Every finding on record at Aurora Brule Nursing Home Inc

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to thoroughly investigate an allegation of abuse involving one of one certified nursing assistant (CNA) (V) who threw an incontinence brief at one of one sampled resident (8), told him to do it yourself, and left him on the toilet without providing care. The provider's failure to conduct a thorough investigation placed the other residents at risk for abuse and neglect by not determining if similar incidents had occurred, or if additional residents were affected. The facility's census at the time of survey was 44. Findings include:1. Review of the provider's 2/24/26 SD DOH FRI revealed that resident 8 reported to licensed practical nurse (LPN) U that a staff member was rude to him that evening. Resident 8 told LPN U that when he needed assistance in the bathroom, the staff member told him to do it himself, gave resident 8 a brief, then left the room. Resident 8 was blind and was unable to provide the staff member's name. The provider interviewed all staff members who were scheduled to work at the facility that night and determined that CNA V was the staff member who provided care to resident 8 on the evening of 2/24/26. CNA V did not provide the resident's care according to the resident's care plan and substantiated the allegation of abuse. CNA V's employment with the facility was terminated on 2/26/26. 2. Interview on 7/29/26 at 10:37 a.m. with social services designee (SSD) D revealed that she interviewed resident 8 after the alleged abuse by CNA V. SSD D remembered speaking with resident 8 but was unable to interview CNA V as her employment was terminated. She stated that she did not interview other residents who were assigned to be cared for by CNA V to determine if any residents may have been abused by CNA V. She explained that she did not interview any other residents because nobody else came to me. 3. Review of the provider's Investigative Protocol Form revealed that an investigation into the incident was initiated on 2/25/26. The protocol form included eight interventions to be completed for the investigation. Those interventions were: description of the issue, immediate action taken, root cause analysis, policy review, in-service education form, focus audit form, investigative summary, and care plan review. The intervention areas for root cause analysis, in service education form, and focus audit form were not completed on the investigative protocol form for the 2/24/26 incident. 4. Interview on 7/29/26 at 11:29 a.m. with director of nursing (DON) B and administrator A revealed that administrator A and SSD D usually investigated allegations of abuse. Resident 8's roommate was interviewed by administrator A after the report of abuse from resident 8's abuse by CNA V and resident 8's roommate did not hear the incident in the bathroom on 2/24/26 because he had headphones on. They confirmed that the root cause analysis, in-service education form, and focus audits were not completed on the investigative protocol form of the 2/24/26 incident. They stated that no other residents under CNA V's care were interviewed to determine the extent of abuse, and that another incident could have occurred between CNA V and another resident while she worked at the facility. 5. Further interview on 7/29/26 at 12:12 p.m. with administrator A revealed that staff education was provided at the all-staff meeting in March 2026 regarding abuse and neglect, but she could not provide a copy of that educational material. The staff education sign-in acknowledgement sheet included signatures of the staff members who attended that meeting, but not all signatures were legible to determine that all staff received the education on abuse and neglect. 6. Review of the provider's 1/14/26 Freedom from Abuse, Neglect, and Exploitation Policy revealed that the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, to ensure all identified incidents of alleged or suspected abuse/neglect are promptly investigated, and to ensure a complete review of existing incidents is documented. Investigation of abuse may include interviewing staff, residents, or other witnesses to the incident.

Based on record review, interview, and policy review, the provider failed to ensure that required physician visits (every 30 days for the first 90 days after the resident's admission and every 60 days thereafter) were alternated between personal visits by the physician and by the physician assistant (PA) after the physician makes the initial comprehensive visit for residents under a SNF stay (skilled nursing care covered by Medicare part A) for four of four sampled residents (4, 8, 29, and 43) who had SNF stays at the facility in the period reviewed from 7/4/25 through 7/29/26. Findings include:1. Review of resident 8's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. He had a SNF stay that began on 10/9/25 and ended on 10/30/25. PA C assessed resident 8 on 7/22/25, 8/12/25, 10/14/25, 11/26/25, 12/10/25, 2/4/26, 4/8/26, 5/27/26, and 7/22/26. There was no documentation in his EMR that indicated he had a medical visit completed by a physician within the last year. 2. Review of resident 29's EMR revealed he admitted to the facility on [DATE]. He was assessed by PA C on 11/19/25 for his initial certification visit, 12/17/25 for his second certification visit, and 1/7/26 for his final 90-day certification visit. There was no documentation in his EMR that indicated he had a medical visit completed by a physician since he admitted . 3. Review of resident 4's EMR revealed she admitted to the facility on [DATE]. She had a SNF stay that began on 3/16/26 and ended on 4/24/26 and another SNF stay that began on 5/10/26 and ended on 5/19/26. PA C assessed resident 4 on 7/8/25, 9/2/25, 10/1/25, 10/28/25, 12/23/25, 1/28/26, 4/8/26, 6/3/26, and 7/8/26. She was assessed by a physician on 2/11/26 for a hospital follow up and on 6/30/26 for an acute issue. 4. Review of resident 43's EMR revealed she admitted to the facility on [DATE]. She had a SNF stay that began on 3/23/26 and ended on 5/25/26. She was assessed by PA C on 3/25/26 for her initial certification visit, 4/22/26 for her second certification visit, and 5/20/26 for her 90-day certification visit. There was no documentation that indicated she had a physician visit or an examination completed by a physician since she admitted . 5. Interview on 7/28/26 at 11:21 a.m. with administrator A revealed that she thought that a non-physician practitioner (NPP), such as a PA, was allowed to see all of the residents for their standard medical visits. She was not aware that a physician was to conduct the resident's initial visit and every other 30-day physician visit after that for residents under SNF stays. 6. Interview on 7/29/26 at 11:15 a.m. with PA C revealed that she completed the residents' first provider visit after they admitted to the facility. She stated that a physician came to the clinic in town at least once a month, but she (PA C) usually saw the residents in the nursing home for their medical care and visits. She stated that there was always a physician on call and available to fill in for her if she was unavailable. 7. Review of the provider's undated Resident Policy Manual revealed that residents were required to have an examination by their physician prior to admission or within 48 hours after admission. After admission, residents would need to see their physician every 30 days for the first 90 days. 8. Review of the provider's April 2026 Policy and Procedure for Physician Rounds revealed that each resident would receive timely medical supervision by an attending physician, physician assistant, or nurse practitioner in compliance with federal and state laws.

Based on observation, interview, and policy review, the provider failed to protect the residents' right to confidential personal medical information for two of two sampled residents (41 and 40) by one of one observed certified nurse aide (CNA) (S) who left residents' electronic medical records (EMR) information displayed on a computer screen mounted to the wall in the East hallway. Findings include:1. Observation on 7/27/26 at 3:40 p.m. in the East hallway revealed CNA S was in the hallway entering data on a computer. She left the computer with resident 41's EMR information displayed on that computer screen and entered another resident's room. CNA S came out of that room and returned to the computer screen. She left the computer and answered another resident's call light at 3:42 p.m. with resident 40's EMR information displayed on the computer screen. CNA S came back out into the hallway and continued to use that same computer. At 3:46 p.m. CNA S left the computer to answer another resident's call light. The computer was left on a screen that displayed all the residents' names. At 3:50 p.m. CNA I walked down the hallway, paused and locked the computer screen, then continued down the hallway. 2. Interview on 7/27/26 at 3:55 p.m. with registered nurse (RN) Q revealed that the computer screens in the hallways were for staff members to use for charting the residents' care in the EMR system. She stated that when staff members were done using the computer, they were expected to lock the screen to protect the residents' private medical information. 3. Interview on 7/29/26 at 11:29 a.m. with director of nursing (DON) B and administrator A revealed that staff were expected to keep residents' medical information private by locking the computer screens when they were done charting in the EMR system. They agreed that any visitor or other resident could potentially use the computer's touch screen and access residents' medical information if the staff did not lock the screen. 4. Review of the provider's undated resident admission packet revealed a booklet called Nursing Home Residents' Rights. The booklet stated that residents have the right to approve or refuse anyone outside of the nursing home access to their personal and care records.

Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to protect the residents' right to be free from verbal and physical abuse for one of one sampled resident (8) who reported that he had an incontinence (involuntary urine or bowel leakage) absorbent brief thrown at him, was told to do it himself, and was left on the toilet without assistance by one of one certified nursing assistant (CNA) (V). Findings include:1. Review of the provider's 2/24/26 SD DOH FRI revealed that resident 8 reported to licensed practical nurse (LPN) U that a staff member was rude to him that evening. Resident 8 told LPN U that when he needed assistance in the bathroom, the staff member told him to do it himself, gave resident 8 a brief, then left the room. Resident 8 was blind and was unable to provide the staff member's name. The provider interviewed all staff members who were scheduled to work at the facility that night and determined that CNA V was the staff member who provided care to resident 8 on the evening of 2/24/26. CNA V did not provide the resident's care according to the resident's care plan and substantiated the allegation of abuse. CNA V's employment with the facility was terminated on 2/26/26. 2. Review of resident 8's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. He had a 6/24/26 Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated that his cognition was intact. He had diagnoses of reduced mobility, blindness, and lumber fusion (the surgical joining of two or more bones in the lower spine). Resident 8's 8/11/21 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area that indicated [resident 8] is completely blind, unable to see shapes, shadows with the intervention for the staff to assist the resident as needed with his activities of daily living (ADLs). Resident 8 had another 4/6/26 focus area that indicated [resident 8] has an ADL self-care performance deficit with the intervention for the staff to provide partial to moderate assistance with personal hygiene. 3. Interview on 7/27/26 at 10:58 a.m. with resident 8 revealed that he needed the staff's assistance with putting on a new incontinence brief due to his blindness, and difficulty bending over due to his history of back surgery. He remembered that a staff member threw a brief at him while he was on the toilet, and when he asked her for assistance with putting it on, she told him to do it yourself, and then left his room. Resident 8 pulled his call light cord, and another staff member helped him put the new brief on and get off the toilet. Resident 8 was not sure of the staff member's name who threw the incontince brief at him. Resident 8 stated that incident was his only negative interaction with a staff member at the facility. He stated that CNA V did not introduce herself when she came into the room and he did not remember hearing her voice taking care of him after this incident. 4. Interview on 7/29/26 at 10:37 a.m. with social services designee (SSD) D revealed that she interviewed resident 8 after the alleged abuse by CNA V. SSD D remembered speaking with resident 8 but was unable to interview CNA V as her employment was terminated. She stated that she did not interview other residents who were assigned to be cared for by CNA V to determine if any residents may have been abused by CNA V. She explained that she did not interview any other residents because nobody else came to me. 5. Review of the provider's Investigative Protocol Form revealed that an investigation into the incident was initiated on 2/25/26. The protocol form included eight interventions to be completed for the investigation. Those interventions were: description of the issue, immediate action taken, root cause analysis, policy review, in-service education form, focus audit form, investigative summary, and care plan review. The intervention areas for root cause analysis, in service education form, and focus audit form were blank on the investigative protocol form. 6. Interview and review of the Investigative Protocol Form on 7/29/26 at 11:29 a.m. with director of nursing (DON) B and administrator A confirmed that the root cause analysis, in-service education form, and focus audits were not completed in the investigative protocol form for the 2/24/26 incident. 7. Further interview on 7/29/26 at 12:12 p.m. with administrator A revealed that no audits of CNA V's interactions with residents or other staff interactions with residents were completed. Administrator A stated that staff education was provided at the all-staff meeting in March 2026 regarding abuse and neglect, but she could not provide a copy of that educational material. The staff education sign-in acknowledgement sheet included signatures of the staff members who attended that meeting, but not all signatures were legible to determine that all staff received the education on abuse and neglect. 8. Review of the provider's 1/14/26 Freedom from Abuse, Neglect, and Exploitation Policy revealed that the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, to ensure all identified incidents of alleged or suspected abuse/neglect are promptly investigated, and to ensure a complete review of existing incidents is documented. Investigation of abuse may include interviewing staff, residents, or other witnesses to the incident.

Based on observation, interview, record review, and policy review, the provider failed to ensure an environment free of accident hazards for two of two sampled residents (29 and 43) who used electronic lift chairs in their rooms and were not assessed to determine the residents' ability to safely use those chairs independently, to mitigate the risk of accidents. Findings include: 1. Observation and interview on 7/26/2026 at 2:50 p.m. with resident 29 in his room revealed he was seated in an electronic lift chair with his feet elevated on the footrest, and the remote for the chair was draped over the armrest, within his reach. When the resident was asked if he knew how to use the remote to raise or lower his feet, he stated he did not know what the chair remote was for or how to use it. 2. Review of resident 29's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had diagnoses of Alzheimer's (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia (a group of symptoms affecting memory, thinking, and social abilities), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Resident 29 fell at home and fractured his right arm and hip before he admitted to the facility in December 2025, and sustained a left hip fracture that was surgically replaced on 12/31/25.Resident 29's EMR did not include any documented assessment of his functional status, cognitive ability, strength, balance, judgment, or safety awareness related to his ability to independently use the electronic lift chair. No documentation indicated that he was evaluated for supervision needs, assistance needs, or environmental safety measures associated with his use of that chair. Resident 29's 5/20/26 Brief Interview for Mental Status (BIMS) assessment score was 4, which indicated his cognition was severely impaired. His current undated care plan indicated his cognition was severely impaired. His current undated care plan indicated that he was to transfer with substantial/maximum assistance from staff, and he was at risk for falls due to his impaired cognition and mobility. His care plan intervention initiated on 2/23/26 indicated that the staff were to encourage him not to elevate his footrest while he was in the electronic lift chair, and that the staff were educated about that intervention. 3. Observation and interview on 7/26/2026 at 1:10 p.m. with resident 43 in her room revealed she was seated in an electronic lift chair with her feet elevated on the footrest, and the remote for the chair was draped over the chair's armrest, within her reach. Resident 43 denied knowing how to use the chair's remote or what the remote was for. 4. Observation on 7/27/2026 at 11:44 a.m. and on 7/28/26 at 1:50 p.m. revealed resident 43 was seated in her electronic lift chair with her feet elevated on the footrest, with the chair's remote draped over the armrest, within reach of the resident. 5. Observation and interview on 7/27/2026 at 5:10 p.m. with certified nursing aide (CNA) N and resident 43 in her room revealed CNA N asked resident 43 in her room revealed CNA N asked resident 43 if she could use her chair remote to lower her feet in the electronic lift chair, and if she knew what the remote was for. Resident 43 stated, It's for a whole lot of nothing. The CNA stated that staff knew which residents could have their feet raised on the footrest while sitting in the electronic recliner. 6. Review of resident 43's EMR revealed she admitted to the facility on [DATE]. She had diagnoses of anxiety and rheumatoid arthritis (inflammation of the joints). Resident 43 fell and fractured her right hip on 3/17/26 before she admitted to the facility.Resident 43's EMR did not include any documented assessment of her functional status, cognitive ability, strength, balance, judgment, or safety awareness related to her ability to independently use the electronic lift chair. No documentation indicated that she was evaluated for supervision needs, assistance needs, or environmental safety measures associated with her use of that chair. Her 6/24/26 BIMS assessment score was 4, which indicated her cognition was severely impaired. Her current undated care plan indicated that she had an activities of daily living (ADL) self-care performance deficit related to her impaired balance, limited mobility, and musculoskeletal impairment due to her right hip fracture. Her 3/25/26 initiated care plan intervention indicated she required partial to moderate assistance from staff to stand and pivot to her wheelchair and needed to use a sit-to-stand mechanical lift (a medical safety device used to safely move people who cannot stand or walk on their own) for toileting. 7. Interview on 7/26/2026 at 3:02 p.m. with contracted travel CNA T revealed she utilized the resident's care plans in Point Click Care (PCC) (an electronic medical records system) to determine how to care for the residents. She indicated that she was trained on how to care for each resident by the facility staff upon hire. 8. Interview on 7/28/26 at 3:25 p.m. with administrator A revealed the staff did not assess residents for safety concerns when using a recliner, whether manual or electric. 9. Interview on 07/29/2026 1:15 PM with director of nursing (DON) B revealed staff were aware of which residents could use the electronic lift chair remote and if their feet should be elevated when they were sitting in those chairs. She indicated that the chair's remote should be left in the chair's side pocket if the resident did not know how to use it. 10. Review of the provider's reviewed 2/24/26 Resident Accident Prevention policy and procedures revealed It is the policy of Aurora [NAME] Care and Rehab to ensure that the resident's environment remains as free as possible of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. An accident is an unexpected, unintended event that can cause bodily injury. It does not include adverse outcomes associated as a direct consequence of treatment or care. Accident hazards include, but are not limited to, physical restraints, poorly maintained resident equipment, bathing facilities lacking non-slip surfaces, hazards such as electrical appliances with frayed wires, cleaning supplies easily accessible to cognitively impaired residents, wet floors that are not obviously labeled and to which access is not blocked, handrails not securely fixed to the wall, and water temperatures that can scald or harm residents. Purpose: to provide a safe and accident-free environment. Procedure: The facility is continuously monitored by all staff for unsafe/hazardous conditions, and corrections are promptly made as needed to maintain a safe environment for residents. Resident equipment is inspected regularly to ensure proper and safe working conditions. All residents are assessed quarterly for their risk of accidents and falls, and receive individualized care planning related to their individual needs

