Every finding on record at Bethany on the Lake LLC

Based on interview and document review, the facility failed to notify the physician for elevated blood sugar for 1 of 5 residents (R2) who was reviewed for unnecessary medications. Findings Include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, diabetes mellitus and arthritis. R2's MDS identified R2 required substantial maximal assistance with transfers, walking and dressing. R2 received insulin. R2's Care Plan dated 9/22/26, identified R2 had self-care deficit related to compression fracture, diabetes, Alzheimer's, dementia and chronic pain. Assist of one with grooming, dressing and bathing. Nails would be cut by nursing department. Review of R2's Order Summary Report signed 8/26/26, included the following:-blood sugar (BS) checks four times a day (QID) before meals and at bedtime. Treat blood sugars less than 70 per policy, document interventions and outcomes, if no improvements after treatment notify Doctor of Medicine (MD). If BS is greater than 400 notify MD.Review of R2's Weights And Vitals Summary from 6/15/26 to 9/22/26, identified the following Blood Sugar:-9/6/26, at 11:32 a.m.- 419 Review of R2's progress notes from 9/6/26 to 9/22/26, lacked documentation notification was made to the primary care provider for elevated blood sugar over 400 as ordered.During phone interview on 9/22/26 at 1:53 p.m., R2's primary care provider (PCP)-A confirmed her expectation was if a resident's BS was greater than 400, she would be notified, as that was a standard order for insulin. PCP-A stated it was important for her to be notified, because the resident's BS could continue to rise or not respond to the insulin. PCP-A indicated she was not notified R2's BS was greater than 400. During interview on 9/22/26 at 3:51 p.m., registered nurse unit manager (RN)-A confirmed R2's BS on 9/6/26, was elevated, and R2's medical record lacked documentation R2's MD was notified. RN-A stated her expectation was to notify MD if R2's BS was over 400. RN-A indicated it was important to notify MD if a resident's BS was elevated because it needed to be brought down, otherwise the resident could have ill effects from high blood sugars, and they could continue to go higher. During interview on 9/22/26 at 4:05 p.m., director of nursing (DON) indicated their blood sugar policy identified if BS was greater than 400, they were to contact the MD immediately. DON stated this was important to address high BS immediately and get orders for a treatment, such as an insulin order to bring down the BS, or it could contribute to a lot of things. The facility policy titled Blood Glucose Monitoring, undated, identified to notify the practitioner of critical test results within your facility's time frame to ensure prompt treatment. The facility policy titled Notification Of Changes Policy dated 11/25, identified changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to authority and reported to the attending physician or delegate. Objective of policy included to ensure facility staff made appropriate notification to the physician when there was a change in the resident's condition, or an accident that may require physician intervention. To provide appropriate and timely information about changes relevant to a resident's condition.

Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for 1 of 1 residents (R2 ) investigated for fall safety.Findings Include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, arthritis, repeated falls and fracture. R2's MDS identified R2 required substantial maximal assistance with transfers, walking and dressing. R2 had one fall with no injury since admission. R2's Care Area assessment dated [DATE], identified R2 was at risk for falls due to history of falls, Alzheimer's disease and R2 did not realize his limitations. R2 was adjusting to new environment. R2 received narcotic and antipsychotic medication which could increase risk for falls. R2 had one fall since admission with no injury. R2 was receiving therapy to improve abilities back to baseline. R2's potential complications were falls and injury. R2's Care Plan dated 9/22/26, identified R2 was at risk for falls related to compression fracture, history of falls, Alzheimer's disease, dementia and chronic pain. R2's interventions included: assist with hour of sleep (HS) cares and to bed at 7:30 p.m., video monitoring, low bed and safety mat, and offering toileting every two hours. The facility form titled Pocket Care Plan-Turtle Beach, undated, identified R2's safety interventions included low bed and safety mat, video monitoring, toilet every two hours, and assist with HS cares and to bed at 7:30 p.m. R2's Fall Review Evaluation form dated 6/15/26, identified R2 was alert and orientated to self, and unable to realize limitations. R2 required assistance of two with Ez-Stand (mechanical lift) for transfers. R2 had standard precautions in place. R2 did not always utilize call light appropriately. During observation on 9/22/26 at 9:21 a.m., R2 was lying in a low bed, covered in bedding with street clothes on and shoes. R2's eyes were closed and his door was open. R2 had a fall mat up against the wall between the bed and wall. R2's beside table was next to the bed. During observation on 9/22/26 at 9:43 a.m., R2 remained lying in a low bed, covered in bedding with street clothes on and shoes. R2's eyes were closed and his door was open. R2's fall mat remained up against the wall between the bed and wall. During observation and interview on 9/22/26 at 9:58 a.m., surveyor asked nursing assistant (NA)-A to check on R2. NA-A immediately noted R2's fall mat was not in place while he was in bed, then entered R2's room and placed the fall mat next to the bed. NA-A indicated she thought therapy staff had placed R2 in bed without the fall mat in place. NA-A indicated R2 was at risk for falls, and his fall prevention interventions included fall mat, soft touch call light, gripper socks in bed, a camera in his room and toileting every two hours. NA-A indicated it was important to put his fall mat on the floor while in bed to protect R2. At 10:24 a.m., NA-A informed surveyor that it was therapy staff who had put R2 in bed without the fall mat in place. During interview on 9/22/26 at 3:51 p.m., registered nurse unit manager (RN)-A reviewed R2's last three falls with surveyor and interventions put in place to help prevent falls. RN-A stated NA-A had informed her that R2's fall mat was not in place while in bed. RN-A stated she had educated therapy staff to assure fall interventions were in place. RN-A stated it was important to ensure that fall interventions were in place to prevent further falls, safety and to prevent injuries. RN-A indicated her expectation was for fall interventions to always be in place every day. During interview on 9/22/26 at 4:05 p.m., director of nursing (DON) indicated her expectation was that fall interventions were in place for the residents. DON stated the care plan and the nursing assistant's pocket care plans were updated with new interventions as needed and should be followed. DON indicated interventions were reviewed by the interdisciplinary team and changed as needed. The facility policy titled Fall Prevention And Management revised 11/25, identified Its purpose was to identify residents at risk for falls, implement fall prevention interventions, provide guidelines for assessing a resident after a fall and to assist staff in identifying cause of the fall. The policy identified facility staff would identify interventions related to residents' specific risks and causes to try to prevent the residents from falling and try to minimize complications from falling. Care plans were dated to reflect fall interventions.

Based on interview and document review the facility failed to protect 1 of 3 residents (R1) reviewed for abuse, from mental abuse when nursing assistant (NA)-A ridiculed, yelled with intent to intimidate, and threatened R1 with physical abuse, to be sent to a locked unit, and for staff to be unwilling to provide cares to R1 in the future. R1's actual response and the use of the reasonable person concept identified serious psychosocial harm to R1 when she exhibited crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The IJ began on 3/11/26 at 8:30 p.m., when NA-A was witnessed to make derogatory aggressive toned statements in the presence of R1 and two other staff. NA-A was not removed from shift and continued to work with R1 and other vulnerable residents despite an internal report being made. The administrator and director of nursing (DON) were notified of the IJ on 3/26/26 at 2:45 p.m. The facility implemented corrective action by 3/13/26 prior to the start of the survey and therefore is issued as past non-compliance. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified admission to facility on 2/26/26, from home/community. R1 had severely impaired cognition, feeling down, depressed, or hopeless (two-to-six days out of seven), and no behaviors noted. R1 required partial/moderate assistance with oral/personal hygiene, shower/bathe, substantial/maximal assistance with upper body dressing, roll left and right in bed, sitting to lying position, lying to sitting on side of bed, was dependent with toileting hygiene, lower body dressing, sit to stand, all transfers, was unable to walk, and used a manual wheelchair for mobility. R1 was frequently incontinent of bowel and bladder. R1's diagnoses included non-traumatic brain dysfunction, arthritis, muscle weakness, Alzheimer's disease, dementia, anxiety, depression, and psychotic disorder. R1's medications include antipsychotic, antianxiety, and antidepressant.R1's St. Louis University Mental Status (SLUMS) (an assessment designed to evaluate various cognitive functions, including memory, attention, and problem-solving skills) dated 3/3/26, identified a score of 4 out of 31 [sic] - dementia (25-30 normal cognition, 20-24 mild neurocognitive disorder, and 1-19 points dementia).R1's care plan dated 3/16/26, identified the following areas of concerns and interventions to address each area:Alteration in behavior as evidenced by (AEB) wandering, yelling in room for help, yelling in hallway, combative with staff, throwing belongings, calling staff names related to psychotic disorder, anxiety, Alzheimer's disease, dementia and chronic pain. Interventions included to call family or granddaughter to assist with compliance of medications and calming R1 down, be alert to mood and behavior changes, approach in a calm voice making eye contact and using therapeutic touch. Behaviors were to be documented. Additional interventions included to validate feelings/provide emotional support, administer medications as ordered, re-direct by offering food/fluids/toileting/repositioning, Alteration in cognition and psychosocial wellbeing. Interventions included to allow her time to communicate her needs/wants, provide and maintain consistent environment, provide cues, reorientation/supervision as needed, monitor and respond to unmet needs, and monitor mood state.Alteration in mood and behavior related to psychotic disorder with delusions. Interventions included to monitor and document mood state/behaviors upon occurrence.R1 was a vulnerable adult while she resided in facility. Interventions included to monitor for signs of emotional distress or mood and behavior changes, continue to follow the facility vulnerable adult and abuse reporting policy. In addition, the local Ombudsman, Adult Protection, Police and/or state/financial agencies were to be notified of any suspected abuse or financial exploitation as needed.Facility investigation 5-day report dated 3/16/26 at 3:10 p.m., indicated on 3/11/26 at 8:30 p.m., NA-A and NA-B assisted R1 with evening cares. R1 was crying, and had ended a phone call with her son when NA-A stated, you need to stop crying, you are acting like a two-year-old. NA-B reported NA-A seemed frustrated and sounded stern. NA-A placed R1's arms on the EZ stand (mechanical device used to lift and lower a resident), R1 swatted out at NA-A. NA-A stated if you hit me again, I am going to hit you back. This statement confirmed by NA-A, who stated she made the comment not thinking but would never hit a resident. Staff assistance was requested over the walkies. NA-C entered R1's room and heard NA-A yell at R1 in a loud toned voice, stop crying, they are going to put you in a locked unit. NA-C felt NA-A was not joking. NA-A left R1's room briefly to assist another resident and returned approximately five minutes later. R1 continued to cry and was distraught. NA-A stated to R1, nobody will want to keep working with you, nobody wants to work with a crybaby.R1's physician orders included:-Monitor for signs and symptoms of emotional distress and place a note in chart three times a day until 3/26/26 at 11:59 p.m. Order date: 3/12/26. Start date: 3/12/26. -Monitor for bruising on upper body every shift. Order date: 3/12/26. Start date: 3/12/26. -Target behavior monitoring: 1. Restlessness, 2. Increase in complaints, 3. Refusing care, 4. Self-isolation, 5. Crying, 6. Not sleeping at night, 7. Wandering into other resident rooms. Non-pharmacological, Document number of those interventions used: 0: N/A, 1. redirection, 2. Ambulate, 3. offer activity, 4. Ambulate, 5. Reposition, 6. Toileting, 7. Provide 1:1, 8. Offer food/fluids, 9. Offer pain relief two times a day. If target behavior observed. Select chart other and enter findings including effectiveness of interventions in the nursing progress notes. Order date: 3/12/26. Start date: 3/12/26. -Sending to ER for evaluation of symptoms of combativeness and emotional distress. Order date: 3/14/26.