covered is because we put items on the top level. L-A verified, the linen carts are covered, and the personal laundry carts are not covered. L-A was unsure the reason to cover the laundry carts. During interview on 4/10/24, at 8:29 a.m., director of environmental services (ES)-A verified that they oversee laundry services and had worked in the facility for many years. ES-A verified that personal laundry carts are not being covered. ES-A verified that they are aware the personal item carts are to be covered during transport as they got notified about a month and a half to two months ago and stated, it doesn't make sense to me. ES-A verified the facility has not been covering the personal laundry carts when delivering items to residents' rooms and this is something we need to fix. During interview on 4/11/24, at 10:52 a.m., administrator verified it is important that any clean linen is covered for infection control purposes. Administrator added that education was provided to the team that carts that have clean linen must be covered at all times. A facility policy titled, Sorting Clean Linen, with a review date of 3/23/23 was provided. Document indicated that clean linen shall be dried, folded and sotred in enclosed, clean, designated locations.

Based on observation, interview and document review, the facility failed to ensure a dry-powder inhaler was administered in accordance with manufacturer instructions and current standards of care for 1 of 1 resident (R121) observed to receive inhalers during the survey. Findings include: A US National Institutes of Health (NIH) National Heart, Lung, and Blood Institute article titled, How to Use a Dry Powder Inhaler, dated 10/2021, identified such devices contained pre-set doses of medicine in a powder form. A section labeled, How To Use It, directed multiple steps to ensure the safe, accurate use of the medication including, 11. If your medicine is an inhaled corticosteroid, rinse your mouth with water and spit it out. Rinsing helps to prevent an infection [i.e., thrush] in the mouth. In addition, a Patient Information Breo Ellipta insert, dated 5/2023, identified Breo Ellipta combined two medications, including a corticosteroid, and was used to treat chronic obstructive pulmonary disease (COPD) and asthma. A section labeled, Instructions For Use, demonstrated how to use the device for oral inhalation along with corresponding photos. This included, Step 6. Rinse you mouth See Figure K . Rinse your mouth with water after you have used the inhaler and spit the water out. Do not [bolded] swallow the water. R121's Hospitalist Discharge Summary, dated 4/4/24, identified R121 was hospitalized with chronic respiratory failure and hypoxia due to aspiration pneumonia. A section was provided labeled, Discharge Medications, which outlined R121's medications for the care center. This included orders for, Breo Ellipta 100-25 mcg [micrograms]/dose inhalation powder . Inhale 1 puff by mouth once daily. R121's subsequent Nursing Admission, dated 4/4/24, identified R121 admitted to the care center on the same date. The completed evaluation identified R121 use oxygen on a continuous basis, and R121 did not wish to self-administer medications while at the care center. R121's MAR, dated 4/2024, identified R121's current medication orders, including the special instructions or directions, and spaces for staff to record their administration. This included an order which read, Breo Ellipta . 100-25 mcg/dose ., along with directions to administer one puff daily and a box labeled, Special Instructions, which read, Rinse mouth after use to reduce risk of thrush. The order had a listed start date, 04/04/2024 - Open Ended. On 4/9/24 at 8:05 a.m., a medication pass with licensed practical nurse (LPN)-A was observed. LPN-A removed R121's medications, including multiple inhalers, from the mobile cart in the hallway and prepared them for administration. Included in these, LPN-A removed a Breo Ellipta inhaler which outlined instructions to take 1 puff every day. LPN-A brought R121's inhalers, including the Breo Ellipta, and prepared oral medications to his room. R121 had oxygen in place via nasal cannula and was soft-spoken with conversation. LPN-A removed the inhaler from the package and asked R121 if he would like to prime the device or if LPN-A should aloud. LPN-A then primed the device and handed it to R121 who inhaled a dose from the inhaler. LPN-A then removed, primed and handed the second inhaler to R121 who inhaled a dose. When done, LPN-A replaced both inhalers back into their respective containers and said aloud, You got your call light. LPN-A removed their gloves, used hand sanitizer and left the room. There was no offer, attempt or direction to have R121 rinse his mouth after using the Breo Ellipta. Following, on 4/9/24 at 8:14 a.m., R121 was interviewed. R121 explained he admitted to the care center a few days prior from the hospital and had been on multiple inhalers for a long time. R121 was questioned about rinsing his mouth with water after using the Breo Ellipta and expressed, You're supposed to do things like that, but I don't [usually]. However, R121 stated the care center staff, so far, had never told or asked him to do that when they administer his Breo Ellipta. On 4/9/24 at 8:18 a.m., LPN-A was interviewed and verified they did not complete or offer R121 any rinse and spit after the inhaler use. LPN-A stated they didn't as the MAR (Medication Administration Record) didn't direct to do so and, typically, it would if such was needed adding aloud, I don't think I missed anything[?] LPN-A then reviewed R121's electronic MAR and expressed it actually did direct to rinse the mouth after use of the inhaler. LPN-A stated, I missed that. LPN-A expressed they would return to R121 and have him rinse and spit adding such was important to do so the medication didn't remain in the oral cavity. LPN-A added, It can be bad for the oral cavity if it sits in there. On 4/10/24 at 11:13 a.m., a telephone interview was attempted with the facility' consulting pharmacist, however, they were unavailable. As a result, a telephone interview was completed with pharmacist (P)-A who worked for the dispensing pharmacy. P-A verified Breo and Incruse were both a dry-powder inhaler, and they expressed a rinse and spit should be done after using the Breo Ellipta because it has a steroid in it, adding failure to do such would cause a chance for developing thrush. P-A explained if giving multiple inhalers, then the recommendation would be to give the Incruse, followed by Breo, and then rinsing the mouth to help avoid medication particles becoming entrapped in liquid in the mouth. On 4/10/24 at 12:15 p.m., the assistant director of nursing (ADON) was interviewed with the administrator present. ADON explained administration instructions, such as rinse and spit, were recorded in the orders and, as a result, the MAR for the nurse to see and follow. ADON stated they had visited with LPN-A about the administration observed (on 4/9/24) who verified they didn't offer or provide a rinse and spit after the inhaler. ADON stated they told LPN-A where to review those instructions in the MAR going forward. ADON stated a rinse and spit should be done to prevent thrush, and education will be completed with the nurses. A facility' Inhaler Use policy, dated 3/2024, identified guidelines for administration for oral inhaled medications. This outlined, After inhalation of corticosteroids such as . resident should rinse their mouth with water and spit it out.