Based on observation, interview, record review, and policy review, the provider failed to ensure medications were labeled and administered according to the physician's orders for one of one (25) sampled resident who was administered lorazepam (an antianxiety medication) by one of one observed certified nursing assistant (CNA)/medication aide (MA) (M) from a medication blister pack (pre-formed plastic and foil packages that hold individual doses of pills or capsules in separate small pockets) with labeled administration instructions that did not match the physician's order for that medication in the resident's electronic medical record (EMR). Findings include:1. Observation on 7/27/26 at 9:49 a.m. with certified nursing assistant (CNA)/medication aide (MA) M revealed that resident 25 received 0.5 milligrams (mg) of lorazepam along with other scheduled medications. CNA/MA M looked at the resident's physician order for lorazepam in her EMR and compared it to the resident's lorazepam medication blister pack card pharmacy label. She identified that the medication card's pharmacy label and the EMR had two different instructions for how often the medication was to be administered. Resident 25's lorazepam 0.5 mg EMR instructions indicated to give 1 tablet by mouth four times daily for anxiety disorder. The resident's lorazepam 0.5 mg medication card pharmacy label instructed to give one tablet by mouth two times daily. CNA/MA M stated, That is weird and administered one 0.5mg lorazepam tablet to resident 25. 2. Review of resident 25's EMR revealed that she admitted to the facility on [DATE]. She had orders for hospice services on 6/26/26. Resident 25 was started on 0.5mg lorazepam medication on 4/23/26, with the physician's order instructions to give one tablet by mouth two times daily. The physician's order was changed on 6/28/26, with the instructions to give one tablet by mouth three times daily. The lorazepam medication was changed by her provider again on 7/9/26, with the instructions to give one tablet by mouth four times daily. 3. Interview on 7/27/26 at 4:11 p.m. with registered nurse (RN) Q revealed that if an order for a controlled (a drug that the government regulates because it can be misused, cause physical or psychological dependence, or lead to an overdose) medication like lorazepam was changed, two nurses were expected to destroy the tablets in that medication's blister pack card and then order a new card from the pharmacy with the updated instructions. 4. Observation and interview on 7/28/26 at 3:23 p.m. of the medication cart from resident 25's hallway with director of nursing (DON) B revealed that resident 25 had three medication cards of 0.5 mg lorazepam tablets. All three of those medication cards were labeled with the instructions to give one tablet by mouth two times daily. DON B stated that two nurses were to destroy the medications if the medication order was discontinued. If the medication administration instructions changed, she expected staff to add a sticker on the medication card to indicate that those instructions had changed. The staff would then order a new medication card when medication supply in the card with the previous instructions ran out. She stated that resident 25's three medication cards should have had two stickers on the prescription label, one for when it changed from twice daily to three times daily, and another for when it changed from three times daily to four times daily. She would have expected staff to apply those stickers. 5. Review of the provider's 4/20/26 General Medication Administration policy and procedure revealed that during the medication pass, the staff was expected to check if there is a discrepancy between the card, label, and MAR, hold the medication until the medication pass is completed and verify with the physician's order.

Based on observation, interview, and policy review, the provider failed to ensure that the staff followed standard safe food service practices regarding handwashing and glove use when handling ready-to-eat (RTE) foods by one of one dietary aide (L) during one of two meals observed.Findings include:1. Observation during lunch on 7/28/26 from 11:52 a.m. to 12:12 p.m. in the kitchen revealed that the menu was chicken parmesan with noodles, lettuce salad, peaches in yogurt, and a slice of buttered bread. Dietary aide L was responsible for dishing the lettuce salad onto the plates, placing a plastic cup of salad dressing on the plates, and delivering the resident's meals using a pushcart. He used his right hand to scoop the lettuce salad onto the plates with a serving spoon, and he used his bare left hand to touch the salad so it would stay on the plate. He placed the plastic cups of salad dressing directly on top of the food on the plates, rather than on the side of the plate. He went back and forth from the kitchen to the dining room delivering the resident's meals at least five times and did not perform hand hygiene or put gloves on his hands during the above observations.2. Interview on 7/28/26 at 12:12 p.m. with dietary aide L about the above observations revealed he confirmed he touched the lettuce salad with his bare hands and did not perform hand hygiene or put gloves on before touching the lettuce salad with his hands.3. Interview on 7/28/26 at 2:46 p.m. with certified dietary manager E revealed that he expected the staff to not touch RTE foods with their bare hands. He expected the staff to use serving utensils or perform hand hygiene and put gloves on when touching RTE foods. He did not realize the potential food contamination that could occur by placing the salad dressing cups directly on top of food. He expected the staff to perform hand hygiene each time they entered and exited the kitchen.4. Review of the provider's 4/8/26 Food Preparation and Handling Policy revealed that foods are prepared and served with clean tongs, scoops, forks, spoons, spatulas, knives, plastic gloves, or other suitable implements to minimize handling and to avoid manual contact of food at all points during preparation and service.5. Review of the provider's 4/8/26 Glove Use in Dietary policy revealed that the employees will wear gloves when handling any ready to eat foods like salad bar items, produce, sandwiches, cooked foods, deli meats, cheeses, breads, and ice.

Based on record review and interview, the provider failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Centers for Medicare and Medicaid Services (CMS) Part A form (CMS-10055) was provided for two of three sampled residents ( 26 and 43) reviewed for notification of Medicare benefits ending or their representatives to inform residents of potential financial liability for non covered Skilled Nursing Facility (SNF) Part A services. Findings included: 1. Review of resident 26's electronic medical record (EMR) revealed that resident 26's Medicare Part A Skilled Services Episode start date was 5/6/26. Resident 26's last covered day of Part A was 7/23/26. The facility provided residents 26 and 43 the CMS R 131 form, which is not the correct notice for SNF non coverage. The CMS R 131 form in the in resident 26's EMR was not signed by the resident or the resident's representative; instead, a phone consent was given on 7/20/26. There was no documentation indicating the correct SNF Advance Beneficiary Notice of Non-coverage (ABN) CMS 10055 form was explained, issued, or given to resident 26 or the resident's representative. 2. Review of resident 43's EMR revealed that resident 43's Medicare Part A Skilled Services Episode start date was 12/16/25. Resident 43's last covered day of Part A was 1/7/26. The facility provided the CMS R 131 form, which is not the correct notice for SNF non coverage. The CMS R 131 form in the EMR was signed by the resident on 1/5/26. There was no documentation indicating the correct SNF ABN CMS 10055 form was explained, issued, or given to resident 43 or their representative. 3. Interview on 07/28/2026 at 9:50 a.m. with Administrator A confirmed the CMS R 131 form was used instead of the CMS-10055 form and acknowledged they did not have a signed CMS 10055 for resident 26 or resident 43.

Based on interview, record review, resident admission packet review, and policy review, the provider failed to ensure the binding arbitration agreement forms provided to residents or their representatives for review and signature contained the required information for one of one sampled resident (25).Findings include:1. Interview on 7/27/26 at 12:32 p.m. with business manager W revealed that she was assigned to develop and implement a binding arbitration agreement policy for the facility in January 2026. The policy was approved in March 2026, and only one resident's representative had signed an arbitration agreement form since then. Resident 25's representative signed the resident's arbitration agreement form.2. Review of resident 25's signed binding arbitration agreement form revealed that it was signed by the resident's representative on 4/22/26. The agreement form did not include the following required items: that the resident or their representative have the right to rescind the agreement within 30 calendar days of signing the form; that the resident or their representative is not required to sign the agreement as a condition of admission to the facility or as a requirement to continue to receive care at the facility.3. Phone interview on 7/29/26 with resident 25's legal representative revealed that she understood the agreement in terms of she would try to work out disagreements or grievances with the provider rather than going over their head, such as submitting concerns to the state survey agency. She could not remember if the provider informed her that she was exempt from litigation by signing the agreement. She further explained that the provider might have explained that to her, but she could not remember that part explicitly.4. Interview on 7/29/26 at 12:57 p.m. with administrator A revealed that business manager W was responsible for the binding arbitration agreement process at the facility. However, she was unavailable that day to discuss the agreements process.5. Continued interview on 7/29/26 at 1:30 p.m. with administrator A revealed that she acknowledged that the facility's arbitration form that the residents or their representatives signed did not include some of the required information. She explained that their policy contained that information, but the form that was given to residents or their representatives did not.6. Review of the provider's current admission packet revealed that a blank Arbitration Agreement form was included, but the policy that contained the required information was not included in that packet.7. Review of the provider's 3/18/26 Voluntary Binding Arbitration Agreement Policy revealed that it was the facility's policy to not require any resident or his/her representative to sign the VBAA [voluntary binding arbitration agreement] as a condition of admission to, or as a requirement to continue to receive care at the facility; provide the resident or his/her representative with a 30-day rescission period.