-Risperidone (used to treat agitation, aggression, and psychosis during dementia) oral tablet 0.25 milligrams (mg) give 0.25 mg by mouth (po) at bedtime for dementia with aggressive behavior. Start date: 3/14/26. Discontinue date: 3/16/26.- Risperidone oral tablet 0.25 mg give po at bedtime related to psychotic disorder with delusions due to known physiological condition. Start date: 3/16/26. Hold date: 3/18/26, through 3/24/26. Discontinue date: 3/24/26.-Alprazolam (anti-anxiety) oral tablet 0.25 milligram (mg) po as needed (PRN) for anxiety related to anxiety disorder for 14 days, three times a day (t.i.d.), morning, noon and evening. Order date: 2/26/26. Start date 2/26/26, and renewed order on 3/14/26. Start date: 3/14/26. End date: 3/28/26.- Quetiapine (Seroquel) Fumarate (antipsychotic) oral tablet give 50 mg po three times a day (8:00 a.m., 2:00 p.m., 8:00 p.m.) related to dementia with other behavioral disturbance disorder with delusions due to psychological condition. Start date: 2/26/26.R1's electronic medication administration record (EMAR) dated March 2026, from 3/11/26 through 3/21/26, identified:-Risperidone oral tablet 0.25 milligrams (mg) give 0.25 mg po. Administered on 3/14/26, 3/15/26, 3/16/26, and 3/17/26. -Quetiapine Fumarate give 50 mg po three times a day. Administered as ordered 3/11/26 through 3/16/26, except on 3/14/26, 8:00 a.m. dose refused. -Alprazolam (anti-anxiety) oral tablet 0.25 mg. Give 0.25 mg po as needed for anxiety three times a day (morning, noon, and evening). Administered one time a day on 3/3/26, 3/4/26, 3/6/26, 3/7/26, 3/8/26, two times a day 3/9/26, 3/10/26, 3/11/26, one time a day on 3/15/26, 3/18/26, 3/19/26, 3/20/26, and two times a day on 3/21/26. R1's nursing target behavior monitoring two times a day (2:00 p.m. and 9:00 p.m.). If target behavior was observed from 3/4/26 through 3/17/26, identified: 1. Restlessness, 2. Increase in complaints, 3 Refusing care. 4. Self-isolation. Document number of those interventions using the code provided. Start date 2/26/26.At 2:00 p.m. on 3/4/26, 3/5/26, 3/9/26, and 3/10/26, no documentation. At 2:00 p.m. on 3/6/26, 3/7/26, 3/8/26, 3/11/26, 3/15/26, 3/16/26, and 3/17/26, no behaviors noted.At 9:00 p.m. on 3/4/36, 3/5/26, 3/6/26, 3/7/26, 3/9/26, 3/11/26, 3/15/26, 3/16/26, and 3/17/26, no behaviors noted.At 9:00 p.m. on 3/8/26, refused care. Intervention: provide 1:1.At 9:00 p.m. on 3/10/26, restlessness. Intervention: redirection, offer activity, reposition, and provided 1:1.At 9:00 p.m. on 3/12/26, restlessness and refusing care. Intervention: redirection, offer activity, reposition, and toileting.At 2:00 p.m. on 3/13/26, restlessness, increase in complaints, refusing care, and wandering into other resident rooms. Interventions: redirection, offer activity, provide 1:1, and offer food/fluids. At 9:00 p.m. self-isolation. Intervention: redirection.At 2:00 p.m. on 3/14/26, no documentation. At 9:00 p.m. X entered each box.R1's NA behavior charting every shift (night, day, evening) from 3/4/26, through 3/16/26, identified:Responses:3/4/36 - Not applicable: all three shifts3/5/36 - Not applicable: all three shifts3/6/26 - Not applicable: nights/days. Crying/expressions of sadness: evening.3/7/26- Not applicable: all three shifts3/8/26 - Not applicable: nights. Crying/expressions of sadness day and evening.3/9/26- Not applicable/none noted: nights and days. Crying/expressions of sadness: evening.3/10/26 - Not applicable: nights and days. Crying/expressions of sadness: evening.3/11/26- Not applicable: nights and days. Calling out/yelling: evening.3/12/26 -Not applicable/none noted: all three shifts3/13/26- Calling out/yelling, hitting or kicking, pinching scratching: nights. Resisting or refusing care: days. Not applicable: evening.3/14/26- Not applicable/none noted: nights and days. Resident not available: evening.3/15/26 - Not applicable/none noted: nights and days. Resisting or refusing care: evening.3/16/26 - Not applicable/none noted: all three shifts.R1's NA meal intake/amount eaten and fluid intake documentation from 3/4/26, through 3/17/26, identified:3/4/26, 51 to 100% of all three meals. Fluids consumed 1200 milliliters (ml). 3/5/26, 51 to 100% of all three meals. Fluids consumed 780 ml. 3/6/26, 51 to 75% of all three meals. Fluids consumed 840 ml. 3/7/26, 51 to 100% of all three meals. Fluids consumed 1060 ml. 3/8/26, 76 to 100% of all three meals. Fluids consumed 720 ml. 3/9/26, refused breakfast and 51 to 75% of lunch and supper. Fluids consumed 490 ml. 3/10/26, 26 to 50% of breakfast, 75 to 100% of lunch and supper. Fluids consumed 840 ml.3/11/26, 26 to 50 % of breakfast, 75 to 100% of lunch and supper. Fluids consumed 840 ml. 3/12/26, 0 to 25% of breakfast, 26 to 50% of lunch, and refused supper. Fluids consumed 360 ml. 3/13/26, refused breakfast and lunch, 76 to 100% of supper. Fluids consumed 450 ml. 3/14/26, refused breakfast and not available for lunch and supper. Fluids consumed 0. 3/15/26, 76 to 100% breakfast and supper, refused lunch. Fluids consumed 490 ml. 3/16/26, breakfast not available, 51 to 75% of lunch and supper. Fluids consumed 690 ml. 3/17/26, 76 to 100% of all meals. Fluids consumed 1210 ml.R1's psychiatric care notes identified:On 2/26/26 at 12:07 p.m., the virtual visit with this writer was cancelled due to her moving from assisted living to a different assisted living facility. R1 will receive ongoing psychiatric medication management by rounding providers at her new home.On 3/16/26 at 3:00 p.m., writer spoke to nursing home facility nurses (2) and was updated R1 had been in ER over the weekend for increased behaviors, anxiety, and agitation. The nursing team was looking for guidance on how to best address R1's psychiatric care going forward. This writer was under the impression she had been moved to a locked memory care unit from AL though her current living situation was not that. Additionally, there had been some hesitancy from the rounding provider at her current place of resident in managing psychiatric conditions and heightened behaviors. Would be best for R1's wellbeing and care to be in an inpatient psychiatric unit, transition to a locked memory care unit and most likely be the best option so aggressive medication adjustments can be made under constant surveillance and supervision and was discussed with her son. R1's progress notes from 3/9/26, through 3/14/26, identified:On 3/9/26 at 8:24 p.m., R1 behaviors this shift very emotional and whiny. Crying at supper and stating she wants to get out of here. Took half of her supper and dumped it on the floor. Sat at nurse's station whining and crying. Called son. Put to bed around 8:00 p.m. and was calm.On 3/10/26 at 5:07 a.m., Tried to slide out of recliner at 4:15 a.m., wanted to get up and look outside. Toileted and transferred back into recliner. Hollered out and tried sliding out again. Unplugged her oxygen (02) concentrator and refused to leave O2 on. Redirected and TV turned on to distract her.On 3/10/26 at 10:55 a.m., Received a call from Mental Health Provider and able to see resident by tele-health but not in person. Will discuss rounding provider.On 3/10/26 at 2:05 p.m., Wandering around the unit redirected back to room. Attempted to get on elevator. Crying episode and anxious behaviors noted. Hollering for ride to go home for over four hours repeated cycle from 10:00 a.m. to 2:00 p.m. Less crying and hollering after Seroquel and alprazolam given earlier.On 3/10.26 at 8:32 p.m., Very emotional this shift. Constantly crying, wanted to go to another facility. Redirected many times and activities offered. Wandered halls did not attempt to exit building.On 3/11/26 at 6:49 a.m., Resident did not calm down after PRN. Continued to cry out and screaming she wanted to leave. Tried to soothe her, offer activities to distract her, 1:1 bathroom multiple times, reason with her, and reposition.On 3/12/26 at 3:18 p.m., Resident cried most of the morning. Very restless and difficult to redirect. Writer attempted to give morning pills at 9:00 a.m., gave her cup of water to drink and she almost threw the cup at the writer. Writer unable to get morning medications in at this time. R1 name-calling staff, hitting staff when trying to redirect or toilet. Staff offered county music, coffee snacks, and repositioning. Resident seen wandering into other resident rooms this shift. Writer was able to administer morning medications at 1:00 p.m., with no behavioral issues at this time.On 3/12/26 at 3:30 p.m., received notification of verbal allegations. OHFC filed per policy. Investigation pending. Resident stated she felt safe in facility.On 3/12/26 at 6:48 p.m., R1 wandering halls this shift going into other resident rooms. Unable to redirect. Yelling at staff you're giving into the shit. Refused blood sugar check and medications, will reapproach later. Crying in the halls stating she wants to go home. Offered activity, toileting both ineffective. Hollering out in the halls she needs help. When writer approached resident, she was unable to express what she needed help with. Wants to go home. Wander guard (device placed on a resident to alert staff when resident is too close to an exit or other unsafe area) and video monitoring in place. On 3/12/26 at 9:26 p.m., R1 continued to have behaviors after supper. Hitting out at staff, refused medications, went into resident rooms and was unable to be redirected. Resident yelling out and crying. DON (director of nursing) updated and stated to call family and see if they would be able to provide 1:1 with resident to help with behaviors or call on-call provider and send to ER (emergency room) if behaviors are unable to be managed. Called daughter who tried talking to resident on phone but was not calm enough and unable to talk. Daughter agreed to call on-call and send in if appropriate. Granddaughter called the desk stating she can usually calm resident down and resident did talk to her on the phone. Resident calmed down and took oral medications plus PRN Tylenol. R1 laughed and joked with staff, ate some ice cream, and placed in recliner. On 3/12/26 at 10:36 p.m., R1 also yelling swear words loudly.On 3/13/26 at 12:38 a.m., R1 in her room screaming get out of here and leave me alone at this time loud enough to hear her at the nurse's station. Staff had attempted to reposition, toilet, and offered snacks. R1 screamed at staff, swings, pinches