Based on observation, interview, and document review the facility failed to ensure the correct application of a neck brace to minimize the risk of spinal misalignment and corresponding adverse effects for 1 of 1 residents (R34) reviewed for neck brace application. Findings include: The undated Maimi J Instructions for Use, indicate the Miami J collar (neck brace) is used to provide immobilization to the cervical spine (bones or vertebrae in the neck) and indicates proper sizing is critical for achieving comfort and immobilization. The manufacturer guidelines indicate collar application must be secure to ensure proper fit, maintain alignment, and prevent the chin from slipping inside the collar. The guideline indicated if the patient can slip his/her chin inside the collar, it is [a] clear indication that it is not snug enough. R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 had moderately impaired cognition and was diagnosed with fractures of the vertebrae in the neck and heart failure. R34 required maximal assistance with oral hygiene, bathing, and bed mobility. R34's Physician Order Report dated 2/10/23, indicated R34 must wear a neck brace at all times, and it must fit properly. R34 ' s care plan dated 2/3/24, indicated R34 disliked the neck brace but neurology had indicated R34 must wear it at all times. R34's neurology note dated 8/8/23, indicated R34 had chosen not to have surgery to treat his spinal fracture and instead was fitted for a Miami J collar. The note indicated R34 was wearing his cervical collar but [the] chin is tucked down in the collar along with his clothing. R34's provider note dated 3/18/24, indicated R34 was using a Miami J collar and expected to wear the Maimi J collar indefinitely. The note indicated R34 was wearing the collar on assessment, and it appeared well fitted but the chin was tucked into the collar. R34's medical record was reviewed and lacked indication R34 had refused proper collar application and if so risk versus benefit education had been provided to the resident and representative. During an observation on 4/8/24 at 1:19 p.m., R34 was observed sitting in his wheelchair in his room wearing a Miami J collar. R34's chin and bottom lip were tucked into the collar and were not visible. The collar had two padded plastic parts, a front part that fit under the chin and a back part that fit behind the neck. The two parts were held together by two blue Velcro strips. On the left side of the collar, there was an approximate 1.5-inch vertical gap between the front and back parts of the collar where the neck was observed. The Velcro strip on the left side of the collar was secured halfway across the bottom strip. There were no noted markings indicating how far/tightly this strip should have been pulled. During an observation on 4/9/24 at 11:05 a.m., R34 was observed sitting in his wheelchair in his room wearing a Miami J collar. R34's chin and bottom lip were tucked into the collar and were not visible. The Velcro strip on the left side of the collar was again secured halfway across the bottom strip leaving a gap between the front and back plastic parts of the collar. During an interview on 4/9/24 at 12:54 p.m., licensed practical nurse (LPN)-D stated he was the nurse in charge of R34's care and had assisted with neck brace application in the past. LPN-D stated he did not have any physical indications that he relied on when applying the brace to ensure correct application but instead relied on reported resident comfort levels. During an interview on 4/9/24 at 1:50 p.m., the director of nursing (DON) stated R34 was last seen by the neurology providers in 8/23 and they had not received a call reporting the collar was ill-fitted or incorrectly applied so she thought it was applied correctly. The DON stated if R34's collar was being misapplied or was ill-fitted, she would have expected a re-consultation of occupational therapy to assess for fit and re-educate nursing staff on the correct application of the device, but this had not happened for over a year. The DON stated she was unaware of R34 refusing to wear the collar correctly although he did tend to tuck his chin into the collar. The DON stated she would review the record and cofirmed that the resident had not refused to wear the collar correctly and if so, a risk versus benefit had been completed with the resident and his representative as she was not immediately seeing that this had occured. During an observation and interview on 4/9/24 at 2:08 p.m., R34 was observed sitting in his wheelchair in his room wearing a Miami J collar. R34's chin and bottom lip were unable to be observed as it was tucked into the collar. The Velcro strip on the left side of the collar was secured halfway across the bottom strip leaving a gap between the front and back plastic parts of the collar. The DON stated that she had never put on or taken off the collar so she was unsure what factors the nursing staff used to ensure that the collar fit properly. During an interview on 4/10/24 at 8:09 a.m., occupational therapist (OT)-A stated R34's Miami J Collar should not have been loose enough so R34 could so easily tuck his chin into it, and it was likely nursing staff needed re-education on correct application as it had been over a year since he had done that with them. OT-A stated he would assess R34 ' s collar later in the day and it should have markings on the Velcro to assist nursing in knowing how far to pull the Velcro strips. OT-A stated correct application of this brace was important for R34 ' s safety and correct spinal alignment. During an interview on 4/10/24 at 11:48 a.m., R34 ' s family member (FM)-B stated he took R34 to his neurology appointments, and the last time R34 was seen by them was last fall. FM-B stated the neurology team had noted R34 would tuck his chin into the collar which he was not supposed to do, so they had recommended to him that the brace be applied tighter. FM-B stated he was unsure if this was something the nursing staff had been doing. FM-B stated that he was not aware of R34 refusing to wear the brace or refusing to wear the brace in a tighter manner. During observation and interview on 4/10/24 at 12:52 p.m., R34 was observed sitting in his wheelchair with his chin resting on top of the brace with both lips visible. OT-A stated he had just reassessed and adjusted R34 ' s neck brace and it had been too loose. The top strip of Velcro on the left side of R34 ' s neck brace was now observed to almost completely cover the bottom strip of Velcro and the back plastic part of the collar was now overlapping the front piece. The OT-A stated he was going to mark the correct placement of the Velcro and see if he could find/create written instructions for nursing staff to follow when applying the brace as that had not been in place previously. A policy/procedure regarding neck brace application was requested and not received.