Based on observation, interview, record review, and policy review, the provider failed to identify necessary care interventions, ensure resident care plans had been reviewed and revised, to reflect the current needs for two of two sampled residents (7 and 15) who had fallen more than once.Findings include:1.Observation and interview on 7/22/25 at 9:30 a.m. of resident 7 in her room revealed:*She was seated in her recliner watching tv with her call light within reach.*Her walker was on the right side of her recliner with a gait belt draped over it.*She stated she walked assisted with one staff person and had fallen a few times. 2. Review of resident 7's EMR revealed:*She was admitted on [DATE].*She had a BIMS assessment score of 13, which indicated her cognition was intact.*Her diagnoses included repeated falls, heart failure, and chronic kidney disease (when the kidneys are damaged and cannot filter waste, fluids, and toxins from the body).*Her care plan indicated she had a high risk for falling on 7/16/2024.-The last updated revision of her fall interventions was on 7/17/24.-The interventions included providing a safe environment, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, and to review information on past falls and attempt to determine the cause of the falls.-She fell on 1/31/25, 2/6/25, and 4/20/25.-There were no interventions added to her care plan regarding her falls on 1/31/25, 2/6/25, and 4/20/25.*The nursing progress notes indicated she had fallen on 5/17/25, and the fall and fall interventions had not been added to her care plan. 3. Review of resident 15's electronic medical record (EMR) revealed:*He was admitted on [DATE].*He had a Brief Interview of Mental Status (BIMS) assessment score of 5, which indicated his cognition was moderately impaired.*His diagnoses included repeated falls, weakness, and abnormalities of gait (walking) and mobility.*His care plan indicated he had a high risk for falling on 3/6/25.-The last revision of interventions for his falls was on 3/6/25.-The interventions included anticipating his needs, to ensure his call light was within reach, to wear appropriate nonskid footwear when ambulating (walking), encourage him to participate in activities, follow the facility fall protocol, and for physical therapy (PT) to evaluate and treat as ordered. -He fell on 3/15/25, 3/29/25, and 4/5/25.-There were no interventions added to his care plan regarding his falls on 3/15/25, 3/29/25, and 4/5/25.*The nursing progress notes indicated he had fallen on 6/27/25, and the fall and fall interventions had not been added to his care plan. 4. Interview on 7/23/25 at 3:32 p.m. with licensed practical nurse (LPN) H revealed:*The director of nursing (DON) W, registered nurse (RN) F, and LPN I updated the residents' care plans.*It was not the responsibility of the charge nurses to update the residents' care plans.*She stated she knew how to update a care plan but had not done that in a long time. 5. Interview on 7/24/25 at 8:14 a.m. with administrator A regarding resident care plans revealed:*Each department was responsible for updating their portion of the residents' care plans.*If a nurse had resident information that needed to be updated in their care plan, the nurse would go to the DON W to update it.*The responsible department were to update the residents' care plans every quarter, for significant changes (declines in residents' health), when a resident had fallen, and when a resident had a change in their behavior/mood.*She expected resident care plans to be updated by the DON W after falls occurred to include updated interventions to prevent future falls.*She was not aware resident 7's care plan had not been updated regarding her falls on 1/31/25, 2/6/25, 4/20/25, and 5/17/25. *She was not aware resident 15's care plan had not been updated regarding his falls on 3/15/25, 3/29/25, 4/5/25, and 6/27/25. 6. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 7. Review of the provider's updated 4/17/24 Comprehensive Care Plan policy revealed:* will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.* 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.*The policy did not address who was responsible for updating the residents' care plans or how often that should occur. 8. Review of the provider's undated Fall Management Policy and Procedure revealed:* 11. Update the Comprehensive Care Plan with any changes or new interventions.*The policy did not address fall interventions had to be reviewed and updated each time a resident fell.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one certified medication aide (CMA) (K) followed accepted standards of practice and facility policy during medication administration that included:*Proper administration technique for two of two sampled resident's (11 and 13) eye drops.*Inquiring about and accurately recording pain level for one of one resident (13) receiving a scheduled pain medication.*Not returning two stock supply acetaminophen (a pain-relieving medication) tablets back into the bottle after being prepared for administration to resident (17).*Appropriately identifying and administering medications per physician orders according to the rights of medication administration.Findings include: 1. Observation on 7/23/25 at 3:52 p.m. of CMA K administering eye drop medication into resident 11's eyes revealed that he touched the resident's eyes with the tip of the eye dropper bottle as he was squeezing the liquid out of the bottle. Review of resident 11's electronic medical record (EMR) revealed a 6/23/25 physician's order for SYSTANE ULTR [ultra] SOL [solution,] INSTILL 1 DROP INTO EACH EYE THREE TIMES DAILY. 2. Observation on 7/23/25 at 3:57 p.m. of CMA K administering eye drop medication into resident 13's eyes revealed that he touched the resident's eyes with the tip of both eye dropper bottles as he was squeezing the liquid out of the bottle. Review of resident 13's EMR revealed physician's orders:*On 3/3/25 for SYSTANE PRESERVATIVE FREE-UD, INSTILL 1 DROP INTO EACH EYE THREE TIMES DAILY.*On 7/6/24 for Alphagan P Ophthalmic [Eye] Solution 0.1 % (Brimonidine Tartrate) Instill 1 drop in right eye two times a day. 3. Observation on 7/23/25 at 3:57 p.m. of CMA K while administering resident 13's medications revealed:*Resident 13 was scheduled to receive two acetaminophen (Tylenol) 325 milligram (mg) tablets three times per day, scheduled for 7:00 a.m., 12:00 p.m., and 5:00 p.m.*He administered two Tylenol 325mg tablets to resident 13.*CMA K did not ask resident 13 what her pain level was at.*He was observed charting in resident 13's EMR that her pain was at a level of 0, which meant that she did not have any pain. Review of resident 13's medication administration record (MAR) revealed CMA K charted resident 13's pain at a level 0 (which indicated no pain) for the scheduled 5:00 p.m. acetaminophen administration. 4. Observation on 7/23/25 at 4:09 p.m. of CMA K while preparing resident 17's medications revealed he:*Explained that resident 17 was scheduled to receive acetaminophen at that time.*Removed two 325mg acetaminophen tablets from the stock medication bottle and placed them in a medication cup.*Realized he had made a mistake, explaining that she was to have received a stronger dose from her prescription medication cards.*Placed those two acetaminophen tablets back into the stock medication bottle.*Found resident 17's medication card for 500mg acetaminophen tablets and popped one pill from the medication card into the medication cup. Review of the stock medication bottle confirmed that it contained 325mg tablets of acetaminophen. Review of resident 17's EMR confirmed she had a 7/29/24 physician's order for ACETAMIN [acetaminophen] TAB 500MG GIVE 1 TAB BY MOUTH FOUR TIMES DAILY. 5. Observations on 7/23/25 from 3:47 p.m. to 5:04 p.m. of CMA K during medication administration revealed he was not comparing the prescription labels on the resident's medication cards or prescription bottles to verify they matched physician's orders in the residents' EMRs. He was relying on memory as to where the resident's medication cards were located at in the medication cart, without verifying the label on the medication cards matched the resident he was preparing medications for. See F759, findings 1 and 2. 6. Interview on 7/23/25 at 5:28 p.m. with administrator A revealed:*She was informed that the surveyors intervened during the medication administration observation with CMA K to prevent him from administering medications to the wrong resident.*She expected all staff who administered resident medications to follow facility policy and the rights of medication administration.*She confirmed that the tip of the eye drop medication bottle should not physically touch the resident's eyes. 7. Interview on 7/24/25 at 8:20 a.m. with registered nurse (RN) G and licensed practical nurse (LPN) H revealed:*They both confirmed that the person administering eye drops should not touch a resident's eye with the tip of the eye drop bottle.*They expected all staff administering medications to compare the resident's MAR with the medication prescription label to ensure the resident received the correct medication. 8. Interview on 7/24/25 at 2:08 p.m. with LPN I revealed:*She was the facility's designated infection preventionist.*She confirmed that staff should not have touched a resident's eye with the eye drop medication bottle.*She confirmed staff should have been comparing the prescription label on the resident's medication card or bottle with their physician's orders in the EMR. 9. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 10. Review of the provider's 7/27/23 General Medication Administration Policy & Procedure revealed:* .Procedure for Medication Pass: -2. During the Medication Pass - Nursing should always check the 6 ‘R's': --a. Right Resident - before administering medications, identify each according to Facility Policy; --b. Right Drug - verify in at least three ways, such as ---1. The drug's size, color and label. ---2. Verify each drug against the MAR before administering. ---3. If there is a discrepancy between the card, label and MAR, hold the medication until the Medication Pass is completed and verify with the Physician's Order Sheet; --c. Right Dose - verify against MAR; --d. Right Dosage Form - verify against MAR; --e. Right Time - administer meds according to facility standard medication administration time or personalized medication administration schedules; --f. Right Route - verify against MAR.-3. If the comparison is correct, the Medication is to be removed from the container and placed into the Medication Cup using appropriate technique. Nursing must document in the eMAR for the appropriate medication, with the appropriate date and time according to Facility Policy. -.7. If a PRN Medication is administered, nursing should document accordingly in the eMAR under the PRN tab, provide supplementary documentation as to why the med has been given, pain level, etc. 11. Review of the provider's 7/27/23 OPHTHALMIC DROPS policy revealed:* Equipment:-Medication Administration Record (MAR)-Prescribed eye medication-Cotton ball or tissue-Gauze pads, dressings, warm water or saline solution (if applicable)* Procedure:-1. Verify medication order on MAR. Check against physician order. Check medication and label. Comments: Make certain medication is labeled for ophthalmic [eye] use (assumes sterility and compatibility for use in the eye). If clear bottle, observe medication for discoloration or precipitates [particles].-2. Identify resident. Explain procedure.-3. Wash hands.-4. Determine which eye is to be instilled and verify dose for each eye.-.6. Have resident lie supine [on their back] or sit. Head should be tilted back and toward the side of the affected eye. Comments: Excess solution should drain away from inner canthus to prevent systemic absorption through nasal mucosa [the tissue inside a person's nose as the tear duct leads to the nose].-.8. Before instilling drop, instruct resident to look up and away. Comments: Moves cornea [the dome-shaped cover over a person's iris and pupil] up and away from conjunctival sac [the space between the eyelid and white of the eye] and minimizes risk of touching cornea with dropper, particularly if patient blinks.-9. Gently pull down lower lid to expose conjunctival sac.-10. Eye drops: Hold dropper in dominant hand approximately [one-half to three-quarters inches] above conjunctival [NAME]. Do not touch dropper to eye. Shake suspensions well. Comments: The eye can retain maximum of two drops at one time.

Based on observation, record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (15) who was transferred without the use of a gait belt (a waist strap gripped as support for safe mobility and transfers) by five of five staff members (certified nursing assistant (CNA) M, administrator A, CNA N, certified medication aide (CMA) J, and registered nurse (RN) G) observed.Findings include:1. Observation on 7/22/25 at 11:17 a.m. of resident 15 revealed: *He stated he needed to use the restroom quickly. *CNA M was walking by and stopped to help him. -She positioned his wheelchair next to the recliner and locked the brakes. -She grabbed resident 15 by his right arm and began hoisting him up. -Administrator A came out of her office and grabbed resident 15 by his left arm and assisted CNA M with transferring him into his wheelchair. -No gait belt was used during that transfer. 2. Observation on 7/22/25 at 12:11 p.m. of resident 15 revealed he was transferred out of the recliner to his wheelchair without a gait belt by administrator A and CNA N. 3. Observation on 7/22/25 at 3:04 p.m. of resident 15 revealed he was transferred out of the recliner to his wheelchair without a gait belt by administrator A and CNA N. 4. Observation on 7/22/25 at 4:30 p.m. of resident 15 revealed he was transferred out of the recliner to his wheelchair without a gait belt by CMA J and RN G. 5. Review of resident 15’s electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview of Mental Status (BIMS) assessment score of 5, which indicated his cognition was moderately impaired. *His diagnoses included repeated falls, weakness, and abnormalities of gait (walking) and mobility. *His care plan indicated he had a high risk for falling on 3/6/25. *He requires “partial/mod assist [the helper provides less than half of the effort needed for the transfer] of staff to move between surfaces as necessary. Stand aid [a device designed to help people who have difficulty rising from a seated position to a standing position] needed at times. Focus on stand pivot transfers [a method of moving a person from one surface to another by first standing and then helping the person pivot to another surface before sitting again].” 6. Interview on 7/23/25 at 3:32 p.m. with licensed practical nurse (LPN) H regarding resident 15 revealed: *Staff had been using a two-person assisted stand and pivot transfer (involves two staff members assisting a person with limited mobility to move between surfaces using a combination of standing and pivoting) between surfaces with him. *She did not know if he was care planned to need a gait belt, but thought it was always a good idea to use one for residents. 7. Interview on 7/23/25 at 3:45 p.m. with CNA Q revealed: *She stated resident 15 was a stand and pivot transfer between surfaces with a gait belt. *When he needed to be transferred out of the recliner, it was easier for two staff members to assist him because he was unsteady. *She had never needed to use a lift to help him stand. 8. Interview on 7/24/25 at 10:08 a.m. with administrator A revealed: *Resident 15 should have had a gait belt on when transferred between surfaces. *She stated that gait belt usage for resident transfers has been an issue. *She had informed the staff at their meetings to use gait belts when assisting residents with transferring. *She expected all staff to use gait belts when assisting all residents with transferring. 9. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 10. Review of the provider’s reviewed 7/27/23 Gait Belt Safety policy revealed: *“All Physical, Occupational, & Speech Therapy personnel are to use a gait belt for all patients involving transfer from one surface to another or to come to standing.” *“The gait belt provides a firm grasping surface for the staff person and protects the resident. The gait belt gives the patient a sense of security as it is tightened. The belt also allows [the] staff person to gradually lower a patient [resident] to the floor (if necessary) without injuring self or patient.” *The policy did not address non-therapy staff and the use of gait belts when transferring residents.

Based on observation, record review, interview, and policy review, the provider failed to ensure the medication error rate remained under 5%. Certified medication aide (CMA) K had three errors out forty-one total medication administration observations, including failing to verify resident physician orders with the medication prescription label, failing to document he had given a PRN (as needed) eyedrop medication, and preparing one sampled resident's (15) medications to administer to another sampled resident (39). This resulted in a calculated error rate of 7.3%.Findings include: 1. Observation and electronic medical record (EMR) review on 7/23/2025 at 3:57 p.m. with CMA K while preparing resident 13’s medications revealed: *CMA K grabbed an orange medication bottle. The label on that bottle read, “artificial tears, instill 1 drop into each eye PRN [as needed].” *CMA K did not check the physician’s order in the resident’s EMR to ensure the prescription label on the bottle matched the physician’s order before administering the eye drops into resident 13’s eyes. *Resident 13’s EMR revealed a physician’s order on 8/13/24 for “ARTIFICIAL DRO [drop] TEARS, INSTILL 1 DROP INTO EACH EYE AS NEEDED.” -CMA K did not document that the PRN artificial tears were administered. 2. Observation and interview on 7/23/25 at 4:42 p.m. of CMA K revealed: *CMA K was preparing medications for resident 39. *CMA K grabbed two medication cards out of the medication cart. He did not check the prescription label on the medication cards to ensure that the cards he grabbed were for resident 39. *Those medication cards were for resident 15 instead of resident 39. -One medication card contained levothyroxine sodium (a thyroid hormone replacement medication) 75mcg (micrograms). -The other medication card contained propranolol (a medication to slow down the heart rate) 10mg (milligram) tablets. *CMA K was not able to describe the “rights” of medication administration when asked. *When asked to verify if the medication cards he grabbed were correct or not, CMA K realized the medication cards he grabbed were not for resident 39. -He thanked the surveyors for pointing that out to him and stated that he “would have already popped those” open to administer to the wrong resident. -He stated that the resident’s medication cards were usually in the same spot in the medication cart. -He guessed that the night shift staff might have rearranged the medication cards in the medication cart when they were replenishing their supply. 3. Interview on 7/24/25 at 8:20 a.m. with registered nurse (RN) G and licensed practical nurse (LPN) H revealed: *They expected all staff administering medications to compare the resident’s medication administration record (MAR) with the medication prescription label to ensure the resident received the correct medication. *If there were discrepancies between the prescription label and the MAR, the pharmacy and resident’s physician should have been contacted. 4. Interview on 7/24/25 at 9:06 a.m. with administrator A revealed she expected staff to contact the nurses on duty if there were discrepancies between the medication prescription label and the resident’s MAR, and all staff administering medications were expected to perform the rights of medication administration to ensure residents were receiving the correct medications. 5. Interview on 7/24/25 at 2:08 p.m. with LPN I revealed she confirmed staff should have been comparing the prescription label on the resident’s medication card or bottle with their physician’s orders in the EMR. 6. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 7. Review of the provider’s 7/27/23 General Medication Administration Policy & Procedure revealed: *“Policy: The facility will assure that medications are administered safely and accurately to Residents for whom they are prescribed.” *Procedures: -“…C. Medications are administered in accordance with written orders of the attending physician…” -“…D. All current medications, dosage schedules, [self-administration]/bedside medications counts are recorded on the Resident’s Medication Administration Record (MAR).” -“…F. All Residents are/will be identified prior to the administration every time a medication is given. Residents should be identified by use of the following: --Verifying Resident’s identity with another Facility Employee familiar with the Resident; --Asking the Resident their Name and Birth Date” -“…H. The Resident’s MAR is immediately documented after medications are administered to the resident in eMAR [electronic medication administration record]. At no time will any medications be pre-documented before medication administration has actually occurred.” -“I. Medications supplied for one Resident will not be administered to any person other than for whom that medication was prescribed.” -“K. Procedure for Medication Pass: --…2. During the Medication Pass – Nursing should always check the 6 ‘R’s’: ---a. Right Resident – before administering medications, identify each according to Facility Policy; ---b. Right Drug – verify in at least three ways, such as ----1. The drug’s size, color and label. ----2. Verify each drug against the MAR before administering. ----3. If there is a discrepancy between the card, label and MAR, hold the medication until the Medication Pass is completed and verify with the Physician’s Order Sheet; ---c. Right Dose – verify against MAR; ---d. Right Dosage Form – verify against MAR; ---e. Right Time – administer meds according to facility standard medication administration time or personalized medication administration schedules; ---f. Right Route – verify against MAR. --3. If the comparison is correct, the Medication is to be removed from the container and placed into the Medication Cup using appropriate technique. Nursing must document in the eMAR for the appropriate medication, with the appropriate date and time according to Facility Policy. --…7. If a PRN Medication is administered, nursing should document accordingly in the eMAR under the PRN tab, provide supplementary documentation as to why the med has been given, pain level, etc.”