at staff with redirection. Staff will monitor.On 3/13/26 at 5:54 a.m., R1 had been waking periodically throughout the night and yelling then fell back to sleep. Writer approached resident to attempt to get her up for the day. Resident yelled no and began getting agitated. Did not get up on the night shift.On 3/13/26 at 12:33 p.m., Resident yelled out at staff this a.m. so slept until 11:30 a.m. Staff got resident up and dressed. No injuries, bruising noted, or complaints of pain. R1 loudly refused to have blood sugar checked, insulin, and medications given. Yelled at writer and stated, your only out for the money! R1 made her way down the hallway and refused food when offered. Went into another resident's room and loudly protested when wheeled out of room. Door shut per request by another resident. Resident protested stated stop slamming doors.On 3/13/26 at 2:26 p.m., R1 refused all food and drink today. Had been wandering halls in wheelchair and made multiple attempts to go into other residents' rooms. Administered Seroquel with a sip of water. Made frequent statements that people want to take her money.On 3/13/26 at 3:12 p.m., primary provider here and ordered resident monitored for emotional distress. Noted OHFC was filed for allegations of verbal abuse. Recommended consult with psych.On 3/14/26 at 10:34 a.m., Usual Mental Status/Cognition Function before the Acute Change in Condition: Alert, disoriented, but cannot follow simple instructions. Behavioral concerns: combativeness, emotional distress, and inconsolable physical and verbal behaviors. Sent to ER for evaluation for the behavioral concerns.On 3/14/26 at 1:35 p.m., R1 slept in this afternoon. She repeated statements what am I doing here and tell me what is going on. Reassurance given. Assisted to wheelchair, started crying and hollering out someone please tell me. Attempted to comfort with non-pharmalogical interventions. R1 swung arms at writer when attempted medication administration, food and fluids. Called son, attempted to talk to her. R1 threw phone when son tried to talk resident into taking scheduled medications. R1 cried and screamed on the phone, I said no I don't want to! Son attempted for five minutes to talk and R1 continued to throw phone. Son gave okay for R1 to be sent to hospital. R1 would not allow staff to have the phone, swung arms, kicked out at staff whenever they attempted to come near her. Contacted provider and called 911 for transport, sent two officers and ambulance crew. R1 continued to be aggressive towards officers and ambulance crew, swore and swung at them while they attempted to transfer her onto the stretcher. Ambulance crew administered an IM medication with assistance from the officers. No further outbursts were noted.On 3/14/26 at 2:42 p.m., R1 returned via EMS (emergency medical services) to facility. She was assisted into recliner by staff and EMS. R1 was sleeping upon arrival to facility. New orders for Xanax and Risperidone. Son called and updated.On 3/14/26 at 6:26 p.m., Resident slept in recliner for three hours after return from ER. At 5:00 p.m., R1 was getting out of recliner and yelled out help me. Staff walked into room and resident yelled, get out of here I don't want you, I need help. Staff attempted to give Risperidone prescribed by ER and R1 hit out and yelled at staff shit and assholes. Staff boosted her due to sliding out of chair and she hollered out and hit at staff. R1's behaviors increased as time went on. On call provider notified. R1 was hallucinating things in her room and told EMS she did not feel good. She was unable to express where she did not feel good. Physician Referral Form dated 3/13/26, identified issues to be addressed: R1 will be monitored 14 days for emotional distress. Office of Health Facility Complaints (OHFC) filed for allegation of verbal abuse. Recommend appointment with psychology.Provider verbal order document dated 3/14/26 at 10:31 a.m., Sending to emergency room (ER) for evaluation of symptoms of combativeness and emotional distress.Emergency Department (ED) provider notes dated 3/14/26 at 11:59 a.m., identified R1 presented to ED today via emergency medical system with concerns about behavioral agitation from her dementia. Agitation/behavior currently managed with Seroquel. Per report from staff in the last couple of days she has had poor oral intake, refused oral medications, and increased agitation. Today she was aggressive with staff so 911 was activated for transport to ED for emergency evaluation. She was given intramuscular (IM) injection 50 mg of Benadryl (relieves allergy symptoms and makes you sleepy), Versed (used for sedation) 5 mg and Haldol (antipsychotic used to treat psychotic disorders) 5 mg by EMS was quite sedated and very drowsy on arrival, and did not appear to be in any acute distress. Blood sugar was 65 (normal range 60 to 100 milligrams/deciliter (mg/dl) on arrival and dextrose 10% in water 200 milliliter (ml) was administered via intravenous (IV). Final diagnoses: dementia with aggressive behavior, hypoglycemia (low blood sugar most likely due to not eating/drinking), and elevated blood pressure. discharged back to nursing home on 3/14/26 at 1:11 p.m.ED provider note dated 3/14/26, arrived at 6:26 p.m., and discharged at 9:19 p.m. identified presented to ED via EMS from a local dementia care unit with concerns about dementia, history of dementia with worsening aggression/behaviors. She was seen earlier today in ED given large doses of Benadryl/Versed/Haldol by EMS and quite sedated, then sent back to nursing home. During the afternoon/evening, since the medications wore off, she had became vocally aggressive and refused to take her morning medications. She does not appear to be in any acute distress. Olanzapine (Zyprexa) (antipsychotic) 5 mg in sterile water 1 ml solution was administered intramuscular (IM) on 3/14/26 at 6:56 p.m. Course: reached out to nursing home to see if there was anything specific, they needed us to do so that they would not send the comfort care dementia patient back to the ED. They had no specific recommendations. Diagnosis: dementia and discharged in stable condition back to nursing home facility with encouraged close follow up with primary care provider.A written interview completed by DON with NA-A on 3/13/26 at 2:00 p.m., identified on 3/11/26 at 8:30 p.m., NA-A walked into R1's room. R1 was on the phone with her son crying. NA-A hung up phone and assured R1 everything would be ok. NA-A stated while she undressed R1, R1 became combative, hitting, hollering, and crying. NA-A told her everything would be ok, please do not hit me, I don't want to hit you back, and called for backup. Three staff assisted R1 to transfer with up/down lift to toilet and then to chair. NA-A stated her voice maybe seemed elevated because R1 was sobbing and hollering the entire time and NA-A tried to get R1's attention. NA-A felt another NA was mad at her because she told her she needed to hurry up with her residents that she assisted to bed. NA-A stated she had been ablet to calm R1 down when crying and did not feel her conversation made her anymore upset. At 8:50 p.m., R1's cares were completed, had stopped crying, placed in her chair, and appeared to be sleeping. At 9:30 p.m., NA-A completed rounds by herself, checked on R1 and was still in her chair sleeping. Additionally, NA-A had assisted five other residents: hearing aids, provided blanket, repositioned and checked brief, assisted to bed, assisted with tootsie rolls, and another checked and changed. NA-A left the facility at 10:30 p.m., end of shift.During an interview on 3/24/26 at 2:00 p.m., trained medication assistant (TMA) stated on 3/11/26, at approximately 9:15 p.m., NA-C and NA-B told her NA-A had been mean to R1. NA-A called R1 names, hollered at R1, and was verbally abusive. Licensed practical nurse (LPN)-A was informed prior to when she left the facility at 9:00 p.m., and nothing was done. TMA stated she encouraged the NAs to call the DON and report it as soon as possible but was unsure if they did. TMA stated both NAs informed her they would report it the next morning, TMA did not report it, left it up to LPN-A to report it as soon as possible and was aware the DON had to be called within two hours so incident could be reported to SA. NA-A continued to work, TMA was unsure if she should have made NA-A leave if abuse was suspected. TMA stated the staff nurse should have taken care of that prior to leaving the shift to protect the residents. TMA monitored NA-A during the remainder of her shift, but was not aware if NA-A had interactions with other residents after the incident with R1. TMA stated NA-A's actions she was aware of included: taking out the garbage and sitting at the nurse's station. TMA-A checked on R1 twice to see if she was ok, R1 was sleepy and didn't really want to talk, no questions were asked.During an interview on 3/24/26 at 3:02 p.m. NA-B stated on 3/11/26, she entered R1's room with the stand lift while she talked on the telephone with her son, persistent she wanted to leave the facility, and cried. Once R1 hung up the phone, NA-A was not being very nice to R1 and repeated loudly, STOP CRYING, STOP CRYING YOU ARE ACITNG LIKE A TWO-YEAR-OLD. NA-A attempted to place sling around R1, was aggressive and could have been gentler, and R1 was in distress and swatted NA-A with her hand. NA-A stated, If you hit me, I'll hit you back, and requested assistance over the walkie. NA-A told R1 she was, in trouble now. NA-B was unsure of what NA-A meant by that. Per NA-B, NA-A stated to R1, they, were going to send her to the locked area so she couldn't get out and she should be, grateful, we were helping her. R1 continued to cry and called NA-A an, asshole. NA-C entered R1's room. A resident call light went on and NA-C instructed NA-A to go answer the call light. NA-A exited R1's room willingly, R1 continued to cry, NA-A returned five minutes later and assisted R1 to the recliner. NA-B along with NA-C informed LPN-A of the allegation of abuse to R1 by NA-A. Licensed practical nurse (LPN)-A informed us to call the floor manager/supervisor registered nurse (RN)-A but did not tell them when they were required to call her. NA-A continued to work the remainder of her shift. NA-B called RN-A the following day at approximately 1:00 p.m.During an interview on 3/25/26 at 11:32 a.m., NA-C stated R1 had behaviors that varied from one day to the next. R1 swore, screamed, cried, wandered, and yelled. NA-C stated on 3/11/26, at approximately 9:00 p.m., NA-C heard a call for assistance with R1 come over the walkie. NA-C entered R1's room. NA-A and NA-B hooked R1 up to the EZ stand and instructed R1 to hold onto the bars. NA-A stated loudly and yelled at R1, HOLD ON! NA-C calmly placed R1's hands on the bars and encouraged her to hold on. NA-A yelled at R1, Stop crying! Where would you be if you were not here? Probably lying on the floor. Stop crying! Who is going to want to take care of you when you cry like a baby? NA-C felt NA-A was obviously upset and overwhelmed dealing with R1. Another resident call light came on and NA-A left room to answer it. Once NA-A left room, R1 was transferred to the toilet and calmed down. NA-B told NA-C about NA-A's comment to R1, If you hit me, I'll hit you back. NA-C stated she told NA-B she needed to report it and NA-B seemed uncomfortable with that suggested. NA-A re-entered R1's room five minutes later and assisted NA-C with the EZ Stand to transfer R1 back into her recliner. NA-C stated she exited R1's room with NA-B and they immediately went to the nurse's station and informed LPN-A what they heard NA-A say to R1, the tone of her voice was loud and stern. NA-C and NA-B told LPN-A, they had never witnessed any staff treat a resident like that before. We made it very clear to LPN-A, NA-A yelled at R1 and threatened to hit her. NA-C stated she felt this was verbal abuse, threatening to hit a resident and yelled at them to stop crying. LPN-A did not appear to take the allegation seriously, was told it needed