Every finding on record at Benedictine Living Community Owatonna

Based on observation, interview, and record review the facility failed to complete a comprehensive fall analysis to identify root cause/causal factors to prevent and/or reduce the risk of falls from self-transferring, failed to follow the care plan, and failed to timely revise the care plan with immediate fall interventions to prevent/mitigate the risk of re-current falls for 1 of 3 residents (R2) reviewed for falls.Findings include:R2's face sheet identified diagnoses of unsteadiness on feet, repeated falls, and muscle weakness.R2's annual Minimum Data Set (MDS) dated [DATE], R2 had severe cognitive impairment, no difficulties with hearing or speech, and wore glasses. R2 did not have inattention, or disorganized thinking. R2 utilized a walker and wheelchair for mobility. R2 required partial/moderate assistance with toileting hygiene, upper/lower body dressing, putting on/taking off footwear, sit to lie/lie to sit, and walking. R2 required supervision/touching assistance to move from sitting to standing, and toilet transfers. R2 was occasionally incontinent of bladder and frequently incontinent of bowel.R2's Mobility care plan dated 1/22/25, identified R2 was limited in ability to transfer self- due to weakness, unsteady gait, and poor endurance. Interventions included assist of one with gait belt, family member (FM)-A and B were able to transfer R2 per therapy, follow therapy recommendations, keep call light easily accessible.R2's care plan dated 2/11/25, identified R2 was limited with ambulation due to weakness. Interventions included on 6/5/25, assist of one staff to stand, pivot with gait belt to/from wheelchair. Walk with front wheeled walker and gait belt distance as tolerated, wheelchair to follow.R2's Falls care plan 1/22/25, identified R2 was at risk for falls due to weakness and unsteady gait. The interventions included:1/22/25-educate on prevention/reduction precautions per facility protocol;5/30/25- therapy consult for transfer training and assessment, follow therapy recommendation, and stop sign to remind R2 to call for help and wait for assistance, and educate on prevention/reduction precautions per facility protocol.6/5/25-pancake call light with fluorescent tape, room rearranged with recliner moved closer to bathroom, and wheelchair next to bed or recliner at all times,7/2/25-R2 was not to be left alone in bathroom, and toilet R2 before and after meals,8/5/25-leave bathroom light on,10/8/25-pharmacy review due to blood pressures,11/5/25-bed to be opened (covers pulled back) around 4:00 p.m. every afternoon,12/8/25-Christmas tree moved away from window and closer to R2, and ensure proper footwear at all times, R2's fall event report dated 2/18/26 at 1:05 p.m. identified R2 had an unwitnessed fall in bathroom; she was found on the bathroom floor lying on her left side with her pants and briefs down below her buttocks. R2 had reported she was trying to use the bathroom. R2 had been toileted at 11:45 a.m., wearing shoes, with no environmental risk factors identified. Fall risk factors checked were gait imbalance, hypotension, impaired memory, lethargic/drowsy, and R2 required one staff assistance with assistive device. Additionally, R2 had an emesis, didn't feel good and was sent to the emergency department (ED). R2 returned to the facility on 2/20/26 and started physical therapy. The report indicated staff would review toileting needs and adjust toileting plan. In review of R2's care plan there was no indication the toileting plan was revised or an immediate intervention to prevent/decrease the risk for falls related to self-transferring and toileting and no indication a comprehensive assessment was completed to determine R2's level of supervision. R2's interdisciplinary team (IDT) progress note dated 2/24/26, identified R2 fell while attempting to self-transfer to the bathroom after independently leaving the dining room and returning to her room. R2 did not request assistance prior to the fall. R2 had been toileted prior to lunch. R2 had been assessed by therapy upon return from hospital. As proactive fall interventions, anti-roll back brakes were added to R2's wheelchair. Additionally, a large yellow stop-sign banner was placed across the bathroom door to cue R2 to stop and request assistance before entering. R2 will continue to be monitored for safety and fall risk. R2's care plan was revised on 2/24/26 to include the intervention of anti-rollback brakes applied to wheelchair, and yellow stop sign banner across bathroom door.R2's progress note dated 6/4/26, identified nursing assistant (NA) walked to the toilet with NA using walker and stated she was feeling short of breath and dizzy. When R2 was done on the toilet, she started to get up off the toilet riser before the NA was right next to her, R2 began to fall after standing and the NA, who was in the bathroom with her, was able to lower her to the floor and have her sit on the floor. Intervention put in place to use the wheelchair for transfers and toileting for the time being until she regains her stamina.R2's Fall Event report dated 6/4/26, identified R2 had a witnessed fall in the bathroom after the aide left R2 alone in the bathroom sitting on the toilet while the NA stood in the bathroom doorway (which was not in accordance to the care plan intervention dated 7/2/25 that directed R2 was not to be left alone in bathroom. R2 was lowered to the floor by NA. NA stated R2 began to get up off the toilet before NA was right next to her. Fall risk factors included recent illness, active infection, and loose stools. R2 transferred at baseline with assistance of one staff with gait belt and device. R2 was alert at time of fall. Immediate intervention implemented was a recommendation to use wheelchair only until R2 felt better. R2's IDT progress note dated 6/5/26, identified IDT reviewed R2's fall incident that occurred during transfer/ambulation following toileting. R2 demonstrated weakness upon standing and was safely lowered to the floor by NA. Team discussion identified recent illness and associated weakness as a contributing factor. Immediate intervention implemented was use of a wheelchair for nighttime mobility to reduce fall risk during periods of weakness. Orders requested for therapies to evaluate and treat. R2 will continue to be monitored, and effectiveness of interventions will be evaluated through ongoing assessment and IDT review. The IDT note did not identify the care plan intervention that directed not to leave R2 alone in the bathroom was not followed which did not address the causal factor of R2 attempting to self-transfer. R2's falls care plan dated 6/5/26, identified an intervention to utilize wheelchair at night for mobility. During an interview on 8/25/26 at 1:30 p.m., NA-A stated R2 frequently self-transferred. Staff would clip the call light on R2's clothes, keep the wheelchair by the bed, and there were signs in R2's room to remind her not to self-transfer she doesn't pay much attention to them. During an interview on 8/26/26 at 9:40 a.m., NA-B stated R2 self-transferred quite a bit. The facility put a stop sign in front of the bathroom door and bright pink tape on the call light. R2 was not always good about remembering to use the call light, even with the pink tape. NA-B stated she would occasionally just pop-in and check on R2. During an interview on 8/26/26 at 10:10 a.m., NA-D stated R2 self-transferred frequently but felt during the day shift she could catch her before she attempted because NA-D knew when R2 woke up and would offer toileting. NA-D stated during shift reports, the night shift staff would report that R2 self-transferred 2-3 times every night. In review of R2's record between 2/18/26 and 8/4/2026, despite multiple staff reports of R2's repeated self-transfers, there was no indication of documentation that tracked R2's self-transfers, nor evident of a comprehensive assessment for level of supervision to prevent or mitigate R2's risk of falls related to self-transfers. R2's progress note dated 8/5/26 at 5:00 p.m., identified R2 had been with her husband and daughter in the cojoining room visiting. Daughter left. R2's wheelchair was located sitting in front of the recliner. R2 had fallen and was observed sitting on her bottom with her back to the bed and feet toward the wheelchair. R2 stated she was trying to get in the recliner.R2's Safety Event-Fall dated 8/5/26 at 5:53 p.m. identified that R2 experienced a fall in her room and was found on the floor by a nursing assistant. Documentation assessment sections were not completed, including the activity at the time of the fall and the staff description of how the fall occurred. R2's description of fall indicated she wanted to get up from wheelchair and go into her recliner. R2 sustained no injuries. She had last been toileted at 4:30 p.m. and was wearing gripper socks. R2 was noted to be alert and confused. The intervention to prevent further falls was to make sure to alert staff to assist her to the recliner. However, this intervention was not further defined to identify frequency of how often and when staff were supposed to assist R2 transferring before she attempted self-transferred.During an interview on 8/26/26 at 9:48 a.m., nursing assistant (NA)-C stated R2 attempted to transfer independently every day and on every shift, although her abilities varied from day to day. Staff attempted to prevent falls by placing signs in R2's room, explaining the use of the call light, securing the call light within her reach, and positioning her walker or wheelchair nearby while she was in bed or seated in a chair. R2 understood these instructions to some extent but did not retain the information and had to be reminded each time she was positioned because she always acts like it is the first time she has heard the information. NA-C stated staff were not given specific timeframes for checking on R2 and were instructed only to check on her during the shift. NA-C stated that on 8/5/26, R2 had been visiting outside with family at approximately 2:00 p.m. NA-C had not assisted R2 before the fall. After hearing yelling from R2's room around 4:45 p.m., NA-C entered and observed R2 and her husband on the floor on opposite sides of the room. R2 was lying next to her bed and yelling for her husband to help her stand.During a phone interview on 8/26/26 at 1:14 p.m., registered nurse (RN)-A stated on 8/5/26, family was visiting R2 and left shortly after the afternoon shift began. Around supper time, RN-A was called to R2's room because she was on the floor. RN-A was unsure when R2 had been toileted last. R2 was on the floor with her feet facing the bathroom and her top half was at the end of the bed. R2 self-transfers pretty frequently, little stinker. RN-A stated R2 will frequently be in her recliner and decide to self-transfer to the bathroom. Normally, staff attempt to go in the room after family leave and get R2 situated to avoid her self-transferring.R2's progress note dated 8/6/26, at 12:22 a.m., identified R2 denied pain from fall. Moves all extremities well without limitation or pain. R2 was directed to use call light if she needed anything, it was clipped to pajama top for easy access.R2's IDT progress note dated 8/6/26 at 3:27 p.m., identified IDT met to review R2's recent fall. R2 remained at an increased risk for falls due to recent hospitalization for ulcerative pancolitis (also called colitis) with resulting generalized weakness and history of recurrent falls. R2 was left unattended in the wheelchair in her room following a visit with family and attempted to self-transfer independently into the recliner, resulting in a fall. New intervention: family to notify staff prior to leaving so assistance could be provided promptly and not leave R2 unattended following visits.R2's care plan was revised on 8/6/26, to include the aforementioned intervention however, did not address the level of supervision to prevent R2's self-transfers.R2's Fall Risk (Acuity) and Functional Limitation Range of Motion (ROM) dated 8/7/26, identified R2 had intermittent confusion, poor recall, judgement, and safety awareness. R2 had adequate vision, required use of assistive devices, had impaired mobility and/or assist with toileting. R2 took antidepressants, and antihypertensives. R2 had a medication change in the past five days which was an antibiotic post hospital. Blood pressure taken while lying and standing was not completed and recorded as unable to measure as resident could not stand. R2 had a history of three or more falls. R2 had a total fall risk score of 16 with a level of At Risk.During an interview on 8/25/26 at 12:30 p.m., family members (FM)-A and FM-B were present and in R2's room. FM-B stated R2 had memory issues and falls. R2 did not ask for help. Two weeks ago, R2 fell when she attempted to move herself from one location to another. R2 had creative Alzheimer's, and does not listen or remember. FM-B stated the family was contemplating R2 being moved to a room closer to the nurses station and wondered if an alarm would assist staff when she tried to self-transfer. R2 would always self-transfer because she did not remember she could not do things independently.During an interview on 8/26/26 at 9:19 a.m., R2 was in the recliner. R2 stated she had been married for 35 years but her and her husband had been together for 17 years. When questioned about her fall on 8/5/26, R2 stated her husband had fallen while attempting to get out of bed and she went to help him I'm as stable as nobody and also fell. Thank goodness my daughter came. R2 then stated well, actually, we were trying to get to each other's room that's why I came down and fell over and then [FM-A] came and we got it all put together. R2 stated I can transfer myself. I hope that will last a while. R2 stated they wanted her to have someone with when she went to the bathroom. R2 picked up her call light from the overbed table next to her I got a little clock here that works, I push it to the right number and they come. They are very good about that.During a follow-up interview on 8/26/26 at 1:45 p.m., NA-B stated NA's reported R2's self-transfers to the nurse whenever she would self-transfer but the NA's did not have anywhere in the chart they would document it.During an interview on 8/26/26 at 1:50 p.m., NA-C stated she would write down all the times R2 self-transferred on the shift she worked and give the paper to the nurse at the end of the shift. NA-C was unaware what the nurse would do with the information after she provided it.During an interview on 8/26/26 at 12:09 p.m., licensed practical nurse (LPN)-A stated R2 self-transferred 2-3 times per day on the day shift and the self-transfers occurred more when R2 was out of bed than when she was in bed. LPN-A stated the NA's would be able to give a better answer on how often R2 self-transferred.During a follow-up interview on 8/26/26 at 1:40 p.m., LPN-A stated NA's are educated to tell the nurse on duty if R2 was self-transferring and nurses were supposed to make a progress note about it. LPN-A stated NA's could meet R2's needs and she could fall two minutes later. When LPN listened to night shift report they state that a lot of the times R2 would say she was fine when they checked on her and when they go back to the room she had self-transferred to the bathroom. When questioned if R2's self-transfers were documented in the nurses progress notes, LPN stated Oh, God, no, probably not.During an interview on 8/25/26 at 11:15 a.m., director of nursing (DON) stated during facility review of incident, falls were reviewed from 8/2025-8/2026, to ensure all information was accurate. Education had been provided to all staff and the specific NA involved.During an interview on 8/26/26 at 2:07 p.m., DON and regional nurse consultant (RNC)-A stated the facility did not have an assessment for self-transfers. R2's fall in February was from self-transferring. Keeping the wheelchair next to wherever she is at was to help make her environment as safe as possible. R2 was not to be left alone in the bathroom. Night shift provided every two-hour rounding, and during the day and evening shift, staff would go in the room frequently to check on R2's husband and would check on R2 at the same time, however, R2's husband had recently passed away. DON conceded there was no intervention for supervision to prevent self-transfer of R2, and self-transfers were an issue that was not specifically addressed to decrease the risk of falls for R2.The facility Integrated Fall Management policy dated 9/2023, identified the purpose of the policy was to complete: fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls.