Based on observation, interview, record review, and policy review, the provider failed to follow food safety standards by not having monitored and documented food temperatures for 29 of 153 meals served from 6/1/25 through 7/21/25, and not having stored applesauce at or below 40 degrees Fahrenheit for three sampled residents (9, 20, and 39) who were given applesauce with their medications administered by certified medication aide (CMA) (K). Findings include: 1. Observation and interview on 7/22/25 at 9:10 a.m. with dietary manger D in the kitchen revealed: *A clipboard hanging on a cupboard labeled temperature log. *Dietary manager D stated kitchen staff were to check and document the food temperatures from each meal on that log. *He expected the cooks to document all food temperatures checked for each meal on the food temperature log. Review of the temperature logs from 6/1/25 through 7/22/25 revealed: *29 of the 153 meals served did not have the food temperatures recorded. *Dietary manager D agreed there were some missing temperatures on the food temperature log and there was no way to know if those foods were served at a safe temperature. Interview on 7/23/25 at 3:35 p.m. with cook T regarding food temperature documentation revealed: *He would sanitize the thermometer and would check the temperature of the food a few minutes before serving it. *He would document the temperatures on the temperature log. *He was aware of safe serving temperatures for food. *He stated if food was not at the proper temperature he would put it back in the oven and continue to heat it unit it was at the proper temperature. Interview on 7/24/25 at 1:20 p.m. with administrator A regarding food temperature monitoring and documentation revealed: *Staff should be checking and documenting the food temperatures for every meal. *She expected the dietary staff to follow the provider's policy regarding safe food temperatures. Review of the provider's undated Food Preparation and Handling policy revealed: *All food items served to the residents are prepared in a central kitchen according to standardized recipes. Food items are prepared using methods and techniques that are designed to preserve maximum nutritive value, enhance flavor, and assure that what is served is free of injurious organisms and substances. *20. Food temperatures are taken and recorded daily, by [the] cook, for each meal, and [the] temp log [is] kept on file in [the] kitchen. 2. Observation and interview on 7/23/25 at 4:21 p.m. of CMA K during medication administration pass revealed: *There was an opened cup of applesauce on the 200-hallway medication cart. The lid was labeled “7/22 10:17 am.” *A second opened cup of applesauce was on the 100-hallway medication cart. The lid was labeled “6:40pm 7/22.” *CMA K stated the nursing staff used the applesauce to help residents take their medication. *Whoever opened the applesauce cup was supposed to write the date and time it was opened on the lid. *Once the cup was opened, the lid was loosely placed back on the cup, and it was stored on top of the medication cart for continued use throughout the day. *They did not keep the applesauce on ice during medication pass or store the opened cups of applesauce in the refrigerator when it was not in use. *He was not aware that the applesauce was considered a potentially hazardous food (food that can grow germs and make people sick) once it was opened and should have been stored at or below 40 degrees Fahrenheit. *He continued to use the applesauce from the cup that had been opened on 7/22/25 at 6:40 p.m. throughout the observed medication pass. -He gave a spoonful of that applesauce to resident 20 at 4:30 p.m., which was 21 hours and 50 minutes after the cup was marked as opened. -He gave a spoonful of that applesauce to resident 9 at 4:34 p.m., which was 21 hours and 54 minutes after the cup was marked as opened. -He gave a spoonful of that applesauce to resident 39 at 4:42 p.m., which was 22 hours and 2 minutes after the cup was marked as opened. Interview on 7/23/25 at 5:28 p.m. with administrator A revealed that she was unaware that the applesauce should have been stored in the refrigerator after it had been opened. Review of the provider’s 1/10/25 Storage Area Policy revealed there was no description of potentially hazardous food storage guidelines. Review of the FoodKeeper App from the U.S. Department of Health & Human Services FoodSafety.gov revealed that commercially prepared applesauce should not be kept at room temperature after opening and should be consumed within seven to ten days if refrigerated after opening.

Based on observation, interview, record review, and policy review, the provider failed to follow infection prevention and control processes to ensure:*Resident personal care products were properly stored and labeled in one of two resident shared bathrooms (shared by sampled residents 3, 16, 19, and 27) reviewed.*Staff (certified nursing assistant (CNA) M, certified medication aide (CMA) K, licensed practical nurse (LPN) H, and registered nurse (RN) G) performed proper hand hygiene and glove use during resident care activities for sampled resident 31, and medication administration for sampled residents 3, 6, 9, 11, 13, 17, 19, 20, 24, 39, and 46.*Proper cleaning and sanitizing of one of one mechanical lifts (a mechanical lift used to assist from a seated to standing position) used to transfer resident 31 to the toilet by CNAs M and R.*Contact precautions protocols were followed by one of three staff observed (CMA K) during medication administration for sampled resident 13 related to a bacterial infection in her urine.*Resident care supplies such as nebulizer machines and tube feed pumps were stored in a manner that minimized risk of contamination from plumbing under the sink in one of one medical supply room.*Resident care supplies, such as catheters, cleaning products, and bath products, were discarded according to the manufacturer's expiration dates in one of one medical supply room, one of two soiled utility rooms, and one of one salon.*One of one salon and one of three shared resident shower rooms were maintained in a clean and sanitary manner.Findings include: 1. Observation on [DATE] at 11:10 a.m. in residents 3, 16, 19, and 27’s shared bathroom revealed: *One container of antifungal powder. *One tube of barrier cream (a cream to keep moisture away from the skin). *One tube of Gold Bond brand healing lotion. *One bottle of Medline Remedy brand lotion. *Two packages of opened wet wipes. *There were no labels to indicate which resident the above products belonged to. *There were approximately five incontinence briefs sitting on top of a short plastic drawer on the floor next to the toilet, uncovered, which potentially increased the risk of contamination from urine and fecal matter splash from the toilet. Interview on [DATE] at 1:58 p.m. with certified nursing assistant (CNA) O revealed: *The residents’ personal care products were not consistently labeled with which resident they belonged to. *They stored the residents’ personal care products on each resident’s assigned side of the sink. -Such as, the resident who resided on the left side of the room had the left side of the sink. *She did not know why the above products were stored in the residents’ shared bathroom. *She said that the packages of wipes should only have been used for one resident. 2. Observation on [DATE] at 11:27 a.m. of CNAs M and R revealed: *CNA M brought a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) from the shower room to resident 31’s room. -She did not clean the lift beforehand. *CNA M did not perform hand hygiene (handwashing) before putting on a pair of gloves. *CNA M helped resident 31 get strapped into the sit-to-stand mechanical lift, took her gloves off, did not perform hand hygiene, and put on a new pair of gloves. *CNAs M and R then assisted the resident to the toilet. After they got the resident situated, CNA M removed her gloves and left the room without performing hand hygiene. *CNA R brought the sit-to-stand mechanical lift back to the shower room without cleaning and sanitizing the lift or sling straps at 11:54 a.m. Interview on [DATE] at 11:56 a.m. with CNA R about the above observation revealed: *She confirmed the sling straps for the sit-to-stand mechanical lift were used for multiple residents. *The purple-top wipes (the Sani-Cloth brand of sanitizing wipes with a purple lid) were available to clean the lifts and sling straps. *She said that the lifts should have been cleaned between each resident’s use. Interview on [DATE] at 4:46 p.m. with registered nurse (RN) G and licensed practical nurse (LPN) I revealed: *RN G was not aware if the sling straps were laundered or not. *LPN I said that the staff were to wipe the sling straps with the sanitizing wipes after every use. Interview on [DATE] at 11:08 a.m. with CNA M revealed she: *Explained that the resident lift equipment should have been cleaned in the resident’s room before it was taken back to the storage area. *Acknowledged that she missed several opportunities for hand hygiene during the above observations. Observation on [DATE] at 3:52 p.m. of CMA K during medication administration revealed: *He placed resident 11’s bottle of eye drops into his pocket. *He did not perform hand hygiene before entering resident 11’s room or before putting on a pair of gloves. *With those gloved hands, he removed resident 11’s eye drops from his pocket and then touched the resident’s face. *He touched the resident’s eye and inner lower eyelid with the tip of the eye dropper. He then placed the lid back onto the dropper. *After he administered resident 11’s medications, CMA K removed his gloves, walked back to the medication cart, and did not perform hand hygiene. *He placed resident 11’s eye drop medication bottle back into the medication cart. Continued observation on [DATE] at 4:06 p.m. of CMA K revealed: *He did not perform hand hygiene before preparing resident 13’s medications. *Resident 13 was on contact precautions (used to prevent spreading infections through touch), according to the sign on her door. *CMA K did not put on a gown, entered resident 13’s room, did not perform hand hygiene, and put on a new pair of gloves. *He administered resident 13 her medications and instilled the eye drops in her eye. He touched the resident’s eye and inner eyelid with the tip of the eye dropper bottle. He then placed the cap back on the eye dropper medication bottle. *After he administered resident 13 her medications, he removed his gloves, exited the room, and performed hand hygiene at the medication cart. Continued observation on [DATE] at 4:09 p.m. of CMA K revealed: *He did not perform hand hygiene when he entered resident 17’s room or before putting on a pair of gloves. *He applied a topical medication to her right shoulder, left shoulder, and back. *He removed his gloves and did not perform hand hygiene before he left the room. Continued observation on [DATE] at 4:30 p.m. of CMA K revealed he performed hand hygiene before he administered resident 20’s medications, but did not perform hand hygiene when he entered or exited the resident’s room. Continued observation on [DATE] at 4:40 p.m. of CMA K revealed he performed hand hygiene at the medication cart before he prepared resident 9’s medications, but he did not perform hand hygiene when he entered or exited the resident’s room. Continued observation on [DATE] at 4:46 p.m. of CMA K revealed he performed hand hygiene at the medication cart before he prepared resident 39’s medications, but he did not perform hand hygiene when he entered or exited the resident’s room. Continued observation on [DATE] at 4:54 p.m. of CMA K revealed he did not perform hand hygiene when he entered resident 46’s room. Continued observation on [DATE] at 4:57 p.m. of CMA K revealed: *He did not perform hand hygiene before preparing resident 6’s medications. *CMA K wiped his forehead with the back of his bare hand and again, did not perform hand hygiene. *He did not perform hand hygiene upon entering the resident’s room, then he filled the resident’s water cup and administered resident 6’s medications into the resident’s mouth with a spoon. Interview on [DATE] at 5:28 with administrator A revealed that she expected staff to perform hand hygiene before starting to prepare a resident’s medications, as staff entered the room, and as staff exited the room. She said it was not proper procedure to touch the resident’s eye or eyelid with the tip of the eye dropper bottle. Observation on [DATE] at 7:38 a.m. of LPN H while preparing and administering insulin for resident 19 revealed: *LPN H did not perform hand hygiene before putting a pair of gloves on. She prepared insulin doses with two separate insulin pens. She then touched the medication cart’s surface and lock with her gloved hands. She did not change those gloves or perform hand hygiene. *She entered resident 19’s room. With those gloved hands, she administered one insulin in the resident’s right upper arm and the second insulin in her left lower abdomen. LPN H did not remove those gloves or perform hand hygiene before exiting the resident’s room. Observation on [DATE] at 7:46 a.m. of RN G while preparing and administering medications revealed: *At 7:47 a.m., RN G prepared two separate insulin medications at the medication cart. *At 7:52 a.m., RN G entered resident 3’s room. She removed her gloves, did not perform hand hygiene, and then put new gloves on. *RN G administered one insulin into the right lower abdomen and one into the left lower abdomen. *RN G did not perform hand hygiene when leaving the resident’s room. She carried the two insulin pens in her hand without the protective caps on them. Continued observation on [DATE] at 7:54 a.m. with RN G revealed: *She prepared resident 24’s insulin dose in an injection pen and brought it to the dining room where the resident was located. *RN G touched the resident’s wheelchair handles and brought him to the nurse’s station. *She pulled two gloves out of her scrub top pocket. She did not perform hand hygiene before putting those gloves on. *With her gloved hands, she then reached into her scrub top pocket to remove an alcohol wipe. She opened the package and cleansed the resident’s skin to prepare for the injection. *With those same gloved hands, she administered the insulin to resident 24 and placed the protective cap back on the insulin pen. RN G then placed the insulin pen in her scrub pants pocket. She removed those gloves and did not perform hand hygiene. *She performed hand hygiene after she exited the nurse’s station. *At 8:20 a.m., she removed the insulin pen from her pants pocket and placed it into the medication cart. Interview on [DATE] at 8:20 a.m. with RN G revealed: *She was not aware that patient care items such as gloves, insulin pens, alcohol wipes, etc., were not supposed to be stored in personal clothing. *She confirmed that she knew the standards of when to perform hand hygiene. She said she “didn’t even realize” that she was not performing hand hygiene at the appropriate times that were listed in the facility’s policy. *She expected staff to refrain from touching the resident’s eyes with the eye drop medication bottle when administering eye drops. Review of the provider’s 3/2023 Hand Hygiene Policy and Procedure revealed: *“Policy: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues .” *“…When to use alcohol-based hand rub -Only when visible soil is absent -After contact with a resident’s intact skin (as in taking a pulse or blood pressure) -After contact with inanimate objects (including medical equipment) -Before donning [putting on] gloves -After doffing [taking off] gloves -Before entering a resident’s room -Before exiting a resident’s room -Have residents use prior to eating or group activities.” Review of the provider’s [DATE] Glove Use policy revealed: *“Policy: Glove will be worn whenever there is potential to come into contact with bodily secretions, blood, body fluids, mucous membranes, non-intact skin, drawing blood, accessing ports, starting IVs.” -“…B. Miscellaneous --…5. Perform hand hygiene after removing gloves. --…6. Disposable (single-use) gloves must be replaced as soon as practical when contaminated, torn, punctured, they exhibit signs of deterioration, or then their ability to function as a barrier is compromised. -…When to use gloves --…1. Gloves should be used ---…c. When cleaning up skills or slashes of blood or body fluids ---…d. When handling potentially contaminated items ---…e. When it is likely that hands will come in contact with blood, body fluids, or other potentially infectious material.” Review of the provider’s 3/2023 Mechanical Lift Policy and Procedure revealed: *“…All Slings are to be wiped down between resident uses, at the end of every shift, and as needed when soiled. The lifts are to be wiped down in the doorway of [the resident’s] room before entering into the hallway. If not visibly soiled staff may wash with a germicidal disposable wipe. Allow sling to dry before contact with resident. If sling is visibly soiled sling will be washed by laundry department. *All lifts with [will] have a bag where the wipes are to be placed. *…All new nursing employees will be educated on use of stand aide and hoyer [Hoyer, a lift brand] lift at [the] start of employment and annually.” 3. Observation on [DATE] at 4:14 p.m. of RN G assisting resident 13 to the bathroom revealed: *There was a sign on resident 13’s door that indicated she was on contact precautions. *RN G performed hand hygiene and put on a gown and a pair of gloves. *She assisted resident 13 into the bathroom and with personal hygiene after resident 13 was done using the toilet. RN G removed the gloves and, without performing hand hygiene, put on a new pair of gloves. Interview on [DATE] at 4:46 p.m. with RN G revealed: *She confirmed she should have performed hand hygiene before putting on a clean pair of gloves. *She expected all staff to perform hand hygiene before putting on gloves and after removing gloves, and to clean the resident lift equipment after each use. Observation [DATE] at 10:44 a.m. of CNA R performing catheter cares for resident 13 revealed: *CNA R performed hand hygiene and put on a pair of gloves and a gown. She gathered a measuring container, a water-resistant pad, and sanitizing alcohol wipes. *She drained the urine out of the catheter bag into the measuring container. She wiped the catheter tubing with the sanitizing alcohol wipe and snapped the tube back into place on the bag. *The date “[DATE]” was handwritten on the catheter bag. *She measured the urine in the measuring container and drained the urine into the toilet. *Two plastic garbage bags were tied to the resident’s bathroom towel bar. CNA R placed the measuring container into one of the plastic garbage bags without rinsing or sanitizing the measuring container. *The other plastic garbage bag contained a leg bag (a small catheter collection bag that could be secured to a person’s lower leg) that had yellow colored liquid, potentially urine, sitting in the leg bag. There was no date on that bag. *CNA R stated she was not sure when those catheter bags or hanging garbage bags were last changed. *When asked if there were face shields or splash guards available for face protection, CNA R said she had never been offered one to use while providing a resident with catheter cares. Review of resident 13’s current care plan revealed: *She was placed on contact precautions on [DATE] due to a bacterial infection in her urine. The bacteria were resistant to antibiotics.-Another urine culture completed on [DATE] indicated the bacterial infection was ongoing. *Interventions included: -“Clean hands when entering and leaving the room.” -“Wear gloves and a gown for the following High-Contact Resident Care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Wound care: any skin opening requiring a dressing.” Review of the provider’s [DATE] Contact Precautions and Isolation Procedure policy revealed: *“In addition to Standard Precautions, use Contact Precautions in the care of Residents known or suspected to have a serious illness easily transmitted by direct Resident contact or by indirect contact with items in the Resident’s environment. *Illness requiring contact precautions may include, but are not limited to: gastrointestinal, respiratory, skin or wound infections. Applies to blood, all body fluids, secretions and excretions (except sweat) whether or not they contain visible blood; non-intact skin; and mucous membranes. *Contact precautions are required to protect against either direct or indirect transmission. *Direct Contact Transmission: Involves body surface to body surface contact and physical transfer of microorganisms between a susceptible person and the infected or colonized person. *Indirect Contact Transmission: Involves contact of a susceptible person with a contaminated object. *Personal Protective Equipment (PPE) to carry out standard precautions includes; gloves, gowns, masks and eye protection. *Contact Precautions Include: Standard Precautions plus, Mandatory Isolation/Cohorting, Gloves and Gown. *Standard Precautions Include: -Hand Hygiene: Wash hands for 20 seconds with soap and water, especially if visibly soiled. Clean hands with alcohol based hand rub if not visibly soiled. -Gloves: Apply clean, non-sterile gloves before touching or coming in contact with blood, body fluids, secretions and excretions. Remove gloved promptly after use and discard before touching non-contaminated items or environmental surfaces and before providing care to another Resident. Wash hands immediately after removing gloves. -Gowns: Apply non-sterile fluid resistant gown to protect clothing during activities that may generate splashes or sprays of blood, body fluids, secretions, and excretions. Remove gown promptly after use and discard before providing care to another Resident. -Mask, face shield, eye protection: Protect eyes, nose, mouth, and mucous membranes from exposure to sprays or splashes of blood, body fluids, secretions and excretions. Apply appropriate protection prior to performing such activities. -Resident Care Equipment: Avoid contamination of clothing and the transfer of microorganisms to other Residents, surfaces, and environments. Clean, disinfect or reprocess non-disposable equipment before reuse with another Resident. Discard single-use items properly…” 4. Observation on [DATE] at 10:21 a.m. in the shower room on the 200-hallway revealed: *The grout around the toilet had turned brown. *Two partially used bottles of perineal cleansing spray were not labeled with any resident’s name or initials to identify which resident they belonged to. *The handle on the shower wall had a buildup of hard water deposits, potentially making it an uncleanable surface. *The shower spout was extensively rusted. *There were anti-slip tape strips on the floor. Several of the strips had been worn away, leaving a sticky residue. *The call light string in the shower did not reach near the floor. If a person fell, they would not have been able to reach the call light string. Observation on [DATE] at 10:30 a.m. in the soiled utility room on the 200-hallway revealed the following expired products: *One container of the Super Sani-Cloth brand sanitizing wipes with an expiration date of “05/2025.” *One container of germicidal (kills germs) alcohol wipes with an expiration date of “2025-06-06.” *One bag of antibacterial foaming skin cleaner with an expiration date of “2021-OC-01.” Observation on [DATE] at 11:15 a.m. and 1:44 p.m. in the storage room near the dining room revealed: *There was one tube feeding pump and one nebulizer machine stored underneath the sink. *Five packages of Cure brand closed system catheters with an expiration date of [DATE]. *16 packages of uncoated intermittent catheters, size 14Fr (French, a unit of size measurements), with an expiration date of [DATE]. *Three packages of coude-tipped Foley catheters, size 16Fr, with an expiration date of [DATE]. *Two packages of silicone coated Foley catheters, size 16Fr, with an expiration date of [DATE]. *One box of skin prep protective wipes with an expiration date of [DATE]. *One tube of Coloplast brand ostomy (a surgical opening connecting an organ to the abdomen) paste in the ostomy care supply drawer with an expiration date of [DATE], that tube was leaking inside the box it was in. -It was in the ostomy care supply drawer. *Three drawers of loose abdominal pads. *One package of “Rocket IPC 1000mL [milliliter] bottle [a type of bottle used to suction materials out of the body]” with an expiration date of [DATE]. *One container of germicidal surface wipes with an expiration date of [DATE]. Observation on [DATE] at 1:09 p.m. in the salon room revealed: *There were several used makeup compacts of eye shadow and blush in the drawers. None of the compacts were labeled with a resident’s name or initials to identify who they belonged to. -There were loose makeup brushes in the drawers with no identifying labels of who they belonged to. *There were loose cotton-tipped swabs in another drawer. *There was a collection of hair in the sink drain. *The hair styling irons, hair curlers, and other heat styling tools were covered in hair and unidentifiable brown and black crusted substances. *The brown upholstered salon chair had several rips in the material. -Some rips were covered by black duct tape. -Other rips were not covered and had fabric strings coming out of the rips. -The metal arms of the chair were covered in rust, creating a non-cleanable surface. -The top of the chair, where a head would rest, was corroded and cracked and had a milky-white residue on it. *There were four gallons of “Cen-Sol II” bath oil with an expiration date of [DATE] in the bottom shelf of the cupboard. *There was another gallon jug of a bath additive skin softener that had no manufacturer’s date or expiration date on the bottle. The bottle appeared to have been old as the label was wearing off. Interview on [DATE] at 1:40 p.m. with administrator A revealed: *She was aware of the condition of the salon chair. -One of the staff members had a plan to reupholster the chair but had not completed that yet. *The salon stylist was responsible for keeping the salon clean. *All the makeup products and hair styling tools belonged to the stylist. *If the makeup compacts and brushes were for resident use, she expected those products to have been used for only one resident. The makeup and brushes should not have been shared among more than one resident. *She said that the staff “don’t usually go back to that area” because the salon was the stylist’s area. Interview on [DATE] at 2:08 p.m. with CNA L revealed: *She was the designated staff person who assisted residents with bathing (bath aide). *There was one whirlpool bathtub in the building located on the 300-hallway. *She had not used the whirlpool bathtub for residents in at least six months because the tub leaked water. *She was not aware of the gallon jugs of bath oil located in the salon or that they had expired in 2012. Interview on [DATE] at 1:40 p.m. with LPN I revealed: *She was the provider’s designated infection preventionist. *To her knowledge, the patient care equipment had always been stored under the sink since she had been working at that facility. *She confirmed there was a risk for contamination from leaking pipes and infection with resident care items stored under the sink. *Everyone in the building was responsible for keeping the storage room organized and discarding outdated products. *She was primarily responsible for monitoring the wound care supplies and discarding the expired items. *She had performed a Performance Improvement Project (PIP) on expectations for hand hygiene with facility staff. She expected staff to have been performing hand hygiene according to the facility’s Hand Hygiene Policy. *She said that the tip of an eye drop applicator should not touch the resident’s eye to prevent infection and contamination of the applicator bottle. *If staff were going into a contact isolation room and did not touch anything, she did not expect them to wear personal protective equipment (PPE). *She expected staff to wear a gown and gloves when completing any activity with the resident on contact precautions. A request was made on [DATE] at 5:50 p.m. for the provider’s medical supply storage policy. The policy was not provided by the end of the survey on [DATE] at 4:09 p.m. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse.