to be reported to someone, LPN-A stated she would talk to RN-A the next day and planned on coming into facility in the morning and would talk to the DON. TMA told NA-C, the DON should be called right away. NA-C trusted LPN-A would take care of it. At 9:30 p.m., NA-A continued to work on the floor. At 10:30 p.m., both NA-C and NA-A clocked out for the night and walked out of the facility together. NA-A stated to NA-C, I will most likely be fired. Prior to this incident, NA-C stated she had witnessed N-A snap at another resident and thought she was just having a bad day. NA-C stated she told NA-A she should not snap at residents, and did not report the incident. NA-A seemed grumpy as time went on. NA-C recalled another occurrence when a resident requested help and NA-A was short with her, tone of her voice stern and loud as NA-A told resident, We'll be right there.During interview on 3/25/26 at 12:41 p.m., LPN-A stated R1 had episodes of behaviors such as resistive to cares, refusals, occasionally cried, verbal with staff telling them to stop talking and to go away. LPN-A was unsure what made them worse, but R1 was not easily redirected. LPN-A stated it was brought to her attention on 3/11/26, between 8:00 p.m. to 8:30 p.m., by NA-B and NA-C concerns of inappropriate interactions between NA-A and R1. NA-A threatened R1, if she hit NA-A, NA-A would hit her back. LPN-A informed both NA's she would talk to nurse manager, RN-A, the next day. LPN-A felt like it was verbal abuse. LPN-A stated according to facility policy, an allegation of abuse was to be reported within two hours, and she thought it was 24 hours due to no injury. The facility policy was not followed. DON called her the next day on 3/12/26 at 2:20 p.m., and informed her NA-A should have been removed from the floor to prevent any further danger to any other residents. After LPN-A found out about the incident, she observed R1 in her room and made sure she was safe in her recliner, eyes were open. R1 acknowledged LPN-A by replying, hi, but did not say anything else. LPN-A did not ask R1 any questions. NA-A remained working on the floor after the allegation of abuse was made until 10:30 p.m. LPN-A left the facility at 9:00 p.m. that day, her shift had ended. LPN- A stated she had previously worked with NA-A and only concern she had was NA-A seemed stressed out at times and frazzled, not enough time to do things, and issues with her home life.During an interview on 3/25/26 at 1:40 p.m., NA-D stated R1 had behaviors but not every day. R1 wandered all over the building in her wheelchair and occasionally cried. NA-D stated R1's behaviors increased when she was rushed, approached in a demanding tone of voice such as get up now, and did not like to be hurried. NA-D stated on 3/12/26, she arrived at work for the day shift and R1 was already up for the day. R1 sat at the nurse's station. This was not typical for R1. After breakfast R1 had increased behaviors: pinching, hitting, crying. NA-D stated R1 had not displayed those types of behaviors when she worked with her prior to this day. She was informed by RN-A about the incident that happened one day ago. NA-D felt this made sense, why R1 was acting out, it was obvious something was bothering her. NA-D charted no behaviors early that morning around 9:18 a.m., noted the change in behaviors after that, and reported the concerns to LPN-B.During an interview on 3/25/26 at 2:04 p.m., LPN-B stated R1 lacked short term memory and had dementia. LPN-B stated approximately two weeks ago she noticed R1's behaviors had increased. On 3/12/26, LPN-B tried to administer R1's medications. R1 refused medications and water. LPN-B stated it appeared R1 was going to through the cup of water at LPN-B. This was an off day for R1, usually happy. R1 seemed irritated. R1 entered another resident's room with family visiting, this was unusual behavior for her. R1 called staff assholes and said t

Based on interview and documents review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being verbally abused by a staff member. Findings Include: Facility Vulnerable Adult Maltreatment Report filed with State Agency (SA) dated 3/12/26 at 5:15 p.m., identified estimated date and time of most recent occurrence: 3/11/26 at 8:30 p.m., in resident [R1's] room. Description of incident: It was reported by nursing assistant (NA) she witnessed verbal aggressive tone and language towards resident by alleged perpetrator (AP) when NA and AP were getting resident ready for bed last evening. NA stated there were no changes with the resident behavior, no signs of injury mentally or physically resulting from the incident. Resident feels safe in facility. Allegations: abuse emotional or mental.Facility investigation 5-day report dated 3/16/26 at 3:10 p.m., indicated on 3/11/26 at 8:30 p.m., NA-A and NA-B assisted R1 with evening cares at 8:30 p.m. R1 was crying, and had ended a phone call with her son when NA-A stated, you need to stop crying, you are acting like a two-year-old. NA-B reported NA-A seemed frustrated and sounded stern. NA-A placed R1's arms on the EZ stand (mechanical device used to lift and lower resident), R1 swatted out at NA-A. NA-A stated if you hit me again, I am going to hit you back. This statement confirmed by NA-A who stated she made the comment not thinking but would never hit a resident. Staff assistance was requested over the walkies. NA-C entered R1's room and heard NA-A yell at R1 in a loud toned voice stop crying, they are going to put you in a locked unit. NA-C felt NA-A was not joking. NA-A left R1's room briefly to assist another resident and returned approximately five minutes later. R1 continued to cry and was distraught. NA-A stated to R1 nobody will want to keep working with you, nobody wants to work with a crybaby.R1's admission Minimum Data Set (MDS) dated [DATE], identified admission to the facility on 2/26/26, from home/community. R1 had severely impaired cognition, feeling down, depressed, or hopeless (2 to 6 days out of 7), and no behaviors noted. She was dependent with toileting hygiene, lower body dressing, sit to stand, all transfers, unable to walk, and used a manual wheelchair for mobility. R1's diagnoses included non-traumatic brain dysfunction, arthritis, muscle weakness, Alzheimer's disease, dementia, anxiety, depression, and psychotic disorder. She takes antipsychotic, antianxiety, and antidepressant medications.R1's care plan dated 3/16/26, identified the following areas of concern and interventions to address each area:An alteration in cognition and psychosocial wellbeing. Staff were directed to allow her time to communicate her needs/wants, provide and maintain consistent environment, provide cues, reorientation/supervision as needed (PRN), monitor and respond to unmet needs, and monitor mood state and refer PRN. AAlteration in mood and behavior related to psychotic disorder with delusions. Staff were directed to monitor and document mood state/behaviors upon occurrence.R1 was a vulnerable adult while she resided in facility. Staff were directed to monitor for signs of emotional distress or mood and behavior changes, continue to follow the facility vulnerable adult and abuse reporting policy, and the local Ombudsman, Adult Protection, Police and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.A written interview completed by DON with NA-A on 3/13/26 at 2:00 p.m., identified on 3/11/26 at 8:30 p.m., NA-A walked into R1's room. R1 was on the phone with her son crying. NA-A hung up phone and assured R1 everything would be ok. NA-A stated while she undressed R1, R1 became combative, hitting, hollering, and crying. NA-A told her everything would be ok, please do not hit me, I don't want to hit you back, and called for backup. Three staff assisted R1 to transfer with up/down lift to toilet and then to chair. NA-A stated her voice maybe seemed elevated because R1 was sobbing and hollering the entire time and NA-A tried to get R1's attention. NA-A felt another NA was mad at her because she told her she needed to hurry up with her residents that she assisted to bed. NA-A stated she had been ablet (able)to calm R1 down when crying and did not feel her conversation made her anymore upset. At 8:50 p.m., R1's cares were completed, had stopped crying, placed in her chair, and appeared to be sleeping. At 9:30 p.m., NA-A completed rounds by herself, checked on R1 and was still in her chair sleeping. Additionally, NA-A had assisted five other residents: hearing aids, provided blanket, repositioned and checked brief, assisted to bed, assisted with tootsie rolls, and another checked and changed. NA-A left the facility at 10:30 p.m., end of shift.During an interview on 3/24/26 at 2:00 p.m., trained medication assistant (TMA) stated on 3/11/26, at approximately 9:15 p.m., NA-C and NA-B told her NA-A had been mean to R1. NA-A called R1 names, hollered at R1, and was verbally abusive. Licensed practical nurse (LPN)-A was informed prior to when she left the facility at 9:00 p.m., and nothing was done. TMA stated she encouraged the NAs to call the DON and report it as soon as possible but was unsure if they did. TMA stated both NAs informed her they would report it the next morning, TMA did not report it, left it up to LPN-A to report it as soon as possible and was aware the DON had to be called within two hours so incident could be reported to SA. NA-A continued to work, TMA was unsure if she should have made NA-A leave if abuse was suspected. TMA stated the staff nurse should have taken care of that prior to leaving the shift to protect the residents. TMA monitored NA-A during the remainder of her shift, but was not aware if NA-A had interactions with other residents after the incident with R1. TMA stated NA-A's actions she was aware of included: taking out the garbage and sitting at the nurse's station. TMA-A checked on R1 twice to see if she was ok, R1 was sleepy and didn't really want to talk, no questions were asked. During an interview on 3/24/26 at 3:02 p.m. NA-B stated on 3/11/26, she entered R1's room with the stand lift while she talked on the telephone with her son, persistent she wanted to leave the facility, and cried. Once R1 hung up the phone, NA-A was not being very nice to R1 and repeated loudly, STOP CRYING, STOP CRYING YOU ARE ACITNG LIKE A TWO-YEAR-OLD. NA-A attempted to place sling around R1, was aggressive and could have been gentler, and R1 was in distress and swatted NA-A with her hand. NA-A stated, If you hit me, I'll hit you back, and requested assistance over the walkie. NA-A told R1 she was, in trouble now. NA-B was unsure of what NA-A meant by that. Per NA-B, NA-A stated to R1, they, were going to send her to the locked area so she couldn't get out and she should be, grateful, we were helping her. R1 continued to cry and called NA-A an, asshole. NA-C entered R1's room. A resident call light went on and NA-C instructed NA-A to go answer the call light. NA-A exited R1's room willingly, R1 continued to cry, NA-A returned five minutes later and assisted R1 to the recliner. NA-B along with NA-C informed LPN-A of the allegation of abuse to R1 by NA-A. Licensed practical nurse (LPN)-A informed us to call the floor manager/supervisor registered nurse (RN)-A but did not tell them when they were required to call her. NA-A continued to work the remainder of her shift. NA-B called RN-A the following day at approximately 1:00 p.m.During an interview on 3/25/26 at 11:32 a.m., NA-C stated R1 had behaviors that varied from one day to the next. R1 swore, screamed, cried, wandered, and yelled. NA-C stated on 3/11/26, at approximately 9:00 p.m., NA-C heard a call for assistance with R1 come over the walkie. NA-C entered R1's room. NA-A and NA-B hooked R1 up to the EZ stand and instructed R1 to hold onto the bars. NA-A stated loudly and yelled at R1, HOLD ON! NA-C calmly placed R1's hands on the bars and encouraged her to hold on. NA-A yelled at R1, Stop crying! Where would you be if you were not here? Probably lying on the floor. Stop crying! Who is going to want to