Based on observation, interview, and document review, the facility failed to educate on risk and prevention of deep vein thrombosis (DVT); failed to ensure applied compression wraps for DVT prevention were clarified upon admission for ongoing use; and failed to ensure physician orders for resumption of anticoagulant (blood thinning) medication were acted upon timely to help reduce the clotting risk for 1 of 3 residents (R1) reviewed. R1 was subsequently hospitalized and died due to severe blood clotting with an ischemic (insufficient blood flow) leg and pulmonary embolism (clot in the lung) resulting in actual harm for R1. In addition, the facility failed to ensure surgical incisions were adequately monitored by nursing staff to reduce the risk of complication (i.e., delayed response to infection) for 1 of 3 residents (R2) reviewed who had surgical wounds. Findings include: R1: R1's Hospitalist Discharge summary, dated [DATE], identified R1 would be transitioned to the care center and listed a principal problem of acute cholecystitis (gallbladder inflammation). R1's other active problems included high blood pressure, heart failure, and atrial fibrillation (irregular heart rhythm). R1 was described as a [AGE] year-old female who admitted to the hospital on [DATE] with acute cholecystitis and underwent surgery for this condition. R1 then developed atrial fibrillation with rapid ventricular rate (RVR). The summary outlined, Eliquis (anticoagulant - blood thinner) on hold postoperatively. R1 discharged the hospital with a Jackson Pratt (JP) drain (a tube placed into a wound to allow drainage of fluid) in place and would follow up in the general surgery clinic. The note added, She will hold Eliquis until JP drain is removed. R1's corresponding After Discharge Orders, dated [DATE], identified R1's hospital discharge orders. These listed a section labeled, Discharge Medications that contained two medications listed under the heading, PAUSE taking these medications. One of the medications listed under this heading was Eliquis 2.5 milligrams (mg) with directions below, Wait to take this until your doctor or other care provider tells you to start again. After JP [Jackson Pratt] drain is out. The orders included no other anticoagulant medications or directions for compression wraps to be applied. R1's progress note, dated [DATE], identified R1 admitted to the care center, and she was alert and oriented. R1 had multiple medical conditions including atrial fibrillation and she had a JP drain in place with bloody drainage present. The note recorded, No edema. Wearing compression socks. HR [heart rate] irregular. R1's vital signs were stable on one liter of oxygen (O2). Licensed practical nurse (LPN)-C authored the note. A subsequent note, dated [DATE], identified R1 was seen by physical therapy (PT) and initial evaluations were completed. The note recorded, Assist of 2 pivot transfers. Assist of 2 toileting and self-cares. R1's progress note, dated [DATE], identified R1 was seen by occupational therapy (OT) and identified, Transfers: 1A [one assist] pivot w/ 4WW [walker] . Self Cares: Extensive assist . Toileting: 1A pivot w/ grab bars. R1's Progress Note, dated [DATE], identified R1 was seen by the general surgery service for post-operative follow-up. The note identified the surgery was on [DATE], and the patient was doing well and the JP drain had not had output for a few days. The JP drain was removed, and the site was reapproximated with Steri-Strips. The note recorded, [R1] is doing well postoperatively . At this point the patient is dismissed from our surgical service. The note identified sections below the dictation which read, Orders Placed, and Medication Changes, but these were both answered with text reading, None. The note did not address R1's Eliquis, which remained on hold since she was admitted to the care center six days prior.R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition along with several medical conditions including heart failure and atrial fibrillation. The MDS identified R1's consumed medications during the evaluation period, where the space to record anticoagulant consumption was left un-checked (i.e., not administered). R1's progress note, dated [DATE], identified R1 was seen by therapy and was now an assist of one for walking to and from the bathroom with a gait belt and walker. The note identified, [R1] is to walk 3x day with a [walker] and 1 A with gait belt and [wheelchair] follow. R1's H&P (History & Physical), dated [DATE], identified R1 was seen by the medical doctor (MD)-A for a routine nursing home visit due to admission. R1 had been recently hospitalized for sepsis (life-threatening response to infection) due to acute cholecystitis and had surgery. R1 developed atrial fibrillation with RVR post-operatively and was discharged to the care center on [DATE] with a JP drain in place. The note recorded, Since discharge she feels generally well and has no nausea. She has significant fatigue . she notes an irregular heartbeat. MD-A completed a physical examination of R1 which outlined, Extremities: Normal without edema. The note listed a section labeled, ASSESSMENT/PLAN that reviewed each medical condition and subsequent orders for them. This included, Atrial Fibrillation Paroxysmal (HCC), and dictation that read, Persistent with mildly elevated ventricular rate after recent sepsis hospitalization . Apixaban [Eliquis] was to be restarted when JP drain was removed. I wrote that order today. R1's subsequent order, dated [DATE], identified directions which included taking Eliquis 2.5 mg orally twice a day. The order was signed by MD-A on [DATE] (four days after the JP drain was removed) at 9:31 p.m., and the fax was time-stamped it was received by the care center at 9:33 p.m. R1's Medication Administration Record (MAR), dated 4/2026, identified R1's administered medications for the month period. This included an order for Eliquis 2.5 mg twice a day with dates recorded, [DATE] - [DATE]. The medication was recorded as not being administered on [DATE] for either dose with comments written, Other . pharmacy will deliver med ASAP, and Drug/Item unavailable. R1's first recorded dose of the Eliquis was on [DATE] (two days after being ordered) in the morning hours. The medication was provided until [DATE] (evening) and the space to record the morning dose on [DATE] was left blank with nothing identified. Further, R1's Treatment Administration Record (TAR) lacked any evidence of use of compression wraps or TEDs despite R1 admitting from the hospital with them on. R1's medical record lacked evidence R1 had been educated on DVT prevention including potential exercises R1 could do on her own while in bed to help prevent blood clots (i.e., ankle pumps); it lacked evidence R1's compression wraps, which were present on her upon admission, were clarified with the provider to determine if these should continue given R1 being off her anticoagulant medication and being at increased risk of blood clot; and lacked evidence of any shift-to-shift nursing monitoring (i.e., calf measurements, leg pain, skin discolorations) for a potential blood clot despite R1 being off her anticoagulant medication. Further, the record lacked evidence that the care center had acted upon the hospital's discharge order and notified the physician to resume the Eliquis when the JP drain was removed prior to [DATE], despite the drain being removed on [DATE] (four days earlier). R1's progress note, dated [DATE], identified the nursing assistant (NA) reported R1 sat on her bedside and was unable to move her left leg. The note recorded the leg, . appeared to be difference [sic] in color and cooler than right side . resident said that she couldn't feel sensation on left foot. Called for ambulance and called daughter . left via ambulance R1's Emergency Department (ED) Encounter, dated [DATE], identified R1 presented with decreased sensation in her left leg with the leg being, cool and dusky with a visible color change. Unable to Doppler pulses extending up to the popliteal. [back of the knee] The note identified a CT was completed which identified an acute pulmonary embolism [blood clot in the lung] and near complete occlusion of the entire left iliofemoral and femoropopliteal system. The note identified when R1 arrived at the acute care hospital ED, she was having pain in her left hip that was, . still severe at 10/10. R1 was given heparin (an anticoagulant) via IV in the ED and the note identified, She is being treated with heparin and will be sent to the OR emergently with vascular surgery for femoral cutdown, thrombectomy, [removal of blood clots], and likely fasciotomies [removal of facia] given the degree of ischemia. [death of tissue]. Both Dr. [name] from vascular surgery and I did impress upon the patient and her family the gravity of the situation and that she may well die in surgery but would almost certainly die without it. R1 agreed to the operation. On [DATE] at 1:21 p.m., R1's family member (FM)-A was interviewed. They explained that R1 was admitted to the care center following a hospitalization for gallbladder surgery and was not considered to be in terminal condition during the hospitalization or while admitted to the care center. R1 planned to return home to their assisted living facility (ALF) when they completed rehabilitation therapy at the care center. FM-A explained R1 had been on Eliquis prior to the hospitalization but it was held for her surgery and R1 discharged from the hospital to the nursing home with orders to resume the medication from their understanding. However, some issue happened that caused R1 to go for almost two weeks without the medication. FM-A stated their other family member had learned the medication was re-started on [DATE], when they started asking staff some questions about the medication. Then on [DATE], R1 developed a blood clot and had to be taken to the hospital where a significant clot was found. FM-A stated R1 must have been off the medication a fatal amount of time as the clot, which happened on [DATE], caused R1 to be hospitalized and R1 then passed away while in the hospital. FM-A stated watching R1 having pain and ultimately dying in the hospital was a very sad thing to experience and reiterated R1 planned to return to their ALF after the care center, until this medication incident happened. When interviewed on [DATE] at 10:17 a.m., nursing assistant (NA)-A stated they recalled working with R1 who needed minimal assistance with most cares. NA-A stated they could not recall R1 using compression wraps or TEDs while at the care center adding, I'm not sure on that. NA-A stated R1 ambulated using a walker but not when she first admitted to the care center, adding the ambulation was more at the end before she was hospitalized . NA-A stated they heard R1 had developed a blood clot and had to be hospitalized but was unsure of the details around it. When interviewed on [DATE] at 10:24 a.m., licensed practical nurse (LPN)-C reviewed R1's medical record and explained she was admitted to the care center following gallbladder surgery with a JP drain in place. LPN-C stated compression wraps or TEDs would need a physician order for use and R1 didn't have them ordered upon admission. LPN-C reviewed the progress note they authored (dated [DATE]), which identified R1 had them physically on when she admitted , and verified the record lacked evidence using them had been clarified with the physician. LPN-C adding that it should be a group of people who could have acted on that. LPN-C stated they did not recall R1 using compression wraps or TEDs while at the care center after she admitted and stated, It was not followed up on. LPN-C stated monitoring for a potential blood clot would likely be charted in the Medicare charting progress notes, however, R1's note template did not have that listed as something to monitor. LPN-C stated if a medication, like Eliquis, was on hold from the hospital then the floor staff wouldn't always know that information, adding unless the person was here for a hip fracture or something of that nature, then staff would likely not be alert to a potential clot risk like R1 had. When questioned about who was responsible for assigning or developing the shift-to-shift monitoring notes, LPN-C stated the health unit coordinator (HUC) used to read the hospital notes and help suggest or implement some monitoring, but the position had been patching together for several weeks due to leaves and resignations. LPN-C then reviewed R1's Eliquis and stated the order to resume it was faxed to the center on [DATE] late in the evening and entered in the EMR to begin on [DATE]. LPN-C acknowledged the doses on [DATE] were not administered and said they were unsure why it wasn't given, as a supply of Eliquis was available in the onsite emergency kit (E-kit). LPN-C stated they were unsure why there had been a delay of multiple days after the JP drain was removed, to when the Eliquis was restarted. LPN-C stated it was likely missed as the order to resume it had not been entered into the EMR for staff to ask about it: We [floor staff] may never have known her Eliquis was on hold if we didn't look at the actual hospital summary. LPN-C stated not entering the orders on hold upon admission caused things to be left to chance sometimes. LPN-C stated they felt all orders, including medications on hold, should be entered into the EMR so the floor staff were aware of them, adding, The more information we have, the better. Further, LPN-C stated Eliquis was considered a high-risk medication and not getting the medication resumed for multiple days which caused missed doses, would be a concern, adding aloud, It's significant. When interviewed on [DATE] at 11:23 a.m., registered nurse (RN)-A explained that when someone admitted from the hospital the HUC would take the information and enter it into the EMR. Then nurse would then verify it: If I have time. RN-A stated if someone admitted with an order to hold Eliquis until a drain was removed, then they would place a general note in the EMR such as an FYI-type thing. RN-A stated the need to resume it should be posted somewhere in the EMR for the floor staff to see repeatedly otherwise the order was likely to be missed. RN-A stated entering the order was not necessarily the policy of the campus but rather something I would do. RN-A stated if someone admitted to the care center with compression wraps on but no order for them, it should be clarified right away. RN-A stated the shift-to-shift monitoring for each resident was determined by either the HUC or the floor nurse and entered into the system using the progress notes. RN-A stated they personally tried to review hospital notes on the residents, but not every nurse does that, adding some newer nurses seem to be very focused on the orders only and not looking at the whole situation of the resident. On [DATE] at 1:59 p.m., unit nurse manager (RN)-B, the director of nursing (DON), and administrator were interviewed. DON stated someone using an anticoagulant medication would more likely be monitored for bleeding risk and they would typically need at least a provider recommendation to monitor for clots before that would be entered and tracked in the EMR. DON reiterated none of the hospital discharge paperwork or subsequent physician notes directed to monitor for potential blood clots. However, DON stated if nursing had concerns about it then they could initiate a nursing order and update the medical provider. RN-B stated there was no order for compression wraps from the hospital when R1 admitted and felt maybe they were not needed anymore, adding it was hard for me to say if someone ever clarified it or not with the provider. DON stated if there were questions about the wraps being used or not, then someone could have reached out to the provider and clarified it. RN-B and DON also verified they were unable to locate any documentation to show R1 had been educated on the risk of blood clots and steps to reduce them. DON then reviewed R1's Eliquis and explained it wasn't an active order when she admitted on [DATE] so it would not have been entered into the EMR as it could cause a medication error. DON stated in R1's scenario that multiple people could have caught the order to resume it once the JP drain was removed including the medical provider who physically removed the drain itself, but they never addressed it in their note. DON stated the person who reviewed the notes on admission would be the system to catch this and resume the medication. When asked how it would be handled if that person was not working or resigned in the meantime, the DON replied, I don't know if we have a fool-proof system in place for that, and suggested maybe using a sticky note on the desk in the office. DON verified there was no system outside of the EMR in place to ensure orders like R1's were identified and acted upon timely. DON explained the pharmacy sends medications to the campus once a day usually in the early morning hours, so an order received late at night wouldn't likely arrive the following day, however, the E-Kit was available and had some of that medication inside at the time on [DATE] to at least provide a dose. DON stated they would consider Eliquis to be a high-risk medication, and it should be given timely when ordered to help prevent blood clots. The DON and RN-B both acknowledged room to improve the communication surrounding this incident with R1 and the administrator expressed they felt the medical provider should have a responsibility to review medications after surgery adding they were unsure why the provider on [DATE] didn't address the medication then. When interviewed on [DATE] at 2:32 p.m., MD-A stated they were the campus' medical director and verified they had physically seen R1on [DATE] for the visit. MD-A stated they did not recall if anyone from the care center had clarified the compression wraps with them or not and expressed an order for their use was typically needed. MD-A stated either them or the nurses could catch that and have clarified it when R1 was admitted . MD-A stated use of compression wraps or TEDs was an intervention to help prevent blood clots in the legs and clarifying the order for R1 on [DATE] would have [been] a reasonable thing to do. MD-A stated they did not recall providing any education to R1 on the prevention of blood clots, either. MD-A reviewed R1's Eliquis and stated they learned it was to be restarted on [DATE] when the visit happened but were unsure if they identified that themselves or if the nurses at the center raised the issue with them. MD-A stated when they saw R1 on [DATE], there was no concern for a blood clot in her leg at that time, so the clotting most likely happened after that visit. MD-A stated if R1 had her Eliquis restarted immediately after the JP drain was removed (on [DATE]) it was hard to say, if a clot and subsequent hospitalization could have been avoided but MD-A added, Its possible it may have changed the outcome. MD-A stated if the medication was available in the E-Kit then a dose could have been removed and provided immediately following the order on [DATE] adding, That would be a med I would administer sooner rather than later. MD-A stated it was hard to say if they expected to be notified by the nurses on [DATE] when the JP drain was removed but added that given the situation with R1 and what happened with her developing a clot it would have been a great loop closure to have been notified. MD-A expressed, The takeaway [from this] is to identify loops that need to be closed and figure out the best process for doing that. MD-A stated, in hindsight, the nurses could have notified their service about the Eliquis adding, That would have been nice, but it didn't happen. On [DATE] at 3:23 p.m., the dispensing pharmacist (DP)-A was interviewed and verified their service distributed the medications to the campus. DP-A stated their current formulary showed Eliquis as being available in the campus E-Kit, but they would have to check and then send a review of the retrospective inventory after the interview to confirm a medication supply was available on [DATE]. DP-A stated nurses were always able to call them and ask about medication supply if they had questions about it. DP-A stated Eliquis was a medication the patient should not be without for a long period and explained the half-life of the medication (the time it takes for the concentration of that drug in your body to reduce by exactly 50%) was about 12 hours, and the medication starts working within an hour of being given. If a patient went for several days without it, then the effects of the medication would likely be totally removed from the body systems. DP-A stated having a period of multiple days unnecessarily going without the medication would make a difference with the risk of blood clots being formed adding, It would matter something. When interviewed on [DATE] at 4:05 p.m., the director of therapy (DOT) stated they were not the primary therapist who worked with R1 while she was at the care center, however, was somewhat familiar with her care and services she received. DOT stated the therapist chart in their own system, and they had reviewed the notes for R1, which identified R1 as not very mobile when she first admitted but then was progressing really well until she discharged to the hospital. DOT verified they were unable to locate any documentation to show R1 had been educated on the risk of blood clots and subsequent prevention techniques she could do on her own such as ankle pumps. DOT also was unable to locate any information on R1's use of compression wraps while at the care center and stated the nurses were able to facilitate those if desired or needed. DOT stated they felt the education on DVT prevention was typically provided, however, there was nothing documented for R1 to show it had happened.An e-mail correspondence received from DP-A on [DATE] at 5:28 p.m., identified Eliquis was available with at least one dose in the E-Kit on [DATE]. The email identified, It appears that the facility had a balance on hand in their [kit] to initiate therapy before the cards were delivered. A provided Physician Services policy, dated 1/2019, identified the care center would provide services related to physician services in accordance with State and Federal regulations. This included a procedure which directed, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. R2:On [DATE] at 12:35 p.m., R2's family member (FM)-D was interviewed. R2 was admitted to the care center after being hospitalized for an extended period due to multiple conditions and he had used a catheter while in the hospital, but it was removed before he discharged to the care center on [DATE]. FM-D stated R2 was doing good with using the bathroom and able to sense the need to go when he left the hospital. R2 also had some healing surgical incisions near his groin which were all intact and open-to-air (OTA). However, then they opened while at the care center and R2 had to eventually go back to the hospital due to them being re-opened and becoming infected. FM-D questioned what wound cares had been provided and how these closed, healing wounds could have re-opened. R2's progress note, dated [DATE], identified R2 admitted to the care center and had several medical conditions including peripheral arterial disease (PAD), acute kidney injury, chronic kidney disease (CKD), and high blood pressure. R2 needed assistance for all activities of daily living (ADLs), needed cues and reminders to ask for help, and was alert and oriented to self. The note identified R2 had been incontinent of urine and was unaware of such. Further, the note included a section labeled, Skin, which identified, . two healing surgical sites in bilateral groin . Bruising to BUE [bilateral upper extremities] . Small scabbed area to posterior calf on LLE [left lower extremity . All areas OTA [open to air] and not draining. No redness, swelling, or warmth to peri-wounds. R2's Care Plan, dated [DATE], identified all the potential or actual problems R2 had along with goals and interventions to address them. This identified a section labeled, Category: Bowel & Bladder Function, which recorded R2 as having bladder and bowel incontinence along with interventions to address it including keeping the call light within reach, monitoring for signs of infection, providing R2 with the urinal/bedpan/commode as needed, and offering him toileting frequently. The care plan continued and listed a section labeled, Category: Pressure Ulcer/Injury, which recorded R2 as admitting with multiple surgical incisions and being at risk of skin breakdown. The plan listed several interventions including monitoring the skin, being involved in the treatment process, and applying barrier creams if needed. R2's medical record, including progress notes and treatment records, lacked evidence of any ongoing or shift-to-shift monitoring of R2's healing surgical wounds from [DATE] to [DATE]. There was no evidence they were being observed by the nurses for symptoms of infection or potential dehiscence (surgical complication where a closed wound or incision ruptures and opens). In addition, R2's Wound Management section of the electronic medical record (EMR) lacked any evidence the surgical incisions were being tracked or monitored. R2's progress note, dated [DATE], identified R2 refused morning cares and his bedding was soiled. The nurse responded and assisted R2 into the bathroom and completed a body audit. The note identified, Writer observed right inguinal/groin with full thickness wound measuring 1.7 cm [centimeters] X 1.9 cm. Large nodule purple in color right inguinal/groin inferior to wound measuring 5 cm X 7 cm. The left groin incision was recorded as well approximated and R2's vital signs were stable. A subsequent note, dated [DATE], identified an SBAR (acute situation update) note was faxed to the hospital and R2's family was updated, . of concern of incisions. When interviewed on [DATE] at 1:24 p.m., nursing assistant (NA)-A stated they recalled working with R2. NA-A explained R2 needed help to use the bathroom and would, at times, refuse basic care like getting cleaned up. NA-A stated they recalled trying to reposition R2 every few hours and were unsure if he ever had skin issues or wounds adding, I don't remember that. When interviewed on [DATE] at 1:27 p.m., licensed practical nurse (LPN)-C stated if someone admitted with surgical wounds then they'd have daily monitoring done when the incision dressing was changed. If the wounds were open to air, such as R2's were, then the monitoring would be done and recorded on the Medicare charting notes in the progress notes or on the TAR. LPN-C stated there should be an order for monitoring with any surgical incision for at least daily [checks]. LPN-C reviewed R2's medical record and acknowledged it lacked evidence of any ongoing monitoring of the surgical incisions from [DATE] to [DATE]. LPN-C stated it was important to ensure incisions, even if closed and healing, were monitored until the wound was completely resolved. LPN-C stated they saw R2's incision on [DATE] when it had re-opened and completed the SBAR update to the physician. LPN-C stated they were unsure what had happened or caused it to open, but R2 ended up going to the hospital a few days later to have it addressed. On [DATE] at 10:33 a.m., the director of nursing (DON) and administrator were interviewed. DON explained a skin observation is completed upon admission and wounds or incisions should be recorded on that evaluation. If a surgical incision was present, which was draining or had concerning presentation, then the nurses could contact the medical provider or onsite wound nurse to review it. DON stated the NA staff were taught to observe the skin each day with cares and felt they'd report issues if seen. DON stated the Medicare charting is determined by the MDS nurses and not everyone would get incisional monitoring included, especially if the incisions were open to air like R2's were upon admission. DON verified they were unable to locate documentation to show any monitoring of the incisions from [DATE] to [DATE] and reiterated the NA staff were taught to check the skin with daily care. A provided Prevention and Treatment of Skin Breakdown policy, dated 9/2018, identified resident skin was assessed upon admission and weekly thereafter. A resident who was at increased risk for breakdown would be provided preventative measures to reduce the potential risk of skin breakdown. A procedure was listed that outlined steps to be completed which included, Skin is observed daily with cares. If any skin concerns are noted, they are reported to the licensed nurse. The procedure then shifted to more pressure ulcer prevention and care and lacked any specific guidance or process for surgical incision monitoring.

Based on interview and document review, the facility failed to develop a baseline care plan to ensure immediate care needs for surgical incision care and his urinary incontinence were addressed for 1 of 3 residents (R2) reviewed. R2's progress note, dated 4/13/26, identified R2 admitted to the care center and had several medical conditions including peripheral arterial disease (PAD), acute kidney injury, chronic kidney disease (CKD), and high blood pressure. R2 needed assistance for all activities of daily living (ADLs), needed cues and reminders to ask for help, and was alert and oriented to self. The note identified R2 had been incontinent of urine and was unaware of such. Further, the note included a section labeled Skin that identified, . two healing surgical sites in bilateral groin . Bruising to BUE [bilateral upper extremities] . Small scabbed area to posterior calf on LLE [left lower extremity . All areas OTA [open to air] and not draining. No redness, swelling, or warmth to peri-wounds. R2's Care Plan, dated 4/22/26, identified all the potential or actual problems R2 had, along with goals and interventions to address them. This identified a section labeled Category: Bowel & Bladder Function that recorded R2 as having bladder and bowel incontinence along with interventions to address it, which included keeping the call light within reach, monitoring for signs of infection, providing R2 with the urinal/bedpan/commode as needed, and offering him toileting frequently. However, this section of the care plan and its interventions were initiated on 4/20/26 (seven days after admission). The care plan continued and listed a section labeled Category: Pressure Ulcer/Injury that recorded R2 as admitting with multiple surgical incisions and being at risk of skin breakdown. The plan listed several interventions including monitoring the skin, being involved in the treatment process, and applying barrier creams if needed. However, again, this section and its interventions were initiated on 4/20/26 (seven days after admission). R2's medical record lacked evidence that a comprehensive baseline care plan had been developed within 48 hours of admission to address these areas of R2's care despite him having active surgical wounds and being incontinent of urine upon admission as recorded in the progress notes. When interviewed on 5/12/26 at 1:24 p.m., nursing assistant (NA)-A stated they recalled working with R2. NA-A explained R2 needed help to use the bathroom and would, at times, refuse basic cares like getting cleaned up. NA-A stated they recalled trying to reposition R2 every few hours and were unsure if he ever had skin issues or wounds adding, I don't remember that. When interviewed on 5/12/26 at 1:27 p.m., licensed practical nurse (LPN)-C stated the facility did not use a specific baseline care plan but rather just started to build the comprehensive one upon admission. LPN-C stated care plans were made usually by the nurse managers, director of nursing (DON) and social worker team as they reviewed the evaluations the floor staff completed. LPN-C reviewed R2's care plan and verified the skin and bladder/bowel sections were initiated on 4/20/26 which was a week after R2 was admitted to the center. LPN-C stated the baseline care plan should be done within a few days after admission. LPN-C stated having a baseline care plan was important as it assisted the staff with caring for the person in the early part of their admission. On 5/13/26 at 10:33 a.m., the DON and administrator were interviewed. DON explained that the MDS (Minimum Data Set) nurses helped complete the care plan by reviewing the floor staff observations and evaluations which included a toileting plan, if needed. DON verified there was not a separate baseline care plan template used and that R2's skin or bladder/bowel plans were not initiated until 4/20/26. DON stated they should have been initiated within 48 hours after admission to the care center but with weekend admission it could take a little bit longer at times. DON stated they would be doing education on this to the staff and added having a baseline care plan was important for the staff to know how to care for the resident. A provided Comprehensive Assessments and Care Planning policy, dated 2/2026, identified the assessment process of a resident begins with the development of the baseline care plan within the first 48 hours of admission. The plan should have the minimum healthcare information needed to care for them on admission including but not limited to their initial goals, physician orders, dietary orders, and social services. The policy continued, The baseline care plan reflects the resident's stated goals and objective, and includes interventions that address his or her current needs.

Based on interview and document review, the facility failed to comprehensively assess and, if needed, develop a toileting program to promote urinary continence and reduce the risk of complication (i.e., skin infection, breakdown) for 1 of 3 residents (R2) reviewed. On 5/12/26 at 12:35 p.m., R2's family member (FM)-D was interviewed. R2 was admitted to the care center after being hospitalized for an extended period due to multiple conditions and he had used a catheter while in the hospital, but it was removed before he discharged to the care center on 4/13/26. FM-D stated R2 was doing good with using the bathroom and able to sense the need to go when he left the hospital. R2 also had some healing surgical incisions near his groin which were all intact and open-to-air (OTA). However, then they opened while at the care center and R2 had to eventually go back to the hospital due to them being re-opened and becoming infected. FM-D stated the family had visited at times and found R2 to be incontinent of urine which made them question if that contributed to the incisions becoming infected, adding, Nursing 101 is keep the incision sites clean and dry. FM-D stated they were unsure if R2 ever attempted or was placed on a toileting plan while in the care center to help reduce the incontinence. R2's progress note, dated 4/13/26, identified R2 admitted to the care center and had several medical conditions including peripheral arterial disease (PAD), acute kidney injury, chronic kidney disease (CKD), and high blood pressure. R2 needed assistance for all activities of daily living (ADLs), needed cues and reminders to ask for help, and was alert and oriented to self. The note identified R2 had been incontinent of urine and was unaware of such. Further, the note included a section labeled Skin that identified, . two healing surgical sites in bilateral groin . Bruising to BUE [bilateral upper extremities] . Small scabbed area to posterior calf on LLE [left lower extremity . All areas OTA [open to air] and not draining. No redness, swelling, or warmth to peri-wounds. R2's Clinical Documentation (Admission), dated 4/13/26, identified a review of system completed upon admission. This identified R2 as needing supervision to complete a toileting transfer and partial/moderate assistance with toileting hygiene. The evaluation listed a section labeled Bowel and Bladder that identified R2 used no appliances, was frequently incontinent of urine and occasionally incontinent of bowel. There was no further assessment of R2's incontinence or dictation of what, if any, toileting program was needed, considered or attempted. R2's Bladder evaluation, dated 4/17/26, identified R2 used no appliances for elimination and was recorded as being frequently incontinent of urine. R2 was unable to recognize the appropriate time or place to urinate but was able to sense the urge to void. R2 had impaired mobility and severe cognitive impairment and was currently incontinent of bladder with his clothes being found wet. The evaluation listed multiple sections to be completed which included Section 5 - Further Assessment that had space to record a physical examination, a post-void residual (PVR), and if a urinalysis was performed, along with spacing to write the results. However, this section was left entirely blank and not completed. The section labeled Section 6 - Incontinence Symptom Profile had options to select which type of incontinence R2 was assessed to have present (i.e., urge, functional), however, this section was also left blank with nothing being selected or recorded. The section labeled Section 7 - Summary of Program Placement Decision identified R2 with functional incontinence, however, the remainder of the section, including spacing to record what toileting program was needed or if was not appropriate, was left blank and not completed. The evaluation concluded with summarized findings reading, Resident incontinent of bladder. Does ask for urinal at times. Known to attempt urinal per self however not appropriately. Staff assist with incontinence cares. The evaluation was completed by licensed practical nurse (LPN)-C. R2's admission Minimum Data Set (MDS), dated [DATE], identified R2 admitted to the care center on 4/13/26 from the acute-care hospital. The MDS identified R2 had severe cognitive impairment and had surgical wounds present. Further, the MDS identified R2 used no elimination appliances (i.e., catheter) and was recorded as always incontinent of bowel and bladder; however, a toileting program had not been attempted since admission. R2's corresponding Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 4/21/26, identified R2 had no modifiable risk factors identified, demonstrated urinary urgency and needed assist with toileting, and demonstrated functional incontinence (i.e., can't get to toilet timely). The CAA identified, CAA triggered due to resident is always incontinent of urine. Contributing factors include need for staff to assist with toileting. He is at risk for skin rashes, skin breakdown, and urinary infection. No referrals at this time. Will proceed to care plan to minimize risks. The CAA did not address if a toileting plan was considered, appropriate, or rationale why not to attempt one despite the incontinence and R2 being recorded as using the urinal at times. R2's Care Plan, dated 4/22/26, identified all the potential or actual problems R2 had along with goals and interventions to address them. This identified a section labeled Category: Bowel & Bladder Function that recorded R2 as having bladder and bowel incontinence along with interventions to address it including keeping the call light within reach, monitoring for signs of infection, providing R2 with the urinal/bedpan/commode as needed, and offering him toileting frequently. This section of the care plan and its interventions were initiated on 4/20/26 (seven days after admission) and the plan lacked any further dictation or description of what frequently meant for his toileting. When interviewed on 5/12/26 at 1:24 p.m., nursing assistant (NA)-A stated they recalled working with R2. NA-A explained R2 needed help to use the bathroom and would, at times, refuse basic cares like getting cleaned up. NA-A stated they tried to help R2 with toileting every few hours or when he used the call light asking for the urinal. NA-A stated R2 was able to sense when he needed to void and would off and on use the call light to alert staff. NA-A stated they did not recall if R2 was on a formal toileting program or not but reiterated R2 would tell them if he needed to use the bathroom or not adding, He usually told us. R2's medical record was reviewed and lacked evidence R2 had been comprehensively assessed for his bladder function and incontinence including to determine what, if any, toileting program may be beneficial for R2 since he was able to sense the need to void, could alert staff for assistance, and had active healing surgical wounds around his groin, which were at risk for infection. When interviewed on 5/12/26 1:27 p.m., LPN-C verified they completed the bladder evaluation for R2 (dated 4/17/26) and explained upon admission each resident has the Clinical Documentation evaluation completed and a Bladder evaluation completed after that. This should happen within the first seven (7) days after admission. LPN-C reviewed R2's completed Bladder evaluation and stated the section for a physical assessment (Section 5) was often not completed unless someone had a recent appliance removed or had pending lab results. LPN-C verified this was left blank on R2's evaluation (despite him using a catheter in the hospital for a period). The section for the incontinence profile (Section 6) was used to record the incontinence type and LPN-C verified the areas not completed and responded, You're right. LPN-C stated they could have completed that section and there was a missing aspect under that [section]. LPN-C stated the section for the toileting program determination (Section 7) was also left nearly blank and acknowledged no decision for a program adding, You're right. LPN-C stated they were unsure why they didn't complete the evaluation and program selection adding, I guess I can't answer that. LPN-C stated the center rarely used a three-day tracking diary or other tool to evaluate potential toileting programs, but the staff could check the recorded point-of-care (POC) responses if needed, but added, I personally do, but can't speak for others. On 5/13/26 at 10:33 a.m., the director of nursing (DON) and administrator were interviewed. DON explained that the Bladder evaluation is completed after a few days from admission and the MDS nurses will then develop a care plan from that information and determine if a toileting program should be implemented with therapies (PT/OT) able to give input on that decision. DON stated the center didn't do a toileting program often, rather just did basic plans like assistance before meals, after meals, and as requested. DON stated the word frequently was a very vague term on the care plan. DON explained each section of the Bladder evaluation and stated they expected the sections left all or mostly blank on R2's evaluation (i.e., 5 - 7) to be completed. This was important to do as it's a requirement and helps staff to have a clearer picture of the resident. DON acknowledged the record lacked evidence or rationale why this had not been done for R2. A facility policy on bladder evaluations was requested; however, none was received.