Based on observation, interview and document review, the facility failed to ensure activities of interest were offered or provided to enhance quality of life for 1 of 1 resident (R19) reviewed who resided on the short-term stay (i.e., TCU) unit. Findings include: R19's admission Minimum Data Set (MDS), dated [DATE], identified R19 had moderate cognitive impairment, demonstrated no delusional thinking, and required moderate/partial assistance to complete most mobility-based activities of daily living (ADLs). Further, under the section labeled, F0500. Interview for Activity Preferences, identified it was, Very Important, for R19 to do things with groups of people and their favorite activities while at the care center. On 4/8/24 at 2:13 p.m., R19 was observed seated in a recliner chair in her room with the television on. R19 was interviewed about her quality of life while at the care center including what, if any, activities she attended. R19 stated she [didn't] really know if she had ever been invited or attended activities while at the care center, but expressed she would like to, if offered. R19 stated her activities of choice would include anything with games including with other residents but nobody at the care center, to her recall, had ever asked about it. R19 reiterated she'd like to attend activities if they had some adding, I think that would be fun. R19's initial Therapeutic Activities Observation, dated 3/19/24, identified R19 admitted to the care center on 3/15/24, and had a planned stay of less than three months. The assessment outlined various questions to be completed by staff including, With consideration to the anticipated length of stay, what is the resident's level of interest in pursuing leisure/activities? This was answered with, Minimal interest due to anticipated length of stay. The evaluation continued and outlined R19 was Lutheran and attended services, along with checkmarks placed next to her preferred program style including large groups, small groups, religious activities, and other (i.e., pet visits, social events). A section labeled, Describe resident's current interests ., was listed which outlined, Knitting, cookinf [sic], social events, cooking, along with social events, coffee, and getting to know others being listed as important for life enjoyment and a meaningful daily routine. The evaluation outlined, Initiate care plan. R19's activities care plan, last revised 3/15/24, identified R19 was able to independently structure her own leisure time and listed a goal, Resident will be content with leisure routine during stay. The care plan listed two approaches to help R19 meet this goal which read, Inform of group activities of interest, Provide leisure materials as requested. R19's progress notes, dated 3/15/24 to 4/10/24, were reviewed and identified the following: On 3/15/24, a therapeutic recreation (TR) note identified R19 admitted to the transitional care unit for rehabilitation. The note outlined, In leisure time resident enjoys reading, knitting, sewing baking, crocheting plus spending time with friends and family . goals for upcoming 90 days are to pursue independent leisure activities of interest. Staff will monitor and provide any independent leisure materials needed. A subsequent note, dated 3/15/24, identified TR staff met with R19 and informed her of the activities department. R19 was provided an activity calendar and a brief explanation of the types of activities available and how they can be attended. R19 requested a book to read and was provided with several feel good books. On 3/16/24 and 3/30/24, respectively, R19 was visited by the onsite chaplain. However, there were no other recorded notes by TR to demonstrate what, if any, activities had been offered, attended, provided or refused by R19 during her admission to the TCU. When interviewed on 4/9/24 at 12:41 p.m., nursing assistant (NA)-B stated they had worked with R19 before and described her as needing help with transfers and having some forgetfulness. NA-B stated R19 was involved with therapy and, of late, had been coming out of her room for meals more often with staff encouragement. NA-B stated R19 had multiple visitors throughout the week and enjoyed her television adding, [R19] likes to relax. NA-B stated TCU residents are allowed to go upstairs to the long-term care unit for activities but there wasn't much, if any, group-based activities done on the TCU adding, There's not too much down here [on TCU], per se. On 4/10/24 at 9:07 a.m., the activities coordinator (AC)-A was interviewed. AC-A explained they had attempted to include R19 a few times with activities but she either had family present or, on one occasion, voiced feeling nauseated and unable to attend. AC-A stated activities participation was tracked using electronic point-of-care (POC) charting and provided such for review. R19's POC History Report, printed 4/10/24, identified a category which read, Activities, and included all shifts. However, the provided documentation only listed two (2) activities had been attended, both on 4/9/24, with no other recorded charting or evidence R19 had been offered, provided, attended or refused any activities prior (i.e., 3/15/24 to 4/8/24) on either unit despite being assessed as enjoying social events and getting to know others. In addition, the medical record lacked evidence R19 had ever been re-evaluated to ensure the program placed upon admission remained in accordance with her wishes or needs. AC-A verified the charting lacked refusals, attempts or completed activities and stated they had not been tracking those but would moving forward. AC-A stated they did round on the TCU unit and try to invite residents' to the various happenings but, again, verified these were not charted. AC-A stated they felt R19 enjoyed spending time more in her room and, when questioned on what, if any, one-to-one (1:1) activities had been attempted or offered in place then, AC-A stated their colleague typically does those but, again, they had not been charted. On 4/10/24 at 10:54 a.m., the administrator was interviewed and stated the activities