take care of you when you cry like a baby? NA-C felt NA-A was obviously upset and overwhelmed dealing with R1. Another resident call light came on and NA-A left room to answer it. Once NA-A left room, R1 was transferred to the toilet and calmed down. NA-B told NA-C about NA-A's comment to R1, If you hit me, I'll hit you back. NA-C stated she told NA-B she needed to report it and NA-B seemed uncomfortable with that suggested. NA-A re-entered R1's room five minutes later and assisted NA-C with the EZ Stand to transfer R1 back into her recliner. NA-C stated she exited R1's room with NA-B and they immediately went to the nurse's station and informed LPN-A what they heard NA-A say to R1, the tone of her voice was loud and stern. NA-C and NA-B told LPN-A, they had never witnessed any staff treat a resident like that before. We made it very clear to LPN-A, NA-A yelled at R1 and threatened to hit her. NA-C stated she felt this was verbal abuse, threatening to hit a resident and yelled at them to stop crying. LPN-A did not appear to take the allegation seriously, was told it needed to be reported to someone, LPN-A stated she would talk to RN-A the next day and planned on coming into facility in the morning and would talk to the DON. TMA told NA-C, the DON should be called right away. NA-C trusted LPN-A would take care of it. At 9:30 p.m., NA-A continued to work on the floor. At 10:30 p.m., both NA-C and NA-A clocked out for the night and walked out of the facility together. NA-A stated to NA-C, I will most likely be fired. Prior to this incident, NA-C stated she had witnessed N-A snap at another resident and thought she was just having a bad day. NA-C stated she told NA-A she should not snap at residents, and did not report the incident. NA-A seemed grumpy as time went on. NA-C recalled another occurrence when a resident requested help and NA-A was short with her, tone of her voice stern and loud as NA-A told resident, We'll be right there.During interview on 3/25/26 at 12:41 p.m., LPN-A stated R1 had episodes of behaviors such as resistive to cares, refusals, occasionally cried, verbal with staff telling them to stop talking and to go away. LPN-A was unsure what made them worse, but R1 was not easily redirected. LPN-A stated it was brought to her attention on 3/11/26, between 8:00 p.m. to 8:30 p.m., by NA-B and NA-C concerns of inappropriate interactions between NA-A and R1. NA-A threatened R1, if she hit NA-A, NA-A would hit her back. LPN-A informed both NA's she would talk to nurse manager, RN-A, the next day. LPN-A felt like it was verbal abuse. LPN-A stated according to facility policy, an allegation of abuse was to be reported within two hours, and she thought it was 24 hours due to no injury. The facility policy was not followed. DON called her the next day on 3/12/26 at 2:20 p.m., and informed her NA-A should have been removed from the floor to prevent any further danger to any other residents. After LPN-A found out about the incident, she observed R1 in her room and made sure she was safe in her recliner, eyes were open. R1 acknowledged LPN-A by replying, hi, but did not say anything else. LPN-A did not ask R1 any questions. NA-A remained working on the floor after the allegation of abuse was made until 10:30 p.m. LPN-A left the facility at 9:00 p.m. that day, her shift had ended. LPN- A stated she had previously worked with NA-A and only concern she had was NA-A seemed stressed out at times and frazzled, not enough time to do things, and issues with her home life.During an interview on 3/26/26 at 10:00 a.m., RN-A stated she was notified on 3/12/26, in the early afternoon by an NA via phone, on 3/11/26, NA-A told R1 while assisting her with cares, if you do not stop crying, NA-A would give her something to cry about and, if R1 hit NA-A again she would, hit her back. This would have made R1 feel belittled, humiliated, unable to express herself verbally, could not put it into words with what was going on, and how she felt in general other than crying. The staff that witnessed the allegation of abuse immediately informed LPN-A, the nurse on duty. LPN-A should have called the manager on call. RN-A thought direction would have been provided to LPN-A to remove NA-A from the facility to protect other residents. RN-A stated there was a lack of immediate, placing other residents at risk. NA-A was allowed to remain working that evening until her shift ended at 10:30 p.m. RN-A was unsure if NA-A was allowed unsupervised contact with R1 or other residents.During an interview on 3/26/26 at 1:00 p.m., DON stated on 3/11/26, the NAs did a great job of recognizing the alleged verbal abuse and reported it to the staff nurse. The staff nurse should have called her immediately. DON was not notified until 3/12/26, approximately 1:30 p.m. We had only two hours to report, the facility policy was not followed and therefore reported late to the SA. LPN-A should have intervened immediately, removed NA-A from the situation and contacted her. DON stated she would have initiated the suspension of NA-A, to protect other residents and reported the allegation of abuse to the SA. DON stated, she was told by LPN-A, she thought only physical abuse had to be reported within two hours and was unsure if verbal abuse had to be reported within two hours or 24 hours. DON stated, NA-A remained working independently after the incident. NA-A had unsupervised contact with five residents that evening until 10:30 p.m., when NA-A's shift ended. DON stated she called NA-A on 3/12/26 at 1:45 p.m., to get her story. NA-A told DON, she spoke before she thought and said to R1, if you hit me, I don't want to have to hit you back. DON stated she suspended NA-A on 3/12/26 at 1:45 p.m. via phone. DON stated LPN-A informed DON, as the allegation was verbal abuse, there was no need to reassess R1 or immediately report the allegation to the manager on call. LPN-A did not think there was anything wrong at the time and planned to inform floor manager, RN-A the following day. LPN-A left the facility at 9:00 p.m., when her shift ended. During an interview on 3/26/26 at 1:51 p.m., administrator stated he was on vacation on 3/11/26. The administrator would have expected staff to notify either the DON or himself immediately on 3/11/26. Staff were expected to always protect the residents. The allegation was verbal abuse, policy was not followed, there was a small delay, reported to the SA the next day. Administrator stated staff had been educated if they hear, see or know of abuse to immediately protect all residents. The alleged perpetrator should have been immediately removed, and either call DON or himself if needed for direction or assistance. Administrator stated he felt the residents were always safe, a staff made a mistake of words they used, resident safety was not in jeopardy at that time.Facility policy Abuse Prohibition/Vulnerable Adult dated 11/2025, identified guidelines for prevention of maltreatment of vulnerable adults in healthcare centers. Purpose: protect residents against abuse by anyone, to promptly report, document, and investigate all incidents of alleged or suspected abuse/neglect and determine probable cause of unknown injuries and identify and remedy any potentially abusive situations. All staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin (including suspicious bruises, skin tears, or other injuries). A supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated. The nurse will take the following actions to mitigate any potential for further abuse: a. If this is staff to resident alleged or suspected abuse, the staff person will be immediately suspended until the investigation is completed and human resources (HR) will be notified. Notification to the facility administrator will occur immediately for any incidents of resident abuse, alleged or suspected abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. If the administrator is absent or unavailable, staff will follow the chain of command for notification. Abuse is defined as the willful (as used in definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition can cause physical harm, pain or mental anguish and include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Suspected abuse shall be reported to OHFC online reporting process not later than 2 hours after forming the suspicion of abuse.

Based on observation, interview and document review, the facility failed to ensure an environment was free of accident hazards, related to hot water temperatures in 8 of 8 resident rooms (114, 2117, 2208.2210, 2211, 2214, 2228, 2234), tested for safe water temperatures. This deficient practice had the potential to affect all 8 residents who used water from the water faucets in the affected area.Findings include: According to Minnesota Administrative Rules 4658.1365 Subp.7. Hot water supplied to sinks and bathing fixtures must be maintained within a temperature range of 105 degrees Fahrenheit to 115 degrees Fahrenheit at the fixtures. On 8/11/25 at 11:33 a.m., during resident screening the water temperatures in room [ROOM NUMBER], 2210, and 2215 felt very warm to the touch after running water for one minute. During an interview on 8/11/25 at 12:05 p.m., R79 stated the water in her bathroom was pretty hot. During an interview on 8/11/25 at 12:12 p.m., R 69 stated he was not able to leave his hands under the faucet in his bathroom too long or the water got too hot. During an observation and interview on 8/11/25 at 12:30 p.m., director of maintenance (DOM) used the facility digital thermometer to measure the water temperatures in resident rooms. DOM - verified the water temperatures were above 115 degrees Fahrenheit (F) and stated resident hot water temperatures were to be maintained between 105- and 115-degrees F. DOM stated the facility just got a new hot water heater a few weeks ago and they are still working on getting water temperatures adjusted. Water temperatures were as follows:-room [ROOM NUMBER] 118.7 degrees F.-room [ROOM NUMBER] 117.6 degrees F.-room [ROOM NUMBER] and 2210 116.6 degrees F.-room [ROOM NUMBER] was 117.5 degrees F.-room [ROOM NUMBER] 117.8 degrees F.-room [ROOM NUMBER] 119.4 degrees F.-room [ROOM NUMBER] 117.6 degrees F.During an interview on 8/12/25 at 10:00a.m., administrator verified hot water temps should be maintained between 105 to 115 degrees F. Administrator stated hot water heater was turned down and maintenance was checking water temperatures. Review of a facility policy titled Hot Water Temperature Policy revised 10/2024, identified domestic hot water in the facility shall be kept within 105 and115 degrees F. to prevent scalding of residents. Identified hot water fixtures that service the resident rooms, bathrooms, common areas, and tub/shower areas shall be set between 105- and 115-degrees F. per MN State Regulation.

Based on observation, interview and document review, the facility failed to ensure all three years of survey results were readily accessible for residents or visitors. This deficient practice had the potential to affect all 78 residents currently residing in the facility.Findings include: During an observation on 8/12/2025 at 11:47 AM, the facility survey results were located in a white binder posted on wall by the nurse's desk on second floor. The last survey results noted in the binder was for a standard abbreviated survey dated 1/10/25. The facility lacked the survey results for the following surveys completed-abbreviated survey completed on 7/3/24-abbreviated survey completed on 9/16/24-abbreviated survey completed on 12/24/24During an interview on 08/12/2025 at 11:55 a.m., administrator confirmed other surveys had been completed and were not included in the binder. Administrator indicated all surveys should have been included in the binder, so residents, visitors, and staff could look at them, as was their right. A policy was requested but not provided. On 8/14/25 at 8:13 a.m., administrator's e-mail indicated the facility did not have a policy but would default to the State Operations Manual.

Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 resident (R1) reviewed for supervision. R1 was assessed at risk for elopement and left the facility in the dark, freezing temperatures, and located outside approximately 25 minutes later. The immediate jeopardy began on 1/6/25, at 6:44 a.m. when R1 set off roam alert, exited the facility through the south door, in the dark in below zero temperature with her walker, and went missing. At 7:10 a.m. approximately two blocks away from the facility R1 was located. The administrator and DON were notified of the immediate jeopardy on 1/10/25 at 1:30 p.m. The facility immediately implemented corrective action and was corrected on 1/7/25, prior to survey and was issued at past noncompliance. Findings include: According to time and date past weather conditions for Minneapolis weather History for January 6, 2025, the temperature at 5:53 a.m. was three degrees Fahrenheit retrieved from Weather in January 2025 in Minneapolis, Minnesota, USA. R1's St. Louis University Mental Status Exam (SLUMS) (an assessment tool for mild cognitive impairment and dementia) dated 11/9/23, identified a total score of 9 out of 30 and indicated dementia (27-30 was normal, 21-26 suggested mild neurogenic disorder, and 0-20 suggested major neurocognitive disorder). R1's annual Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition, was able to communicate but had difficulty with some words or thoughts without prompting and given time. She felt down, depressed, and hopeless several days (2 to 6 days out of the 7 days during the look back period). She required partial to moderate assistance with personal and toileting hygiene, bath/shower, dressing, and was able to transfer/ambulate up to 150 feet in corridor independently. Her diagnoses included: diabetes mellitus (DM)/insulin dependent, dementia, psychiatric disorder, and required the use of a wander/elopement alarm daily. R1's elopement risk evaluation dated 10/17/24, identified she had a habit/history of wandering or attempts to leave the unit/building, ambulatory, exhibits pacing or agitated behavior, had a cognitive deficit diagnosis, and currently taking opioid or psychotropic medications which may cause confusion. R1's elopement risk score was a 5 (a score of 4 or greater indicates potential for elopement) and care plan goal was identified as resident will not leave the building alone. R1's fall risk assessment date 10/17/24, identified she has had one to two falls in the past six months. Medications used and diagnoses that may have contributed to falls: Hypoglycemic agents (used for low blood sugars), antihypertensives, psychotropics, and peripheral neuropathy (nerves outside the brain and spinal cord are damaged causing weakness, numbness, and pain in the hands or), a diabetes type I, heart disease, and Alzheimer's. Agitation occurred less than daily. Gait analysis: used an assistive device (e.g., cane, walker, etc.) and wore poorly fitting shoes. R1's care plan date 10/29/24, identified she was at risk for elopement, wandering, had a diagnosis of dementia with psychosis with a goal she will not leave the building alone. Staff were instructed to redirect her during attempts to leave the building using calm language, calling her son, offering a snack and/or wheelchair to bring her back to her room, answer door alarms promptly, and monitor wander guard for proper functioning. She was at risk for alteration in mobility with a history of falls and staff were directed to follow physical therapy (PT) orders, and independently transfer and ambulate in hallway with walker. Additionally she was at risk for falls due to encephalopathy (brain dysfunction and can appear as confusion, memory loss, personality changes and/or coma in the most server form), history of falls, left foot drop (difficulty lifting the front part of the foot to help clear the floor), lumbar stenosis (narrowing of the spinal cannel can cause pressure on the spinal cord or nerves that go from spinal cord to your muscles), and diabetes. Staff were directed to follow PT and occupational therapy (OT) instructions for mobility function. She had an alteration in psychosocial well-being and was to be monitored for safety concerns such as elopement. R1's progress note dated 11/5/24 at 6:33 a.m. Resident walked the halls before midnight with her coat on. Approached doors and talked about getting a kid on the bus. Redirected back to the nurse's station. She eventually fell asleep in the recliner at the nurse's station until 2:00 a.m. R1's electronic medication administration record dated December 2024, identified the roam alert on her walker was documented as checked every night shift at 11:30 p.m. 12/1/24 through 12/31/24. R1's PT evaluation dated 12/10/24, identified she had dementia with anxiety, history of falls, generalized muscle weakness, and other abnormalities of gait and mobility. She felt unsteady when walking and worried about falling. Walking 10 feet on uneven surfaces was not attempted due to medical conditions or safety concerns and curb/steps (1 step/curb) not applicable. She had decreased (3 out of 5) musculoskeletal strength identified in left lower extremity (hip, knee, and ankle). Assessment summary identified decreased dynamic balance, motor control deficits, postural alignment/control, and strength impairments. R1's progress notes from 1/6/24 through 1/7/25 identified: -On 1/6/25 at 8:22 a.m. Late Entry: at 6:44 a.m. she set off roam alert and exited the building through the south facing door of facility. She left wearing a coat, shoes, and walker with intentions of finding two boys. Writer responded to door alarm, was unable to locate resident immediately after turning off alarm. Other staff were asked for assistance in locating resident in and outside building, and a code white was called. Director of nursing (DON) and all staff assisted at this time. Resident was found by facility staff one block away ambulating with walker, directed to staff vehicle, and brought back to her room at the facility without incident. A skin check was immediately performed with nursing and medical doctor (MD). Her skin was intact without injury and was provided a warm blanket that was changed out once it cooled down. Her roam alert was functioning and on her walker. An additional roam alert was added to her ankle. MD updated to incident and delusions reported during incident. Medications reviewed and nursing requested a lab check and urinalysis (UA) for possible infection. Every 15-minute checks were initiated for 24 hours. Staff education provided on elopement policy. If resident wandered to an exit she would be redirected to her room or nurse's station. She will remain in line of sight while in hallways. Her son was notified and updated at 11:10 a.m. today. -On 1/6/25 at 3:02 p.m. orders for urinalysis/urine culture (UA/UC) and basic metabolic panel (BMP) due to increased confusion and possible urinary tract infection (UTI). -On 1/6/25 at 6:34 p.m. orders regarding resident leaving building. Observe face, hands, feet for any cold related injury times 48 hours. Review of facility's Vulnerable Adult Maltreatment Report identified on 1/6/25 at 6:44 a.m. R1 set off the roam alert and exited the building through the south facing door of the facility. She left wearing a winter coat, socks, shoes, pants with her walker and intentions of finding two boys. She was located approximately one block away ambulating with her walker and hood up. She was standing with two other individuals who were neighbors to the facility. She was directed to staff vehicle and brought back to her room without incident. Upon immediate return to the facility MD and staff assessed her for injury. No injuries or sin alterations were observed. She denied injury, maltreatment, or falling while out of the facility. R1's electronic medication administration record dated December 2024, identified the roam alert on her walker was documented as checked every night shift at 11:30 p.m. 1/1/25 through 1/6/25. Facility Device Activity Report dated 1/6/25, identified: -1/6/25 at 6:44 a.m. alarm on south entrance door two. -1/6/25 at 6:48 a.m. (4 minutes 14 seconds) user cleared alarm on south entrance door two. R1's medical doctor (MD)-B assessment dated [DATE], identified she was seen today at the request of the nursing supervisor to evaluate for possible injury related to elopement. She had a history of dementia and elopement. With an alert device in place, exited the building through the south facing door having navigated steps to get there. She reported left the facility with the intention of finding two boys. She wore a coat, shoes, no mittens/gloves, and used her walker. She the facility for approximately 30 minutes [sic]. There was reference to her seeing wheels on the walls of her room. She returned to the facility at the time of my visit and stated, well that was stupid, regarding her leaving the building. Her main complaint was cold hands and denied fall, injury, or maltreatment. Her temperature was 97.3 degrees Fahrenheit and physical exam identified she was alert, cheerful, hands cool to the touch with no evidence of frost nip or frostbite with adequate capillary refill, and normal sensation. She did not appear to have suffered any ill effects from her elopement. Nursing staff will closely monitor her for skin changes. R1's progress noted dated 1/7/25 at 9:39 a.m. Follow up note from elopement episode on 1/6/24. Resident skin is intact, denies pain., and made no mention of elopement except that it was cold yesterday. Conversation was nonsensical per baseline. No exit seeking noted. Resident has a wander guard on right ankle and walker. Will continue to monitor for changes. Memo dated 1/7/25, written by DON provided to staff identified: The wanderguard or Roam Alert system requires and emergency response when it is alarming. The alarm cannot be disarmed unless you visualize and account for all residents with a wander guard or roam alert. Remember a thorough search is indicated by searching inside and out the facility. We have created a new elopement binders for each station. They have face sheets for those residents that have a wander guard or roam alert currently in house. Please use these binders as reference to who you should account for when a roam alert is sounding. R1's MD-A 60-day medical review visit 1/8/25 at 8:00 a.m. unfortunately two days ago she had an elopement episode. She was confused and did not really have any intentions of eloping. She went outside looking for someone. She has had hourly checks since that day and expressed no further desire to exit seek. During an interview on 1/9/25 at 11:30 a.m. PT stated she had arrived at work on 1/6/25 at 7:05 a.m., parked her car on the street (11th street) by the facility south exit/entrance door. PT stated she was approached by a registered nurse (RN)-A, informed R1 was missing, and was asked for help to locate her. She stated it was dark outside and cold with the temperature somewhere around zero. She got back in her car and drove west down 11th street, past the side street located at the west side of the facility building where the side walk ended with an egress ramp for easy exit onto the street, down a hill past four houses past another side street to the right and where the fifth house was located on the right side of the road. PT stated at approximately 7:10 a.m. she observed R1 as she stood with her walker on the side of the road with a neighbor (approximately two blocks away from facility). R1 was fully dressed in pants, shirt, shoes, socks, and a black coat with the hood placed over her head, and nothing on her hands. She approached R1, she knew who she was, but seemed confused/forgetful, unsure as to why she was outside, and said her hands were cold. She walked R1 around to the passenger side of the car, assisted her inside, and placed the walker in the car. She drove her to the front of the facility building and assisted her inside, and back to her room. She stated R1 was able to walk on flat surfaces with her walker, had foot drop, and made an extra effort to pick that foot when walking so that she did not trip. PT stated the ground outside was uneven and placed her at a higher risk for a fall. She was unsure as to how R1 managed to go outside and down two steps with her walker from the facility south exit door to get to the sidewalk. During an observation on 1/9/25 at 12:20 p.m. located on the inside of the south exit door at eye level was a printed sign: CAUTION this door leads to stairs without an egress ramp. For safe transition to the outside, please use either the east or west doors located approximately 50' away to the left and right. Additionally located off to the right of that sign was a red stop sign at waist level, underneath the sign was a horizontal metal bar used to push door open and below the bar was another red stop sign posted. Off to the right side of the door at eye level located on the wall was wall pad with numbered buttons on it used to unlock the door with an entered code. PT entered the code and opened the inside exit door and observation showed an entry way that had an outside glass door with long vertical glass windows on each side of the door where outside could be seen. She pushed open the outside door and there was a cement platform that led to two long horizontal step that spanned the length of the south entry/exit door with a black railing located on each side and one in the middle between the steps. There was a sidewalk from the steps that extended out to the main public sidewalk which was horizontal from the facility building running both east and west the sidewalk going west ended prior to reaching the side road on the west side of the building with an egress ramp. The road continued down the street without a sidewalk. During an interview on 1/9/25 at 12:40 p.m. RN-A stated R1 walked independently with her walker, was confused and forgetful, unable to make any of her own decisions, and would have not been safe out in the community by herself. She had seen a decline in R1's dementia and confusion were severe. R1 frequently mixed up her days with her nights, did not sleep well and up a lot during the night. She stated R1 for the most part was usually up by 6:15 a.m., fully dressed herself in shirt, pants and shoes but also wore gripper socks and sometimes her jacket. R1 made her appearance in hallways with her walker about every 30 minutes unless she was sleeping, came to dining room for meals but if not there 15 minutes prior to the meal staff would go get her. R1's ambulation had worsened since admission, did not understand the concept of her foot drop and front end of foot drug on the floor, which made her a high risk for falls. She stated a roam alert was attached to R1's walker and had not tried to open an exit door prior to 1/6/25, of which she was aware. She arrived at work on 1/6/25 at 6:15 a.m., report started at 6:30 a.m. at the medication cart located by the nurse's station. She had seen R1 last during the middle of the report when R1 came out of her room and turned to the left, headed south down the hallway (away from where report was) with her walker, fully dressed in shoes and jacket on. She stated she did not attempt to redirect R1, continued with report until right before 6:45 a.m., walked through the dining room, grabbed water for medication pass, unlocked medication room, grabbed apple sauce and nebulizer treatments out of the refrigerator then heard the exit door alarm go off. She left her walkie on the medication cart, walked down to the south end of the hallway where one exit door was