Based on observation, interview, and document review, the facility failed to ensure high-risk medications were provided timely after being ordered to help prevent potential blood clots for 1 of 1 resident (R1) reviewed. R1 had Eliquis (an anticoagulant, blood thinning, medication) ordered by the medical doctor (MD)-A on 4/10/26; however, this was not provided to R1 until 4/12/26 despite supply of the medication available in the emergency kit (E-Kit) onsite. R1's Hospitalist Discharge summary, dated [DATE], identified R1 would be transitioned to the care center and listed a principal problem, Acute cholecystitis (gallbladder inflammation). R1's other active problems included high blood pressure, heart failure, and atrial fibrillation (irregular heart rhythm). R1 was described as a [AGE] year-old female who admitted to the hospital on [DATE] with acute cholecystitis and underwent surgery for this condition. R1 then developed atrial fibrillation with rapid ventricular rate (RVR). The summary outlined, Eliquis on hold postoperatively. R1 discharged the hospital with a Jackson Pratt (JP) drain in place and would follow up in the general surgery clinic. The note added, She will hold Eliquis until JP drain is removed. R1's corresponding After Discharge Orders, dated 4/1/26, identified R1's hospital discharge orders. These listed a section labeled, Discharge Medications that contained two medications listed under the heading, PAUSE taking these medications. One of the medications listed under this heading identified the Eliquis and directions below, Wait to take this until your doctor or other care provider tells you to start again. After JP [Jackson Pratt] drain is out. The orders included no other anticoagulant medications.R1's Progress Note, dated 4/6/26, identified R1 was seen by the general surgery service for post-operative follow up. The note identified the surgery was on 3/26/26, and the patient was doing well and the JP drain had not had output for a few days. The JP drain was removed, and the site was reapproximated with Steri-Strips. The note identified sections below the dictation that read, Orders Placed, and Medication Changes, but these were both answered with text reading, None. The note did not address R1's Eliquis, which remained on hold since she was admitted to the care center six days prior.R1's H&P (History & Physical), dated 4/10/26, identified R1 was seen by the medical doctor (MD)-A for a routine nursing home visit. The note recorded, Since discharge she feels generally well and has no nausea. She has significant fatigue . she notes an irregular heartbeat. The note listed a section labeled, ASSESSMENT/PLAN, which reviewed each medical condition and subsequent orders for them. This included, Atrial Fibrillation Paroxysmal (HCC), and dictation which read, Persistent with mildly elevated ventricular rate after recent sepsis hospitalization . Apixaban [Eliquis] was to be restarted when JP drain was removed. I wrote that order today. R1's subsequent order, dated 4/10/26, identified directions which included taking Eliquis 2.5 mg orally twice a day. The order was signed by MD-A on 4/10/26 at 9:31 p.m., and the fax was time-stamped as received by the care center at 9:33 p.m. R1's Medication Administration Record (MAR), dated 4/2026, identified R1's administered medications for the month period. This included an order for Eliquis 2.5 mg twice a day with dates recorded, 04/11/2026 - 4/15/2026. The medication was recorded as not being administered on 4/11/26 for either dose with comments written, Other . pharmacy will deliver med ASAP, and Drug/Item unavailable. R1's first recorded dose of the Eliquis was on 4/12/26 in the morning (AM) hours. R1's progress note, dated 4/15/26, identified the nursing assistant (NA) reported R1 sat on her bedside and was unable to move her left leg. The note recorded the leg, . appeared to be difference [sic] in color and cooler than right side . resident said that she couldn't feel sensation on left foot. Called for ambulance and called daughter . left via ambulance When interviewed on 5/12/26 at 10:24 a.m., licensed practical nurse (LPN)-C reviewed R1's medical record and explained she was admitted to the care center following gallbladder surgery with a JP drain in place. LPN-C reviewed R1's Eliquis and stated the order to resume it was faxed to the center on 4/10/26 late in the evening and entered in the EMR to begin on 4/11/26. LPN-C acknowledged the doses on 4/11/26 were not administered and expressed they were unsure why it wasn't given as a supply of Eliquis was available in the onsite emergency kit (E-kit). LPN-C retrieved a black-colored binder that had the E-Kit supply listed and Eliquis was included. LPN-C then showed the surveyor the medication room which had an AlixaRx machine present. On the front of the machine, a white-colored paper was taped with the medications available. Eliquis was listed and the paper was dated, 4-Nov-24. Further, LPN-C stated Eliquis was considered a high-risk medication and not getting the medication resumed timely when ordered would be a concern adding aloud, It's significant. On 5/12/26 at 1:59 p.m., unit nurse manager (RN)-B, the director of nursing (DON), and administrator were interviewed. DON explained the pharmacy sends medications to the campus once a day usually in the early morning hours, so an order received late at night wouldn't likely arrive the following day, however, the E-Kit was available and had some of that medication inside at the time on 4/11/26 to at least provide a dose. DON stated they would consider Eliquis to be a high-risk medication, and it should be given timely when ordered to help prevent blood clots.When interviewed on 5/12/26 at 2:32 p.m., MD-A stated they were the campus' medical director and reviewed R1's Eliquis. MD-A visited R1 on 4/10/26 and on that day learned it was to be restarted but were unsure if they identified that themselves or if the nurses at the center raised the issue with them. MD-A stated when they saw R1 on 4/10/26, there was no concern for a blood clot in her leg at that time, so the clotting most likely happened after that visit. MD-A stated if the medication was available in the E-Kit on 4/11/26 then a dose could have been removed and provided immediately following the order on 4/10/26 adding, That would be a med I would administer sooner rather than later. On 5/12/26 at 3:23 p.m., the dispensing pharmacist (DP)-A was interviewed and verified their service distributed the medications to the campus. DP-A stated their current formulary showed Eliquis as being available in the campus E-Kit, but they would have to check and then send a review of the retrospective inventory after the interview to confirm a medication supply was available on 4/11/26. DP-A stated nurses were always able to call them and ask about medication supply if they had questions about it. DP-A stated Eliquis was a medication the patient should not be without for a long period and explained the half-life of the medication (the time it takes for the concentration of that drug in your body to reduce by exactly 50%) was about 12 hours, and the medication starts working within an hour of being given. If a patient went for several days without it, then the effects of the medication would likely be totally removed from the body systems. DP-A stated having a period of multiple days between an order and actual administration would make a difference with the risk of blood clots being formed adding, It would matter something. An e-mail correspondence received from DP-A on 5/12/26 at 5:28 p.m., identified Eliquis was available with at least one dose in the E-Kit on 4/11/26. The email identified, It appears that the facility had a balance on hand in their [kit] to initiate therapy before the cards were delivered. A provided Emergency Pharmacy Service and Emergency Kits policy, dated 12/2017, identified emergency pharmacy services were available on a 24-hour basis through the approved emergency medication supply. The supply was maintained in the ADU (automated dispensing unit) room along with a list of supply and expiration dates. The policy then listed a procedure to withdraw and use the medication and document it on the medical record.

Based on interview and record review the facility failed to timely implement physician's order to administer an anti-nausea medication and timely follow an order for transfer to emergency department for 1 of 3 residents (R1) which resulted in delay of treatment reviewed for change of condition. Findings includeFindings include:R1's face sheet dated 3/25/26, identified diagnoses of perforation of intestine (non-traumatic) (hole or tear develops in the intestine), and colostomy status (surgical opening in colon that allows stool to exit through stoma).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive issues. R1 had no behaviors. R1 used a walker and wheelchair for mobility. R1 required one staff assistance with dressing, transfers, repositioning, toileting, and walking. R1 had an ostomy.During a phone interview on 3/25/26 at 8:37 a.m., nursing assistant (NA)-B stated on 2/27/26, around 4:00 p.m.-4:30 p.m. she emptied R1's colostomy bag. Afterward, she walked R1 out to dinner. Five to ten minutes later, R1 stated he was not feeling well and wanted to go back to his room. NA-B walked R1 back to his room. R1 stated his stomach hurt, he was not hungry, and he wanted to lay down but went to his recliner.R1's vital signs at 6:43 p.m. BP 171/95, 02 94%, P 90, T 96.7 at 6:55 p.m. R 18, pain 3/10.R1's clinician note dated 2/27/26, identified R1 had developed nausea that afternoon and chose not to eat supper. Nursing staff noted BP was high but had been taken after an episode of dry heaving. R1 did not complain of pain. Vital signs BP 171/95, 02 94% on room air, P 90, T 96.7 R 18. R1 was in bed, awake, and alert. R1 had a colostomy mid abdomen with a small amount of stool and air in bag. Bowel sounds are present. There is diffuse mild tenderness. R1 had nausea over the past couple of hours with no abdominal pain. Zofran is available. Nursing to update MD-A later this evening.R1's signed physician order dated 2/27/26, and written on facility Physician Orders, identified R1's name, Ondansetron (Zofran) 4 mg by mouth every 6 hours as needed for nausea. The order also had handwritten called and spoke to [pharmacy] 9:24 p.m.R1's medication administration record (MAR) for 2/27/26, identified Zofran 4mg administered at 9:40 p.m. for nausea/vomiting; upset stomach comment: 9:15 p.m. Results indicated not effective.During an interview on 3/26/26 at 12:40 p.m., medical doctor (MD)-A clarified that the order for Zofran was written between 6:00 p.m.-7:00 p.m. on 2/27/26. MD-A expected Zofran would have been administered at that time as R1 had acute issues that required addressing immediately and not leisurely.During a phone interview on 3/25/26 at 8:33 a.m., NA-A stated on 2/27/26, she first had contact with R1 around 7:00 p.m. registered nurse (RN)-A had just walked out of R1's room. R1's stomach was a little bigger, but NA-A was unsure if it was from gas or something like that. R1 did not complain of pain in the area when she looked at the colostomy area. Around 9:00 p.m., RN-A requested NA-A to get vital signs on R1 because he wanted to go to the emergency department (ED). NA-A went to R1's room. R1 was in bed, head elevated, and oxygen on 1 liter per minute (LPM). R1 appeared gray in color he didn't look the greatest. R1 had a basin he was spitting phlegm into. NA-A asked R1 if he had pain and R1 pointed to his sternum area. R1 looked sweaty and was anxious. NA-A told RN-A that R1 did not look good, and his vital signs are not normal. RN-A called the doctor after NA-A gave her R1's vital signs. R1 put on his call light multiple times between 9:00 p.m.-10:00 p.m. and asked to go to the ED. NA-A did not know why RN-A did not call the paramedics.R1's progress note dated 2/27/26 at 9:53 p.m., identified R1 refused to come out for supper, rested in recliner in room complained of stomachache. R1 refused supper when tray offered. R1 hollered for nurse to come in because his colostomy bag was going to burst open, noted to be almost empty, no need for emptying. R1 completed HS (hour of sleep) cares and transferred into bed after taking night medications orally. R1 tolerated sips of water. R1 complained of pain in epigastric (upper abdominal) region, noted to dry heave and spitting clear phlegm. R1 given Zofran 4 milligrams (mg) at 9:15 p.m. with no relief noted. R1 stated he would like to go by ambulance to the emergency room. An edit to the progress note was completed on 2/27/26 at 10:03 included: medical doctor (MD)-A was at facility to see R1 and gave order for Zofran every 6 hours as needed for nausea, and call placed to MD-A to inform of R1 not getting any better and current vitals despite having Zofran that was ordered. An edit to the progress note was completed again on 2/27/26 at 10:22 p.m. which included MD-A stated to send R1 to emergency room for increased belly pain.R1's progress note dated 2/27/26 at 10:37 p.m., identified R1's power of attorney (POA) was notified of R1 being sent to the emergency department (ED). R1 stated he had chest pain to nursing assistant (NA)-A and nothing made him feel better. R1 was pale, no emesis noted, vital signs taken with blood pressure elevated.R1's MAR for 2/28/26, identified a routine standing order for Mylanta 2-4 teaspoons. Time given was 12:17 a.m. with reason nausea/vomit; upset stomach comment: gave at 10:50 p.m. (2/27/26)R1's progress note dated 2/27/26 at 11:43 p.m., identified R1 continued to complain of sharp epigastric pain that was 10/10 [edited to note at 12:14 a.m.]. R1 was dry heaving, received antacid with no relief from pain. R1 continued to have elevated blood pressure at 146/93, which had gone down from earlier reading on evening shift. R1 had an audible expiratory wheeze and oxygen saturation ranging from 87-90% on 1 liter per minute of oxygen, oxygen was increased to 2 liters and oxygen saturations increased to 94%. R1 was pale and diaphoretic (sweaty). R1 was asked if he still wanted to go to the ED and he stated yes. Non-emergency dispatch was called for transport to ED. ED notified of R1's transfer to them.R1's progress note dated 2/27/26 at 12:13 a.m., identified R1 left with paramedics at 12:05 a.m.During a phone interview on 3/25/26 at 11:18 a.m., NA-C stated on 2/27/26, R1 was in his recliner and she assisted R1 to bed by walking to the bed. R1 stated he did not feel well and mentioned that he felt like throwing up. NA-C raised the head of the bed, put on oxygen, and gave R1 a basin in case he did throw up. NA-C reported that to RN-A. R1 called between 9:00 p.m.-10:00 p.m. and requested to go to the ED. NA-C notified RN-A.During a phone interview on 3/25/26 at 11:40 a.m., registered nurse (RN)-A stated on 2/27/26, R1 refused to come out for supper. This was unusual for R1 but happened occasionally. RN-A thought MD-A may have seen R1 after suppertime. RN-A did not communicate to MD-A until after MD-A had already seen R1 about him feeling nauseous, having high blood pressure, and refusing to eat supper. MD-A gave RN-A her phone number to call if R1 needed to be sent to ED. MD-A wrote an order for as needed Zofran. Around 7:00 p.m., R1's stomach pain moved from the ostomy site to epigastric pain. RN-A did not administer the Zofran. RN-A thought the pain could be associated with indigestion. RN-A stated only R1's BP stood out to her when she took vital signs at 6:43 p.m. and associated that with R1 not feeling well. R1 had stated he wanted to go to the ED between 9:30 p.m.-10:00 p.m. in addition to 2-3 different reports from NA's R1 wanted to go to the hospital. RN-A had other paperwork she was trying to finish up and get done with documentation during that time. RN-A could not articulate why she did not call the paramedics but guessed she was waiting to see if anything else was going to show, exactly what am I going to tell the ED for a nurse to nurse report? During shift change report licensed practical nurse (LPN)-B and RN-A decided to give R1 Maalox. RN-A stated she had edited her progress note at 9:53 p.m. to add information from MD-A and clarify the timeline of events.During a phone interview on 3/26/26 at 7:03 a.m., LPN-B stated she came to work on 2/27/26 at 10:00 p.m. for the overnight shift. RN-A reported R1 would need to be sent to the ED because R1 was sick to his stomach, dry heaving and basically vomiting up saliva. RN-A had stated he had pain on the top of his stomach at the xyphoid process (breastbone) and thought R1 could also be having a heart attack. LPN-B assessed R1 while he was in bed with the head of the bed raised and he was really nauseous. LPN-B noted that he had a lot of gas in his colostomy bag. LPN-B and NA changed R1's gown prior to paramedics arriving as it had a rancid smell to it. LPN-B called the non-emergency number for the ambulance and the paramedics came to the facility within 10-15 minutes after she called. LPN-B was unaware that R1 had pain until the paramedics came. LPN-B edited her progress note to add that R1 had pain 10/10.During a phone interview on 3/25/26 at 10:16 a.m., MD-A stated she examined R1 towards the end of her day on 2/27/26 but could not recall the specific time. R1 had not been feeling well, had not eaten, and had some nausea. MD-A was aware of R1's elevated BP reading but that the reading had been obtained after R1 had an episode of dry heaving. MD-A advised RN-A to notify her later in the evening on R1's status. At that time, MD-A had not thought R1's condition was acute enough to send to the emergency department but deserved continual monitoring and rechecking of VS as a resident would not typically be sent to the hospital because of an upset stomach. MD-A's expectation was that an ambulance should be called right away immediately after the order to go to the emergency room was given.During an interview on 3/25/26 at 12:59 p.m., Administrator and DON were present. DON stated with the VS taken at 6:43 p.m., she would have expected a focused abdominal assessment completed, especially after noting there was no bowel movement in the colostomy bag and MD notification with results of the assessment. From VS taken at 9:10 p.m., RN-A should again assess R1, update MD if that had not occurred, update family, and begin transfer to emergency room process. The ambulance should have been called when the order was obtained. At 10:17 p.m., DON would have expected the ambulance to be enroute to the facility and a nurse to stay with R1 until transport complete.An email dated 3/26/26 at 12:01 p.m., identified the facility did not have a policy regarding if an ambulance required lights and sirens but the determination was made by the ambulance company when it was triaged. The facility does not have a policy on administering newly ordered medications for a change of condition.The facility Change in Condition, Resident Examination and Evaluation dated 11/10/25, identified a thorough resident examination and evaluation will capture any abnormalities in health status, physical function, or an acute change of condition. When a significant change in the residents physical, mental, or psychosocial status is identified by licensed nurse, the license nurse consults with attending provider and notified the resident/resident representative. Obtain VS and repeat as needed or ordered. Notify the provider of change in condition and implement orders for treatment and appropriate monitoring as directed. Notify the resident/resident representative. Document symptom(s), assessment, observations, resident/resident representative, and medical provider notification. Monitor and provide treatment as ordered by the attending provider.

Based on interview, and document review the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident are addressed and met 24 hours per day for 1 of 1 resident (R2) reviewed for hospice services.Findings include:R2's face sheet dated 10/31/25, identified diagnoses of heart failure (a condition where the body's heart does not pump enough blood for the body's needs), atrial fibrillation(a common heart rhythm disorder), and anxiety disorder (a mental health condition defined by excessive worry and fear).R2's admission Minimum Data Set, dated [DATE], identified R2 was dependent for all transfers, received hospice services, and was cognitively intact.R2's hospice focus care plan dated 8/14/25, identified R2 received hospice services with a goal of preferred wishes for end of life to be honored. Interventions were as follows: facility will coordinate with hospice providers and reference hospice care plan located in hospice binder; see hospice care plan for resident choices and preferences related to comfort, cognition, pain, and functional status.During an interview on 10/31/25 at 8:45 a.m., licensed practical nurse (LPN)-B stated R2's hospice binder kept in the nursing station, however, did not contain a hospice care plan, visit schedule, or any notes kept in the binder. LPN-B stated when R2's hospice nurse comes to visit R2 in the facility they do not communicate with the nursing staff to let them know what was done during the visit or if any of the care had changed and this seems to be a constant problem. During an interview on 10/31/25 at 8:51 a.m., LPN-A stated R2's hospice binder did not contain a current hospice care plan, nurse/aide visit schedule, nor any documentation of the nursing visits. LPN-A further stated this information should be located in the binder, so staff are aware of what cares is supposed to be done for any hospice resident. During an interview on 10/31/25 at 2:38 p.m., registered nurse (RN)-A stated she is the contact person for hospice agencies and had not been getting consistent communication from R2's hospice agency and she was unaware the R2's hospice binder did not contain a care plan nor a visit schedule. During an interview on 10/31/25 at 3:54 p.m., hospice registered nurse clinical manager (H-RNCM) stated, R2's hospice care plan had been sent to the facility on 8/24/25 but had not verified that it was received by the facility. Weekly/Monthly nurse/aide hospice visit schedules should have also been provided to the facility and she was unaware the facility had not been receiving this information. H-RNNM further stated that hospice staff should be completing documentation in the note section of the binder and also communicate with the nursing staff after each visit to discuss if any changes to the plan of care. During an interview on 10/31/25 at 3:36 p.m., director of nursing (DON) stated R2's hospice plan of care had not been added to the hospice binder nor the electronic health record and this should have been added to ensure that collaboration of care was done with R2's hospice. DON further stated the facility had not been getting informed consistently following visits from R2's hospice nurse.Review of the facility's Nursing Home Hospice Agreement dated 8/15/13, indicated hospice will document in the facility chart any assessments and care provided to the patient and will communicate verbally as well with each visit to facility staff the results of its visit. The facility staff will receive Hospice's 24-hour phone line number to report any needs or concerns when hospice staff are not present in the facility. Review of the facility's Hospice Policy undated, identified the community will provide collaborative care with hospice providers to ensure the resident's end of life preferences and choices are honored. The policy's procedures were as followed: -There is a designate a member of the community's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the community associates and hospice staff; The designated interdisciplinary team member is responsible for: -collaborating with the hospice representatives and coordinating community associate's participation in the hospice care planning process for those residents receiving these services. -Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family.- Ensuring that the community communicates with the hospice medical director, theresident's attending provider, and other practitioners participating in the provision of care.to the resident as needed to coordinate the hospice care with the medical care provided byother physicians. Obtain the following information from hospice:i. The most recent hospice plan of careii. Hospice election formiii. Physician certification and recertification of the terminal illness specific to eachresidentiv. Names and contact information for hospice personnel involved in hospice care ofeach residentv. Emergency instructions on how to access hospice's 24-hour on-call system.vi. Hospice medications information specific to each residentvii. Hospice physician and attending physician (if any) orders specific to each resident.viii. Ensure that the community associates provide orientation in the policies andprocedures of the community, including resident rights, appropriate forms, andrecord keeping requirements, to hospice staff furnishing care to the residents. -The resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the community to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required.