director had resigned a few weeks prior. The administrator explained they had visited with AC-A and reviewed R19's medical record which supported R19 had been educated on activities in the building and provided a calendar of them upon admission. The administrator stated they discussed R19 with AC-A (after the surveyor discussion) and AC-A was going to check with R19 to see if more books could be provided on her topics of interest adding, I [administrator] don't know her that well. The administrator stated R19 had more weakness and illness when she first admitted but within the last few weeks now had been doing much better and coming out of her room more often adding, She's now feeling better and completely different person. When asked if R19 had been re-evaluated for her activities-involvement, in the setting of feeling better and coming out of her room more often now, the administrator explained there had been discussion of it, as a whole, in the morning clinical meetings but it wasn't specific to activities. The administrator reviewed R19's charted activity involvement and verified activities, including attempts and refusals, should be documented so, as a result, they were going to work with AC-A to implement a spreadsheet similar to the one used on the LTC unit. The administrator stated charting should be done as, That is your proof [offered]. A facility policy on activities was requested, however, none was provided.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 1 residents (R38) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R38's quarterly Minimum Data Set (MDS), dated [DATE], indicated R38 had moderate cognitive impairment with signs of delirium and no behaviors or rejection of care. MDS indicated R38 required maximal assistance to dependent on assistance for activities of daily living (ADLs) including personal hygiene. R38's care plan, printed 4/9/24, identified R38 is at risk for decline in ability to participate in grooming. The document directed, staff to provide extensive assist with grooming. The document lacked evidence of R38 refusing or having a history of refusing staff assistance with cares or personal hygiene. R38's Visual Body Inspection, dated 4/6/24, lacked documentation of R38 refusing staff to trim and clean her fingernails. Document does instruct to observe resident nails and provide nail care as indicated. R38's progress notes, dated 3/20/24 to 4/9/24, lacked documentation of R38 refusing or declining staff to trim or clean fingernails. The notes further lacked documentation of refusals of showers or assistance with cares. On 4/08/24, at 3:06 p.m., R38 was observed sitting in her room in her wheelchair. R38's fingernails were observed to be long with numerous nails to have jagged edges with dark colored debris underneath. R38 stated that I have asked for a clipper from the desk, but they won't give me one, adding that it would be nice if they would clip and clean her nails for her. R38 expressed that her nails are dirty. R38 stated she has an emery board to file them but that doesn't help with the jagged edges or the dirt underneath. During a subsequent observation made n 4/09/24, at 11:23 a.m., R38 was observed sitting in her wheelchair and preparing to go to lunch. R38's fingernails continued to be long with numerous nails to have jagged edges with dark colored debris underneath. During an additional subsequent observation made on 4/10/24 at 7:12 a.m., R38's fingernails continued to be long with numerous nails to have jagged edges with dark colored debris underneath. On 4/10/24, 7:17 a.m., licensed practical nurse (LPN)-B verified that they were currently working with R38 and familiar with R38. LPN-B stated that R38 requires a Hoyer lift (mechanical lift) for transfers, no longer ambulates and needs a lot of care. LPN-B indicated that R38 can perform some cares after staff set up items. LPN-B verified that nail care is done by staff, adding that R38 has a nail file but staff is responsible to clean and cut nails. LPN-B stated she is unaware if R38 refuses nail care and if R38 does then it would be documented in a progress note. LPN-B stated that nail care is done weekly on bath/shower days and as needed. LPN-B observed R38 fingernails and stated, there is some debris underneath her fingernails that could be cleaned. On 4/10/24, at 7:25 a.m., LPN-C verified that they are familiar with R38 and have worked with her frequently. LPN-C stated that they are unaware of R38 refusing cares, more specifically nail care. LPN-C stated that I have clipped her nails in the past and she has never refused. LPN-C indicated that if a resident refuses nail care it should be documented in a progress note. LPN-C stated that nail care is done weekly on bath/shower days and as needed. On 4/10/24, at 7:31 a.m., nursing assistant (NA)-A verified they are familiar with R38 and work with her frequently. NA-A verified that R38 does not have a history of refusing cares. NA-A stated they don't typically give her showers as that is done on the afternoon shift. NA-A observed R38's fingernails and stated they are little dirty inside and could be cleaned. She likes them longer. On 4/10/24, at 12:52 p.m., registered nurse (RN)-B verified that they are familiar with R38. RN-B stated that the expectation would be that nail care is done weekly on bath days and as needed. RN-B stated if a resident refused nail care, it would be documented in a progress note. RN-B stated, to my knowledge, [R38] does not routinely refuse nail care, at times she might say she wants to do it herself. RN-B verified this would be documented in a progress note. During interview on 4/11/24, at 10:50 a.m., administrator stated that nail care is important for infection control, hygiene, and dignity. Administrator verified that nail care is offered on bath days and as needed for all residents. A facility policy titled Nail Care, review date of 3/27/24, was provided. The document indicated that nails will be maintained in a clean and neat manner to support resident dignity and to avoid problems associated with rough, cracked, overly long, or broken nails.