located, looked outside through the window, then realized it was the south door alarm down the south hallway to the left that had alarmed. She approached the south end door, unable to hear anything, so turned off the door alarm. RN-A stated staff were expected to respond the door alarm immediately and should have been left on until R1 was found. She opened the inside exit door and walked into the entry way, looked out the widows and thought how could R1, an elderly woman, maneuver herself down those steps with a walker without falling and was no evidence she exited that door. She opened the outside door, was dark outside and looked around. RN-A stated she did not step outside, it was cold, near zero temperature, no coat or phone, and had not processed yet if R1 was inside or outside the building. She walked from the entry and back into the facility building, combed through sitting areas inside the building, went down to east/west hallway and asked NA-C for assistance to help locate R1, then called director of nursing (DON) and a Code [NAME] (missing resident). She went outside through the west door for about two to three minutes, walked down the sidewalk, between vehicles in the parking lot, was still dark out and relied on the street for light. RN-A stated staff would have been expected to go outside and check the surrounding areas right away, but her point of view was she had no sight of her, there was only one streetlamp, and did not see anyone. PT found R1 outside by the side of the road with her walker approximately 20 minutes after she exited the facility. Once R1 was brought back to the tacitly she completed an assessment along with the provider on site, no injuries were noted. She initiated every 15-minute checks for 24 hours, applied another roam alert to R1's ankle and education was provided to all staff that same day. During an interview on 1/9/25 at 2:40 p.m. maintenance director (MD) stated once a resident with a roam alert approached and exit door a warning beep would sound. When the exit door was breached (opened) the alarm beeped faster, and alerted staff on their walkie's. He stated the staff were expected to respond to the alarm immediately and go to exit door, and complete outside and inside building. following the policy guidelines. There were only two residents in the facility that had roam alerts on. The door alarm log indicated the south entrance/exit door alarm on 1/6/25 went off at 6:44 a.m. and was cleared at 6:48 a.m. (4 minutes). He was unsure of the temperature that morning, the snow had pretty much melted, and the road was clean. During an interview on 1/9/25 at 3:39 p.m. nursing assistant (NA)-B stated she had worked the night shift on 1/5/25 through 1/6/25 morning. R1 would walk around the facility with her walker fully clothed with either gripper socks or tennis shoes on. Occasionally, R1 would walk in hallway with her coat which occurred about every two months. She last saw R1 at 6:25 a.m. laid in bed, sleeping, fully clothed with gripper socks on, no agitation noted during the shift, and when shift ended at 6:30 a.m. went home. NA-B stated R1's cognition was very forgetful, confusion went in spirits but was never totally clear, refused cares at times, would not have been safe outside in the community by herself. NA-B stated R1 was unable to find her way back to the facility. During an interview on 1/9/25 at 4:24 p.m. floor manager RN-C stated R1's had progressive Alzheimer's, significant cognition impairment, and would have not been safe out in the community by herself. R1 had limited mobility, transferred, and ambulated independently but at risk for a fall. RN-C stated R1 refused cares, had psychosis, delusional thinking patterns, hallucinations, and could be verbally and physically aggressive at times. She said R1 had vascular dementia, made for a behavioral pattern, and was at risk for elopement. R1 walked the hallways with her walker with roam alert attached to it, fully dressed and not uncommon for her to wear her coat. She stated RN-A was giving shift to shift report, saw R1 in hallway with her coat on, ambulating with her walker and had not verbally expressed she wanted to leave. She expected staff to respond to an exit door alarm immediately, it was an emergency, and the alarm should have been left on until resident was found and all clear was sounded. She also expected staff to go outside immediately and searched right away for the resident. RN-C stated when the exit door alarm was triggered on 1/6/25 it was dark and cold out and would have been important to see the physical environment and at least walked out to the sidewalk and important to find the resident as soon as possible. She stated R1 was outside approximately 20 minutes before she was found. There was a lack of supervision for R1, staff should have initiated an outside search sooner and staff failed to follow the care plan, R1 should have not been outside alone. During an interview on 1/10/25 at 11:05 a.m. occupational health and learning RN-B stated once the exit door alarm went off staff were expected to go to the door that alarmed, and the alarm should have remained on until resident was found. Staff were expected to go outside and look for the resident immediately because it was cold outside, could have gotten hurt, and needed to get R1 back into the building. RN-B stated that information was provided in the facility policy and wanted to prevent residents from leaving the facility unassisted such as elopement. She stated all staff education was provided on 1/6/25, and a facility drill was completed on 1/7/25 at two separate times after the elopement so that staff could take part in it and re-educated. R1 had told staff she was looking for the boys and had a purpose to go outside. Previous to the elopement on 1/6/25 R1 had not verbalized she wanted to leave the facility nor pushed open an exit door. During an interview on 1/10/25 at 11:16 a.m. family member (FM) stated R1 had a history of falls at home prior to her admission and one at the nursing home. He had talked to the staff, and they had asked R1 why she went out of the building, she told them she saw a little boy out there. He said she most likely thought it was her grandson and wanted to go out there after him. FM stated R1 wore a black Vikings jacket with a hood, refused to wear a cap/hat, and had no gloves or mittens. He had not noticed any change in behaviors recently except when R1's blood sugars dropped too low in the morning, she became moody. FM stated on the morning she left the building it was very cold and right around zero outside, and she was not safe to be outside alone with her dementia. During an interview on 1/10/25 at 12:08 p.m. DON stated R1 required cues, did not make safe choices and was not safe out in the community by herself. She had not seen R1 in the hallways ambulating with her jacket on, the night shift indicated they had seen her at times in the hallway with her jacket on. She identified R1's elopement risk had slowly increased, in November 2024, R1 had talked about looking for some children with her coat on, care plan interventions were updated in July 2024, staff were expected to redirect R1 from exits due to her risk for elopement. She was notified on 1/6/25 at 7:02 a.m. by RN-A via phone R1 was missing and had not been found yet. She asked RN-A if she had checked outside and was told yes, then RN-A informed her she felt that R1 could have not made it down the steps and did not think she was outside. She instructed RN-A to call a Code [NAME] and focus search efforts outside immediately due to the possibly of her being out there was pretty good since it was an exit door that alarmed. DON stated the facility policy was not followed, the exit door alarm should have been left on until the R1 was found and most likely why other staff did not respond to assist with the search. Additionally, when staff look through the glass door/windows it would have been super reflective in the dark and if she would have physically immediately gone outside and taken five steps R1 would have been right there. she was on her way into work from home when the call came through and showed a temperature between zero to one above. She estimated the time R1 was outside was 20 to 25 minutes, walked down the south west sidewalk, crossed a street intersection at the end of the side walk then walked down the road past four houses, crossed another street intersection, and found in front of the fifth house off the side of the road with two neighbors located nearby. Every 15-minute checks were initiated times 24 hours and supervision required when out in hallways ambulating. She expected staff to have intervened and redirected R1 when they saw her with her jacket on in the hallway early that morning. She completed staff interviews, and some felt that if they saw R1 with her coat on in hallway would have intervened and other staff indicated it was normal for her. Most of the staff were educated on 1/6/25. During a follow up interview on 1/10/25 at 12:15 p.m. PT stated the wording on the PT evaluation form dated 12/10/24, curb/steps (1 step/curb) not applicable, was the language used to complete an evaluation. She stated R1 was not tested for the steps, not something she did in her routine but by reviewing her evaluation that day the results confirmed if she had tested her, she would have been dependent and not able to do it safely on her own. During an interview on 1/10/25 at 12:45 p.m. NA-B stated she worked the morning shift 1/6/25 and had not seen R1, assisted another resident at 6:30 a.m. She stated her walkie alerted her an exit door alarm had been set off after 6:30 a.m., unsure exactly what time it was at. NA-B stated she finished up transferring another resident then spoke to RN-A and was asked if she had seen R1. She started looking inside the facility then went outside without a coat on along with another staff to search the facility grounds, it was dark and cold out. She went back inside the facility, unsure of time, was notified R1 had been found. She kept a close eye of R1 especially when in the hallway ambulating the rest of her shift. NA-B stated R1 had a history of forgetfulness, easily distracted, and turned around, and confused. We were expected to respond to those alarms immediately and the alarm was to be left on until the resident was found. During an observation on 1/10/25 at 1:10 p.m. R1 ambulated in hallway, pushed her four wheeled walker from the north end of the hallway towards the south end where her room was located. In the middle of the hallway, R1 stopped and let go of her walker, grabbed her waist band on her pants and with both hands and pulled them up which revealed a roam alert located on her right ankle. An additional roam alert was located on the left upper side of her walker. R1 was fully dressed in shirt, pants, socks, shoes and did not have her jacket on. R1 ambulated by raising her left thigh up high in order to lift her left foot off the ground so that her left foot toes hung down, and barely cleared the floor with each step. R1 ambulated past her room doorway and was almost at the end of the hallway when an unidentified staff intervened and redirected her. R1 was cooperative. During an interview on 1/10/25 at 1:16 p.m. MD-A stated R1 had a history of wandering would have not been safe outside by herself in the community and expected staff to monitor her to keep her safe. During an interview on 1/13/25 at 3:02 p.m. licensed practical nurse (LPN)-A stated she was in a resident's room, came out of the room, heard the exit door alarm, walked towards the south end of the building and alarm had been shut off when she was only 1/2 way down the hallway. She was approached by RN-A between 6:45 a.m. and 7:15 a.m. and was told RN-A had lost R1. She asked RN-A if she had looked outside and was told yes. RN-A walked away and then came back and stated to her, really, I cannot find R1 while she talked on the phone. She called a Code [NAME] and we started to search all over the facility inside and outside. She crossed the street by her car and looked through the school parking lot around six cars, southwest corner, down the block to the north and the southwest corner and was unable to locate R1. LPN-A stated staff were expected to respond to an exit door alarm right away, checked to see if there was a resident by the door, and go outside to the end of the block and if how far they may have gotten. She stated it was dark and cold out, unsure of the temperature, and no snow on the ground. She was unsure as to how R1 had been able to go down two steps with a walker. Facility Elopement policy date 6/2023, identified a safe environment will be provided for all residents. Assure that each resident is properly assessed on an ongoing basis and has appropriate safety precautions in place. Only the administrator or designee may authorize the disabling of the alarm system and is responsible for monitoring for resident safety and resetting the alarm. Documentation should include Entries that are time specific to reflect the responsiveness and timeliness of actions taken to locate and assess the resident. Facility policy Wander Guard/Roam Alert dated 11/2023, identified the roam alert system was designed to secure perimeter that helps detect residents from leaving the protected areas of the facility. All staff is required to respond to the roam alert and ensure the safety of our residents. When responding to the alert always open the door at the exit site and look for any resident that may have left the building. Walk around the building to see if resident was on the sidewalk, property, or surrounding area. Once you have checked outside and the resident located and returned inside the facility you can clear the alarm. It should not be cleared prior to locating the resident. Staff need to continue responding to the alert and assist with the search. Facility policy Code [NAME] - Missing Residents dated 1/2025, identified all personnel must investigate and report all cases of missing residents. If a resident's whereabouts are not discovered the nurse caring for the resident will page overhead by pressing the page button on the phone: Code [NAME] (name of resident) please return to your room. Staff, please turn walkies to channel one. Repeat this three times. All staff will begin a thorough search for resident. Searching outside maybe an option as the search area is expanded. Staff can utilize their vehicles to search the perimeter of the building, searching outside maybe needed earlier in the search, depending on the situation. An outside search should take no longer than 15 minutes. When resident is located page overhead Code [NAME] Canceled repeat this three times. The past noncompliance immediate jeopardy began on 1/6/25. The immediate jeopardy was removed and the deficient practice corrected by 1/7/25, after the facility implemented a systemic plan that included the following actions: began immediate investigation, reviewed policy and procedures, placed a roam alert on R1's right ankle, initiated all staff education the DON provided a memo to staff identifying the wanderguard or Roam Alert system requires and emergency response when it is alarming, conducted audits and drills with staff, tested all current roam alerts for functional use, updated R1's plan of care, provided corrective action and education regarding missing resident and elopement to RN, created a missing resident check list and elopement binder that identified residents in the facility at risk for elopement with roam alerts, and ongoing staff education and audits will be provided.