Based on interview, record review, and policy review, the provider failed to provide documentation of a signed bed-hold notice from the resident and/or their responsible party regarding a transfer to the hospital for one of two sampled resident (7) who had transferred to the hospital.Findings include:1. Interview on 7/22/25 at 9:30a.m. with resident 7 revealed she did not think she had gone to the hospital since she admitted to the facility on [DATE]. 2. Review of resident 7's electronic medical record (EMR) revealed:*She was transferred to the hospital on 1/26/25.-The responsible party was notified of her transfer.-There was a note that the bed hold policy was sent to the resident's responsible party.-There was no documentation that the resident or the responsible party signed a bed hold notice. 3. Interview on 7/23/25 at 8:14 a.m. with administrator A regarding resident 7 's bed hold notice revealed:*Social services designee C provided the initial bed hold policy to residents and their responsible party.*A bed hold notice was sent with the resident to the hospital on transfer.*The business office manager is responsible for sending a reminder of their bed hold policy in the mail to the responsibly party when a resident is sent to the hospital. *The business office manager sent a bed hold policy reminder to the responsible party for resident 7. *The administrator was unaware that they needed a reply from a resident or their responsible party regarding their decision about holding the resident's bed while the resident was in the hospital. *The administrator stated they had never received a reply from a resident or their responsible party about their decision on the bed notice. 4. Interview on 7/23/25 at 10:16 a.m. with social services designee C regarding the bed hold policy revealed:*She reviewed the bed hold policy on admission with residents and their responsible party.*She was unaware of resident 7's bed hold notice that was sent by mail. 5.Review of the provider's January 2024 updated Bed-Hold Policy and Procedure revealed:* It is the policy of this facility to reserve the resident's right to return to the facility after therapeutic leave or hospitalization, to the same bed and room. This will be attained through the following procedure.* 1. All residents and/or responsible party will receive written notice of the bed-hold policy on admission to the facility.* 3. In case of hospitalization, Medicaid will pay the first five days of the [resident's] hospital stay, if the resident is Medicaid qualified. After these five days, the bed can be reserved through payment by the resident and/or responsible party at the daily Medicaid rate.* 5. At the time of a leave or hospitalization, the resident and/or responsible party will be informed of the bed-hold policy in writing.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of thirteen sampled residents (39) observed during medication administration observation were free from significant medication errors when certified medication aide (CMA) K would have administered the wrong resident's medications without surveyor intervention.Findings include: 1. Observation and interview on 7/23/25 at 4:42 p.m. of CMA K revealed:*CMA K was preparing medications for resident 39.*CMA K grabbed two medication cards out of the medication cart. He did not check the prescription label on the medication cards to ensure that the cards he grabbed were for resident 39.*Those medication cards were for resident 15 instead of resident 39.-One medication card contained levothyroxine sodium (a thyroid hormone replacement medication) 75mcg (micrograms).-The other medication card contained propranolol (a medication to slow the heart rate) 10mg (milligram) tablets.*CMA K was not able to describe the rights of medication administration when asked.*When asked to verify if the medication cards he grabbed were correct or not, CMA K realized the medication cards he grabbed were not for resident 39.-He thanked the surveyors for pointing that out to him and stated that he would have already popped those open to administer to the wrong resident.-He stated that the resident's medication cards were usually in the same spot in the medication cart.-He guessed that the night shift staff might have rearranged the medication cards in the medication cart when they were replenishing their supply. 2. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 3. Review of resident 39's electronic medical record (EMR) revealed the following medication orders related to thyroid hormone replacement and heart/cardiovascular medications:* ELIQUIS TAB [tablet] 5MG GIVE 1 TAB BY MOUTH TWO TIMES DAILY.* LEVOTHYROXINE SOD [sodium]-100MCG-TA GIVE 1 TAB BY MOUTH ONCE DAILY BEFORE BREAKFAST.*She was not prescribed any beta-blockers or other cardiovascular-related medications.*Had she received resident 15's propranolol, her heart rate and blood pressure may have decreased, which potentially increased her risk of falls and injury.*Had she received resident 15's levothyroxine, she would have received a total of 175mcg for that day as she had already received her prescribed levothyroxine dose that morning. 4. Review of the provider's 7/27/23 General Medication Administration Policy & Procedure revealed:* .Procedure for Medication Pass:-2. During the Medication Pass - Nursing should always check the 6 ‘R's':--a. Right Resident - before administering medications, identify each according to Facility Policy;--b. Right Drug - verify in at least three ways, such as---1. The drug's size, color and label.---2. Verify each drug against the MAR before administering.---3. If there is a discrepancy between the card, label and MAR, hold the medication until the Medication Pass is completed and verify with the Physician's Order Sheet;--c. Right Dose - verify against MAR;--d. Right Dosage Form - verify against MAR;--e. Right Time - administer meds according to facility standard medication administration time or personalized medication administration schedules;--f. Right Route - verify against MAR.-3. If the comparison is correct, the Medication is to be removed from the container and placed into the Medication Cup using appropriate technique. Nursing must document in the eMAR for the appropriate medication, with the appropriate date and time according to Facility Policy.-.7. If a PRN Medication is administered, nursing should document accordingly in the eMAR under the PRN tab, provide supplementary documentation as to why the med has been given, pain level, etc.

Based on observation, interview, record review, and policy review, the provider failed to ensure insulin pens had pharmacy labels on them that included the required identifying and instructional information for one of three sampled resident (24) who used insulin.Findings include: 1. Observation and interview on 7/24/2025 at 7:54 a.m. with registered nurse (RN) G and licensed practical nurse (LPN) H during the morning medication pass revealed: *RN G removed a plastic tube from the medication cart with resident 24’s name handwritten on it. *She removed a Novolog insulin pen from that plastic storage tube. The pen did not have a pharmacy prescription label on it with identifying information, such as the resident’s name, the name and dose of the medication, and instructions for use. *She did now know why there was no pharmacy prescription label on that insulin pen. *LPN H then went to the medication storage room to grab the bag of resident 24’s insulin pens that came from the pharmacy. There were at least three insulin pens in that bag. The plastic bag had a pharmacy prescription label on it, but there were no pharmacy labels on any of those individual insulin pens. *When asked how they knew that that particular insulin pen was resident 24’s, both LPN H and RN G said because it was stored in the plastic tube with his name on it, they knew it was resident 24’s insulin pen. -There was no indication on that insulin pen that it was specifically for resident 24. *The pharmacy usually placed the prescription labels on the insulin pens. *RN G stated they should have called the pharmacy to confirm the insulin pens were for resident 24 and to obtain prescription labels for all of his insulin pens. *RN G stated that the insulin pen was almost empty, which indicated that insulin pen had been used consistently without a pharmacy prescription label on it. 2. Review of resident 24’s electronic medical record (EMR) revealed he was to receive scheduled doses of Novolog insulin injections three times daily and additional doses up to three times daily based on his blood sugar levels. 3. Interview on 7/24/2025 at 9:06 a.m. with administrator A revealed: *The pharmacy supplied the insulin pens for resident 24. The pens should have had the complete pharmacy prescription labels on them. *She expected the licensed nurses to have contacted the pharmacy if the prescription labels were missing and to follow the pharmacy’s recommendations. 4. The director of nursing was not able to participate in the survey. Interview questions related to nursing services were directed towards administrator A, who was a registered nurse. 5. Review of the provider’s 8/2023 Medication Ordering and Receiving from Pharmacy policy revealed: *“Policy: Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy/registered pharmacist can modify, change, or attach prescription labels.” *Procedures -“A. Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly onto the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident’s name, at least, must be maintained directly on the actual product container. -B. Each prescription medication label includes: --1. Resident’s name. --2. Specific directions for use, including route of administration… --3. Medication name… --4. Strength of medication… --5. Prescriber’s name. --6. Date dispensed. --7. Quantity of medication. --8. ‘Beyond use’ (or expiration) date of medication. --9. Name, address, and telephone number of dispensing pharmacy. --10. DEA number of dispensing pharmacy, if required. --11. Prescription number. --12. Accessory labels indicating storage requirements and special procedures. Example: ‘Shake well’ ‘Take on an empty stomach, one hour before or 2 hours after meals.’ --13. Container number and total number of containers (e.g., 1 of 3, 2 of 3, 3 of 3) when multiple containers are dispensed for one prescription/order. --14. Initials of [the] dispensing pharmacist. --15. Lot number of [the] medication dispensed… - .E. Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy. - .I. Medications dispensed by physicians must conform [to] the above labeling requirements.”

Based on facility reported incident review, observation, interview, record review, facility elopement investigation review, and facility policy review, past noncompliance was confirmed for incident occurring 5/3/24. Findings include: Substantial compliance was confirmed on 5/14/24 after: record review revealed care planning had occurred to minimize the risk of elopement, observations and interviews revealed staff responded promptly to door alarms and understood how to recognize and minimize the risk for elopement, confirming the exit door alarms were all functional and monitored on a monthly basis, review of elopement investigations and required reporting that confirmed appropriate actions were taken after elopements occurred, and review of the provider's revised elopement policy confirmed a clear definition of elopement.