Based on observation, interview and document review, the facility failed to ensure proper food temperatures and provide attractive food in order to ensure palatability for 15 of 15 residents (R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, R78, and R90) reviewed for concerns of cold food. In addition, the facility failed to provide palatable food for 4 of 4 residents (R22, R25, R47 and R78) reviewed for dining. This had the potential to affect all residents who ate food provided by the facility. Finding include: R2's significant change in status Minimum Data Set Assessment (MDS) dated [DATE], indicated severe cognitive impairment. R25's quarterly MDS dated [DATE], indicated severe cognitive impairment. R26's quarterly MDS dated [DATE], indicated cognitively intact. R29's quarterly MDS dated [DATE], indicated cognitively intact. R45's comprehensive MDS dated [DATE], indicated cognitively intact. R52's comprehensive MDS dated [DATE], indicated cognitively intact. R55's quarterly MDS dated [DATE], indicated severe cognitive impairment. R61's quarterly MDS dated [DATE], indicated cognitively intact. R63's quarterly MDS dated [DATE], indicated severe impairment. R64's quarterly MDS dated [DATE], indicated cognitively intact. R69's quarterly MDS dated [DATE], indicated cognitively intact. R74's admission MDS dated [DATE], indicated cognitively intact. R75's annual MDS dated [DATE], indicated cognitively intact. R78's quarterly MDS dated [DATE], indicated severe impairment. R90’s admission MDS dated [DATE], indicated cognitively intact. During interview on 7/21/25 at 3:17 p.m., R26 stated he was part of the facility food committee. R26 further stated residents made several suggestions for food improvement and staff did not do anything about it. R26 stated food had no flavor, was cold and sometimes even frozen. During interview and observation on 7/21/25 at 6:23 p.m., R26 had a plate with sweet potato fries on his table in his room. R26 picked up a sweet potato fry and demonstrated it was weak and limp by showing how it fell apart in his fingers. R26 stated the sweet potato fries were cold when served to him and he was not going to eat them. R26 stated food was cold all the time and he did not eat most of it. On 7/21/25 at 3:45 p.m., R90 stated she ate her meals in her room per her preference and consistently received cold food. R90 reported that the macaroni and cheese was repeatedly delivered cold and was not enjoyable. On 7/21/25 at 5:08 p.m., dietary aide (DA)-A removed food from a thermal cart in the Kindle Wing and placed items in the steamer. DA-A took the temperature of the sweet potato fries, at 138 degrees Fahrenheit (F), and the grilled ham and cheese sandwiches, at 140 degrees. DA-A stated the sweet potato fries and sandwiches would be returned to the kitchen for reheating since the food was under 145 degrees. On 7/21/25 at 5:17 p.m., culinary supervisor (CS)-D stated that staff took food temperatures before leaving the kitchen and stated that some foods were known not to hold temperature well. On 7/21/25 at 5:24 p.m., DA-A returned to the Kindle Unit with a thermal cart and removed the reheated sweet potato fries and grilled ham and cheese sandwiches. DA-A took the temperature of the fries, which registered 151°F, and the sandwiches, which registered 173°F. DA-A plated and served the residents in the Kindle dining room. On 7/21/25 at 5:40 p.m., R90’s meal tray was plated and was delivered to her room and meal included tomato soup, a grilled ham and cheese sandwich, sweet potato fries, and coleslaw. R90 stated that the fries were not warm and were cold and would not eat the fries because they were cold. On 7/21/25 At 5:44 p.m., a resident meal tray meal tray containing sweet potato fries and a grilled ham and cheese sandwich was prepared for delivery to a resident. CS-D removed a fry from the plate and stated it did not feel warm. CS-D took the temperature of the fries, which measured 107°F, and confirmed the fries were not warm. CS-D stated that sweet potato fries were a difficult food item to keep warm. On 7/23/25 at 11:12 a.m., during a resident council group interview, 14residents (R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, and R78) consistently reported receiving cold food, food that did not match the menu, and food that lacked taste and appeal. R26 stated the group had discussed food concerns for six months during council meetings and had not seen any results. R64 described the food as “awful.” R63 stated the menu listed “chicken and dumplings,” but the facility served chicken without dumplings. R26, R61, and R64 stated that the grilled ham and cheese sandwiches served on 7/21/25 were so hard they could not be eaten, and the cake served on 7/22/25 was frozen. The residents expressed frustration that they often had to request alternative meals because the food they originally received was either cold or incorrect and agreed it would be preferable to receive the correct, warm food on the first attempt. The residents stated that staff acknowledged their complaints with comments such as “you’re right, the food is cold,” and were stated education to the staff would be provided, residents stated no improvement had occurred. On 7/23/25 at 2:36 p.m., social services (SS)-A confirmed that residents routinely voiced food concerns during resident council meetings. SS-A stated the resident's complaints were documented on a spreadsheet and forwarded the food concerns to the culinary director. SS-A confirmed that management was aware of the issues but stated the facility lacked the bandwidth. SS-A reported that the facility had formed a Dining Experience Committee to address ongoing complaints, but no measurable improvements or data had been observed. Resident concern report form provided on 7/22/25, indicated the following: 7/16/25, R2 stated the country fried steak was burnt and tough to eat. 6/28/25, R9, R25, R26, R29, R48, R63, R64, and R74, food was undercooked, served cold, and not what was ordered. Food served late. FOOD TEMPERATURE LOG During observation and interview on 7/23/25 at 11:30 a.m., DA-B was observed taking temperatures of chicken, potatoes, vegetables, gravy, and rice as they were pulled from a standing warmer in the kitchen. [NAME] (C)-A was observed writing down temperatures on a document titled Food Temperature Log. Review of the log showed no documented cooking temperatures for the above foods. DA-B and C-A stated they did not know if there was a formal procedure for taking temperatures of foods, they sometimes temped food when it came out of the oven, sometimes when it came out of the warmer, and sometimes both. C-B stated it should be temped when it comes out of the oven to ensure proper safe cooking temperatures. During interview on 7/23/25 at 11:33 a.m., CS-D stated DA-B and C-A should have taken the temperature of the food when it came out of the oven, rather than when it came out of the warmer. CS-D stated she was new to the facility and not sure on a formal procedure for food temperatures. During interview on 7/23/25 at 11:35 a.m., culinary services director (CS)-F stated staff should take food temperatures when the food comes out of the oven, and that temperature should be logged on the Food Temperature Log. CS-F further stated he could not say for sure that the staff knew the process and the staff could use some education on proper procedure for food temping. CS-F further stated there had been a lot of food concerns related to timing of meals, appearance of food, and temperatures of food. CS-F stated they started a food committee and audits to work on problems but confirmed little improvement since April. CS-F stated the sandwiches served on 7/21/25, were not up to expectations, did not appear appetizing, and the menu should have been followed. CS-F further stated he was not aware of any formal culinary education but had been completing as-needed education with dietary staff. During interview on 7/24/25 at 9:45 a.m., administrator stated there had been a lot of food concerns. Administrator further stated they had been working on timing of meals and temperature of food. Administrator stated there had been concerns with presentation and appearance of food and they were aware through the dining experience meetings. Administrator agreed sandwiches on 7/21/25, were not appetizing or made as directed by the recipe. Administrator further stated education was provided to culinary staff on 7/21/25. During interview on 7/24/25 at 1:29 p.m., facility dietician stated she was not aware of the food concerns at the facility and her role was more clinical. Dietician further stated she would expect the recipes to be followed and was not aware culinary staff were not following provided recipes. Dietician stated she would expect staff to cook foods to proper temperatures and document the cooking temperatures, rather than the holding temperatures. Dietician reviewed the facility provided Food Temperature Log for 7/25, and stated the form needed to be updated for ease of understanding and accurate temperatures for food safety. Review of facility documents titled Meeting minutes for dining experience committee dated 2/6/25 through 6/25/25, indicated ongoing problems with food concerns. Notes from meetings included the following: 2/6/25: concerns with food temperature, consistency of times of food service, soggy food, and overcooked desserts. 4/17/25: concerns with food temperature, potatoes not cooked through 3 times, poor food quality, approval requested and received for a pizza oven, pot pies not cooked through, and lack of consistent serving times. 5/28/25: room trays with cold food, late delivery of meals, melted ice cream on trays, serving time consistency. 6/25/25: quality of ham and cheese sandwiches, some are rock hard and some are not cooked, fries not getting crispy, serving time consistency. During observation of facility dining experience committee meeting on 7/23/25 at 10:00 a.m., concerns included food temperature, consistency of serving times, soggy foods, appearance of food, and lack of pizza oven being ordered although it had been approved in April 2025. Review of facility training documents printed 7/24/25, indicated culinary staff were trained in two online courses: Culinary 4U Course and Dining, Nutrition, and Food Safety for New Hires. PALATABLE FOOD R22's quarterly MDS assessment dated [DATE], indicated cognitively intact. R25's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition. R47's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment. R78's quarterly MDS assessment dated [DATE], indicated a BIMS (brief interview for mental status) score of 00 (as a result of declining the assessment). The dinner menu for 7/21/25, indicated grilled ham and American cheese sandwiches. During meal service observation on 7/21/25 at 5:07 p.m., DA-C brought food from the main kitchen to the kitchenette on the Dawn Unit via a small thermal cart on wheels. During an observation and interview on 7/21/25 at 5:36 p.m., CSA-C removed whole sandwiches from the thermal cart and plated them. Nursing assistants (NA) delivered the plates to residents seated in the dining room. During an observation and interview on 7/21/25 at 5:42 p.m., R22 stated, Look at this – the ham is paper thin as he removed the top slice of bread from his sandwich to view the inside. On the bread were two very thinly sliced pieces of deli ham on top of either butter or a pale-yellow cheese spread. No slice of cheese was visible on the sandwich. R25 spoke up and stated the same thing. In addition, the sandwiches had not been grilled nor where they golden brown in color. CSD-F was asked to look at the sandwiches that both R22 and R25 received. CSD-F was asked if that was the way the sandwiches were supposed to have been made. Culinary Services Director (CSD)-F stated there should have been a slice of cheese on the sandwich. CSD-F stated there were recipes for each of the meals served to residents and he would look to see how the sandwiches were supposed to have been made. At 5:50 p.m., while seated at a dining table, R47 stated his sandwich was, Skimpy with the meat. During an observation and interview on 7/21/25 at 5:55 p.m., licensed practical nurse (LPN)-B walked into the dining area from a resident's room with a tray of untouched food. R78 told her the sandwich was not acceptable and to take it back to the kitchen. During an interview on 7/21/25 at 6:04 p.m., CSD-F presented the weekly menu which indicated residents were supposed to have received ham and American cheese grilled sandwiches. CSD-F stated the sandwiches should have had a slice of cheese on them and should have been grilled. CSD-F provided the paper recipe for the sandwiches which indicated: place one slice of cheese and two ounces of ham between two slices of bread. Brush sandwiches with butter. [NAME] sandwiches on a flat top on both sides until golden brown and the cheese melts. During an observation and interview on 7/21/25 at 6:42 p.m., together with the administrator and CSD-F, looked at R78's sandwich that he did not eat, along with the weekly menu and recipe for the sandwiches. The administrator stated, the sandwiches did not look like they were grilled and admitted the cheese and ham were very small portions. The administrator stated she would also have expected the sandwiches to be cut in half for the residents. During an interview on 7/23/25 at 7:37 a.m., R78 stated the ham and cheese sandwich served to him for dinner on 7/21/25, was not grilled, barely had any meat, and the cheese looked like the kind you would get at a gas station machine. During an interview on 7/23/25 at 8:01 a.m., CSD-F stated one cook made the sandwiches on 7/21/25, and another cook baked them rather than grilling them on the flat top. This cook told CSD-F that he did not have time to grill them on the flat top. CSD-F stated he reviewed with both cooks how the sandwiches should have been made. Facility Food Production Methods and Standards policy dated 2012, indicated the following: Foods will be prepared to meet the individual nutritional and therapeutic needs of the residents. Foods will be prepared in a manner to retain nutritive value, enhance flavor and appearance and promote food consumption. The Culinary Services Director is responsible for directing the Culinary Services personnel in proper food preparation and monitoring the food preparation process to promote the highest quality food production and service. The Culinary Services Director is responsible for proper food preparation which includes the following: following the written menu, food preparation according to the standardized recipes in sufficient quantities using correct methods, tasting all foods prior to service, assuring foods are of appropriate quality, food temperature appropriateness at cooking, holding, and service, monitoring for high standards of food preparation in flavor, appearance, and nutrition. Facility Food Production Methods and Standards policy dated 2012, indicated the following: Foods will be prepared to meet the individual nutritional and therapeutic needs of the residents. Foods will be prepared in a manner to retain nutritive value, enhance flavor and appearance and promote food consumption. The Culinary Services Director is responsible for directing the Culinary Services personnel in proper food preparation and monitoring the food preparation process to promote the highest quality food production and service. The Culinary Services Director is responsible for proper food preparation which includes the following: following the written menu, food preparation according to the standardized recipes in sufficient quantities using correct methods, tasting all foods prior to service, assuring foods are of appropriate quality, food temperature appropriateness at cooking, holding, and service, monitoring for high standards of food preparation in flavor, appearance, and nutrition.

Based on observation and interview, the facility failed to ensure care was provided in a dignified manner for 1 of 2 residents (R24) reviewed for dignity, when the resident was left in bed, unclothed. Findings include:R24's face sheet provided on 7/24/25, included diagnoses of hemiplegia (weakness or partial paralysis on one side of the body) following a stroke.R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had moderately impaired cognition, clear speech, could understand and be understood. R24 required partial or substantial assistance with activities of daily living and did not walk. R24's physician order dated 7/3/24, indicated to apply barrier cream to penis and scrotum daily, 6:30 a.m. - 11:00 a.m.R24's care plan with revised date of 7/10/25, indicated R24 needed assistance with dressing, personal hygiene, and bathing due to decline in mobility related to but not limited to hemiplegia.During an interview on 7/21/25 at 3:52 p.m., R24 stated that morning an agency nursing assistant (NA) got him up to dress. R24 stated he didn't know the name of the NA and she wasn't wearing a name tag. R24 stated that was the first time he had seen her, and she didn't seem to know what to do. R24 stated he had a very detailed morning routine where a NA dressed him halfway, then a nurse came in and put cream on his skin, then the NA returned to finish dressing him. That morning, R24 stated the NA came into his room and started cleaning him up. Then the NA informed R24 he had better find someone else to do the job and left the room. R24 stated there had been another NA across the room with his roommate so he called out and asked her if someone else could finish with him. R24 stated, I didn't like it - I don't know where they got her from - she didn't know anything.The director of nursing (DON) was asked on 7/22/25 at 4:27 p.m., who had been assigned to care for R24 and his roommate the morning of 7/21/25. The DON indicated NA-D had been assigned to R24, and NA-E had been assigned to his roommate. During an interview on 7/23/25 at 11:13 a.m., NA-E recalled the events of 7/21/25, when she was working with R24's roommate. NA-E stated NA-D was a brand-new NA with no prior experience who was afraid to do anything with residents. NA-E stated R24 had called out to her to come to his side of the room. Immediately NA-E observed R24 in bed with his shorts down and his brief open with his genitals exposed. NA-E stated she covered R24 right away and finished his cares and reported the incident to the licensed practical nurse (LPN)-C on duty. NA-E stated she did not know where NA-D went when she left R24's room. Neither LPN-C nor NA-D were available for interview.During an interview on 7/23/25 at 12:20 p.m., registered nurse (RN)-C who was also the clinical manager for the unit on which R24 resided, stated she was unaware of the situation that occurred on 7/21/25, with R24 and NA-D. During an interview on 7/24/25 at 12:00 p.m., the DON stated she learned of the 7/21/25, incident with R24 from her staff on 7/23/25. The DON stated she was informed NA-D had left R24 in his bed with his brief open, door open, curtain open and window blinds open. The DON stated she was informed that NA-E covered R24 and reported it to LPN-C who did not report it to nursing leadership, telling the DON he didn't think of it. The DON stated LPN-C was removed from the schedule pending investigation and in addition, the DON had not been able to reach NA-D for interview. The DON stated the incident was reported to the State Agency on 7/23/25. The DON stated she would have expected LPN-C to report the incident to a nurse leader right away. The DON stated licensed staff had training on reporting incidents involving concerns of resident dignity. The DON stated NA-D was a new employee who had completed orientation the week prior. The DON stated she was aware of training concerns and registered nurse (RN)-B, who was also the staff development nurse, had talked to NA-D on 7/16/25, about adding more orientation days. NA-D's new hire competency checklist was reviewed which indicated NA-D had received training on values including respect - acknowledges resident dignity in carrying out duties dated 7/16/25. NA-D had received training on personal care on7/16/25, and perineal care on 7/17/25.Facility Resident Rights and Notification of Resident Rights policy with revised date of 1/16/24, indicated the purpose was to provide for prompt notification of resident rights. The facility acted to protect and ensure the rights of residents.

Based on observation and interviews the facility failed to provide a method for residents and resident representatives to submit grievances anonymously. In addition the facility failed to follow their grievance process for missing/damaged personal property for 1 of 1 resident (R69) who reported a missing item. This had the potential to prevent all 72 residents in the facility.Findings include: On 7/23/25 at 11:20 a.m., during resident council R2, R25, R26, R29, R45, R52, R55, R61, R63, R64, R69, R74, R75, R78 each stated that they were unaware of any method to submit concerns anonymously and stated that no anonymous grievance process had been made known to them. On 7/23/25 at 3:00 p.m., during a facility tour, social services (SS)-A confirmed there was no grievance box or any other designated area for anonymous grievance submission accessible to residents available in resident accessible locations. Further, no signage or posted information indicated an option for submitting concerns confidentially or anonymously. On 7/24/25 at 11:58 a.m., the administrator confirmed the facility did not currently have a grievance box and stated residents could place the concern form under the door of SS-A. During a tour of the Dawn Wing, an acrylic wall mount containing a binder with concern forms was observed high on the wall. The administrator acknowledged that the location of the binder would be difficult for residents to reach independently. Facility Policy titled Concerns, Grievances dated 6/29/22, indicated: Purpose: To create an environment where resident and customer concerns are solicited and readily resolved. Policy: I. A resident/customer/resident representative has the right to voice grievances and concerns without discrimination or reprisal and without fear of discrimination or reprisal. II. The term “voice concerns” is not limited to a formal, written grievance process, but may include a resident’s verbalized concerns to staff. Concerns and grievances can be made anonymously. III. The community views customer concerns as a primary method to learn of and meet customer expectations. In keeping with this belief, staff is trained to obtain and respond to resident/resident representative customer concerns. When a resident, resident representative, visitor or family member voices a concern to a staff member, the staff member completes a concern form and forwards the form to the Social Services department/Grievance Officer /designee in a confidential container. II. Completed forms are processed in a timely manner a. The social worker/grievance officer /designee checks the confidential container daily; removes the completed forms, logs the concern, and routes the copy to the staff responsible to acknowledge, investigate, and resolve the concern. MISSING ITEM R69’s face sheet printed 7/24/25, indicated diagnoses of chronic pain, restless leg syndrome, muscle weakness, and type two diabetes mellitus. R69’s care plan revised 7/10/25, indicated R69 enjoyed being busy and needed invitations and escorts to activities of interest. R69’s goal was to express satisfaction with daily routine and leisure activities. R69’s quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition and no behaviors or rejection of care. During interview on 7/21/25 at 4:12 p.m., R69 stated she had been missing a windchime with cats on it. R69 further stated it had gone missing when she moved from one neighborhood to another neighborhood within the facility back in December 2024. R69 stated activity assistant (AA)-A helped her move and knew about the missing item. During interview on 7/23/25 at 11:02 a.m., AA-A stated she clearly remembered helping R69 move to her new room and reporting R69’s missing windchime to her supervisor. AA-A further stated she put the windchime in R69’s nightstand for the weekend and when she came back the next week, it was gone. R69 stated she did not know if the facility had a form to fill out for missing items or if there was a grievance form, and she thought when she told her supervisor it would be taken care of by management. During interview on 7/23/25 at 11:15 a.m., wellness director stated she did not recall being told about missing items by AA-A, but recalled being told about some of R69’s broken figurines, which also occurred during the move to the new neighborhood. Wellness director stated she told social services (SS)-A about the broken items but did not follow-up with him to see if an investigation was started and had not heard any more about it since then. During interview on 7/23/25 at 11:22 a.m., SS-A stated he did not know anything about R69’s missing or damaged items. During interview on 7/23/25 at 11:45 a.m., administrator stated wellness director must have forgotten to tell SS-A about the missing items, therefore the concern was not handled. Administrator further stated the missing and damaged items should have been reported to SS-A, a customer concern filled out, and an investigation into the missing and damaged items completed. Administrator stated the facility would speak to R69 about it today. Facility Missing Items policy dated 4/2012, directed; All personnel are responsible for reporting missing items to supervisor staff prior to the end of their shift. Staff works to locate the missing items. If missing item is not located within a 4-hour window, a customer concern is initiated.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R26) reviewed for mood and behaviors, specifically post traumatic stress disorder (PTSD). Findings include: R26's face sheet printed 7/24/25, indicated diagnoses of major depressive disorder and post traumatic stress disorder.R26's care plan revised 7/10/25, indicated the potential for trauma responses related to military service in Vietnam, as evidenced by anxiety around fireworks and being around other people. Interventions included ensuring clear paths to doors if resident was in a room with multiple people and honoring wishes regarding position of entry door.R26's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors, and lacked a diagnosis for post traumatic stress disorder.During observation on 7/23/25 at 10:00 a.m., R26 was observed entering chapel A for a dietary meeting. Activity Assistant (AA)-A directed R26 to sit near the door to ensure an escape route based on his care plan interventions.During interview on 7/24/25 at 11:08 a.m., registered nurse (RN)-D, also identified as clinical reimbursement manager, confirmed R26 had an active problem in the last 60 day visit note from the provider. RN-D indicated it had to be on the most current provider note or it doesn't get marked on the MDS. RN-D further stated there was a care plan with active interventions in place for R26. During interview on 7/24/25 at 12:45 p.m., administrator stated she thought they had worked with the clinical team last year to make sure only documented active cases of post traumatic stress disorder were marked on the MDS and she would have to look at that again.Facility Comprehensive Assessments and Care Planning policy dated 8/2019, directed: The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