Based on observation, interview and record review, the facility failed to implement their antibiotic stewardship program, to include proper testing, to reduce unnecessary antibiotic use to ensure good clinical outcomes and to reduce potential drug resistance for 1 of 2 residents (R4) reviewed for antibiotic stewardship who received 2 antibiotics without proper testing. Findings include: The Centers for Disease Control and Prevention (CDC) identifies antibiotic stewardship as the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. An article by the National Institute of Medicine, titled Antimicrobial Stewardship - Can We Afford to do Without it?, dated 1/20/2015, stated the risk of prescribing and using inappropriate antibiotics leads to not only poor clinical outcomes but an increase in the risk of antibiotic resistant bacteria. R4's quarterly Minimum Data Set (MDS), dated [DATE], indicated R4 was cognitively intact and was independent with most ADLs but required partial to moderate staff assistance with bathing and toileting. R4's progress notes, dated 3/20/24 - 4/11/24, indicated R4 had ongoing complaints of dysuria (painful urination) and frequent urination from 3/20/24 to 4/9/24 despite being treated by two different antibiotics. The progress notes documented the following; -On 3/20/24, R4 had complaints of a burning sensation and urgency when urinating. R4's nurse practitioner (NP) was notified who ordered a urinalysis (a urinalysis, or UA, is a test of your urine. It's used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine.) with a conditional urine culture (a urine culture, or UC, test can identify what bacteria or yeast is causing a urinary tract infection (UTI). If bacteria multiply, an antibiotic sensitivity test can identify the antibiotic most likely to kill those particular bacteria.) -On 3/21/24 R4's UA results were received which indicated R4 had a urinary tract infection (UTI) and R4 received an order to start Macrobid (an antibacterial drug used to treat urinary tract and bladder infections caused by Escherichia coli or Staphyloccocus saprophyticus strains of bacteria that are sensitive to this drug) 100 mg twice a day for five days. R4 had continued complaints or a burning sensation with urination. -On 3/22/24 R4's UC results came back indicating mixed flora and was unable to determine what bacteria was causing R4's UTI. On-call providers stated since R4 was already on an antibiotic there was no further treatment. R4 continued to have complaints of dysuria and frequent urination. -On 3/23/24 R4 continued to have complaints of dysuria and frequent urination. -On 3/24/24 R4 continued to have complaints of dysuria, frequent urination and increased weakness and stated she didn't think the antibiotic was working. The on-call provider was notified. -On 3/26/24 R4 completed her course of Macrobid, did not complain of dysuria but reported continued weakness and spent most of the day sleeping. -On 3/28/24 R4 had continued complaints of painful and burning urination, stating that she was treated with an antibiotic called Augmentin in the past. On-call providers were notified. A visual assessment of R4's peri-area/urethra opening for skin breakdown was done and noted no external abnormalities that could lead to burning with urination. Due to R4's continued symptoms of burning with urination and urinary frequency, R4 was stated on Keflex (an antibiotic utilized in the treatment of urinary tract infections caused by Staphylococcus aureus or Proteus mirabilis) 500 mg twice a day. -On 3/30/24 R4 continued to have burning with urination. -On 3/31/24 R4 received her last does of Keflex. R4 requested to speak with the provider as she was still having UTI symptoms. An order was received from the NP to extend the Keflex an additional two days. -On 4/3/24 R4 continued to have complaints of dysuria and frequency with urination. The NP ordered a second UA/UC. -On 4/4/24 R4's UA results came back with abnormal results indicating a UTI. The NP was updated and no new orders were given at this time. -On 4/8/24 R4's UC results came back and R4 began a third treatment for her UTI, Cefuroxime Axetil (used for the treatment of urinary tract infection particularly when due to beta-lactamase producing bacteria) 250 mg twice a day for 5 days. -On 4/9/24 R4 stated she was finally starting to feel better. -On 4/10/24 R4 stated she slept better and was not up as frequently to use the bathroom. -On 4/11/24 R4 had no complaints of UTI symptoms, stating she was feeling like herself again. R4's Order History, printed 4/11/24, indicated R4 had 2 scheduled antibiotic time outs (Antibiotic time-outs are formal reassessments of prescribed antibiotics. A time-out provides a structured opportunity to review a residents antibiotic therapy 36 to 72 hours into the regime)on 3/22/24 and 4/9/24, lacking an order for an antibiotic time out for the Keflex prescribed on 3/28/24. During an interview on 4/8/24, R4 stated she had a UTI and had been sick for weeks stating the facility had given her a couple different antibiotics but they were not working. R4 stated she was urinating a lot and it was painful, stating she felt very weak and had not been able to get out of bed in the past few weeks since becoming so sick. R4 stated she normally enjoyed going to activities and eating in the dining room however she was too weak to get out of bed because of her UTI and staff were bringing food to her in bed. R4 stated she was still bringing herself to the bathroom but that her legs felt like rubber. During an interview on 4/10/24 at 10:45 a.m., registered nurse and nurse manager (RN)-B stated she was aware R4 had been complaining of abdominal pain and dysuria. RN-B stated when a resident had complaints of dysuria or frequent urination, they would treat based on what the provider recommends, whether that be obtaining a UA/UC, pushing fluids, or just continuing to monitor. RN-B stated typically they would wait for the urine culture results to start an antibiotic, but not always, if a resident's symptoms were severe. RN-B stated it was not their typical practice to start antibiotics without a UA/UC which would determine what antibiotic will work based on what flora is present in a resident's urine. RN-B stated not knowing if the correct antibiotic will work can delay treatment. RN-B stated R4's nurse practitioner was aware that R4 was started on Keflex without a UA/UC and was still complaining of UTI symptoms (dysuria and frequent urinations) and had instructed staff to continue the antibiotic despite this until a visit was made to R4. During an interview on 4/10/24 at 11:56 a.m., the infection preventionist (IP) stated their process was to generally follow what the providers were recommending for treating a UTI but they would usually wait until the urine culture is received back to ensure they are treating the right bug stating it was best to not give antibiotics [NAME]-nilly as this could lead to super bugs. The IP further stated she was was surprised when the Keflex was extended as it was not working, further stating that starting the Keflex without a UA/UC was against their Antibiotic Stewardhip protocol and could delay proper treatment for R4. The IP stated their protocol was to always follow antibiotic stewardship. A facility policy titled Antibiotic Stewardship , reviewed 3/28/24, stated it was the facility's process to, monitor compliance with prescribing expectations and clinical practice guidelines relevant to antibiotic stewardship.