Substantial compliance was confirmed on 4/23/24 after record review revealed the facility had followed their quality assurance process; after the dietitian was contacted for acceptable hot beverage temperatures; after the hot beverage vender was contacted to lower the dispenser's temperature; after the dispensers were unplugged until the vender could arrive; after the facility created new policies and provided education to all staff regarding: acceptable hot beverage temperatures, monitoring of assisted dining, and first aid to a burn; after observations of residents and staff during the assisted dining meal service; after assisted dining residents were assessed for safety; after assisted dining resident interview confirming safety lids were provided and hot beverages were not served until staff were present; and after staff interviews confirming knowledge on the new policies.

Based on observation, interview, and record review, the provider failed to perform routine assessments, revise care plans, and provide interventions for residents who were at risk for developing skin integrity issues for 8 of 8 sampled residents (9, 10, 13, 18, 20, 22, 23, and 32). Findings include: 1. Observation and interview on 8/3/21 at 11:19 a.m. with resident 20 revealed: *She had a wound on her bottom. -It caused her pain. *She stated she also had wounds on her feet and on her hip. Surveyor Observation on 8/4/21 at 11:15 a.m. of resident 20's skin with licensed practical nurse (LPN) E and certified nursing aide (CNA) M revealed: *Resident's right heel revealed: -An approximate 1.5 centimeter (cm) yellow scab with a 0.2 cm dark brown center. This area also had approximately 3.0 cm of pink, newly healed skin surrounding the yellow scab. -LPN E cleansed the area with wound cleanser, applied [MEDICATION(S)] ointment to the scab, and covered it with a 4 inch by 4 inch gauze pad. -She then wrapped the entire foot with a gauze wrap and applied a netting cover. *Resident's coccyx (tail bone) revealed: -A deep stage 4 (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and [MEDICATION(S)] tracts also may be associated with stage 4 pressure ulcers) measuring approximately 6 cm in circumference. Surrounding tissue had been a normal tan skin tone. No surrounding redness had been identified. -LPN E had been unable to identify if this had been facility acquired or was present upon resident's admission. -LPN E cleansed the area with wound cleanser spray along with using a sterile cotton swab covered with wound cleanser soaked gauze to clean around the inside periphery of the wound. -She packed the wound with twelve inches of alginate packing, swabbed the outside periphery with skin prep, and applied an adhesive gauze cover. *Resident's left hip revealed: -A 2.0 cm by 1.0 cm pink, intact skin surrounded by dry flaky skin. -No open areas had been observed to this site. -LPN E stated the area had been healed for approximately one week. -CNA M stated they had applied lotion to the site every day. Surveyor Review of resident 20's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Braden assessment scale was scored at 17, that meant she was at risk for developing pressure injuries. -That was the only Braden assessment that had been completed on resident 20. *On 3/1/21 LPN L completed a skin assessment which indicated: -She had a unstageable pressure ulcer to her sacrum/coccyx region. *On 5/13/21 LPN L completed a skin assessment which indicated: -A stage four pressure ulcer to her coccyx that measured 3 cm long by 2.5 cm in width. -A 3.5 cm by 2.5 cm suspected deep tissue injury on her right heel. *On 5/19/21 LPN L noted: -She had a stage four pressure injury to her coccyx and stage two maceration to her left buttock. *On 7/13/21 she was listed as having a stage four injury to her coccyx and a stage three pressure injury to her right heel. *On 7/21/21 she had the stage four injury to her coccyx and an unstageable injury to her right heel. *On 7/29/21 she had a stage four injury to her coccyx. *On 8/2/21 she had a stage four pressure injury to her coccyx. Review of resident 20's August 2021 care plan revealed: *Staff were to: -Monitor/document/report PRN [as needed] any s/sx [signs or symptoms] of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury . -Help the resident lay as flat as possible to reduce shear. -Administer treatments as ordered and monitor effectiveness. -Assess/record/monitor wound healing (weekly) Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the MD. -Avoid positioning the resident on her back. -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Inform the resident/family/caregivers of any new area of skin breakdown. -The resident requires (SPECIFY: Pressure relieving/reducing device) on (SPECIFY: bed/chair). --This was not specified or completed. Review of resident 20's skin observation that was completed by CNAs revealed: *Out of a 30 day time period, she was marked to have an open area two times. *Most of the documentation stated: -None of the above observed. *In 30 days she was listed as have no red areas. 2. Review of resident 10's EMR revealed: *He was admitted to the facility in 2017. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Traumatic brain injury. -[CONDITION(S)]. *He was unable to perform movements, and only responded to painful stimulus. *He was totally dependent upon staff for every need. Surveyor Observation on 8/4/21 at 3:00 p.m. of resident 10's skin with LPN E revealed: *Resident's right fifth toe revealed: -LPN E stated the resident had a bath the day before and a dressing had not been applied following his bath. --Stated, I missed it (dressing change). -The outside edge of his right fifth toe had a raised approximate 0.5 cm dry callous, with an approximate 0.1 cm black depressed center. -There had been no surrounding redness. -LPN E cleansed the toe with wound cleanser soaked gauze and covered it with adhesive gauze and [MEDICATION(S)] wound tape. *LPN E stated resident had not been seen by podiatry but his primary doctor inspected the toe last month. *Resident's inner buttocks revealed: -This surveyor had to ask to inspect the inner buttocks as LPN E had been preparing to leave the room. --LPN E stated she did not have the supplies for this and had left the room to retrieve the supplies. -His left upper inner buttock near his coccyx had revealed a white macerated (moisture associated skin discoloration) area measuring approximately 2.0 cm with a stage 2 slit (partial thickness skin loss involving the epidermis, dermis, or both) measuring approximately 1.0 cm in length by 0.2 cm in width. -LPN E measured the area with a paper towel and stated it had not been open the last time she had viewed it several days ago. -She cleansed the area with wound cleanser and applied a mix of collagen cream and skin barrier cream. --She stated this had been a daily treatment until it was healed. Surveyor Review of resident 10's progress notes regarding skin issues revealed: *He has had some open skin areas. *He had been dealing with open areas on his coccyx for the last 6 months or so. *He also had an area on his right foot. *From 2/1/21 through 8/4/21 he was documented to have: -Off and on open slits on his coccyx. -An open area on his right foot, by his fifth toe. Review of resident 10's Braden assessments revealed he was at a very high risk to develop skin sores. Review of resident 10's skin assessments revealed: *He had a skin assessment that was started by registered nurse (RN) D on 7/4/21. -It had not been completed or filled out. *The last skin assessment completed before 7/4/21 was completed on 6/18/20. *There was a twelve month period without a completed skin assessment for resident 10. Review of resident 10's May 2021 care plan revealed: *He had a pressure ulcer due to incontinence. *[resident's name] is totally dependent on 2 staff for repositioning and turning in bed Q2hrs [every two hours] and as necessary . *[resident's name] requires SKIN inspection every shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. *Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage. Review of resident 10's turning and repositioning chart revealed: *On 8/1/21 he was repositioned at 10:00 a.m. *He was next repositioned/changed at 3:30 p.m. *He was in his wheelchair from 10:00 a.m. until 6:30 p.m. when he was positioned on his left side. *The repositioning chart that was filled out for resident 10 included: -Missing information. -Wrong dates/times. -Gaps longer than two hours. Review of resident 10's skin observation that was completed by CNAs revealed: *Out of 30 days he was noted to have an open area three times. *There were a few times where he was documented to have a reddened or discoloration area. *Most of the documentation revealed that he had None of the above observed. 3. Review of resident 9's EMR revealed: *He was admitted on [DATE]. *He was admitted with a stage 2 pressure injury to his coccyx. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Type II Diabetes with foot ulcer. -Ischemic [CONDITION(S)]. -[CONDITION(S)]. -[CONDITION(S)] and [CONDITION(S)] following cerebral infraction. -Amputation. Review of resident 9's progress notes revealed: *He had been receiving dressing changes to his coccyx, amputation site, and skin tears. *His coccyx wound had been documented as healed on 5/13/21. *He was receiving dressing changes to his amputation site. *He also had frequent skin tears. Review of resident 9's skin observations that had been completed by CNAs revealed: *From 7/4/21 through 8/4/21 he had been marked as not having any skin tears. *He had been documented as having some skin discoloration a couple of times. *Most of the time he was documented as having none of the above observed. Review of resident 9's assessments revealed: *He had not had a skin assessment completed since he was admitted on [DATE]. *LPN L completed his admission assessment and admission skin assessment. *His Braden assessments listed him as: -On 4/29/21 moderate risk for skin issues. -On 5/6/21 high risk for skin issues. -On 5/13/21 high risk for skin issues. -On 6/1/21 at risk for skin issues. Review of resident 9's May 2021 care plan revealed: *He had the potential impairment to skin integrity related to neglect of left arm, had noted skin tears on admit-applied geri sleeve to protect arm and removed watch due to it catching on things and causing skin tears. *Staff were to: -Monitor/Document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes. Interview on 8/4/21 at 9:27 a.m. with director of nursing (DON) C revealed: *Wound assessments in the EMR were under assessments. *Anyone who had skin issues would have skin assessments done weekly. *Someone who did not have issues or was at risk, their skin was checked weekly by the CNAs giving baths. 4. Review of resident 13's EMR revealed: *He was admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Intellectual Disabilities. -Major Depressive episode. -Dementia with behavioral disturbance. -Scoliosis. *On 4/5/21 it was documented he had small open area on his scrotum. Review of resident 13's assessments revealed: *On admission he was at moderate risk for skin break down. *He had never had a skin assessment completed since he was admitted to the facility. Review of resident 13's June 2021 care plan revealed: *His interventions included: -Avoiding scratching. -Educating family/resident/caregivers of causative factors and measures. -Encourage good nutrition. -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Use a draw sheet or lifting device. -Identify potential causative factors and eliminate/resolve where possible. -Use caution during transfers. Review of resident 13's 7/5/21 through 8/5/21 skin observation task list that was completed by CNAs revealed: *He had been marked as having skin discoloration six times. *He was marked as having a red area once. *All the other documentation stated, none of the above observed. Phone interview on 8/4/21 at 9:42 a.m. with resident 13's legal guardian and power of attorney revealed: *He had been in the facility for about 6 months. *She had never been asked to help participate in his care conferences. *She participated in resident 13's care conferences at another facility. *Since this was his first stay in a nursing home she did not know if they completed care conferences or if she could join. 5. Review of resident 18's EMR revealed: *He was admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)]. -[CONDITION(S)]. -Amputation. -[CONDITION(S)]. -[CONDITION(S)]. -Chronic ulcer of the right heel. *He was admitted with a right heal wound. Review of resident 18's progress notes revealed: *On 5/3/21 a dressing was changed to the left and right foot: - .left foot removed [MEDICATION(S)] from top of foot no drainage noted, noted blister to heel cleaned and applied gauze to heel and top of foot wrapping with kerlix no pain or tenderness reported. right foot removed dressing cleaned heel with NS [normal saline] and applied [MEDICATION(S)] soaked gauze followed by dry gauze wrapped in kerlix . *On 5/4/21, the dressing to right heel was intact. The left foot did not have any openings or drainage. *On 5/5/21 dressing to the right heel was completed, a foul odor was noted. *On 5/6/21 right heel dressing was changed, foul odor continued to be noted. They popped a blister to his left heel. *From 5/6/21 through 5/19/21 he was in the hospital. *On 5/20/21 he was documented to have pressure ulcers to heel, coccyx, and surgical incision to right amputation. *On 5/21/21 he was documented to have a pressure ulcer to his left heel. *On 5/26/21 he was documented to have a purple discolored ulcer to right buttock. *The next note regarding the buttock was on 5/30/21: - .stage II pressure ulcer noted to right buttock . *The next note regarding buttocks was on 6/3/21 -Res [resident] has two spots on his Lt [left] bottom . *Documented note from wound care which stated: - .If any changes in redness-please-call-do-not wait. *On 6/15/21 he was documented to have blisters on his amputation site that popped. *On 6/21/21: .Resident's stump has an open area with scabbing. Open areas appear to have some purulent drainage. Surrounding tissue is red. *On 6/24/21, .stump is bright read [red] no drainage incision healing . *On 6/28/21, .Dress [dressing] was changed on res [resident] stump. Area had some scabbing. There was a small amount of drainage. Incision had some open area with the wound bed that had some white area. *On 7/4/21, Yellow drainage was noted to old dressing. *On 7/9/21, .open area that has purulent drainage . *There was no documentation of notifying the wound clinic. Review of resident 18's April 2021 care plan revealed: *Monitor/document/report PRN any s/sx [signs or symptoms] of skin problems related to PVD: Redness, [CONDITION(S)], Blistering, Itching, Burning, Bruises, Cuts, other skin [CONDITION(S)]. *[resident name] had R [right] BKA [below knee amputation], surgical wound intact. Apply lotion to stump, do not apply on surgical incision. *Assess/record/monitor wound healing daily Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Review of resident 18's skin observation which was documented by CNAs revealed: *In 30 days he was documented once of having an open area. *Five times he was documented as having discoloration. *Majority of the 30 day documentation listed, none of the above observed. Review of resident 18's 6/28/21 podiatry note revealed, R[right] stump- new wound from tape-stop using tape. Dressing secured with [MEDICATION(S)]-extra provided . Resident 18's podiatrist was called for an interview on 8/4/21 at 3:04 p.m., left a message with the nurse. Survey team did not receive a return call. Interview on 8/4/21 at 9:35 a.m. with administrator A revealed: *They did not have a designated wound nurse. *They had a wound consultant from American Medical Technologies (AMT) that came in about once per month. Interview on 8/4/21 at 4:00 p.m. with wound clinic RN N revealed: *They had been seeing resident 20 and resident 18. *Resident 20 was referred to wound care from the emergency department prior to arriving at the facility. *They had been seeing resident 20 for a wound on her sacrum and right heel. *They had not been informed of the stage 2 injury on her hip. *Resident 18 was referred to wound care by his podiatrist. *They were very adamant the provider should have called them if the residents had any drainage, redness, or changes. -RN N stated, That is a big thing for us. *They had not had phone calls from the provider regarding resident 20 or 18, only phone calls confirming appointments. Interview on 8/5/21 at 9:28 a.m. with DON C revealed: *She believed RN D completed weekly wound assessments on the residents. *The LPNs documented wound information in the progress note but the RNs should be doing an assessment. *She was also in charge of Minimum Data Set assessments (MDS) for the residents. *She relied on the nurses' notes for updates. *She had been seeing issues with documentation, especially with wound documentation. *If a resident had a wound, then the RN would write up the assessment. *Families and physicians should have been updated with changes. *She did not believe LPNs could assess wounds. *CNAs look at the residents' skin weekly. -She agreed CNAs may not be aware of what to look for. *Care plans were not being updated as often as they should be. *Surveyor asked how she was made aware of changes that needed to be made to the resident's care plans: -She stated sometimes nurses will leave Post-It notes on her desk. Phone interview on 8/4/21 at 5:09 p.m. with AMT wound consultant RN O revealed: *He provided wound consulting for the residents that use AMT's products. *He provided clinical support. *He did not provide clinical support if the resident was not using AMT's products. *He provided clinical support for resident 10 in July. *The first time he saw resident 10 was a couple of weeks ago. *He had also helped with resident 20 as needed. *Those were the only two residents he had recently provided clinical support for. Interview on 8/5/21 at 11:00 a.m. with infection control registered nurse (IC RN) D revealed: *She was designated as the wound care nurse. *She monitored residents' skin and wounds weekly. *Sometime last year was when she stopped assessing the wounds. *It fell by the wayside with the COVID. *CNAs looked at resident's skin weekly. *She had received no wound care training. *She really did not understand wounds or what slough meant. 6. Review of resident 22's medical record revealed: *She was admitted on [DATE]. *Her 12/8/20 Braden assessment score was 12 indicating high risk for pressure ulcer. *Her 3/9/21 quarterly MDS assessment revealed: -Her cognition was severely impaired. -She was at risk of developing pressure ulcers. -No pressure ulcers were present. -Care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] *A 4/28/21 skin observation tool indicated Skin intact, Dry areas noted to bilateral feet and heels lotion applied, skin warm and dry color pink, no open areas noted continue to monitor and assess. *A 5/31/21 skin observation tool indicated her right heel had a 2 x 2 unstagable area. -The right inner heel was noted to have hard black tissue. *A 5/31/21 note to her physician Resident has a 2cm x 2cm DTI [deep tissue injury] to her right inner heel. Wound is black, hard, and edges are intact. No drainage noted. Area is slightly tender for resident when touched. Protective heel boots applied. [Daughter's name] has been notified. Recommendations: Can we have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? *A 6/1/21 order for protective heel boots on at all times and [MEDICATION(S)] twice a day until area healed. *Her 6/9/21 Braden assessment score was 12 indicating high risk for pressure ulcer. *Her 6/9/21 annual MDS assessment revealed: -Her Brief Interview for Mental Status (BIMS) score was 2 indicating severe cognitive impairment. -She was at risk of developing pressure ulcers. -She had one unstageable pressure ulcer. -Care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her pressure ulcer healed on 6/23/21. Interview on 8/4/21 at 9:31 a.m. with DON C regarding resident 22 revealed: *Her weekly skin assessments had not been done. *She had been treated with [MEDICATION(S)]. *The area had healed on 6/23/21. Further interview on 8/5/21 at 8:28 a.m. with administrator A and DON C regarding skin issues revealed: *Resident 22 was at high risk for pressure ulcers. *They believed resident 22 had protective boots prior to 5/31/21 but were unable to provide the documentation. *Nurses should have been doing weekly skin assessments. 7. Interview on 8/4/21 at 10:26 a.m. with resident 23 revealed she had a wound on her right foot that started as quarter size and is healing now. Observation on 8/4/21 at 4:21 p.m. of resident 23's wound care by LPN E revealed: *A callous on the ball of her right foot approximately the size of a quarter and light tan in color. *A wound within the callous measuring approximately 0.5 cm by 0.5 cm, round in shape, and appeared dark brown in color. Review of resident 23's revised 8/14/20 care plan revealed: *She had been at risk for impairment to both feet related to fragile skin and had hyperkeraotic (a condition of thickening of the outer layer of the skin) [CONDITION(S)] on her foot. *The intervention had been weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid from cells) and any other notable changes or observations. -There had not been any interventions to prevent or heal the wound. Review of resident 23's medical record revealed: *On 5/10/21 a progress note stated there was a blister and planter ulcer noted to right foot. *A 6/30/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *On 8/3/21 an appointment had been made with wound clinic for 8/5/21. *On 8/4/21 a progress note stated the wound bed was black/brown. *There had been no weekly measurements of the wound. *A licensed nurse had not completed any skin assessments in the last year. 8. Observation and interview on 8/3/21 at 3:45 p.m. with resident 32 revealed: *He had been sitting in a recliner watching television with no pants on. -He had been wearing an incontinent under garment covering his groin. -Stated he did not like to wear pants. *He had a prosthetic leg applied below his right knee. *He had a right below the knee amputation a few years ago. -It had been caused by an infected sore to his right foot that had not healed. *He denied any current skin issues. *It had been his choice to remain in his room for the majority of the day, including meals. -Stated he did not like to be around people and usually sat in his recliner all day and watched television. *He moved from his bed to his recliner with a walker and staff assistance. *He had a suprapubic catheter. -Stated he had difficulty urinating normally and wore the incontinent brief in case the catheter leaked. Review of resident 32's EMR revealed: *His BIMS was 15, meaning he was cognitively intact. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *His 7/7/21 quarterly Braden assessment scale for predicting pressure sore risk had a score of 21, meaning he had been determined to not be at risk for pressure ulcers. *His 7/9/21 quarterly MDS revealed he was at risk for pressure ulcers. -This MDS revealed there were no pressure ulcers or skin wounds present. *His revised care plan dated 7/20/21 revealed interventions of monitoring residents body for breaks in skin, complications of immobility, and to treat promptly as ordered by the doctor. *There had been no: -Nursing skin assessments located in the medical record. -Skin assessments provided by the facility when requested. Interview on 8/4/21 at 2:39 p.m. with administrator A revealed the staff member in charge of wound care and skin assessments had been IC RN D. Interview on 8/4/21 at 2:42 p.m. with IC RN D revealed: *She had not done skin assessments since having personal health issues for the last six months. -LPN L had been following the wound care and skin assessments. --LPN L had not been in the facility during the survey. *IC RN D stated skin assessments should be found in point click care under the 'assessments' tab but that she had doubted it had been done. *Skin assessments might also be found in the nursing progress notes and she would try to locate these. -She provided one progress note for resident 32 dated 7/9/21 which had been a Quarterly Assessment review stating, Resident is a risk for skin breakdown, no concerns noted. *The current way they monitor residents for skin issues was having the CNAs observe resident's skin during their bath and report any issues to the charge nurse. *There had not been regular nursing assessments and documentation of resident's skin. Interview on 8/5/21 at 9:18 a.m. with CNA K regarding reporting of skin issues revealed: *The CNAs observed resident's skin during their bath. -All the CNAs had been expected to give baths to their assigned residents on the resident's scheduled bath day. -There were no bath aides. *She summoned the nurse if she observed any new skin issues. -They also had a bath book where they wrote any new observations. *Reporting of new skin observations was common sense, and she had been trained on how to report to the nurse and document in the bath book. *She did not know if there was a skin/wound nurse, but all concerns should have been reported to the charge nurse and placed in the bath book. On 8/4/21 at 10:00 a.m. LPN E had been given a list of the residents (9, 10, 13, 18, and 20) the surveyors identified as opportunities to view for skin conserns. At the conclusion of survey on 8/15/21, surveyors had not been summoned to view residents 9, 13, or 18. They had been told resident 18 was scheduled in the evening only. Interview on 8/4/21 at 11:30 a.m. with LPN E regarding documentation of skin wounds revealed: *All wounds were measured once per week. *Stated, Everybody [nurses] had their own way of documenting. *She documented her dressing changes and wound measurements in the nurse's progress notes. Surveyor : Review of the provider's February 2014 Pressure Ulcer Prevention and Wound Care Policy and Procedure revealed: *In order to promote healthy, intact skin, all new residents admitted to [nursing home name] will be assessed to determine if they are at risk for Pressure Ulcers, have a current pressure ulcer, or any current skin issues . *Licensed nurses would visually assess all boney prominence's on admission and document findings on skin admission assessment form on point click care and in nurses notes as indicated. *A Braden scale would be completed by a licensed nurse within 24 hours of admission. *Any resident with a Braden score of less than 12 would have a weekly skin inspection by the licensed nurse. *CNAs will inspect skin during showers, bathing, incontinence episodes and report to Charge Nurse any changes. *Braden scales will be completed quarterly. *Resident will have an individualized plan of care which will include, problem identification based on risk factors, realistic time-framed goals, interventions that address risk factors. *1. Residents who have a pressure ulcer will have assessment completed weekly and as needed due to changes, by a Licensed Nurse. Assessment will be recorded on the Weekly Pressure Ulcer Record. This will be noted on the resident's TAR that this assessment is to be completed. Each Pressure Ulcer will have its own Weekly Pressure Ulcer Record Sheet. *Dressing changes and treatments will be completed by the licensed nurse per Physician orders. *Physician will be notified of any new pressure ulcers or of anytime a pressure ulcer is not responding to treatment. *All non-pressure skin issues (Skin tears, abrasions, bruises, venous/stasis ulcer, arterial ulcers, surgical wound) will be monitored weekly and as needed due to changes, on the Non-pressure skin condition report. This will be placed on the TAR [treatment administration record] to monitor weekly and document any Non Pressure Skin Condition Report. Each skin issue will have its own sheet. Review of the provider's undated Wound Assessment Policy and Procedure revealed: *All wounds will be evaluated weekly and whenever a change occurs in the wound. Pressure Ulcers will be documented on the Weekly Pressure Ulcer Record and Non Pressure wounds are to be documented on the Non-Pressure Skin Condition report. Further details may be documented in the Nurses Notes in the chart, which will be documented on each report sheet that a nurses note was made . *Specific instructions for wound assessments included: -Measuring the size of the wound. -Depth of the wound. -Edges of the wound. -Undermining of the wound, by using a cotton-tipped applicator. -Documenting the necrotic tissue style and amount, indicating the percentage of wound involved. -Type of drainage and amount. -Skin color surrounding wound. -Peripheral Tissue [CONDITION(S)]. -Induration, by assessing the tissues surrounding the wound. -Granulation of the tissue. -Any infection. -Any discomfort. -Wound status. -Staging of wound. -Notification of the Primary Physician. Review of the provider's February 2014 Care Plan Policy and Procedure revealed: *Care plan meetings would consist of the facility's interdisciplinary team. *They would notify the family of the meetings. *Care plans allowed each department to get a clear understand of the resident's conditions/needs and set attainable goals. *Care plans would be updated as needed.