Based on observation, interview and document review, the facility failed to ensure that medications were administered in accordance with accepted professional standards and failed to disinfect the rubber septum of an insulin pen with an alcohol wipe prior to attaching the needle and administering insulin for 1 of 1 resident (R87) observed during insulin administration. Findings include: R87's face sheet printed 7/24/25, indicated R87 was admitted on [DATE], and diagnosis included type 2 diabetes.R87's care plan dated 7/22/25, indicated alteration in nutrition/hydration related to diabetes and obesity and medications reviewed quarterly and prn (as needed). R87's medication administration history dated 7/1/25-7/24/25, indicated Novolog Flex Pen U-100 Insulin; insulin pen; per sliding scale.On 7/22/25 at 12:30 p.m., licensed practical nurse (LPN)-A was observed preparing to administer a subcutaneous insulin injection to R87 using a prefilled insulin pen. LPN-A removed the pen cap and immediately attached the needle without disinfecting the rubber septum with an alcohol wipe. LPN-A then proceeded to prime the pen and inject the insulin into R87's abdomen.On 7/22/25 at 12:33 p.m., LPN-A confirmed the insulin pen was the same pen R87 used each day and confirmed the rubber top of the pen was expected wiped with alcohol prior to attaching the needle and administering insulin.On 7/23/25 at 3:33 p.m., the director of nursing (DON) confirmed the rubber septum of an insulin pen is to be disinfected with an alcohol wipe prior to attaching a new needle and administering each dose.Facility Safe Injection Practice dated 9/23, indicated:Purpose: Injection safety, or safe injection practices, is a set of measures taken to perform injections in an optimally safe manner for the residents and healthcare associates.Policy: It is the policy. to educate and ensure compliance of associates in regards to safe injection practices.Disinfect the rubber stopper of medication vials and the neck of glass ampules with sterile 70% alcohol before inserting a needle or breaking the ampule.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R54) brief was changed according to his care plan, and who was reviewed for activities of daily living (ADLs).Findings include:R54's face sheet provided on 7/24/25, included diagnoses of dementia and Alzheimer's disease. R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had moderately impaired cognition, clear speech, could understand and be understood. R54 was always incontinent of bowel and bladder and was dependent upon staff for toileting. R54 did not walk. R54's care plan with edited date of 7/10/25, indicated R54 had urinary incontinence. Care plan approach with edited date of 6/2/25, indicated R54 was on a toileting plan; to check and change brief with AM (morning) and HS (evening), before and after meals and activities and per resident or family request and PRN (as needed). Every Shift: Day 06:00 AM - 02:00 PM, Evening 02:00 PM - 10:30 PM, Night 10:30 PM - 06:00 AM. Care plan dated 4/7/25, indicated camera in use, R54's family had installed a camera in his room. Care plan dated 6/27/25, indicated R54 had impaired bed mobility and required assistance with turning and repositioning related to decreased strength, decreased endurance, impaired range of motion, and cognitive deficit.R54's care sheet (a paper document used by nursing assistants (NA's) to provide them with brief and specific information about residents) undated, indicated to check and change R54's brief with AM and HS cares, before and after meals and activities, per resident or family request and PRN.Documentation of a facility grievance dated 7/5/25, indicated family member (FM)-B expressed concern about R54 being left in wet briefs for extended periods of time. Registered nurse (RN)-E who was also the clinical manager, was assigned to the grievance. Resolution indicated R54 wore high absorbency briefs and was not on a routine toileting schedule. Grievance also indicated a discussion was held with FM-B regarding toileting preferences and R54's care plan was updated to reflect wishes. During an interview on 7/22/25 at 12:51 p.m., FM-B and FM-C both expressed concern about R54 being left in wet briefs for long periods of time. They were aware of this because they placed a Ring camera in R54's room, which the facility was aware of, and FM-B and FM-C monitored. FM-B and FM-C provided documentation of dates and times R54's briefs were changed from 6/29/25, to 7/4/25. The data was obtained from watching the Ring camera in R54's room. FM-B stated she also filed a grievance but did not hear back from anyone. Ring camera footage according to FM-B and FM-C indicated: 6/29/25: R54's brief was changed seven times. Longest period between changes was 5.5 hours. This occurred twice. 6/30/25: R54's brief was changed five times. The longest period between changes was seven hours and 45 minutes. 7/1/25: R54's brief was changed six times. The longest period between one change and 5.5 hours between another. 7/2/25: R54's brief was changed seven times. The longest period between changes was four hours and 15 minutes. 7/3/25: R54's brief was changed four times. The longest period between changes was eight + hours. 7/4/25: R54's brief was changed seven times. The longest period between changes was four hours. During an interview and observation on 7/24/25 at 11:34 a.m., in R54's room, nursing assistant (NA)-C stated R54's brief should be changed every two or three hours and documented on a clipboard located on the wall in R54's room. The form on the clipboard was titled Toileting Schedule. It had 14 columns for dates and 24 rows for times from 7:00 a.m., to 6:00 a.m. The form indicated R54 was to be toileted every 2-3 hours and PRN. The form had many missing entries and was only initialed by staff 25 times. There was no consistency to documenting when R54 had been checked and/or changed. The form also indicated R54 had not been checked and changed every 2-3 hours. The first date on the form was 6/21 with the following dates after that: 6/23, 7/1, 7/10, 7/15, 7/17, 7/24. NA-C stated she could only speak to when she changed R54 and that was every two to three hours. NA-C stated the clipboard was the only place she documented changing R54's brief. At the bottom of the form in small print was: Continue to add BMs (bowel movement) in POC (Point of Care was where NA's documented in the electronic medical record [EMR]).During an interview on 7/24/25 at 12:26 p.m., RN-E was aware of the grievance filed by FM-B about R54 being left in wet briefs for long periods. RN-E stated R54 should be checked and changed roughly every two to three hours - as listed on his care plan. RN-E was asked to provide documentation R54 was being checked and changed at those time intervals. RN-E was also asked to provide documentation that RN-E followed up with FM-B regarding her grievance dated 7/7/25. RN-E was not able to provide documentation for either.During an interview on 7/23/25, at 6:04 p.m., FM-B and FM-C stated emails had been sent to RN-E regarding their concerns about R54 being left wet for extended periods of time and they had shown some of the Ring camera footage to the director of nursing (DON), as well as provided them dates and times R54's brief was changed according to Ring camera footage. Despite this communication FM-B and FM-C stated nothing had improved. During an interview on 7/24/25 at 12:49 p.m., with the DON and RN-E, again asked for documentation that R54's brief was being changed according to his care plan. They were shown the form from the clipboard in R54's room indicating when R54's brief was changed with many blank spaces. The DON was not aware of the form and had not seen it before. The DON stated R54's brief should be changed according to his care plan and would expect NAs to document this in the EMR. The DON acknowledged there was no documentation and therefore could not verify R54's briefs were being changed according to his care plan and the wishes of FM-B. In addition, RN-E again stated she was not able to provide documentation confirming she had spoken to FM-B regarding her grievance of R54 being left wet for extended periods of time. The DON stated she would expect staff to follow-up on family concerns and to document those conversations.During an interview on 7/24/25, at 3:04 p.m., RN-E stated she had found the Toileting Schedule form used in R54's room in a file cabinet in her office and had implemented it as a way for NAs to document real-time when R54's brief was changed. RN-E admitted the form had not been used as she had intended, and she had not audited the form to see if staff had been documenting the date/time when R54 had been checked and changed.Facility Activity of Daily Living policy dated 6/2021, indicated residents would be provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility. Care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination (toileting).

Based on observation, interview and document review, the facility failed to implement a process to ensure that the resident received their scheduled insulin dose while out of the facility for 1 of 1 resident (R90) reviewed for medication administration.Findings include:R90's admission Minimum Data Set Assessment (MDS) assessment dated [DATE], indicated R90 was admitted [DATE], cognitively intact, required supervision with personal hygiene, sit to stand, toilet transfer, utilized a walker and wheelchair, diagnoses included: diabetes, seizure disorder and anxiety.R90's care plan dated 7/24/25, indicated R90 receives an insulin that places them at risk as a high risk medication, monitor for signs and symptoms of hyperglycemia and hypoglycemia; visual impairment related to cataracts as evidenced by difficulty reading fine print writing, legally blind in my left eye, provide large print reading materials or talking books as needed; alteration in nutrition/hydration related to DM (diabetes mellites), anxiety, pain, diet as ordered, encourage consistent meal intakes, avoid skipping meals and high concentrated sweetsR90's Medication Administration Record (MAR) dated 7/1/25-7/23/25, indicatedaccu check four times a day 8:00 a.m., 12:00 p.m., 5:00 p.m., 8:00 p.m.insulin aspart U-100 insulin pen; 100 unit/mL (milliliter) 8 units; subcutaneous three times a day; 8:00 a.m., 12:00 p.m., and 5:00 p.m.,insulin aspart U-100 insulin pen subcutaneous three times a day 8:00 a.m., 12:00 p.m., and 5:00 p.m., Amount to Administer: Per Sliding Scale:If Blood Sugar is 140 to 179, give 2 Units.If Blood Sugar is 180 to 219, give 4 Units.If Blood Sugar is 220 to 259, give 6 Units.If Blood Sugar is 260 to 299, give 8 Units.If Blood Sugar is 300 to 339, give 10 Units.If Blood Sugar is 340 to 379, give 12 Units.If Blood Sugar is 380 to 399, give 13 Units.If Blood Sugar is greater than 400, call MD.R90's MAR documentation indicated, 7/22/25 at 12:00 p.m., LPN-A indicated Blood sugar 2027/22/25 at 12:44 p.m., insulin pen; 100 units, administer 8 units; subcutaneous; LPN-A documented comment indicated: not administered: resident left for home, no insulin given.7/22/25 at 12:44 p.m., insulin pen; 100-unit amount to administer: Per Sliding; LPN-A documented comment indicated: not administered: resident left for home, no insulin given.Review of R90's progress notes and nursing documentation failed to indicate that an alternative plan was in place for administration while R90 was out of the facility.On 7/22/25 at 12:21 p.m., R90's family member presented to the facility and informed LPN-A R90 would be leaving the facility for awhile and would return later. LPN-A was observed to check R90's blood sugar and was 202. LPN-A informed R90, she was not going to administer the insulin due to her not eating and leaving the facility. LPN-A instructed R90 to take insulin when she was at home and ate, R90 stated she was not going to take insulin at home, and LPN-A stated, your blood sugar is kind of high. R90 was observed to leave her room in a wheelchair with FM-A.On 7/22/25 at 12:38 p.m., LPN-A stated R90 had been a diabetic for a long time and would expect her to know her insulin sliding scale, expect her to have insulin at home and would assume she would know the amount and how to administer the insulin. LPN-A further stated she did not know for sure if R90 knew her insulin dose or if she had insulin at home and confirmed R90 was not asked that information. LPN-A stated R90 had been diabetic for so long R90 knew what to do.On 7/23/25 at 7:43 a.m., registered nurse (RN)-A, known as the case manager, stated the facility process for when a resident was out of the facility and had insulin administration was to send the insulin pen, copy of orders, and ensure the resident and/or family were educated prior to the resident leaving the facility.On 7/23/25 at 10:37 a.m., R90 stated when she left the faciity on 7/22/25, with FM-A she did not take any insulin as she did not know the dose she was currently getting at the facility, R90 stated her dose has changed since admitted to the facility and did not eat until returning the facility.On 7/23/25 at 3:33 p.m., the director of nursing (DON) confirmed R90 would not be expected to administer insulin that she had at home, stated would expect the nurse to send the medication, copy of the orders, insulin pen, needle and alcohol and educate resident and family of the medication orders prior to leaving the facility. Facility Out-On-Pass Medications/Leave of Absence policy dated 12/17, indicated:The charge nurse on duty assures that residents have their necessary medications before leaving the facility on pass or therapeutic leave of absence.ProceduresA. When receiving a physician's order for a resident to go out on pass, the charge nurse on duty reviews the resident's medication orders and directions for use with the physician and determines if pass medications are needed. It may be possible to alter administration times to eliminate the need for leave of absence medications if the resident's physician concurs and gives an order to do so. The physician's order should list the medications to be dispensed for the leave of absence, including controlled substances.B. The nurse should determine the total number of doses of each medication that will be needed based on the length of the leave of absence before notifying the pharmacy.D. All medications provided to the resident and/or responsible party for administration while on pass are properly labeled by the pharmacy with full directions for use. At least twenty-four hours notice is given to the provider pharmacy so that the medications can be prepared, if the need is known in advance. If an entire medication container is to be taken on pass, the resident or responsible party must sign out for it on a record of medication release/receiptF. Current medication orders and directions for use are reviewed with the resident or responsible party before the resident leaves the facility. If there is a question about the medication that the charge nurse is unable to answer, the provider pharmacy is called for the information before releasing the medication.H. The leave of absence medication( s) taken by the resident are recorded on the resident's current medication administration record (MAR or eMAR. Doses are not documented on the MAR or eMAR unless the nurse administers the medication. However, the licensed nurse on duty at the time the resident returns to the facility may enter, in the nurse's notes, a summary of the resident's or responsible party's report of compliance with the dosage instructions. (Example: 5/17/2011, 7 :00 p.m., [NAME], daughter of Mrs. [NAME] states that resident took digoxin, as directed, each morning. (signed) M. [NAME], R.N.)I. A circled initial is placed on the MAR or eMAR for each dose of regularly scheduled medications that would normally have been administered by the facility while a resident is out on pass. The reason for the circled initial (for example, out on pass with meds) is explained in the nursing comments section of the MAR or eMAR.J. Medications may be self-administered by residents participating in facility-sponsored activities away from the building under the following conditions: A self-administration order was given by the resident's physician.

Based on observation, interview and document review the facility failed to ensure an insulin pen included resident name and dated when opened for 1 of 1 resident (R87) reviewed for medication administration. Findings include: R87's face sheet printed 7/24/25 indicated R87 was admitted on [DATE], and diagnosis included type 2 diabetes.R87's care plan dated 7/22/25, indicated alteration in nutrition/hydration related to diabetes and obesity and medications reviewed quarterly and prn (as needed). R87's medication administration history dated 7/1/25-7/24/25, indicated Novolog Flex Pen U-100 Insulin; insulin pen; per sliding scale three times a day before meals and Toujeo Solostar; 50 units; subcutaneous at bedtime.On 7/22/25 at 12:30 p.m., during observation of medication administration, licensed practical nurse (LPN)-A was observed entering R87's room and unlocking the medication cabinet. LPN-A removed a NovoLog FlexPen insulin pen from the cabinet, attached a needle, primed the pen with two units, dialed to nine units, and administered the insulin to R87's lower abdomen. The NovoLog insulin pen in use had a manufacturer label that included an E-Kit sticker and a blank space for the resident name, which had not been filled in. Additionally, there was no date written on the pen to indicate when it had been opened. LPN-A confirmed during the observation that the insulin pen had been removed from the facility's emergency kit (E-Kit) and acknowledged that the resident name and date opened should have been documented on the pen label, but were not. Further inspection of the medication cabinet revealed a second insulin pen (Toujeo Solostar) that also lacked documentation of the date it was opened. The pen was labeled with the resident's name but did not include date opened information. LPN-A stated insulin pens were expected labeled with both the resident's name and the date the medication was opened.On 7/23/25 at 7:43 a.m., registered nurse (RN)-C, case manager, stated insulin pens were expected labeled with resident identifiers including name and were also expected labeled with open date.On 7/23/25 at 3:33 p.m., director of nursing (DON) stated when a insulin pen was removed from the E-kit the nurse was expected to label the pen with resident name and open date.Facility Safe Injection Practice policy dated 9/23, indicatedInsulin Pens:1. Provide training and oversight on the use of insulin pens to assure competency and use ofproper infection prevention practices.2. Dedicate insulin pens for use with only one resident.3. Do not use unassigned or unlabeled insulin pens.4. Affix resident label directly to the insulin pen.5. Label the pen only, not the outer bag, which could contain an incorrect pen

Based on observation, interview, and document review, the facility failed to ensure appropriate treatment and services for a Foley catheter for 1 of 1 resident (R11) reviewed for catheter cares. In addition, the facility failed to follow proper infection control practices for 1 of 1 resident (R54) observed during peri care. Findings include: FOLEY CATHETER CARE R11's face sheet printed 7/24/25, included diagnosis of acute kidney failure, and obstructive and reflux uropathy (blockage in urinary system) and benign prostatic hyperplasia (enlarged prostrate) with lower urinary tract symptoms. R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R11 had moderately impaired cognition, was dependent on staff for bathing, toileting, dressing and transfers and R11 had a Foley catheter. R9's care plan dated 7/11/25, identified R11 had a indwelling Foley catheter with interventions including keep catheter tubing free of kinks, keep drainage bag below bladder level, maintain a closed catheter drainage system, and secure catheter tubing to upper leg to prevent catheter being pulled out. On observation 7/21/2025 7:00 p.m., an unidentified staff was exiting the room and R11 was in his recliner chair with urinary drainage bag lying on the floor. On observation on 7/22/25, at 1:28 p.m. R11 was in his recliner chair with the catheter bag lying on the floor next to the chair. R11 stated the catheter is always laying on the floor. On interview 7/23/25 at 12:46 p.m., nursing assistant (NA)-A stated she has found the catheter bag laying on the floor many times, but she always ensures it is hooked to the material on the side of the chair. NA-A added the catheter bag should not be on the floor. On interview 7/24/25 at 11:40 a.m., registered nurse (RN)-A stated the catheter back should be hooked up to whatever is available and off the floor below the level of the bladder. On interview 7/24/25 at 11:49 a.m., the director of nursing (DON) stated the catheter bag should be hooked so the bag is not on the floor below the level of the bladder. The DON confirmed the catheter bag should not be on the floor. On interview 7/24/25 at 11:52 a.m., RN-B, also identified as infection prevention nurse stated the catheter bag should not be on the floor. A request for Catheter Care was requested but none was received. PERI-CARE R54's face sheet provided on 7/24/25, included diagnoses of dementia and Alzheimer's disease. R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had moderately impaired cognition, clear speech, could understand and be understood. R54 was always incontinent of bowel and bladder and was dependent upon staff for toileting. R54's care plan with edited date of 7/10/25, indicated R54 had urinary incontinence. Care plan approach with edited date of 6/2/25, indicated R54 was on a toileting plan; to check and change brief with AM (morning) and HS (evening), before and after meals and activities and per resident or family request and PRN (as needed). During observation and interview on 7/24/25 at 11:34 a.m., while changing R54's brief and providing peri-care, observed nursing assistant (NA)-C wipe around R54's genitals with a wet washcloth, then set the washcloth on R54's overbed table. R54's overbed table had personal items on it including his water mug, telephone and was where he ate his meals. NA-C did this twice with two separate washcloths. NA-C initially stated she placed the soiled washcloths on the edge of the wastebasket when done with them and when informed of the observation of her placing them on the overbed table, then stated she set the soiled washcloths on top of a strip of plastic garbage bag that was still folded. NA-C admitted the strip of plastic would not provide adequate coverage to protect the surface of the overbed table from being contaminated by two soiled washcloths. During an interview on 7/24/25 at 12:49 p.m., the director of nursing (DON) was informed of the observation of a NA placing soiled washcloths on a strip of a plastic bag on R54’s overbed table. The DON stated that was not acceptable at any time, and especially since that was where R54 ate his meals. Facility Activities of Daily Living policy dated 6/2021, indicated residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility.

Based on observation, interview and document review, the facility failed to ensure that the posted nurse staffing information accurately reflected the actual number of nursing assistants (NA) and the total number of hours worked for posted schedules. This had potential to affect all 74 residents or visitors who wished to review the information.Findings include: On 7/22/25 at 1:28 p.m., the posted nurse staffing information was observed posted in the hallway across from the main reception area. The posted information included shift, category of shift, shift times scheduled and staffing hours. 10 CNAs scheduled from 6:00 a.m. to 2:00 p.m. with 65 staffing hours, and1 CNA from 6:00 a.m. to 12:30 p.m. with 6 hours, totaling 81 hoursThe actual staffing schedule for 7/22/25, reviewed concurrently, indicated:1 CNA from 7:55 a.m. to 2:00 p.m. (7 hours and 5 minutes), and8 CNAs from 6:00 a.m. to 2:00 p.m. (72 hours total),Resulting in 79 hours and 5 minutes, not the 81 hours posted.On 7/22/25 at 1:58 p.m., the staffing hours posted was observed with the director of nursing (DON) and the DON further confirmed the posted nurse staffing information lacked accurate data to reflect the total number and actual hours today (7/22/25) of nine NA's not ten.On 7/23/25 at 8:07 a.m., the staffing coordinator (SC-B) stated she had posted the staffing hours on 7/22/25, and confirmed that the data was not updated to reflect staff call-outs or last-minute changes, leading to discrepancies between the actual and posted staffing hours.Facility Posting of Nursing Hours policy dated 9/20/22, indicated :Purpose: To provide the number of direct care associates available during any given shift.Policy: On a daily basis for each shift, the number of nursing associates responsible for providing directcare to the residents is posted.Procedure1. At the beginning of each shift, the number of Licensed Nurses (RN's, LPN's, and LVN's) and the number of unlicensed nursing associates (CNA's) directly responsible for resident care will be posted in a prominent location that is accessible to residents and visitors and is in a clear and readable format. Schedule will be amended as schedule changes.2. Shift staffing information will be recorded for each shift. The information includes:a) The facility nameb) The date for which the information is postedc) The resident census at the beginning of the shift for which the information is postedd) Twenty-four (24) - hour shift schedule operated by the communitye) The shift for which the information is postedf) Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shiftg) The actual time worked during that shift for each category and type of nursing staffh) Total number of licensed and non-licensed nursing staff working for the posted shift3. Records of the posted information are kept on file at the community for 18 months