Based on interview and document review, the facility failed to ensure the Office of Ombudsman for Long-Term Care (OOLTC) was notified in a timely manner of resident' hospitalization s (i.e., facility-initiated discharges) for 1 of 2 residents (R40) reviewed for hospitalization ; and 11 of 11 residents identified to have been hospitalized within the last month. Findings include: R40's Minimum Data Set (MDS) records, dated 12/12/23 to 3/23/24, were reviewed. This identified a total of four (4) discharge - return anticipated records were completed on 12/23/23, 1/12/24, 2/9/24, and 3/20/24, respectively, with each of these recording the discharge location as, 04. Short-Term General Hospital. On 4/8/24 at 3:07 p.m., R40 was interviewed with his family member (FM)-A present. FM-A explained R40 admitted to the care center in December 2023 and had been in and out of the hospital since then for various reasons. FM-A explained a hospitalization happened in February 2024, when R40 had a medication miscommunication and was too sedated as a result. R40's progress notes, dated 2/9/24 to 2/11/24, identified R40 developed tremors and increased weakness; and he was sent via ambulance to the hospital. R40's subsequent note, dated 2/11/24, identified R40 readmitted to the care center with dictation, . recurrent weakness secondary to be caused by increase in Lyrica [medication] dose . However, R40's medical record was reviewed and lacked evidence the OOLTC had been notified of any of these hospitalization s. During the recertification survey, from 4/8/24 to 4/11/24, evidence of such notification for R40 or any hospitalized residents' for the past months was requested. On 4/10/24, an email (dated 4/9/24) was left for the surveyors which was addressed to the regional OOLTC with dictation, Hello - attached you will find d/c's [discharges] from the past month, with a Admit/Discharge Report, dated 3/1/24 to 3/31/24, attached. This report identified a total of 11 residents, including R40, had been hospitalized in March 2024. An e-mail correspondence with the OOLTC, dated 4/10/24, identified the care center was supposed to be sending the monthly notices of hospitalization to the main office who then placed them into each respective Ombudsman' folder for review, however, there was no record of notices from the care center for an undetermined amount of time. The Ombudsman was unaware if they were receiving the notices or not depending on where the care center had potentially been sending them. When interviewed on 4/10/24 at 12:23 p.m., the administrator stated the medical records personnel was responsible to send the monthly listing of hospitalization s to the OOLTC, however, upon review they discovered it hasn't been done. As a result, they had just sent the listing (provided to the surveyors) for March to the OOLTC the day prior. The administrator stated the list was supposed to be done on a monthly basis and just got dropped at some point, so they would review and revise the process, if needed. The administrator stated it was important to update the OOLTC with hospitalization s to help ensure residents' get the help needed. A facility' policy on OOLTC notification was requested, however, none was received.

Based on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was posted daily and updated with each shift. This had the potential to affect all 58 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation and document review on 4/8/24 at 12:26 p.m., the nursing staff posting was observed in a hallway off the main lobby near the entrance. The posting was dated 4/5/24, with a resident population of 61, and the first shift starting at 6:30 a.m. During an interview on 4/10/24 at 8:55 a.m., the staffing coordinator (SC) stated she went on vacation recently, and registered nurse (RN)-B, the long-term care nurse manager, oversaw updating the staff posting on the weekdays when she was gone, and it must have been missed 4/8/24. The SC stated before she left the facility, each Friday, she would fill out the staff postings for the weekend and the morning charge nurse was supposed to discard the previous day's posting to display the current one when they arrived. The SC stated RN-C was the charge nurse this weekend and it must have been forgotten. The SC stated if the staffing levels or the census changed, she would update the weekend numbers when she arrived on Monday. During an interview on 4/10/24 at 9:56 a.m., RN-C stated that she worked at the facility every other weekend and was the day charge nurse the previous weekend. RN-C stated the SC normally managed the staff posting but wasn't sure who posted it on the weekend. During an interview on 4/10/24 at 12:21 p.m., the assistant director of nursing (ADON) stated that the SC oversaw the staff posting and would be a better resource for information regarding this. The facility Posting of Staffing Hours policy dated 10/20/23, indicated a staff posting containing the census, the current date, the name of the facility, and the total actual number of hours worked by nursing staff in each category, would be displayed daily by 9 a.m. The policy indicated that updates would be made to the posting for each shift as needed throughout the day.

Based on interview and record review the facility failed to notify the medical provider for guidance with ten abnormal laboratory results for 1 of 3 residents reviewed for significant change. The medical provider was notified of the abnormal lab results 24 hours after the facility received the lab report. The day following the lab results, during a family visit R1 had a change in condition, family notified the Nurse Practitioner (NP), who was onsite. The NP reviewed R1's chart and found the abnormal lab results. R1 was sent to a hospital and admitted to the ICU. The findings include: R1's face sheet, not dated, indicated R1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's vital sign record indicated R1's blood pressure readings: [DATE] at 9:59 p.m. was ,d+[DATE] mmHG, 10:01 p.m. ,d+[DATE] mmHG [DATE] at 6:08 a.m. was ,d+[DATE] mmHG, at 10:17 a.m. was ,d+[DATE] mmHG, at 2:49 p.m. was ,d+[DATE] mmHG, at 4:38 p.m. was ,d+[DATE] mmHG, at 7:55 p.m. was ,d+[DATE] mmHG. [DATE] at 8:20 a.m. was ,d+[DATE] mmHG [DATE] at 10:33 a.m. was ,d+[DATE] mmHG R1's physician initial visit noted dated [DATE] indicated upon physical exam R1's appearance was alert and comfortable. R1's vital signs were reviewed for the date of [DATE] at 10:33 a.m. to include blood pressure ,d+[DATE] mmHG, respirations 18, pulse 73 bpm, temperature 98.5, and on [DATE] at 12:01 a.m. oxygen saturations at 96%. R1's hospital lab results were reviewed: dated [DATE] sodium 138 within normal limits (WNL), chloride 101 (WNL), urea nitrogen 11 (WNL), creatinine 0.71 (WNL), GFR >90 (WNL), white blood cell count 9.7 (WNL), red blood count 4.11 (WNL), Hemoglobin 12.7 (WNL) R1's Hemoglobin on [DATE] was low at 10.7 and on [DATE] a hemoglobin reading was low at 10.5. R1's vital sign record indicated R1's blood pressure reading on [DATE] at 10:17 a.m. was ,d+[DATE] mmHG (a normal blood pressure level ,d+[DATE]). R1's lab results received by the facility on [DATE], at 11:02 a.m. indicated ten abnormal laboratory results. Sodium 126 low (L) the range was ,d+[DATE] mmo/L, Chloride 90 (L) range ,d+[DATE] mmo/L, Urea Nitrogen 44 high (H) range ,d+[DATE] mg/dL, Creatinine 1.50 (H) range 0.60 - 1.10 mg/dL, glucose 135 (H) range ,d+[DATE] mg/dl, GFR Estimate 34 (L) >60 mL/min1.73m2, white blood cell count 18.0 (H) range 4.0 - 11.0 10e3/ul, red blood cell count 2.31 (L) range 3.80 - 5.20 10e/6/UL, hemoglobin 7.3 (L) range ,d+[DATE]%. R1's nursing progress notes dated [DATE], at 3:06 p.m., at 3:21 p.m., and 3:22 p.m. indicated licensed practical nurse (LPN)-A did not include any documentation of receiving, reviewing, or notification of the lab results received on [DATE] at 11:02 a.m. There was no indication that R1 was reassessed based on the significant lab results that identified a change in condition. R1's vital sign record indicated R1's blood pressure reading on [DATE] at 7:24 p.m. was ,d+[DATE] mmHG (a normal blood pressure level is ,d+[DATE]). R1's nursing progress note dated [DATE] at 8:02 p.m. indicated R1's blood pressure was low at ,d+[DATE] mmHG, R1's [MEDICATION(S)] medication was held. R1's nursing progress noted dated [DATE] at 11:07 a.m. indicated R1's vital signs were temperature 98.7 degrees (a normal body temperature can range from 97.8 to 99 degrees), pulse 70 bpm (a normal pulse ranges from 60 to 100 bpm), respiratory rate 17 (a normal respiratory rate is 12 to 16), blood pressure ,d+[DATE] mmHG (a normal blood pressure level is ,d+[DATE]), oxygen saturations 95% on room air (a normal oxygen saturation is 95% to 100%). R1's family member is concerned about R1's increased confusion. The facility nurse practioner at the facility recommended R1 be sent to the emergency room for evaluation due low [CONDITION(S)], low hemoglobin, and increased creatinine. R1's medical provider note dated [DATE] indicated family was present with R1, nursing reports drop in R1's blood pressure. R1 with significant increased confusion, eyes are crossing. R1 has low blood pressure today, blood pressure medication held this morning. labs returned with leukocytosis, significant hemoglobin drop, and elevated creatinine. Family reports R1 is not eating and drinking will send to emergency room . Physical exam, abdomen is soft, non-tender, and distended. Assessment and Plan indicated lower abdominal pressure, constipation resolved, blood pressure's drop this morning, patient distended, pale, very confused. UA ordered and negative. CBC/BMP lab results elevated white blood cells at 18, hemoglobin drop from 12.7.3, elevated [MEDICATION(S)]. Discussed with family and sent R1 to emergency department. Visit diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's nursing progress note recorded as late entry on [DATE] at 10:23 a.m. for [DATE] at 3:06 p.m. indicted LPN added an addendum to the note dated [DATE] at 3:06 p.m. indicating blood pressure low this shift at ,d+[DATE], physician updated. New orders to hold [MEDICATION(S)] if systolic blood pressure is less than 90. Resident denies symptoms of low blood pressure. Labs results obtained, faxed to NP and NP updated via voicemail. This addendum came after LPN-A interviewed with evaluator and then spoke with the director of nursing (DON). Upon interview on [DATE], at 9:07 a.m. family (FA)-A member reported My Mom almost died last Wednesday, I still shudder to think what would have happened if I wouldn't have shown up at the facility that day. FA-A reported coming to the facility to visit and her mother's skin was yellow, and abdomen was hard as a rock, and during the conversation her eyes would cross. FA-A asked staff if there was a provider on site and was informed that her NP was. FA-A found the NP and reported what she had witnessed. FA-A reported the NP grabbed her mother's chart and noted some labs that had come in the prior day. The NP was surprised at the results, she immediately said we need to send her in her hemoglobin is extremely low. The NP called 911 immediately. FA-A suggested that R1 be sent to the same hospital R1 had her surgery and had been discharged from. The lead emergency transport team (EMT) said they needed to send her to a higher-level care hospital and recommended a different hospital. FA-A followed the ambulance to the hospital. R1 was admitted to the ICU and remains there. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her condition was critical, and she was given a blood transfusion the ICU told me. Upon interview on [DATE], at 11:15 a.m. the NP reported not being aware of the labs before seeing them on ,d+[DATE] at approximately 11:00 a.m. when R1's daughter approached her about R1's change in condition. The NP reported the facility had notified her about a decrease in R1's blood pressures, but that was the extent of the report and parameters were given to the facility for blood pressure readings. The NP stated that she and the M.D. were watching the hemoglobin level as the reading was a little low in hospital and is common following surgery. The NP stated, This was an acute change and if I would have known of this, I would have sent her into the hospital upon reviewing the results. The NP indicated upon her examination of R1 she was extremely pale, and her abdomen was distended and hard, and her eyes were crossing as the daughter indicated. Upon interview on [DATE], at 12:26 a.m. licensed practical nurse (LPN)-A reported she recalls receiving the labs on [DATE]. She explained the process is to look the labs over and fax them to the medical provider. If labs are abnormal, we call the provider as well. I do recall she had a low hemoglobin that day. LPN-A also recalled a urinalysis had returned on [DATE], as well. It was at the end of my shift that day. I know I faxed it, I can't remember if I called it in or not. LPN-A stated she always charts in the progress notes if the labs were normal or abdominal and that they were faxed and/or called in to the provider. LPN-A denied reporting this information to the nurse manager or report to incoming nurse to follow-up for any orders that may result from the NP. Upon interview on [DATE] at 1:01 p.m. with the hospital physician it was verified