Based on observation, interview, record review, and policy review, the provider had failed to ensure: *One of one sampled resident (1) had received safe and appropriate care to prevent a significant burn injury from a hot pack. *Assessments, interventions, and monitoring had been completed for safe hot pack use. *Policies had been developed that included guidelines and instructions for hot pack use. *Staff were trained regarding appropriate use of hot packs and residents' safety. Findings include: 1. Review of resident 1's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He was alert and oriented, and he required extensive assistance of staff with his transfers, bed mobility, and dressing. *His upper and lower extremities had impaired range of motion. *His 1/4/19 Braden Scale for Predicting Pressure Sore Risk indicated he had slightly limited sensory perception. *On 2/15/19 at 9:10 a.m. a nurses note stated: Resident has a red area with serous filled blister to left inner thigh/knee area. The blister measures 4cm (centimeters) x (by) 2cm and red area around blister is 11cm x 5cm. Protective bandage put over it since we don't currently have any burn cream. Resident states it does not hurt. He states he asked for a hot pack last night from the temp (temporary) night nurse (name). She did state this morning that she got a hot pack for him for his left leg pain. DON (name) notified of burn to left inner leg. Appointment set up with (physician) in (another town) to have leg looked at. Resident's wife aware and she will meet him there.-At 2:15 p.m.: Resident returns to facility without incident from appt (appointment). New orders for silver sulfadiazide ([MEDICATION NAME]) thin layer 2-3 times per day on burn until healed. Cover with [MEDICATION NAME] or another nonadherent dressing directly on wound. Then make sure adhesive dressing doesn't touch blister. Use skin protectant and rotate bandage sites. Don't put heat on blister until healed. Care with heating pads - DO NOT put directly on skin. Care with microwave as there may be hot spots.*The previous nurses note had been on 2/13/19. *There had been no documentation by the night nurse indicating: -That she had given him a hot pack. -Her process for the hot pack use including what type it was. -If she had monitored his skin before or after using it for any concerns. -If the resident had complained of pain or burning at all during or after the use of the hot pack. *There was no evidence to support: -A physician's orders [REDACTED]. -An assessment had been completed for the safe and appropriate use of a hot pack for him. -What type of hot pack was being used or how it was being administered. Review of resident 1's revised 5/14/19 care plan related to his skin integrity revealed:*He had fragile skin and had a potential for skin impairment. *There was no mention of him using a hot pack or him having been burned by one in (MONTH) 2019. *It stated: (Name) has wound to left thigh. -The intervention was: See physician orders [REDACTED]. Review of resident 1's 5/3/19 South Dakota Department of Health (SD DOH) event reporting form revealed: *The date of the event was listed as 2/26/19. -According to the notes it should have been 2/15/19. *The brief explanation was: On Friday, (MONTH) 15, it was reported that resident (name) was experiencing leg pain the previous evening and requested a hot pack from the charge nurse (name), who was a temporary nurse. The nurse prepared the hot pack in the microwave oven and placed it on his leg. Apparently the pack had a spot that was overly warm and caused the leg to develop a superficial burn with a blister. The blister was approximately 11cm x 5 cm. On the morning of Friday, (MONTH) 15, he was transported to a clinic for treatment for [REDACTED]. *The conclusionary statement was: The investigation supported the fact that the resident was experiencing pain in his left leg. That he had requested a hot pack from the charge nurse to address the pain and as a result of the hot pack having a hot spot and no barrier being placed between the hot pack and the skin, a blister developed on the leg. Resident was transferred to a clinic for treatment of [REDACTED]. Nursing staff were advised to be extremely careful when preparing the hot pack. We currently do not have a policy on the application of hot packs, but as a result of this incident, we are developing a policy and will train staff in regards to it. Attached are copies of resident skin assessments. We will be monitoring (name) skin to determine that no additional concerns develop. We will also be looking into alternative methods of dealing with this sort of discomfort. (Nurse name) worked for RTG medical (address). The nurse was appraised (apprised) of the situation and educated as to the proper method of treatment. The wound has healed and there have been no reports from the resident or the staff caring for him of any reoccurring issues. Our new policy involves placing a barrier between the hot pack and the resident skin. It will also include directives to complete and a skin assessment before and after applying a hot pack. *The above report and investigation had not been completed thoroughly. Refer to F610, finding 1. Interview on 5/14/19 at 8:45 a.m. with physical therapy assistant C regarding hot pack use revealed:*She was not aware of what nursing staff used for hot packs or the processes related to them. *Therapy had their own specialized hot packs that had instructions listed right on them. *She confirmed hot packs should have had instructions for use and monitoring of them to ensure they were used safely. Observation and interview on 5/14/19 at 9:00 a.m. with resident 1 in his room revealed: *He confirmed his left inner thigh had been burned by a hot pack in (MONTH) 2019. *The staff had been putting a cream on it since that time. *It used to have a dressing over the top of the cream, but it did not anymore. *The skin on his left inner thigh near his knee had an area with a darkened appearance and several scab-like areas within it. *It had hurt when it happened and for awhile after that. *He thought it would have been healed by now, but he thought it was looking better. *He stated he would not be asking for hot packs ever again. Interview on 5/14/19 at 9:35 a.m. with the director of nursing (DON) regarding hot pack use revealed: *She was aware of resident 1's significant burn injury from a hot pack in (MONTH) 2019.*When asked where the hot packs were located or what the nursing staff would have used she stated: -They would have used a wet towel in a plastic bag that they had heated up in the microwave. -Then they should have had a towel wrapped around the bag prior to putting it on the resident. *Therapy staff were the only ones who used their specialized hot packs. *There was no policy or written instructions for using a hot pack. *She was unsure if the resident would have required a physician's orders [REDACTED]. *There were no assessments completed for the use of hot packs. *She confirmed using hot packs could have been a safety risk for residents due to the risk of burns. -There should have been written guidelines for the staff to follow related to them. *There had not been any staff training related to hot packs completed prior to or following resident 1's burn injury. Interview on 5/14/19 at 9:55 a.m. with registered nurse D regarding hot pack use revealed:*She worked the day shift on 2/15/19 and had assessed resident 1's burn injury. -The night nurse had told her she had given the resident a hot pack during the night for leg pain. *She stated the burn was significant, so she had called to make him an appointment to be seen by his physician. *The nurses had been treating the burn area since (MONTH) 2019, and it still was not healed. *She thought the hot pack would have been a wet towel in a baggie that was heated up in the microwave. *They should have heated those hot packs up for thirty seconds each side in the microwave and used a towel or covered it prior to putting it on the resident's skin. *She confirmed there were no written instructions or guidelines for the use of hot packs. *She agreed there was a risk of another resident getting a burn when there was no standard process or policy for staff to follow. *She had not been trained on the appropriate and safe use of hot packs or a policy related to them. Phone interview on 5/14/19 at 12:25 p.m. with licensed practical nurse A regarding hot pack use revealed she:*Had never used a hot pack for resident 1. *Was not sure what types of hot packs were available for staff to use. *Was aware of resident 1's burn injury from a hot pack in (MONTH) 2019 that was still being treated. *Was not aware of any policies or instructions for using hot packs and had not been trained regarding their use. Interview on 5/14/19 at 1:06 p.m. with certified nursing assistant (CNA) B regarding hot pack use revealed she: *Had gotten residents hot packs in the past. *Would have microwaved a wet towel in a baggie for thirty to forty-five seconds per side, and then wrapped that with a dry towel before putting it on the resident's skin.*Had never seen instructions or guidelines for using hot packs. *Had been shown the hot pack process by another CNA. *Was aware of resident 1's burn from a hot pack. Interview on 5/14/19 at 3:45 p.m. with the DON and the administrator regarding hot packs and residents' safety revealed:*They confirmed there were no policies or instructions for using hot packs, and there should have been. *There was no process for the assessment of residents using hot packs. *There had been no staff training prior to or after resident 1's burn injury related to appropriate use of hot packs. -There was no documentation to support the night nurse involved with the injury had been questioned about the event or had further training. *They agreed there should have been corrective action implemented to prevent other residents from the same type of injury. *The corrective action listed in the SD DOH event report had not been completed. Interview and review of the provider's undated Resident Accident Prevention policy and procedure with the administrator on 5/14/19 at 1:00 p.m. revealed:*It was a new policy as of that day. -They had no policy related to safety prior to this one. *It is the policy of Aurora Brule Care and Rehab to ensure that the resident's environment remains as free as possible of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. *An accident is an unexpected, unintended event that can cause bodily injury. It does not include adverse outcomes associated as a direct consequence of treatment or care.*1. The facility is continuously monitored by all staff for unsafe/hazardous conditions and corrections are promptly made as needed, to maintain a safe environment for residents.