Based on observation, interview, and document review the facility failed to ensure safe transfers with a full body mechanical lift for 1 of 3 residents (R1) reviewed for falls/safety. This resulted in actual harm when R1 fell from the lift, had severe back pain, and needed to be sent to the emergency department (ED) for evaluation. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's face sheet dated 7/9/25, identified diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), acquired absence of left leg above the knee, and burst fracture of the T11-T12 vertebrae (a serious spinal injury when the vertebra breaks). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was dependent on staff for all transfers and cognitively intact. R1 had no falls since previous assessment.R1's Safe Lifting and Movement assessment dated [DATE], identified R1 had an amputation, paraplegia, and required two persons transfer using a full mechanical lift.R1's mobility focus care plan dated 10/13/20, identified R1 had limited ability to transfer self, related to lower body paraplegia. Interventions included: assist of two with total mechanical lift and large amputee sling. R1's fall focus care plan dated 9/14/20, identified R1 was at risk for recurrent falls related to lower body paraplegia, left leg above the knee amputation (AKA), and use of total mechanical lift for transfers. Interventions included: R1 needed an large amputee sling, two staff for all mechanical lift transfers, and remind resident not to lean forward during total mechanical lift transfers.R1' s fall event dated 6/25/25 at 3:00 p.m., identified R1 had a witnessed fall from the total mechanical lift) while being transferred from wheelchair to bed. R1 stated he fell out of the total mechanical lift. R1 complained of severe pain all over. Immediate intervention of assist of three for all total mechanical lift transfers was put into place. Review of R1 care plan identified revision on 6/25/25 to reflect the aforementioned intervention. R1's progress note dated 6/25/25 at 3:34 p.m., identified R1 found lying on the floor on his back with his head towards the wall. R1 was being transferred with the total mechanical lift into bed and the sling slipped out of the lift and resident landed on the floor. R1 was assisted back into bed and was then sent by emergency management services (EMS) for evaluation. R1's emergency department (ED) notes dated 6/25/25, identified R1 was seen in the ED for evaluation after a fall from elevation when lift strap broke causing patient to slide down onto floor, hit back of his head and left side. R1 noted pain in the back of head and had tenderness along midline thoracic spine. Computed tomography (CT) of brain, abdomen, pelvis, and cervical spine did not identify any hemorrhage or fractures. R1 was discharged back to the skilled nursing facility. R1‘s progress note dated 6/25/25 at 6:55 p.m., identified R1 returned from ED with no new orders and no fractures from the fall.R1's progress note dated 6/26/25 at 1:53 a.m., R1 reporting during repositioning he was in pain, particularly his chronic pain was bothering him. R1 rated pain six out of ten in a pain scale and was given an as needed pain medication. R1's medication administration record (MAR) identified on 6/26/25 R1 received a one dose of opioid narcotic pain medication and had not received any dose since 6/13/25. R1's progress note dated 6/26/25, identified a fall screen was completed by occupational therapy and recommended physical therapy (PT) for transfers, positioning, and bed mobility.R1's progress note dated 6/30/25, identified R1 had a PT evaluation completed and R1 would benefit from ongoing services for range of motion and low chronic back pain. R1 and spouse declined PT at this time. Additionally recommend wheelchair assessment for positioning, pressure offloading, and ease of mechanical lift transfers (i.e., reclining wheelchair), however, R1 and spouse declined, stating he is happy with current wheelchair. Recommended returning to assist of two staff for mechanical lift for all transfers. During an interview on 7/9/25 at 11:40 a.m., physical therapist (PT)-G stated she performed R1 evaluation on 6/30/25 and did not observe any concern during the transfer. R1 did not have any shift of weight and had proper body positioning during the transfer. The correct size sling was being used and did not feel the need to have three staff were needed for the transfer, therefore she recommended to return to assist of two for all transfers with the total mechanical lift.R1's interdisciplinary team (IDT) note dated 7/1/25, identified the IDT team met to discuss R1's fall on 6/25/25. R1 was being transferred from wheelchair to bed when he fell from the total mechanical lift sling. R1 had been slowly rotated at the same time he was being lifted from the chair when family member (FM)-A began removing his wheelchair from underneath R1. Staff and FM-A reported R1 was 10-12 inches above his wheelchair seat when he fell, landing on the edge of the wheelchair and slid down to the foot pedal. R1 complained of increased neck and back pain and had three abrasions on left elbow. R1 was transferred to the ED for evaluation and found to have no fractures. Root cause of fall was related to R1 being rotated at the same time his wheelchair being removed, potentially causing weight to shift and sling loop to obtain enough slack to slide off hook on the lift. Immediate intervention of assist of three for all transfers. Physical and occupational therapy to evaluate transfers and recommended to resume assist of two for transfers with the total mechanical lift. R1's care plan was revised on 7/7/25 to reflect resume assist of two for all transfer with the total mechanical lift.During an interview on 7/8/25, licensed practical nurse (LPN)-A stated, R1's care plan was not revised to assist of two for the total mechanical lift transfers until 7/7/25, due to the facility wanted to ensure all of the transfers were going well with the resident before they revised the care plan back to assist of two for all transfers with the total mechanical liftDuring an interview on 7/8/25 at 10:30 a.m., FM-A stated she was present at the time R1 fell out of the lift on 6/25/25. FM-A stated nursing assistant (NA)-F and NA-I hooked R1's sling to the total mechanical lift, and when R1 was being lifted out of his wheelchair about a foot above it, one of the straps by R1's left shoulder came off the hook and R1 slid to the floor. R1 was hanging from the lift head towards the floor when NA-F and NA-I lowered R1 to the floor. FM-A states she will assist staff by pulling R1's wheelchair out from under R1 during transfers and will look at the sling straps to ensure all the straps are hooked correctly, however she did not check that day. R1 was then lifted back into bed; he later had pain and had to be sent to the emergency department (ED) for evaluation because R1 was having terrible pain all over. During an interview on 7/8/25 at 2:10 p.m., NA-F stated that her and NA-I were performing a transfer of R1 using the total mechanical lift, and as they were lifting R1 out of the wheelchair they began to turn R1 towards the bed when they needed to adjust R1's right foot so it would not hit the bed. R1's FM-A was removing R1's wheelchair from under R1 when the sling became unhooked from under R1's left shoulder and R1 began to slide down to the floor. NA-F further stated they hooked the sling correctly to the lift and double checked the tension; however, she thinks it could have been user error and we might have forgotten to check something. During a follow up interview on 7/9/25 at 10:23 a.m., NA-F stated the only rationale she could think of what caused the fall was that we must have done something wrong, however did not recall doing anything incorrect when R1 was attached to the total mechanical lift.During an interview on 7/9/25, licensed practical nurse (LPN)-B stated he was called to R1's room on 6/25/25 after R1 had a fall. R1 was observed lying on the floor with his head towards the wall, with the lift sling already unhooked and underneath R1. NA-F and NA-I had been doing a transfer of R1 from wheelchair to the bed and as R1 was being lifted, R1's right leg was positioned so it would not hit the bed, when one of the sling straps came loose and R1 fell to the floor. R1 was assessed and then lifted from the floor and placed back in bed. R1 was later sent to the ED due to severe pain, however, was found to have no fractures. R1 was changed to assist of three for all transfers.During an interview on 7/8/25 at 12:54 p.m., director of nursing (DON) stated after R1's fall on 6/25/25, the facility wanted to see if a different type of amputee sling (hourglass) may had been appropriate for R1 however, the total mechanical lift representative (MLR) came to the facility on 6/30/25 and determined the current type and size of sling was appropriate for transfers. R1 had been evaluated by physical therapy (PT) and recommended R1 could return to assist of two for all transfers using the total mechanical lift. During a subsequent interview at 3:51 p.m. DON stated it was her expectation for all staff to follow manufacture directions to ensure all residents were safely transferred using all mechanical lifts. DON further stated all staff had started re-education on safe lift transfers and following manufacture directions after R1's fall and audits were being done to ensure this is being done correctly.During an interview on 7/8/25 at 12:58 p.m., mechanical lift representative (MLR) stated she evaluated R1's sling and the lift had been used during R1's fall on 6/30/25 and found no issues with either. MLR explained the correct sling was used; if a resident's leg had been repositioned while in the sling, it would be difficult for a sling strap to become unhooked from the lift if it had been hooked up properly. MLR further stated that some things that could have been done incorrectly for a resident to slide out of the sling could be like double looping if the second loop was not hooked up correctly, pushing the lift over something while resident in the sling, or not having the legs of the lift when the resident being turned. Review of the facility's Use of Mechanical Lift policy dated 9/30/24, identified the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Steps in the procedure include:-Before using a lifting device, assess the resident's current condition, including: Physical: Can the resident assist with transfer? Is the resident's weight and medical condition appropriate for the use of a lift? Cognitive/Emotional: Can the resident understand and follow instructions? Does the resident express fear or appear anxious about the use of a lift? Is the resident agitated, resistant, or combative?-Measure the resident for proper sling size and purpose, according to manufacturer's instructions.-Prepare the environment: Clear an unobstructed path for the lift machine. Ensure there is enough room to pivot. Position the lift near the receiving surface. Place the lift at the correct height. The following corrective actions were verified as implemented prior to the survey:-R1 was sent to the hospital on 6/25/25 and found to have no injuries identified during the evaluation.-Immediate intervention for R1 on 6/25/25 was to have staff assist of three for all transfers of R1 with the total mechanical lift. -On 6/25/25 an email communication was all nursing staff to remind about safe transfer procedures when using the total mechanical lift: to ensure weight is being distributed in the sling throughout the entire transfer and to be cautious when rotating the resident to not bump the wheelchair side to cause the resident's weight to shift; If notice resident's weight begin to shift while elevated in the sling to safely lower the resident back into the wheelchair or bed, ensure using the proper equipment, and ask for more assistance. -All like residents who utilized the total mechanical lifts were interviewed regarding transfers and no concerns noted. -All facility residents utilizing the mechanical lifts had sling sizing completed per manufactures guidelines.-All facility residents utilizing the mechanical lifts had care plans reviewed and revised as necessary to include lift and sling specifics.- R1 was evaluated by PT on 6/30/25 and no concerns with sling size and determined R1 could remain at assist of two for all transfers with the total mechanical lift.-Staff involved in the fall from the lift had re-training on safe lift and competency redone on 6/25/25-Beginning on 6/25/25 education began with all nursing staff on safe transfers with total mechanical lifts-Total Mechanical Lift competency testing of all nursing staff began being completed on 6/25/25.-Audits of mechanical lift positioning during transfers are being completed on a 6-week tapering schedule for resident utilizing the mechanical lifts by the DON or designee-Audits will be brought to Quality Council after 6 weeks to determine need for ongoing and/or additional audits.

Based on observation, interview, and record review the facility failed to observe the rights of medication administration to ensure the right medication was safely administered for 1 of 3 residents (R2) reviewed for significant medication errors. This resulted in an immediate jeopardy for R2 who required hospitalization , continous monitoring and intravenous fluid recovery to return to baseline. The immediate jeopardy (IJ) began on 10/16/24 when licensed practical nurse (LPN)-A injected R2 with 100 units (U) of short-acting insulin instead of the prescribed Heparin (blood thinner that prevents blood clots) 5,000 milliliter (ml). The Administrator, Director of Nursing (DON), and clinical nurse manager were notified of the IJ on 10/23/24 at 5:13 p.m. The IJ was issued as past non-compliance (PNC) when facility implemented immediate corrective action prior to survey entrance to prevent recurrence. Findings include: R2's Continuity of Care document dated 10/23/24, identified R2 had diagnoses that included hypertensive chronic kidney disease with stage 5 chronic kidney disease (gradual loss of kidney function) with dialysis (treatment for kidney failure that filters and purifies blood using a machine), infection and inflammatory reaction due to nephrostomy (tube that drains urine from the kidney into a bag) R2's quarterly Minimum Data Set (MDS) dated ,d+[DATE], identified R2 did not have cognitive impairment and was not diabetic or insulin dependent. R2's physician orders dated 10/8/24, included: Heparin 5,000 mL injection every 8 hours at 12:00 a.m., 8:00 a.m., and 4:00 p.m. from 10/8/24-10/16/24. R2's progress note dated 10/16/24 at 5:52 p.m. and 5:53 p.m., identified R2 was transferred to emergency department, family, and provider aware. Vital signs (VS) were normal. Normal ranges: oxygen saturation 95-100%, blood pressure 120/80, and pulse 60-100. R2's hospital discharge summary dated 10/17/24, identified reason for admission of iatrogenic hypoglycemia (low blood sugar because of too much insulin) on 10/16/24. On 10/16/24 at 5:37 p.m., emergency medical technicians (EMT) obtained a blood glucose reading of 135. At 5:46 p.m., blood glucose was 98 (normal range 70-110), at arrival to the emergency room blood glucose was 65. R2 received an intramuscular (IM) injection of glucagon (raises blood sugar by causing the body to release sugar stored in the liver) and an amp of D50 glucose which increased the blood glucose reading to 244. On recheck the blood glucose dropped to the 160's and R2 was started on D10 infusion. Poison control was called and informed ED the insulin would peak around 6 hours and recommended R2 continue infusion for at least 6 hours and observe for another 4 hours after that. Glucometer readings from the hospital were: On 10/16/24: -8:16 p.m. 76 -9:18 p.m. 120 -10:46 p.m. 57 On 10/17/24: 6:03 a.m. 226 8:02 a.m. 135 Normal blood glucose ranges from 70-110. R2's progress note date 10/17/24 at 11:38 a.m., identified R2 returned to facility. During an observation and interview on 10/22/24 at 10:26 a.m., R2 was lying in bed. R2 reported she had gotten insulin instead of heparin on 10/16/24, but was not sure where the insulin came from that was given to her. R2 stated she had to spend the night in the Hospital. R2 stated she felt ok following the incident. During an interview on 10/22/23 at 11:07 a.m., LPN-A stated she worked the floor from 2:00 p.m. to 6:00 p.m. on 10/16/24. At approximately 4:45 p.m., LPN-A could not locate R2's heparin in the med cart. LPN-A searched the medication cart, and reviewed R2's medical chart for verification that the medication was available. LPN-A went to the medication room and looked in the refrigerator and among the insulin pens she saw a vial in a bag. LPN-A removed the bagged vial and misread the label on the bag thinking it read R2's information. LPN-A took a needle and drew from the vial into the needle 100 U of medication, injected the medication into R2's abdomen, and then left the room. LPN-A returned to the medication cart and was going to date the vial she opened. LPN-A noticed the vial was not heparin but insulin, realized the error, and notified case manager (CM)-A. CM-A then called an ambulance and R2 was transferred to the emergency department (ED). LPN-A stated she had never given a resident heparin before and was not aware of what the vial would look like. During an interview on 10/23/24 at 12:14 p.m., CM-A stated on 10/16/24, LPN-A notified her she had given R2 insulin instead of heparin. CM-A told LPN-A to get a set of VS and she would inform nurse practitioner (NP)-A, who was in the building, of the incident. CM-A went to R2's room to complete an assessment. R2 was alert and orientated, stated she did not want to go to the hospital and was aware of the medication error. CM-A stated that neither she nor LPN-A checked R2's blood glucose reading after the incident. During an interview on 10/23/24 at 2:48 p.m., NP-A stated on 10/16/24 she was at facility when CM-A notified her R2 was given 100 U of insulin and asked if R2 could be sent to the ED. NP-A directed R2 to be sent into the hospital. NP-A stated the medication error would be considered significant in nature and could result in serious harm or death. During a phone interview on 10/23/24 at 10:19 a.m., pharmacist (P)-A stated Fiasp is a quick acting insulin that takes effect 20 minutes after injection. Peak would be 1-3 hours and typically last 3-5 hours. P-A was informed of the amount administered to R2, P-A stated Yikes, that is a lot of insulin especially for a non-diabetic, even if diabetic that is a lot. During an interview on 10/23/24 at 3:32 p.m., director of nursing (DON) stated with each and every medication the nurse should go through the six rights of medication administration. If LPN-A would have done that the error would not have occurred. DON stated LPN-A was suspended following investigation along with completing re-education with her before returning to the floor, interviewed residents for medication error concerns, provided competency testing, and education for all nurses, replaced the bottle of Fiasp with an insulin pen, removed the vial of heparin from the medication cart and placed in residents locked cupboard, updated the MAR for licensed staff to write in the lot number and expiration date of all injectable medications, began an auditing system to review with Quality Assurance Performance Improvement. The IJ that started 10/16/24, was removed on 10/17/24, after it was verified the facility implemented the following corrective actions: -LPN-A suspended pending investigation and then completed re-education and competency education on 10/16/24 and 10/17/24. -interviewed residents for any medication error concerns on 10/16/24. -provided education and competency testing on the rights of medication administration to licensed nursing staff 10/17/24 and continuing until all staff complete. -replaced the vial of Fiasp insulin with insulin pen on 10/17/24. -removed the vial of heparin from the medication cart and placed in resident's locked medication cupboard on 10/17/24. -updated procedure for administration of all subcutaneous injections, when signing off in the electronic medication administration record, to include the lot number and expiration date of the medication on 10/17/24. -implemented an auditing system for administration of subcutaneous injections on 10/17/24. The facility Administering Medications policy revised 8/31/23, identified staff to ensure safe administration of resident's medication as indicated and ordered by the provider by following the 6 rights of medication administration: a. Right resident b. Right medication c. Right dose d. Right time e. Right route f. Right documentation The facilities Medication Error/Occurrence policy revised 8/31/23, identified the licensed nurse to provide immediate care and notification of provider and resident/representative when nursing or medical intervention, observation, or treatment is indicated. The resident condition is assessed including obtaining VS. Action is taken to prevent the error from reoccurring.

Based on observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 4 of 9 residents (R8, R7, R9 and R6) observed during a medication pass. In addition, the facility failed to ensure proper cleaning of glucometer for 1 of 3 residents (R6) and failed to utilize enhanced barrier precautions (EBP) for 2 of 2 residents (R1 and R5) during wound dressing changes. Findings include: R8's face sheet dated 10/24/24, identified diagnoses of type 2 diabetes mellitus (condition that affects how the body uses sugar as fuel). During an observation on 10/23/2024 at 7:15 a.m., Licensed practical nurse (LPN)-C entered room for R8. Hand hygiene was not performed prior to entering room. The glucometer was removed from locked medication cabinet, along with strips, alcohol pad, and cotton ball. LPN-C applied gloves without performing hand hygiene, assisted R8 to reposition with same gloved hands, then obtained blood sugar. LPN-C then removed gloves and did not perform hand hygiene prior to leaving R8's room. R7's face sheet dated 10/24/24, identified diagnosis of Type 1 diabetes mellitus (chronic condition that affects the pancreas ability to produce insulin). During an observation on 10/23/2024 at 7:20 a.m., LPN-C entered R7's room. Hand hygiene was not performed prior to entering room, donned (applied) gloves and took R7's blood sugar. LPN-C removed gloves and did not perform hand hygiene prior to leaving room. R9's face sheet dated 10/24/24, identified diagnoses of systemic lupus erythematosus (autoimmune disease that affects many body systems and causes inflammation, rash, fatigue, and fever). During an observation on 10/23/2024 at 7:40 a.m., LPN-C entered R9's room. Hand hygiene was not performed prior to placing gloves on. A patch was applied to R9's lower back, and ace wraps applied to both legs. LPN-C removed gloves without performing hand hygiene and then pushed R9 to dining room. LPN-C then got coffee and juice for R9 and touched beverage buttons in dining room. R6's face sheet identified diagnosis of Type 2 diabetes mellitus. During an observation on 10/23/2024 8:00a.m., LPN-C removed a glucometer out of the bottom of the medication cart. LPN-C did not perform hand hygiene, donned gloves, and obtained blood sugar for R6. The glucometer was not disinfected and was placed back in the bottom of the cart for universal use. LPN-C removed gloves and did not perform hand hygiene. At 8:15 a.m., LPN-C administered insulin injection without performing hand hygiene before and after. During an interview on 10/23/24 at 8:30 a.m., LPN-C stated the glucometer in the bottom of the cart is a universal one and we use this one is just in case the resident does not want to go back to their room. LPN-C stated that every resident had a glucometer in their room, But this one is for everyone, if needed. LPN-C stated that the glucometer should have been cleaned after use, and that handwashing/hand hygiene should be performed before entering room and leaving room, when hands soiled, in between residents, and before/after glove removal. Per the Centers for Disease Control (CDC) dated 6/28/24: EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted multi-drug resistant organisms (MDRO) (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device. High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. R5's face sheet dated 10/24/24, identified diagnoses of burn of unspecified degree of left thigh. During an observation on 10/24/24 8:11 a.m., LPN-B performed dressing change to R5's left upper thigh. EBP was not used to perform this dressing change. No signage instructing staff to use EBP, or supplies noted outside of R5's room. R1's face sheet identified diagnoses of laceration to right lower leg. During an observation on 10/24/24 at 10:38 a.m., LPN-B performed dressing change on R1's right lower leg. EBP was not used to perform this dressing change. No signage instructing staff to use EBP, or supplies noted outside of R1's room. During an observation on 10/24/24 at 12:29 p.m., nurse practitioner (NP)-A, clinical manager (CM)-A, and infection preventionist/wound nurse (IPWN)-A obtained a culture and sensitivity test from R1's laceration on right lower leg and performed wound dressing care. EBP was not used during this dressing change. No signage instructing staff to use EBP was noted outside of R1's room. R1's culture and sensitivity dated 10/27/24, identified results from the laceration to the right shin/calf as 4+ staphylococcus aureus. During an interview on 10/23/24 at 11:40 a.m., the director of nursing (DON) stated the glucometers in the bottom of the medication carts are only to be used for emergency situations and should not be used for individual residents. The glucometer should have been cleaned after use. During an interview on 10/24/24 at 2:16 p.m., IPWN-A stated the glucometers in the bottom of medication cart is for emergency use only, nurses should clean them before and after use. IPWN-A stated hand washing/hand hygiene should be done before and after entering rooms, before and after touching residents and before applying gloves and after removal. IPWN-A stated the process to determine if residents need EBP, would be to check the CDC grid. IPWN-A stated R1 will be placed on EBP due to having an open wound. During an interview on 10/24/24 at 4:26 p.m., DON stated any resident with an indwelling catheter, chronic wound, wound with significant drainage or open wound should have enhanced barrier precautions. The facility policy on Hand Hygiene review/revision dated 09/23, identified hand hygiene to be performed before and after resident contact, before and after performing invasive procedure (e.g., fingerstick blood sample); Before and after assisting with personal cares and after removing gloves. The facility policy on Resident Care Equipment dated 06/2017, identified that reusable equipment is not used for the care of another resident until it has been cleaned and reprocessed appropriately. It also stated glucometers to be cleaned between residents. The facility policy on Enhanced Barrier Precautions revised on 04/01/24 identified enhanced barrier precautions will be used for any chronic wounds. According to the Centers for Disease Control and Prevention document Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC: If a resident does not have a history of a Multi Drug Resident Organism (MDRO) and has a wound, they should be placed on Enhanced Barrier Precautions (EBP). who do not otherwise meet the criteria for Contact Precautions.