R1 was still in the ICU department. The physician stated R1 had an acute change in symptoms and his expectation would be the facility report reading of this nature and follow-up from provider immediately. The outcome could have been poor. Upon interview on [DATE], at 3:15 p.m. with the director of nursing, (DON) stated the process is to fax laboratory results to triage and leave a message with the provider and put in a progress note. The DON stated she is certain LPN-A was on top of this, however verified there was not a note written on [DATE] about the labs. She also mentioned the NP had mentioned her pager isn't working so well lately. The DON stated she had spoken with LPN-A following the interview LPN-A had with the evaluator today and the LPN-A stated she did fax and call the NP on [DATE], and LPN-A put in an addendum to her note on [DATE]. The DON found a fax face sheet that LPN-A had faxed on [DATE], however at the top of the fax receipt it said error. The DON attempted to look for a fax that had gone through from LPN-A on [DATE] but stated the shredding company came and took the papers the other day. Upon interview on [DATE], at 1:07 pm the Administrator stated her expectations of the nursing staff would be to notify the provider as the facility policy states by whatever means possible, phone call, pager, fax, or the call the triage line and then document results. Upon interview on [DATE], at 2:39 p.m. with the facility Medical Director she stated that if she would have received the lab results on the [DATE], she would have monitored R1 to make sure she was hemodynamically stable (monitored heart rate and blood pressure), ordered imaging tests and rechecked the basic metabolic panel (BMP) the following day, which may have kept R1 out of the hospital. She reported she could not answer specifics on the policy of the facility, but abnormal labs need to be reported and documented. Review of policy titled Change in Condition revision date [DATE], indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. A significant change requires interdisciplinary review and/or revision to the care plan. Prior to notifying the physician the nurse will make detailed observations and gather relevant and pertinent information (complete SBAR) for the provider. Unless other instructed by the resident, a nurse will notify the residents representative. Facility staff will also notify the RN in charge or the RN on call.

Based on interview, observation and document review, the facility failed to follow through with an established restorative nursing program for 1 of 1 resident (R21) reviewed for ambulation. Findings include: R21's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition. R21 required extensive assist of one staff for bed mobility and transfers, required limited assist of one staff to walk in room and extensive assist of one staff for locomotion on and off the unit. R21 had no behaviors and had not rejected care. R21 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R21's activity of daily living (ADL) care area assessment (CAA) dated 2/17/22, indicated R21 required assistance of one staff using her prosthetic and walker for support. R21 used a wheel chair with staff assistance during locomotion on/off the unit. R21's restorative nursing care plan dated 2/14/22, indicated a risk for decline in ambulation related to [CONDITION(S)], [CONDITION(S)], weakness, pain and history of lower extremity amputation. The care plan directed one staff to provide stand by assist for R21 to ambulate 100 feet in the hall two to three times daily, using a walker and wheelchair to follow. During an interview on 4/11/22, at 7:15 p.m. R21 stated her walking program was not being provided and she was afraid of losing her ability to walk. R21's nursing assistant care card provided on 4/11/22, indicated under ambulation resident to ambulate 100 feet in hall 2-3 x/daily with SBA [stand by assist] of one staff using walker and w/c [wheelchair] to follow. During a follow up interview on 4/12/22, at 3:00 p.m. R21 stated staff had not walked her yet today either and they should have. During an interview on 4/12/22, at 1:20 p.m. nursing assistant (NA)-A confirmed having had worked with R21. NA-A stated walking programs would be listed on nursing assistant care cards, and under the Point of Care (POC) tasks (POC is a portable electronic medical record and documentation system). NA-A stated even though R21's care card and POC indicated a walking program, NA-A was not sure that was accurate. During an interview and observation on 4/13/22, at 10:48 a.m. R21 stated staff still had not walked her this week. R21 stated she wanted to walk but no one had offered to assist her. R21 stated she needed to use the bathroom and then put her call light on. NA-B entered R21's room, adjusted R21's lower leg prosthesis in place and used a mechanical lift standing device to assist R21 into the adjoining bathroom. NA-B had not offered the option of walking to R21. During an interview on 4/13/22, at 10:54 a.m. NA-B stated R21 used to walk with staff when R21 resided in the transitional care unit but did not think R21 walked with staff in the long term care unit where she currently lived. R21's POC History form provided on 4/13/22, indicated R21's restorative nursing program for walking was completed two times in February 2022, one time in March 2022, and zero times in April 2022. R21's Census History form provided on 4/13/22, indicated she was hospitalized [DATE] - 3/5/22, but was otherwise in the facility. R21's progress notes were reviewed for February 2022 through April 2022 and there was no documentation R21 had refused her restorative walking program or that it was being held. During an interview on 4/13/22, 10:12 a.m. physical therapist (PT) stated she had worked with R21 periodically and R21 was capable of walking 50-100 feet with staff assist. R21 stated she would have expected nursing staff to carry out restorative programs as written and update PT if R21 needed a re-evaluation. During an interview on 4/13/22, at 11:57 a.m. registered nurse (RN)-A confirmed R21 was on a restorative nursing ambulation program. RN-A stated she expected nursing staff to follow through with the program. During an interview on 4/13/22, at 12:20 p.m. the director of nursing (DON) stated she expected restorative nursing programs to be completed and documented. Facility policy Restorative Nursing dated 2/25/20, indicated residents would be provided with appropriate programs to achieve skills to enable their highest level of function. Additionally, care documentation was expected to be entered by restorative staff and/or nursing assistants.