Based on observation, record review, interview, and policy review, the provider failed to investigate falls and implement interventions for three of three sampled residents (1, 3, and 4) who had recurrent falls with injuries. Findings include: 1. Review of resident 1's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. Observation and interview on [DATE] at 1:45 p.m. with resident 1 revealed: *He had been lying in bed with a bed alarm under him. *The alarm device was hooked to the back of his shirt on his shoulder area. * Then he sat up on the edge of his bed and stood up. *The bed alarm started to sound when he started to walk away from the bed. *He turned off the alarm that was hooked on the back of his shirt. *He stated he thought he should go into the bathroom and started to walk there. *He was oriented only to person. *No staff entered the room when his alarm was sounding. *A physical therapist (PT) came into the room to help him into the bathroom after alerted by the surveyor. Review of resident 1's [DATE] significant change documentation by registered nurse (RN) C Minimum Data Set Coordinator (MDS) revealed: *Resident requires extensive assist of 1 for bed mobility, transfer, walk in room, dressing, toileting, bathing, and hygiene. *Resident is incontinent of bladder at times related to urgency. *Is a fall risk related to impaired balance. Noted falls on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No injury. *Received order for PT to evaluate and treat related to multiple falls and decline. *Had bed alarm in place to decrease falls. Review of resident 1's [DATE] through [DATE] incident detail reports revealed: *[DATE] at 8:00 p.m.: -Found on floor on back. Lost balance and slipped. No injury. -Reinforced to call for help while up in room until he feels stronger. Resident agrees to call for help. *[DATE] at 7:30 p.m.: -Found on floor lying on back. Lost balance. No injury. -Resident independent in room with activities of daily living. Was wearing proper footwear and using walker at time. No changes at this time. *[DATE] at 9:40 p.m.: -Found on floor. Lost balance, tripped, and slipped. Was walking from bathroom to chair. No injury. *Given orientation to call light, education to use call light, and frequent checks on resident. -Continues on antibiotic for infection. Has seen doctor due to weakness. Discussed chair/bed alarm to prevent further falls. Was moved rooms closer to nurse's station. *[DATE] at 10:40 p.m.: -Found on floor. Lost balance, slipped, and lost strength/weakness. Complains pain left cheek. -No personal alarm in place at time of incident. -Activity was ambulating to/from bathroom and transfer on/off toilet. -Bed alarm in place. *[DATE] at 4:15 p.m.: -Laying down in doorway in old room. Lost balance and lost strength/weakness. Ambulating to/from bathroom in old room. No injury. -There was no personal alarm in place at the time of the incident. -Resident continues to be confused. In PT and occupational therapy. Educated multiple times, alarms in place, was not sure about where he was found in old room. No new changes made at this time. *[DATE] at 8:30 a.m.: -Found sitting on buttocks in resident bathroom. -Chair alarm was in place at time of incident. No injury. -Educated resident to use call light and request assistance. Has increasing dementia and forgetful. *[DATE] at 2:05 a.m.: -Found on floor sitting by his bed. Lost balance. -Bed alarm was in place at time of incident. No injury. -Was assisted back into bed in lowest position with call light in reach. He was educated on calling or using his call light as much as possible. Still gets confused and forgetful. *[DATE] at 6:35 p.m.: -Found on floor sitting on buttocks in east side bathroom and later laid on floor. Lost balance. -No personal alarm in place and call light not within reach. No injury. _Educated on asking for help as much as possible. Educated staff on importance of utilizing chair alarm as this was not on at time of fall. Continue education to resident with no changes made. Resident continues to have confusion/forgetfulness. Review of resident 1's [DATE] care plan revealed: *Has impaired cognitive function or impaired thought processes related to dementia. Brief Interview for Mental Status (BIMS) score 10 that indicated moderate impairment. *Has potential for falls related to vision problems, gait/balance problems, seizure disorder, and recent fall resulting in hip fracture. *Be sure the call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. *Educate the resident about safety reminders and what to do if a fall occurs. *Place bed alarm in bed when resident is in bed and in wheelchair when resident is in the wheelchair. Be sure alarm is in good working order. Resident does turn alarm off when it is alarming. Check resident even when alarm quits alarming. *The resident does require extensive assistance of one for toileting, does wear pull-ups, and change when incontinent. Review of resident 1's [DATE] through [DATE] bowel and bladder elimination record completed by the certified nursing assistants (CNA) revealed the following times where no documentation of toileting or incontinent care: *[DATE]: 1:17 p.m. to 9:59 p.m. *[DATE]: 1:30 p.m. to 9:59 p.m. *[DATE]: 1:05 p.m. to 9:59 p.m. *[DATE]: 10:16 a.m. to 9:59 p.m. *[DATE]: 4:07 p.m. to 11:59 p.m. *[DATE]: 11:06 a.m. to 7:23 p.m. *[DATE]: 1:41 p.m. to 9:22 p.m. *[DATE]: 4:00 p.m. to 8:59 p.m. *[DATE]: 6:28 p.m. to 11:59 p.m. *[DATE]: 3:59 p.m. to 9:59 p.m. *[DATE]: 10:20 a.m. to 7:53 p.m. *[DATE]: 8:57 a.m. to 4:59 p.m. *[DATE]: 2:52 p.m. to 9:59 p.m. Interview on [DATE] at 10:30 a.m. with the MDS coordinator regarding resident 1 revealed: *He was not on a toileting schedule. *He would usually alert them to his need to toilet when he attempted to transfer to the toilet, and his bed/chair alarm would sound. *She agreed sometimes he would remove his alarm and get into the bathroom and fall. *She agreed his [DATE], [DATE], [DATE], and [DATE] falls were a result of his attempting to transfer into the toilet area. *She stated the CNAs might be assisting him more times to toilet but not documenting that. They had reminded the staff to make sure they were documenting after each assistance. 2. Review of resident 3's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She received hospice services at the facility from [DATE] until she died on [DATE]. Review of resident 3's [DATE] through [DATE] incident accident reports revealed: *[DATE] at 7:00 a.m.: -Resident slid off side of bed. No injury. -Time last toileted was left blank. -Medications given in last eight hours prior to fall diuretic. -Resident stated was trying to go to the bathroom before they fell . -Root cause of fall was resident trying to go the bathroom and sat on edge of bed and slid off. -Gripper socks put on. Re-instructed on call light use. *[DATE] at 1:15 a.m.: -Lost balance and found on floor. -Resident was calling out for help. Found resident sitting directly in front of bed. She had ambulated to restroom and was attempting to sit on edge of bed and slid to bottom in front of bed. -Encouraged need to call for help and will need to reinforce to her. *[DATE] at 7:45 p.m.: -Resident lost their balance and slipped. Found on floor. -Resident unable to voice what she was doing due to confusion and forgetfulness. -Resident does not have cognitive ability to turn on call light. -Continue to take resident to restroom on schedule. Alarm for wheelchair and bed put in place. *[DATE] at 9:50 a.m.: -Found lying on her back in her room. -Wheelchair was behind resident with wheels unlocked. -There was no investigation into fall or review of interventions. *[DATE] at 3:30 p.m.: -States was going to bathroom from recliner and slid out of the chair. Found on floor. -Has walker but was not by her. -Was incontinent of urine at 3:00 p.m. -Resident does not have cognitive ability to push call light. She states she was going to go to the bathroom and slid out of recliner. -Resident placed in wheelchair and taken out for snack. Alarm placed. -Alarm being used at time of fall was checked no. *[DATE] at 8:00 a.m.: -Lowered to floor related to unable to stand. -Two assist with transfers at all times. -Weakness root cause of fall. *[DATE] at 7:00 p.m.: -CNA helping resident to transfer and assisted resident to the floor. -CNA notified care plan had been changed to two assist at all times. -Weakness. Aide not following recent change to care plan. Review of resident 3's [DATE] care plan revealed: *BIMS score 0 that indicated severe memory impairment. *Is at risk for falls related unaware of safety needs, confusion, and gait/balance problems. *Assist with 2 all transfers. *Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. *Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. *The resident uses chair and bed electronic alarm. Ensure the device is in place as needed. *The resident requires total assist by 2 staff for toileting. Change brief in bed and provide peri care. Interview on [DATE] at 11:30 a.m. with the director of nursing regarding resident 3 revealed: *She had not been employed at the facility when the majority of her falls had occurred. *They had educated the staff on making sure the bed/chair alarms were on residents who needed them. *The CNAs were to also follow the resident's care plan for the required transfer assistance. *The resident was not able to use the call light for assistance as stated on the care plan. 3. Review of resident 4's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. Observation and interview on [DATE] at 1:30 p.m. with resident 4 revealed: *She was oriented to person only. *Her conversation was garbled, and she talked about other topics when asked a question. *She was sitting in her wheelchair and was trying to open the bathroom door. *She was unable to state if she needed to go to the bathroom. *There was a bed/chair alarm pad in her wheelchair. *She had turned off the alarm. *Her walker was beside the bed. Review of resident 4's [DATE] and [DATE] physician's progress notes revealed: *[DATE]: -She has had some falls, but they discovered that her bed alarm had inadvertently been left behind when she moved rooms. -They have replaced it and it seems to have cured her nighttime falling. -Recurrent falls with the bed alarm it seems to be better. *[DATE]: -Resident took a fall at the nursing home again. She was in the emergency room . -No fractures but did have a small sacral fracture. -She does have a history of a great deal of anxiety and has had some increasing falls. Review of resident 4's [DATE] at 12:50 p.m. incident report revealed: *Found on floor sitting on buttocks with legs out front. *Footwear in place was Ted hose. *Personal alarm was not in place. *Call light was not within reach. *Two skin tears on right arm. Pain in left hip. *Alarm put in wheelchair and reminded her to use call light. *Resident stated she just got done going to the bathroom and took her shoes off. She was not aware why she had taken off her shoes. Review of resident 4's revised [DATE] care plan revealed: *Resident has impaired cognitive function related to cerebrovascular accidents, seizure disorder, and memory loss. BIMs score was six indicating severe memory impairment. *Is a fall risk related to osteoporosis, pain, and limited mobility. *Assure resident call light is within reach and encourage resident to call for assistance. *Bed alarm to be applied in bed and wheelchair for safety. Keep in place at all times. *Educate resident to call and wait for assistance. *Resident required extensive assistance of one staff for toileting at times. *Ensure taking resident to the restroom on rounds during the night. *Resident had urge bladder incontinence. Review of resident 4's significant change assessment by RN C, MDS coordinator revealed: *Resident is a fall risk related to impaired balance, weakness, and unsteady gait. *Resident is a high fall risk. *Resident does have bed alarm in place for fall prevention. *Resident has had falls [DATE] with no injury, [DATE] with minor injury, [DATE] with no injury, and on [DATE] with major injury. *Uses her walker with assistance for pivoting and transfers. *Requires extensive assist of 1 for dressing, bed mobility, toileting, transfers, and hygiene. *Has pain to tailbone related to fall and fractured tailbone. Resident states she has pain daily but not constantly and is on scheduled Tylenol and as needed medication available. *Resident incontinent at times with bladder. Does wear incontinent products for protection. Review of resident 4's [DATE] through [DATE] bowel and bladder elimination record completed by the CNAs revealed the following times had no documentation of toileting or incontinent care: *[DATE]: 6:01 a.m. to 2:58 p.m. and 2:58 p.m. to 11:59 p.m. *[DATE]: 9:45 a.m. to 11:59 p.m. *[DATE]: 12:00 a.m. to 1:54 p.m. and 3:00 p.m. to 11:59 p.m. *[DATE]: 7:41 a.m. to 9:06 p.m. *[DATE]: 1:59 p.m. to 8:52 p.m. *[DATE]: 12:00 a.m. to 11:09 a.m. and 4:44 p.m. to 11:59 p.m. *[DATE]: 7:01 a.m. to 9:59 p.m. *[DATE]: 12:00 a.m. to 7:19 a.m., 7:19 a.m. to 4:25 p.m., and 4:25 p.m. to 11:59 p.m. *[DATE]: 10:24 a.m. to 9:59 p.m. *[DATE]: 6:42 a.m. to 4:55 p.m. and 4:55 p.m. to 11:59 p.m. *[DATE]: 6:34 a.m. to 9:55 p.m. *[DATE]: 6:31 a.m. to 7:59 p.m. *[DATE]: 12:23 a.m. to 7:18 a.m., 7:18 a.m. to 4:47 p.m., and 4:47 p.m. to 11:59 p.m. Interview on [DATE] at 10:30 a.m. with RN C regarding resident 4 revealed: *It was likely the CNAs were assisting her to the toilet more but were failing to document that. *The resident would often go into the bathroom on her own, and the staff were alerted by her chair alarm going off. *She was not being toileted on rounds at night according to the care plan. Review of the provider's updated [DATE] Fall and Accident Prevention and Management policy and procedure revealed: *Evaluate resident and environment for future prevention. *Update the comprehensive care plan with any changes or new interventions.