Based on interview and document review the facility failed to safely use a mechanical lift per manufactures recommendations to transfer 1 of 1 resident (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to sustain a fractured sternum and left pelvic hematoma that required a hospital admission and blood transfusion. The IJ began on 7/21/24 at 9:40 p.m., when staff failed to ensure lift sling was properly secured prior to the transfer causing R1 to fall from the mechanical lift. The administrator, regional nurse manager, and director of nursing (DON) were notified of the IJ on 7/24/24 at 4:13 p.m. The IJ was removed on 7/22/24, when the facility implemented immediate corrective action before survey to prevent recurrence, therefore, the IJ was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1' had intact cognition R1 used a motorized wheelchair, was dependent with all transfers, and did not walk. R1 took anticoagulants (blood thinners). R1's mobility care plan dated 3/27/24, directed staff to transfer R1 with a full body mechanical lift (hoyer-brand name) using a medium sized sling and two staff. indicated transfers with hoyer lift. R1's progress note dated 7/21/24 at 9:40 p.m., indicated licensed practical nurse (LPN)-A was called to room by nursing assistants (NA)s. When nurse entered room R1 was laying on the floor beside the bed. R1 stated she did not hit her head. R1 was assisted with hoyer lift to bed. NA-B and NA-S stated R1 was hooked up and lifted per protocols During the transfer R1 fell to the floor in the sling. NA-B and NA-S unaware what caused sling to fall. The note indicated R1 sustained skin tears to right index and middle finger that were covered with band aids, a skin tear with bruising to left bicep that measured 8.0 centimeters (cm) x 8.0 cm which was covered with a dressing, and bruising to the top of left shoulder. R1 declined being examined in the emergency department (ED). R1's progress note dated 7/22/24 at 1:55 a.m., indicated R1 was reporting total body pain post fall and pain in upper left thigh that had light blue bruising, was slightly swollen and tender to touch. R1 requested and was given acetaminophen (Tylenol) 650 milligrams (mg) approximately 1:40 a.m. R1's progress note dated 7/22/24 at 3:34 a.m., R1 reported her neck and right side of her head hurt, no redness, swelling, bruising or any signs of injury. R1 declined to go to emergency department for further evaluation, ice pack was applied to right side of her head and neck. R1's progress note dated 7/22/24 at 8:33 a.m, indicated R1 was transferred to the hospital. R1's hospital records indicated on 7/22/24, R1 presented to a local emergency room however was then air lifted to a higher level hospital for further trauma evaluation. Records indicated R1 had concerning blood pressure of 68 with a repeat of 79/43 (normal is 110/70). Imaging identified R1 had acute to subacute nondisplaced transverse fracture of the manubruium (sternum) and a large left hip hematoma measuring 20.6 centimeters (cm) x 8.8 cm x 5.3 cm. Additionally, was given a diagnosis of anemia with a hemoglobin of 6.3 grams/deciliter (normal is for females is 12-16 g/dl) secondary to hemorrhage that required a blood transfusion. During an interview on 7/24/24 at 8:37 a.m., family member (FM)-B stated R1 remained in the intensive care unit (ICU). R1 remains in the hospital. During an interview on 7/23/24, (NA)-B indicated on 7/21/24 around 9:30 p.m. she was working with NA-S when R1 fell from the lift when they were transferring R1 off of the commode. NA-B indicated she was running the controls of the lift; she lifted R1 up into air off the commode. While R1 was suspended in the air NA-S performed peri-care. NA-B then started to push the lift towards R1's bed, that was when the upper right sling strap came off the hook of the lift and R1 fell approximately three feet to the floor. LPN-C was notified via radio of the fall. LPN-C arrived to the room and completed assessments. R1 sustained skin tears and complained of pain in both her shoulders. R1 was transferred off the floor to her bed using the same lift and sling she had just fallen from. LPN-C applied dressings to the wound and R1 was given ice packs for pain. NA-B indicated NA's had checked and confirmed they both used the same color sling straps were connected to the lift, however, could not articulate they had checked the tension of the straps once R1 was lifted up and prior to the transfer. NA-B stated she had received education on following the manufacturer's instructions after the incident. During an interview on 7/24/24 at 12:50 p.m., NA-S stated she was working with NA-B on 7/21/24. They were transferring R1 from the commode to the bed when the top right strap came off the lift causing R1 to fall to the floor. NA-B called LPN-C on the radio, while NA-S stayed with R1. NA-S stated she did not know how the loop came off the lift. NA-S explained they had checked to ensure the same color straps were used however, did not articulate the placement and/or tension were checked after R1 was raised in the air and prior to the transfer to ensure the straps did not loosen or move. NA-S stated she had received education on how to complete safe lift transfers after R1's fall. During an interview on 7/24/24 at 12:05 p.m., LPN-A stated on 7/21/24 at 9:40 p.m., she was called to R1's room as R1 fell from a mechanical lift and was on the floor. LPN-A did an assessment of R1 prior to moving her, skin tears to right index and middle finger and able to move all major joints. LPN-A, NA-B and NA-S used the same sling and lift to get R1 off the floor and into bed. Once in bed staff noticed bruising and a skin tear to the left bicep. LPN-A indicated R1 refused to go to the hospital on her shift, however, was sent in on 7/22/24. LPN-A further stated since the incident, the procedure was to report falls from lifts immediately to the on-call nurse, DON, administrator as well as the provider immediately. LPN-A stated she received education on safe lift transfers following R1's fall. Review of the facility's smart lift safety and maintenance checklist for the lifts dated 7/22/24 indicated that both lifts were inspected by maintenance per protocol, with no issues noted. Inspection of the slings were also completed, no frays or other damage was noted. During an interview on 7/24/24 at 1:01 p.m., director of nursing (DON) explained the lift and sling that was involved in the incident were inspected, there were no issues found with either. The fall was likely a result of operator error because there were no issues found with the equipment. DON stated it was her expectation for staff to follow manufactures recommendations when using mechanical lifts. Equipment that is involved in accidents needs to be removed from operation and checked by Maintance to ensure the lift/lift accessories are safe to use. DON indicated all nursing staff were re-educated with return demonstration on using the mechanical lifts on 7/22/24. During an interview on 7/24/24 at 11:50 a.m., lift representative (LR)-A stated staff were to remove the lift and the lift sling from operation until maintenance can perform preventative maintenance per manufacture recommendations. LR-A explained staff needed to check the tension of the sling loops/straps by touching each one to make sure they are secured onto the lift. This check is completed while the resident is being lifted and still on/over the surface that they are being raised off of. The immediate jeopardy that started on 7/21/24, was removed on 7/22/24 after it was verified the facility implemented the following corrective actions: -On 7/22/24 the facility implemented re-education that included return demonstration to all nursing staff per the manufacture's recommendations prior to working the floor. -On 7/22/24 maintenance inspected all the lifts for function and safety. Additionally checked the slings for any issues. -Residents who used mechanical lifts were all reassessed to ensure proper sling size and confirmed accuracy of care plans by 7/22/24 -Facility contacted the manufacturer for additional in person re-iteration of training on 7/25/24 -On 7/22/24, the facility revised policy/procedure to include that all falls are reported to the nurse on call, provider, and family of significant falls, even when resident ask staff to not notify. -On 7/22/24, the facility revised their post fall follow up to include documentation and monitoring guidelines, anticoagulation, vital sign and assessment with neuro checks if hit head. EZ-Way Smart Lift Operator Manual included the following: -the EZ Way Smart Lift was designed to lift patient/resdient's from bed, chair, toilet and floor. -all washable EZ Way slings are capable of bearing a 1,000 pounds weight load, but must only be used to hold the amount of weight dictated by the EZ Way Smart Lift capacity. -do not modify the sling design in any way, make the accessories used with each lift are appropriate for both the patient and the transferring situation. -all EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. -while lifting the patient upward, continue until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars before moving resident from over the surface transferring from.

Based on observation, interview and document review the facility failed to comprehensively assess resident's skin to prevent facility acquired pressure ulcers and provide consistent skin monitoring for 1 of 3 residents (R28) reviewed for pressure ulcers. This caused actual harm for R28 who developed a stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough [non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed] may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.). Findings include: R28's face sheet printed 3/9/22, indicated R28 was admitted to the facility 5/15, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R28 had moderately impaired cognition, no rejection of care, required extensive assist with bed mobility and transfers, limited assist with dressing, utilized a walker and wheelchair. Further, the MDS identified R28 was at risk for developing pressure ulcers/injuries, had two venous (type of chronic wound due to damage of skin tissue from lack of proper circulation of the blood back to the heart or stagnation of the blood) and [CONDITION(S)] (type of chronic wound due to the damage to skin tissue from a lack of blood flow to the tissues from the heart) ulcers present, required a pressure relieving device for the chair and bed, application of non-surgical dressings, application of ointments/medications, and application of dressings to feet. R28's Care Plan printed 3/8/21, identified R28 had impaired skin r/t (related to) [CONDITION(S)] to bilateral lower extremities; interventions included monitor for s/s (signs/symptoms) if infection noted notify MD/NP (medical doctor/nurse practitioner), observe for s/s (signs/symptoms) of pain, wraps bilateral to LE (lower extremity) as ordered, conduct a systematic skin inspection during weekly with bath, daily checks with daily am/pm cares, pay particular attention to the bony prominence, and report concerns to nursing. for prompt treatment, provide staff assist of 1 for guiding legs into bed. Resident can assist with repositioning. R28's care plan lacked identification of R28's stage 3 pressure ulcer to left heel and lacked any further interventions related to the care of R28's pressure ulcer to minimize the risk of additional pressure ulcer development, including floating heels, refusal of care, following dressing change orders per wound nurse or as ordered, monitoring for healing, signs of infection. R28's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Order started on 2/8/22, indicated clean left heel with NS [normal saline], apply [MEDICATION(S)] (antibiotic ointment), apply [MEDICATION(S)] (absorbent foam dressing) once daily. R28's Event Report: Skin Integrity Event's Pressure Sore/Statis Ulcer dated 2/8/22, completed by licensed practical nurse (LPN)-A, wound nurse identified pressure ulcer treatment and measuring of stage 3 pressure ulcer was completed. The form had a section to include interventions, skin treatments applied during last 7 days, measures taken, however section on form incomplete. The form further indicated treatments dated 2/8/22, float heels while in bed. LPN-A note on the form indicated, writer was completing resident AM treatment. When writer was wrapping resident's legs, resident c/o [complained of] of her left heel being sore. Writer observed resident heel and noted an open area on the back of her heel. Area was measured 1 cm x 0.8 cm x 0.3 surrounding tissue intact. R28's Skin Condition documentation from 2/8/22-3/9/22, included the following: On 2/8/22, a new pressure ulcer was identified on R28's left heel as a stage 3 pressure ulcer and measured 1 cm x 0.8 cm x 0.3 cm The pressure ulcer was described as left heel being pain sore, open area on the back of her heel, surrounding tissue is intact. On 2/9/22, at 3:19 p.m. wound treatment completed with measurements. Left heel wound 1 cm x 0.8 cm x 0.3 cm. Both calves surrounding tissue dry scaly irritated skin. On 2/9/22, at 12:36 a.m. left heel painful but ok when floated on pillow. Continue to monitor. On 2/16/22, at 3:18 p.m. wound tx [treatment] completed with measurements. Left heel wound 0.6 cm x 0.8 cm x 0.2 cm. On 2/16/22, at 4:51 a.m. refused to float heel with pillow. She (R28) states it hurts more with pillow. Has legs elevated with bed controls. Continue to monitor heels. On 3/3/22, 2:53 p.m. wound treatment complete Left heel wound 0.8 cm x 0.6 cm x 0.3 cm. On 3/9/22, 12:59 p.m. left heel measures 0.8 cm x 0.9 cm x 0.2 cm. Wound bed 100% granulation. No drainage. No odor. Wound edge calloused. Peri-wound intact without redness. Resident denied pain at time of writers assessment. R28's medical record lacked a comprehensive assessment: to include the potential causative/contributing factors when the pressure ulcer developed, and education to staff to ensure appropriate interventions were identified and implemented to promote pressure ulcer healing and reoccurrence. On 3/8/22, at 1:46 p.m. R28 was in her room seated in her wheelchair, and indicated her legs were wrapped with ACE wraps, R28 was observed and used her feet to self propel in the wheelchair from her room to the dining area, approximately 30 feet. On 3/9/22, at 12:37 p.m. observed R28 in her room seated in wheelchair with medical doctor (MD) and LPN-C. LPN-C stated resident had COVID in early January and indicated R28 may had been weaker during that time. LPN-C indicated staff were expected to assist R28 with reposition and assist resident in bed, MD-A stated today was the first time she visually accessed the left heel pressure ulcer, and described the area as round shallow, dry, and clean. MD-A stated the left heel open area would be related to pressure. MD-A stated staff had notified her of the ulcer and orders were given. MD-A stated staff were expected to visually monitor bony prominence and including heels daily. On 3/9/22, at 1:14 p.m. LPN-C stated she had completed a course in wound certification. LPN-C indicated she was notified by LPN-A on 2/8/22, of an open and painful area on R28's left heel. LPN-C further indicated she assessed R28's left heel 2/8/22, and the left heel was staged at a stage three pressure ulcer due to full thickness loss. LPN-C indicated R28's interventions prior to the resident identified pressure ulcer were weekly body audit, staff assist of one to guide into bed and resident can assist with repositioning, daily checks of bony prominence, and was expected for nursing assistants or nurse to report for prompt treatment. LPN-C sated R28 was dependent of staff to put her socks on daily. LPN-C indicated and IDT [interdisciplinary team] was completed 2/11/22, and indicated comorbidities of R28 included diet, cognition and added interventions interventions daily treatment until area is healed, encourage resident to elevate legs and to use right foot for locomotion to and from room and lounge. LPN-C stated the new interventions were expected to be included on the care plan and confirmed the interventions were not on the care plan prior to 3/9/22. LPN-C further indicated NA's and nursing staff would be aware of the interventions through the care plan. LPN-C indicated the left heel pressure ulcer was still identified as a healing stage three. On 3/9/22, 1:37 p.m. the director of nursing (DON) stated the expected staff to identify a pressure ulcer prior to a stage three and expected residents at risk including R28 to have intervention that included pressure reliving mattress, skin inspections, float heels. On 3/9/22, at 3:44 p.m. an interview with the DON and LPN-C indicated the facility had not completed audits on residents with risk of skin breakdown or pressure sores and had not provided staff education on comprehensive skin assessment that included heels to ensure other like residents were assessed comprehensively On 3/10/22, at 9:17 a.m. during a phone interview with MD-A indicated she expected staff would have identified R28's heel sore prior to a stage three pressure ulcer and expected causative factors and interventions to prevent future skin concerns for R28, and confirmed the stage three pressure ulcer with the comprehensive visual assessment and interventions could have been prevented. On 3/10/22, at 10:21 a.m. LPN-A, stated she completed weekly body audits on R28 and confirmed R28's wound on right calf, lower left leg, and pressure ulcer on the left heel left heel which showed up within the last month. LPN-A indicated R28 self propelled in her wheelchair, and was not in bed that much except for at night when R28 slept. LPN-A confirmed she identified the pressure ulcer on R28's left heel on 2/8/22. LPN-A indicated for the week prior to 2/8/22, R28 complained of left heel pain daily and LPN applied lotion to her heel and felt the residents heel, but confirmed she failed to visually assess R28's heel. LPN-A stated if R28's heel was visually inspected prior to 2/8/22, and possible interventions would have been implemented, R28's possible could have been prevented the left heel to develop to a stage 3 pressures ulcer. LPN-A indicated assessment of bony prominence would include the heels LPN-A stated the facility had not provided any additional education related to comprehensive skin assessments after the incident, and further stated the incident, opened my eyes to look at heels Policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Purpose: maintaining intact skin is integral to resident health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur. Procedure: 1. Skin Assessment: A resident centered care plan is implemented updated for skin risk with interventions based upon area of risk, resident assessment, Braden new valuation score 15 or less clinicians assessments less evaluation, resident preferences 2. Members of the care team are notified and consulted as necessary 3. Skin integrity is monitored and abnormal findings are documented, skin is observed daily with cares, if any skin concerns are noted there reported to the licensed nurse, weekly skin audits are performed by a licensed nurse. 4. A therapy evaluation is requested as appropriate 5. Education is provided the resident and resident representative as indicated treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. notify supervisors/designee, 2. evaluate current pressure reduction interventions and revise resident centered care plan 3. notify dietitian for nutritional intervention 4. Notify therapy associates and other members of the care team as appropriate for possible interventions, 5. When pressure injury is present, the dressing or wound is monitored as appropriate 6. Weekly the licensed nurse will stage, measure and examine the wound bed and surrounding skin. If the wound bed has deteriorated notify provider. 7. Documentation reflex areas as addressed above Definitions : Stage three pressure injury full thickness skin loss full thickness loss skin, in which adipose is visible and ulcer in granulation tissue enrolled wound engines are often present. Sloth or eschar may be visible the depth of tissue damage varies by location

Based on observation, interview and document review, the facility failed to implement interventions to promote comfort and reduce pain for 1 of 1 residents (R71) reviewed for pain care and management whom had visible and verbal complaints of pain during the survey. This resulted in actual harm for R71 who experienced severe pain when staff failed to provide ordered pain control medication(s) on a consistent and timely basis. Findings include: R71's undated face sheet identified R71 had [DIAGNOSES REDACTED]. R71's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R71 was cognitively intact, was totally dependent on two persons for transfer and locomotion on/off the unit, required extensive assistance of two persons for bed mobility and toilet use and required extensive assistance of 1 person for dressing and personal hygiene. The MDS also indicated R71 received scheduled and non-scheduled pain medication, as well as, non-medication interventions for frequent, severe pain which limited R71's day-to-day activities. The MDS further indicated R71 received antianxiety medication daily and opioid medication 6 days during the look back period. R71's Care area assessment dated [DATE] indicated [REDACTED]. R71's Care Plan dated 11/11/19, indicated [REDACTED]. The care plan directed staff to implement interventions which included: -administer pain medications as ordered -assess the characteristics of pain: location, severity on a scale of 1-10, type, frequency -discuss the factors that precipitate pain and what may reduce it -discuss the need to request pain medications before pain becomes severe -monitor for potential side effects of pain medication -offer comfort measures: acupressure, acupuncture, biofeedback, brace, cold, comfort food, decreased stimulation, distraction, guided imagery, heat, massage, music, prayer, psychotherapy, relaxation, repositioning, rest, sleep, television, TENS unit, whirlpool bath. R71's physician order [REDACTED]. - [MEDICATION NAME] .25 milligrams (mg) two times per day (for [MEDICAL CONDITION]) - [MEDICATION NAME] 3 mg at bed time (for sleep) - [MEDICATION NAME] 12 mcg/hour change patch every 3rd day (for pain) - [MEDICATION NAME] 200 mg every 8 hours as needed (for pain) - [MEDICATION NAME] concentrate 10 mg every 4 hours as needed (for pain) The facility's Pain Interview/Pain Management interview with R71 on 11/5/19, at 9:30 a.m. identified R71 received scheduled, and as needed pain medications. During the interview R71 stated she had frequent plan, which had limited her day to day activities because of pain. Further R 71 identified her pain as severe. Resident does have pain and in her hips and lower back making it very painful to reposition and move into, out of bed. Hospice working to adjust doses for the optimal comfort most of the time. On 11/20/19, at 7:13 a.m. R71 was observed sleeping in bed with the head of the bed elevated approximately 25 degrees and was lying on her back. -At 8:05 a.m., R71 turned her call light on. -From 8:11 a.m. until 8:17 a.m. R71 could be heard calling out from a distance of approximately 25 feet from her room. A housekeeper walked by R71's room to the housekeeping closet, next door to R71's room and obtained supplies from the closet. The housekeeper did not respond to R71's call light. R71 could be hear calling out more frequently and whimpering. This continued until a nursing assistant (NA) walked by the room to a laundry closet just outside R71's door. The nursing assistant also did not respond to R71's call light or look in on R71. -At 8:13 a.m. a page directed staff to R71's room -At 8:26 a.m. R71 could be heard making a squealing sound, and whimpering. -At 8:29 a.m. R71 could be heard calling out help, help, and whimpering louder, R71's call light was still on. -At 8:34 a.m. R71 called out for help. -At 8:36 a.m. R71 called out help, help!. -At 8:41 a.m. R71 could be heard crying. -At 8:43 a.m. (38 minutes after R71 had turned on her call light) trained medication aide (TMA)-A entered the room, TMA-A told R71 she would tell the nurse that she requested medication for her pain. The surveyor then entered the room, and found R71 complaining of pain, and whimpering. R71 rated her pain at a 9/10, and her breathing was rapid, she was whimpering, her eyebrows were furrowed with a grimaced look. R71 was unaware and unsure of the last time she received pain medication. -At 8:50 a.m. (45 minutes after R71 had turned on her call light) licensed practical nurse (LPN)A entered the room, and administered a dose of [MEDICATION NAME] 10 milligram (mg) liquid, and changed R71's [MEDICATION NAME]. -At 9:04 a.m., R71 continued to whimper softly. -At 9:11 a.m., NA-A brought R71 her breakfast tray, and R71 continued to whimper, and told NA-A she was having pain. NA-A stated when she worked 2 days ago R71 had never indicated this intensity of pain. The surveyor observed no one had repositioned R71. During interview on 11/20/19, at 9:39 a.m., LPN-A re-entered R71 room, and explained he planned to wait until the medication kicked in so he could do her dressing changes. During observation on 11/20/19 at 10:01 a.m., TMA-A entered the room and gave R76 her morning medications. R71 smiled and reported it (pain) is a lot better. On 11/20/19 at 10:11 a.m., LPN-A returned to do the dressing change to R71 lower extremities, with LPN-D assisting. During the procedure, R71 states do not press on my hip, she states that her pain is getting better, then asked LPN-A how long the pain medication will last. During a interview with LPN-A and TMA-A on 11/20/19 at 11:35 a.m., LPN-A indicated that it was his expectation that call lights be answered in 5-10 minutes. When the surveyor explained the observation above to him he stated we are not meeting our expectations and that he would be talking with the staff. When LPN-A was informed R71 was in pain, and wanted a medication for pain, LPN-A stated he would get this to her right away. During interview on 11/22/19, at 1:22 p.m., the director of nursing (DON) confirmed she was aware of the long call light time for R71 on 11/18/19, and confirmed it was her expectation that the response time be 10 -15 minutes to respond, and all staff were responsible to answer call lights. The DON confirmed she was aware R71 was asking for a medication for pain. Although policies wer requested for call light response time, and pain management none was provided.

Based on interview and record review, the facility failed to provide needed care and or services, recognize risk factors, implement treatment according to care plan and failed to monitor and or revise resident's response to interventions for 1 of 1 resident (R76) reviewed for hospitalization . This practice resulted in harm due, R76 had increased pain and decline in condition. R76's face sheet indicated she'd been admitted to the nursing home on 9/5/17 with [DIAGNOSES REDACTED]. An admission Minimum Date Set ((MDS) dated [DATE] indicated R76 had a Brief Interview for Mental Status(BIMS) score of 11, which indicated she had moderate cognitive impairment. A subsequent MDS for R76, dated 9/19/17, identified a BIMS score of 7 which indicated severe cognitive impairment. A Care Area Assessment (CAA) dated 9/12/17, indicated R76's family had reported at admission that R76 suffered from some forgetfulness. The CAA for pain indicated R76 had acute pain related to (r/t) the left humerus and vertebra FX. Interventions indicated staff would administer pain medications as directed by the medical doctor (MD), and would monitor the effectiveness of the pain medication. In addition, the CAA indicated staff would attempt non-pharmacological interventions prior to administering as needed (PRN) medications, and would notify the MD of changes or uncontrolled pain. The care plan for R76 identified a problem with cognition and interventions for staff to: anticipate needs, encourage verbalization of feelings and concerns, to address concerns timely. Another problem area on the care plan indicated R76 had complaints of acute pain r/t left humerus FX and collapsed vertebra. Interventions were identified for staff to evaluate the effectiveness of pain management interventions, to notify MD/NP (nurse practitioner) if ineffective, or if adverse side effects emerged, and to monitor and record any complaints of pain including: location, frequency, intensity, effect of function, alleviating factors and aggravating factors. The physician's orders [REDACTED].discharge potential: good, rehab potential: good, estimated length of stay less than 30 days. Medications listed included: [MEDICATION NAME] on in the morning off at bedtime, [MEDICATION NAME] (a narcotic pain medication) 25 mg every 4 hours PRN (try non-pharmacological methods first: distract/divert with tasks, exercise, music, reminiscing, activities, assess for hunger, cold, toilet/reposition before giving, and chart tasks attempted and results.) Given left arm FX. Tylenol 325mg 2 tabs every 4 hours. Given per standing orders for pain or fever. R76's Progress Notes indicated she had suffered from pain throughout her stay at the facility. Review of administration of medications given identified: [MEDICATION NAME] 25mg as needed was administered 9/5 (day of admission) once 9/6 through 9/17 was given 3 times per day. 9/18 was given 4 times-for all reasons were for pain With 41 times given staff only documented 19 times the results with 9 of those times mediation was not effective. Tylenol 650mg as needed administered 9/5 (day of admission) once 9/7 was given 2 times 9/8 through 9/10 was given once 9/11 through 9/14 was given 2 times 9/15 given once 9/16 given 2 times 9/17 given once 9/18 given 2 times With 20 times given staff only documented 9 times the results with 6 of those times medication was not effective. Review of progress notes summarized: 9/5/17 at 11:26 p.m. R-76 able to verbalize needs and pain, R-76 long and short term memory appears primarily intact at this time. At 11:33 left note for NP for care and maintenance of left arm splint, some discomfort at beginning of shift, meds given, has 101.1 temperature at 6:30 p.m. at 8:30 p.m. temperature was 99. 9/6/17 at 2:47 p.m. R-76 reports continuous pain to left shoulder At 11:25 p.m. daughter here visitinig this evening, R-76 was noted to sitting at supper and just looked at her food, staff assisted to fed her and give her drinks, no attempt was made by R-76 to feed self, daughter states this is new for her. Food assessed to be able to use a fork or hands to feed self. Does make verbal noises with transfers which may be related to pain or anxiety with transfers. Pleasant and co op with cares. 9/7/17 at 3:37 a.m. R-76 complained of extreme 8 out of 10 scale pain, [MEDICATION NAME]/Tylenol given, moans/screams with toileting/movement. At 12:23 p.m. R-76 unable to walk due to back pain, unable to maintain standing position, requires w/c and assistance with mobility at this time. 9/8/17 at 3:39 a.m. R-76 does have verbal and nonverbal s/s/ of pain with activity, [MEDICATION NAME]/Tylenol given. At 2:16 p.m. R-76 continues to complain of severe lower back pain and left arm pain, rates pain 10/10 at its worst and currently 6/10. At 11:29 p.m. fed supper by staff this evening, R-76 has significant increase in pain with movement, pain in both left arm and back. Daughter plans on discussing R-76 chronic pain with ortho doctor Tuesday. 9/9/17 at 11:57 a.m. R-76 continues to complain of extreme increase in pain in her lower back and left arm with transfers, rates pain 8/10 at its worst during shift and 0/10 while at rest in bed. At 9:45 p.m. daughter here this evening states she does not feel that the [MEDICATION NAME] is covering the pain well. Daughter is advised to discuss this with the doctor on Tuesday when R-76 has appointment, daughter stated she has some narco (pain medication ) at home if that would help, assured the doctor she is currently see will be able to adjust and prescribe her medication as needed. 9/10/17 at 12:28 p.m. R-76 continues to complain of severe pain in lower back with transfers At 10:18 p.m. R-76 continues to have significant back and left shoulder pain. States back hurts more than her arm. 9/11/17 at 4:30 a.m. R-76 slept a few hours of shift, but awoke with pain. [MEDICATION NAME]/Tylenol given because toileting transfers seemed almost impossible, seems to be almost painless while resting in bed. At 12:20 p.m. R-76 reported back/left shoulder pain, rated pain 8/10. 9/12/17 at 11:41 a.m. care conference was held with R-76 and family, staff spoke to family regarding the increase in blood pressures and may be due to pain, has had a 4 pound decrease in weight since admission, discussed pain and possibly increase or change in pain medication. Encouraged family to discuss with the ortho doctor today at R-76 appointment. 9/12/17 at 12:05 p.m. Social services met with R-76, note reads R-76 did answer yes to having thoughts of being better off dead. At 6:01 p.m. return from ortho appointment with orders for physical therapy, note reads humerus fracture is causing minimal achy pain. Most pain is from t-spine. Follow up with doctor for t-spine pain. At 11:18 p.m. pain is primarily in the back. Appetite has been poor in the evening since admit. R-76 likes to rest on side while in bed to take pressure off her back. 9/13/17 at 3:09 a.m. R-76 yelled out and complained of pain in her back and left shoulder when transferred to the toilet around 2am. At 11:26 p.m. R-76 noted to have severe pain with movement. States feels better when laying or sitting still. R-76 has had a noted decline in appetite. Family left note for doctor regarding some of concerns regarding R-76. 9/14/17 at 2:56 p.m. doctor here on rounds. Received an order for [REDACTED]. At 11:54 p.m. return from x-ray about 4:30 p.m. very fatiqued. R-76 at 50% of supper fed to her. 9/15/17 at 7:09 p.m. family expressed concerns about treatment for [REDACTED]. These are most often best treated with pain control and mobilization as tolerated. Copy given to daughter. 9/16/17 at 10:48 p.m. R-76 remained in bed all evening, using beside commode. Extreme pain noted with movement, transfers with 2 to 3 staff to maximize support and gentle movement. At 1:27 a.m. R-76 has extreme pain with movement, bedside commode used this shift, however did scream with pain with all motion, R-76 has already had as needed pain medications with little effect. R-76 much less pain once positioned and not moving. 9/17/17 11:03 a.m. note from physical therapy, R-76 increased c/o right hip pain this date with increased difficulties weight bearing right lower extremity with stand pivot transfer. Finding communicated with daughter and floor nurse. At 3:07 p.m. R-76 reported increased pain to right hip, stabbing like pain, rated pain 8/10 when sitting up and with transfers, R-76 sometimes screams with transfers. 9/19/17 12:31 p.m. R-76 complained of generalized pain rated 5-8/10 during this shift. At 4:02 p.m. telephone order from doctor to change [MEDICATION NAME] to 50mg every 6 hours scheduled, start calcitonin 200iu daily alternating nostrils, [MEDICATION NAME] 100mg TID, Tylenol every 8 hours scheduled, d/c as needed dose and follow up with NP in morning if pain does not subside for possible increase in pain medications. At 10:45 p.m. R-76 standing with 2 assist, lost control and collapsed. 9/20/17 at 6:13 p.m. R-76 calling out in pain with movement this shift, refused to get up for supper. R-76 claimed is in too much pain to get up and just wants to be left alone. Rated pain 10/10 in her back. R-76 also refused to eat her supper in bed, but did drink some of her ensure. 9/20/17 NP change ensure to one can by mouth twice daily and occupational therapy to evaluate wheel chair positioning (family reports slouching, not using arm due to holding self up in wheel chair.) 9/21/17 NP note [MEDICATION NAME] brace to be used as needed while oob (out of bed) for support and pain relief(compression FX) 9/21/17 at 1:38 p.m. R-76 continues to complain of severe pain in her back, upper arm, left hip and general joint aches. Medications given with very little relief. R-76 unable to use right arm to preform ADL's or feed self. R-76 severely self-limiting this shift. 9/22/17 at 7:11 a.m. R-76 requested to go the bathroom at 2am. R-76 is a 2 person assist with Hoyer for transfers (mechanical lift) R-76 did not want to use. Staff attempted transfer 2 times with the Hoyer. Once one inch off bed R-76 screamed in pain. Used bedpan with large void. Will continue to monitor and contact therapy regarding pain/discomfort with transfers. At 10:57 a.m. new orders to discontinued [MEDICATION NAME] and Tylenol. Increase [MEDICATION NAME] to 25mcg and start narco 5/325mg tabs 5 times daily scheduled, with a 2am PRN dose then change to every 4 hours as needed after 10days. Hold med if becoming to sedated. 9/23/17 7:56 p.m. R-76 resting well most of shift. Until shortly before dinner. R-76 began to experience pain not able to rate. Moaning audibly in pain even while at rest. Daughter visiting expressed concern the confusion and irritability R-76 had was too far from her baseline. Scheduled dose of narco given which has not appeared to have an effect on pain or irritability. Vitals record shows last recorded urination was around 9am on 9/22 and aides reported there has not been any this shift. R-76 skin tents and has a slight tremor in her right hand. On call physician contacted received order to send to emergency room for assessment. 9/24/17 at 12:06 a.m. received call R-76 will be spending the night in hospital due to [MEDICAL CONDITION]. Bed hold signed. 9/25/17 at 1:48 p.m. received phone call will be transferred due to kidney failure and being anemic. Creatinine in 4.81 and hemoglobin 6.7. Review of dismissal summary for medications does not have an order for [REDACTED]. Reads: SHO will expire after three days and the provider will need to be contacted if there is a need for the order to be continued. Order found to be continued without contact of provider per SHO Interview on 12/15/17 at 04:32 p.m. registered nurse(RN)-L recalls pain never really got under control - back pain bothering her the most - scheduled [MEDICATION NAME] every 6 hours 50mg - she seemed to respond less and less to pain medication. They started using a Hoyer because was not transferring well for protection of the staff and her. Started a [MEDICATION NAME] and changed to [MEDICATION NAME] because not responding to [MEDICATION NAME] - shortly after change went to hospital. Interview on 12/15/17 at 3:18 p.m. Licensed practical nurse (LPN)-C was asked regarding the concern sheet the staff fill out for the provider to see and make notes. If surveyors would find them in the chart. LPN-C stated no. Requested the document if any information was there. LPN-C stated they are left in the nurses station. Later updated no additional papers found verifying provider was updated with continued pain complaints. Phone interview with family member FM-F on 12/15/17at 3:50 p.m. Reviewed time line of R-76 stay in the facility. FM-F stated wanted only facts to be shared and will keep opinions to self. FM-F added they felt they had to come in do their own assessments to make sure R-76 was being cared for. FM-F requested several times to have labs completed but was denied the request with staff stating they were trying to get the pain under control first. FM-F commented the day R-76 went in to hospital they stepped out side to get some fresh air when R-76 requested not to go back in the facility. Family assessment completed after consulting a physician in the family for help. FM-F suspected R-76 was dehydrated after completing a pinch test on the arm. FM-F requested the physician be called for an evaluation. Staff told FM-F providers do not come over to evaluate. Order was requested to transport to emergency room . FM-F asked staff if they were not in the facility if they would have called the family. FM-F stated the findings from the emergency room was dehydration with no improvement in kidney function. Was then transferred to another hospital with talks of starting [MEDICAL TREATMENT], creatinine levels rose to 5.5. Review of policy titled Pain-Clinical Protocol reads: monitoring, the staff will reassess the individuals pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. For example, review frequency and intensity of pain, ability to perform ADL's, sleep pattern, mood, and behavior. If a resident pain is complex or not responding to standard interventions, the attending physician may consider a psychiatric evaluation or referral to a pain clinic or specialist. Policy review titled: Pain Assessment and Management under general guidelines, Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain at least weekly in stable chronic pain. For monitoring and modifying approaches: If pain has not been adequately controlled, the multidisciplinary tram, including the physician, shall reconsider approaches and make adjustments as indicated.

Based on observation, interview and document review, the facility failed to comprehensively reassess falls to determine possible causative factors in order to develop resident centered interventions to minimize the risk of further falls for 1 of 3 residents (R48) who had a history of [REDACTED]. Findings include: R48 was observed on 12/11/17, at 5:38 p.m. wheeling himself in a wheelchair down a hallway on his unit, with rooke boots on both feet and a cervical collar in place around his neck. R48's [DIAGNOSES REDACTED]. R48's admission fall risk assessment dated [DATE] was reviewed and found to be blank. R48's fall risk assessment completed 9/1/17 indicated R48 was at high risk for falls. A Care Area Assessment (CAA) dated 8/9/17, identified R48 to be at risk for falls r/t to weakness from recent hospitalization and impaired mobility following recurrent hip dislocations. The CAA further indicated staff were to keep the resident's call light easily assessible and assist as the resident as needed,and indicated the resident was to work with therapy for strengthening. Staff will monitor for attempts to self-transfer. Notify medical doctor of changes. Proceed with plan of care. R48's care plan last revised on 12/13/17, indicated the resident was at risk for falling related to history of falls and dependency upon staff for assist with transfers and ambulation. Approaches for care included: Pharmacy review of medications (initiated 12/13/17), hospice consult/admit related to resident needing extra care/attention (initiated 11/26/17), resident moved to room closer to the nurses' station (initiated 10/29/17), give verbal reminders not to transfer without assistance (initiated 10/23/17), hourly checks (initiated 8/29/17), two stop and wait for assistance/use call light signs were placed in resident's room (initiated 11/14/17), keep bed in lowest position with brakes locked, keep call light easily accessible, keep personal items and frequently used items easily accessible, provide environment free of clutter, provide proper, well maintained footwear (all initiated on 8/25/17). R48 did not have a fall care plan developed until 8/25/17, after R48 had fallen in the facility, even though R48 had been admitted for a recurrent dislocation of the left hip, had a history of [REDACTED]. Review of progress notes from (MONTH) (YEAR) through (MONTH) (YEAR), indicated R48 had continued self-transferring attempts when in his room. Review of fall incident reports from (MONTH) (YEAR) through (MONTH) (YEAR) included the following: A fall on 8/25/17, at 1:15 a.m. occurred in R48's room. R48 had self-transferred and was found lying on his right side at the foot of his bed. R48 had used his urinal, and then was unable to state why he was getting up. R48's right elbow was visibly bleeding, and he was assisted to turn on his back. The report indicated R48 had complained of right ankle pain, right elbow pain and bilateral hip pain. R48 was sent to the emergency room for evaluation. R48 sustained a 6 centimeter (cm) by 5 cm skin tear to the right elbow. Fall intervention implemented: Resident was re-educated to use call light for assistance and two stop and wait for assistance signs were placed in his room. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. An incident report for a fall on 8/26/17, at 2:00 a.m. indicated the fall had occurred in R48's room. The report indicated R48 had slid out of his recliner, with no new injuries noted and at the time, R48 had stated he was ready to get up. A fall intervention implemented following this fall included every one-hour checks. R48's medical record lacked documentation of a root cause analysis or interdisciplinary team meeting review of the fall. A fall incident report also indicated R48 had fallen on 9/20/17 at 5:40 a.m. in his room. R48 was found lying on the floor, on his back. When asked what he was doing R48 had stated, I was getting up to get a quilt for my legs, they were cold. The report indicated R48 had been yelling and that is what had alerted the nursing assistant to his room. R48 had no new injury. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new fall interventions were implemented. A fall incident for 10/17/17, at 3:14 a.m. indicated the resident had fallen in his room. The report indicated R48 was heard yelling out for help from his room although he did not have his call light on. R48 was found lying on the floor at the foot of the bed, on his right side. R48 did not have his gripper socks on, his feet were wrapped in ace bandages and he had removed his Rooke boots. When R48 was asked what he was doing before he ended up on the floor, r R48 stated he was standing and bending over to work his bed control remote at the foot of his bed as he was about to get back into bed. The report notes indicated R48 sustained a 2 centimeter (cm) by 1 cm skin tear on the right elbow, which was bleeding moderately. R48 was reminded to use the call light. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new fall interventions were implemented. A fall on 10/27/17, at 7:40 a.m. occurred in R48's room. R48 was found sitting on floor at the side of his bed on the floor. The notes indicated R48 had stated he needed to get out of here to go to work in the grain bin. R48 was assisted back to bed with a Hoyer lift (mechanical lift device) back to bed. The report indicated R48 had suffered no apparent injury, had no complaints of pain, and his vital signs were stable. The call light was secured on his chest with a clip following the fall, and R48 was instructed to call if he needed help, and to stay in bed. New fall intervention implemented included R48 being moved to a room closer to the nurses' station. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. A fall on 11/22/17, at 4:30 a.m. occurred in R48's bathroom. R48 was found on the floor in the bathroom lying on his stomach. R48 had a cut his forehead that was bleeding and his nose was bleeding. The notes indicated pressure was applied to areas with a wet cool cloth and passive range of motion was done. R48 was able to move all extremities freely with no complaints of pain. However, documentation indicated R48 was moaning from the injury to the head so an order was received to send R48 to the emergency department by ambulance. The report indicated R48's bed was in the low position and he had gripper socks on at the time of the fall. R48 sustained serious injuries including lacerations to forehead and nose, open fracture of nasal bone, [MEDICAL CONDITION] cervical vertebra, and multiple skin tears. R48 required 3 stitches. Following the fall, the new fall intervention implemented was to initiate hospice services. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. A fall on 12/13/17, at 11:45 p.m. occurred in R48's room. R48 was found with his knees on the floor and his arms on the bed nearest the window. When asked what R48 was doing he replied, Well, getting the hay. R48 sustained a small 1 cm by 1 cm abrasion on his right knee. The report indicated R48 had gripper socks on at the time of his fall, and the bed was in the lowest position. The fall intervention implemented post fall included: medication review completed by the pharmacist. R48's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. During an interview on 12/13/17, at 2:06 p.m. the director of nursing (DON) stated they do not complete a root cause analysis of each fall unless there is a significant injury that would require medical follow-up for the fall. The DON stated each fall was reviewed at an interdisciplinary team (IDT) meeting, held every morning at 8:30 a.m. Monday through Friday. The DON stated the fall incident was on a report sheet and the staff working at the time of the fall identified interventions, and the IDT team could add more interventions later. The DON stated meeting minutes were not recorded during the IDT team meetings. The DON stated R48 was a frequent faller, an impulsive resident that did not use the call light, and the DON added, we have gotten rid of all of the alarms. During an interview on 12/14/17, at 12:09 p.m. registered nurse (RN)-A stated a falls risk assessment was not completed for R48 upon admission. RN-A verified the falls risk assessment in the computer dated 8/1/17 was blank and R48's fall care plan was not initiated until 8/25/17. RN-A stated upon admission a fall risk assessment should have been completed for R48 and that would have determined the need for a care plan and interventions to be developed. During an interview on 12/14/17, at 12:53 p.m. nursing assistant (NA)-A stated, the only behavior I am aware of is he self-transfers, we try to make sure he is where he wants to be so he does not self-transfer. NA-A was not aware of any set time that staff should be checking on R48, and stated, I check on him every two hours and I do peek in his room whenever I walk by, as he does like to self-transfer. During an interview on 12/14/17, at 1:05 p.m. nursing assistant (NA)-B stated R48 was on one hour checks and the checks are documented in the computer system. During an interview on 12/15/17, at 10:48 a.m. registered nurse (RN)-A stated hospice was implemented as a fall intervention to have a better sense to get R48 more comfortable and to help R48 be less anxious and restless during the night. RN-A stated R48 would get extra care with hospice services in place and they would review his medications. RN-A verified 6 of R48's falls, including the fall on 11/22/17, occurred during the night shift when extra care from hospice would not be occurring. RN-A verified no new fall interventions had been put into place for the night shift since the hourly checks were implemented for R48 on 8/28/17. RN-A verified the facility did not increase safety checks at night after the 11/22/17 fall when R48 sustained significant injury. During an interview on 12/15/17, at 11:27 a.m. the DON verified R48 was at high risk for falls upon admission. The DON stated R48 had surgery for [REDACTED]. A Fall Risk Management-Accident Prevention undated policy included, Fall risk assessment, identification and implementation of appropriate interventions is necessary to reduce the risk of significant injury for those we serve.

Based on interview and record review, the facility failed to communicate and implement fall interventions to minimize the risk of falls for 1 of 3 residents (R1) who sustained injuries due to a fall from the wheelchair that resulted in actual harm when R1 sustained a head injury, fracture of the vertebrae of the neck, a dislocated shoulder, and a broken shoulder socket. Findings include:Record review established R1 was alert and oriented to self. R1 used a wheelchair to self propel. The electronic care plan dated [DATE] (the day of the fall) directed staff that foot pedals were to be used on the wheelchair due to increased weakness and limited wheelchair mobility. The Nursing Assistant (NA) worksheet, dated [DATE] did not include the use of foot pedals as an intervention for R1. Nursing Assistant/(NA)(E) was interviewed on [DATE] at 10:25 a.m. and stated on [DATE] (the day of the fall) she pushed R1 to the dining room in the wheelchair for breakfast. About half way into the dining room, R1's right foot got caught under her left heel, and caused the wheelchair to stop suddenly. R1 fell forward out of the wheelchair, hitting her forehead on the floor. Registered Nurse/(RN)(J) was notified, assessed R1, and sent her to the hospital for evaluation. NA(E) stated R1 did not have foot pedals on the wheelchair at the time of the fall, and NA(E) was not aware R1 required foot pedals during transfers in the wheelchair. NA(E) stated the foot pedals were not written on the NA worksheet, which is the guide for staff to use for resident care, and she was not aware foot pedals were a new intervention for R1. Following the incident, she and NA(I) looked at R1's care plan on the computer, and foot pedals were not listed as an intervention for R1. NA(E) stated she was trained to use the NA worksheet for resident care, and has never been told to check the care plan in the computer for interventions related to resident care. NA(I) was interviewed on [DATE] at 4:25 p.m. and stated he witnessed R1 fall from the wheelchair, and stated R1 fell forward and hit her forehead on the ground. NA(I) called RN(J) who assessed R1, and sent R1 to the hospital. Following the fall, NA(I) did not see foot pedals on R1's wheelchair, and stated the foot pedals were not included as an intervention on the NA worksheet. Following the fall, he looked at the care plan in the computer and the foot pedals were not listed as an intervention on the care plan. He also looked in R1's room for foot pedals, and the foot pedals were located behind the bed in the room, not in visible site. NA(I) stated the NA's use the NA worksheet for resident care, and the use of foot pedals was a new intervention for R1, and should have been included on the NA worksheet. NA(I) stated he does not have access to the computer, so the NA worksheet is the guide he uses for resident care. RN(J) was interviewed on [DATE] at 3:35 p.m. and stated she was the nurse on duty at the time of R1's fall. She was notified by NA(I) that R1 had fallen out of her wheelchair. She assessed R1 and sent her to the hospital for evaluation. She stated R1 was bleeding from her forehead, but was conscious when she left for the hospital. R1 did not have foot pedals on the wheelchair at the time of the fall. RN(J) stated the use of foot pedals had been discussed with LPN (C) and family several days prior to the fall, but was unsure if R1 had been assessed or care planned to use foot pedals the day of the fall. RN(J) stated the nursing assistants use the NA worksheet for the care of the residents, and following the fall, NA(E) told her the foot pedals were not documented as an intervention on the NA worksheet. When she discussed the incident with the Director of Nursing/(DON)(A), DON(A) stated the care plan included the intervention for foot pedal use for R1. RN(J) stated the NA's use the NA worksheet for resident cares, and do not access the care plan in the computer to check for any new interventions related to resident care.Licensed Practical Nurse/(LPN)(K) was interviewed on [DATE] at 2:18 p.m. and stated she worked on another unit of the facility the day of the fall, and was called to assist with R1 following the fall from the wheelchair. LPN (K) stated she saw R1 lying face down on the floor, and was bleeding from her forehead. LPN (K) and RN (J) assessed R1, and sent her to the hospital for further evaluation. Following the fall, LPN (K) stated she did not see the foot pedals on the wheelchair, and NA (E) told her that she forgot to place the foot pedals on the wheelchair, prior to the fall. Following the fall, LPN (K) verified foot pedals were included as interventions on the care plan and on the NA worksheet. LPN (K) stated the NA's use the NA worksheet for resident cares, and do not access the care plan in the computer. She stated the foot pedals would be included on the NA worksheet if R1 required the use of foot pedals on the wheelchair. LPN(K) stated the unit manager is responsible to update the care plan and NA worksheets with any new interventions.Administrator(F) was interviewed on [DATE] at 12:10 p.m. and stated he was at the facility following the incident. He went to R1's room and found the foot pedals in R1's room, and verified the foot pedals fit the wheelchair. RN (J) reported to him the foot pedals were not included as an intervention on the NA worksheet, but he stated the foot pedals were found on the care plan in the computer following the incident. DON(A) was interviewed on [DATE] at 12:50 p.m. and stated R1's care plan included foot pedals as an intervention on the care plan. She stated the NA worksheet did not include the foot pedals as an intervention. She stated the foot pedals were not added to the NA worksheet, as they expect all staff to use foot pedals for residents in wheelchairs. DON(A) stated the care plans are available to all NA's on the computer. DON(A) stated that on [DATE], NA(E) told her she was aware R1 required foot pedals on the wheelchair, but NA(E) told her the foot pedals did not fit the wheelchair. The DON (A) spoke with LPN(C) who stated she added the foot pedals to the care plan prior to the fall, (unsure of date), but did not include the intervention on the NA worksheet for R1 at the time of the fall. LPN(C) was interviewed on [DATE] at 1:20 p.m. and stated she talked to the family approximately one week prior to the incident, and reviewed the use of the foot pedals for R1, and the family agreed to the use of the foot pedals. She also ensured the foot pedals were in R1's room, and fit the wheelchair appropriately. At the time of the interview, LPN(C) was unsure if the foot pedals were added as interventions on the care plan or NA worksheet. Individual (G)/family member was interviewed on [DATE] at 1:08 p.m. and stated that two days prior to the fall, she was notified by LPN(C) that R1 was unable to propel herself in the wheelchair due to increased weakness. She gave LPN (C) permission to use foot pedals when R1 was transported in the wheelchair. Individual (G) was told R1 would receive foot pedals, and would be transported in the wheelchair with the foot pedals on at all times. She was unsure why R1 did not have foot pedals on the wheelchair at the time of the fall. She stated following the fall, R1 was transferred to the hospital and was diagnosed with [REDACTED]. Following the fall, R1 was placed in hospice care, and died five days later.