Based on interview and document review the facility failed to ensure an appropriate facility-initiated discharge for 1 of 3 residents (R1) reviewed who admitted to the facility, was told to discharge due to a sexual abuse charge and was re-hospitalized . Findings include: R1's admission record indicated he admitted to the facility on [DATE] and discharged [DATE]. R1's diagnosis included paraplegia, muscle weakness, need for assistance with personal care and pressure ulcer of right buttock, stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining. R1's hospital discharge summary note dated 11/19/24 indicated due to mobility issues the patient is not ready to discharge back to independent living. He is discharging to skilled nursing facility. R1's physical therapy (PT) Evaluation and Plan of Treatment dated 11/19/24 indicated he required supervision or touching assistance for transfers and bed mobility. The evaluation indicated; reason for Referral / Current Illness: R1 was referred to skilled PT following hospitalization for a right ischial decubitus ulcer. He was also a paraplegic. R1 presented with decreased dynamic balance, trunk weakness, low activity tolerance, and difficulty with transfers and indicated R1 would benefit from PT to increase safety and independence with transfers. R1's progress note dated 11/19/24 indicated R1 received antibiotics for wound Infection. Incontinence care provided. Unable to visualize wound due to non-removable dressing. R1 turned and repositioned frequently. Positioning devices applied as ordered. Offloading of affected area. R1 displayed difficulty with movement in multiple extremities. Had weakness in bilateral lower extremities. Skilled need: PT, OT, treatment of Stage III or IV pressure ulcer. Management & evaluation of patient care plan. Observation & assessment of resident condition. Teaching & training to manage resident's condition. R1's occupational therapy (OT) Evaluation and Plan of Treatment dated 11/20/24 indicated the following: Toilet transfer = Dependent. Mobility Function Score (ranges from 0 - 12; 12 being the highest function) = 0 Toileting hygiene = Dependent. Bathing Shower/bathe self = Dependent. Dressing Upper body dressing = Partial/moderate assistance. Lower body dressing = Dependent. Putting on/taking off footwear = Dependent. Self-Care Function Score (score 0 - 12; 12 being the highest function) = 6 R1's base line care plan dated 11/20/24 identified a risk for decline in activities of daily living and mobility related to paraplegia (paralysis of the lower body). The care plan indicated R1 transferred himself. The care plan identified a risk for skin breakdown related to incontinence and directed staff to provide incontinent products and assist to change as needed and indicated R1 was able to manage incontinent products and external catheter independently. Identified a chronic wound on his coccyx and directed staff to provide turn and reposition or reminders to offload every 2-3 hours and as needed. R1's progress note dated 11/20/24 indicated discharge plan to home with homecare services to manage R1's wound. R1 indicated he was able to manage cares and mobility independently and had support from family members. R1 was accepting of homecare services to complete wound care three times a week. R1 stated he felt comfortable with this discharge plan and was willing to discharge tonight or tomorrow. R1 had transportation available by his niece. R1's admission Minimum Data Set, dated dated dated [DATE] indicated intact cognition and indicated he was dependent on staff for toileting hygiene, required partial to moderate assistance for transfers and did not ambulate. R1's progress note dated 11/21/24 indicated social services met with R1 earlier to review discharge plan and complete admission assessments. R1 was accepting of discharge plan and would receive home health services through Homecare and transportation through the facility bus. R1 was from a different county with multiple disciplines involved in his care, both for medical care and for criminal activity. Social services and facility care team members worked with those parties to coordinate return to his apartment and back to an area more familiar to him. R1 scored 15 on the BIMS, indicating his cognition was intact. R1 did not have questions at this time. Social services had called family members to provide updates. Social services will remain available to him throughout stay. R1's progress note dated 11/21/24 indicated R1 was discharged to his home at this time with his medications and all personal items sent with him. Transported by facility bus. Discharge paperwork and instructions completed by nurse manager, signed with copy given to resident. During an interview on 12/10/24 at 1:20 p.m., R1's health plan care coordinator (HPCC) stated after R1 was discharged from the facility back to his home, he did not make it very long before returning to the hospital. The HPCC stated prior to his admission to the facility R1 had been hospitalized , then went to a swing bed (A swing-bed is a service that rural hospitals and critical access hospitals provide that allows a patient to transition from acute care to skilled nursing facility care without leaving the hospital. This allows a patient to continue receiving services in the hospital even though acute care is no longer required). The HPCC said the swing bed facility felt he needed more ongoing care, so they discharged him the a skilled nursing facility on 11/19/24. The HPCC stated she spoke to the social services director (SSD) at the facility on 11/20/24, who told her R1 would be there for a few months. She stated the SSD asked her about R1's pending court date and they looked up the information. The HPCC said due to the nature of the charges, the facility told her they were going to discharge R1 immediately and R1 was discharged back home. The HPCC stated R1 went back to the hospital on 11/24/24, because his wound vac (vacuum assisted closure is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate and promote healing in acute or chronic wounds) had come off. She stated R1 was discharged back home again on 12/2/24, and re-hospitalized on [DATE]. The HPCC said R1 was currently in another rehab facility. The HPCC stated she had verbalized to the facility SSD her concerns about the discharge being unsafe and was told the higher-ups had decided to discharge R1. During an interview on 12/10/24 at 2:07 p.m., the SSD stated after R1 admitted to the facility she received a call from R1's HPCC who mentioned R1 needed to speak with a lawyer related to a sexual abuse charge. The SSD stated R1 had sexually harassed someone at the hospital but she was unsure of the circumstances and said R1 had not yet been convicted. The SSD stated she notified the administrator and director of nursing (DON) due to the vulnerability of the facility population. The SSD said they sought consult from the corporate leadership. R1 was independent with therapy so they set up home care services for wound care. R1 was accepting of the discharge. The SSD stated the facility had initiated the discharge. During an interview on 12/10/24 at 2:17 p.m., the administrator stated he had spoken to R1 after he was alerted R1 needed to speak to a lawyer about ongoing legal proceedings. The administrator said he talked to R1 and said we both agreed it would be appropriate for him to go home. The administrator stated he had spoken to an acquaintance with the local police department who said R1 should go back to his county of residence but had not documented the conversation. The administrator stated R1 had not received a discharge notice because he had asked R1 if he wanted to leave and R1 agreed. The administrator further stated the risks and benefits of discharge were not discussed with R1. During an interview on 12/10/24 at 2:39 p.m., R1's family member (FM)-A stated R1 was currently in another rehab facility and said she spoke with R1 frequently. FM-A stated the facility told R1 he could not rehab there because of his sexual abuse charge. FM-A stated they sent him home and R1 was hospitalized again because the wound dressing kept falling off when he got in his wheelchair. FM-A stated I think they ([NAME] on the Lake) violated his rights). During an interview on 12/10/24 at 3:37 p.m., the hospital swing bed social worker (SW) stated R1 had been sent to them following a hospital stay. R1 was discharged to the facility skilled nursing for the wound vac. R1 was able to transfer from the bed to his wheelchair but said every time he self-transferred the wound vac dressing came off. The SW stated home care would have been able to assist with changing the wound vac every three days but could not go to R1's home and replace the wound vac every time it came off, which was why he was referred to the skilled nursing facility. During an interview on 12/10/24 at 3:44 p.m., the facility medical director (MD) stated she had done a face-to-face visit for the referral to homecare. The MD said when R1 admitted to the facility she was told he was upset and asking about his court date and his lawyer communication about the pending court date. The medical director stated R1 was at the facility for wound care and was doing well. The MD stated she had not been aware the swing bed facility had sent him to the rehab facility because they had concerns about R1's wound vac coming off when he self-transferred. During an interview on 12/10/24 at 4:24 p.m., the DON stated R1 was admitted to the facility due to a chronic pressure injury that was infected. The DON stated R1 had orders for therapy and a wound vac. The DON said R1 had legal concerns, so the administrator had a conversation with him and discharge had been discussed. She spoke with R1 and he was concerned about his location. The facility had not assessed R1 as no longer having a skilled nursing need and no risk and benefits of leaving had been discussed with R1. The DON said R1 was able to self-transfer, even though therapy assessed R1 to need further rehab, so wound care could be done at home with home health. During an interview on 12/10/24 at 4:45 p.m., the SSD stated the only concern she heard from R1 was he wanted to talk about how to get hold of his lawyer. She had not assisted R1 to reach his lawyer, nor had she offered to assist with transportation to his court appearance. The SSD stated, I just did what was directed by my superiors. During an interview on 12/11/24 at 7:30 p.m., R1 stated he was told by the administrator he could not be at the facility because of his sexual abuse charge and said, I think it sucked actually. R1 stated the administrator had not asked him if he wanted to leave but told him he had to leave. R1 said the facility had not given him a notice nor had they asked him what happened related to the charge and said they more or less just said since the court date was happening, he could not stay. R1 stated after he discharged from the facility his wound did not do well and said the wound vac kept coming off. R1 said he had to have a friend come over and try to help with the wound vac and she had him sent back to the hospital. Facility policy Transfer or Discharge Notice for Facility Initiated Transfers dated 7/2024, indicated a facility initiated discharge referred to a discharge that a resident objects to or did not initiate and did not align with the residents goals for care and preferences. The policy indicated the resident and or family were notified in writing: Specific reason for transfer or discharge, effective date, location and an explanation of their right to appeal.

Based on interview and document review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours to address the individualized needs for 1 of 2 residents (R174) who was recently admitted . Findings include: R174's progress note dated 5/31/24, indicated R174 was admitted to the facility from a hospital on 5/31/24, with a primary diagnosis of chronic obstructive pulmonary disease (COPD). Identified R174 required staff assistance to transfer and was on two liters of oxygen via nasal cannula. R174's baseline care plan initiated on 6/3/24, lacked areas to prevent skin breakdown or toileting. In addition, the care plan lacked any interventions for the use of oxygen. Further, the care plan was developed a day past the 48 hour time frame requirement. During an interview on 6/5/24 at 8:02 a.m., nursing assistant (NA)-C stated she was unsure what R174's care plan identified. During an interview on 6/5/24 at 8:27 a.m., registered nurse (RN)-A verified R174's baseline care plan was not completed within 48 hours of R174's admission. In addition, RN-A confirmed the care plan lacked interventions to prevent skin breakdown, toileting, and oxygen therapy. RN-A stated she was aware the baseline care plan should have been completed within 48 hours. RN-A indicated she was unsure why the care plan had not been completed within 48 hrs of R174's admission or why the care plan did not include all problems. RN-A stated her expectation was staff would complete the baseline care plan within 48 hours after R174's admission and the care plan would have contained all the required components to care for R174. During an interview on 6/5/24 at 10:47 a.m., director of nursing (DON) verified R174's baseline care plan had not contained all the required components to care for R174 and had not been completed within 48 hours of R174's admission. DON stated her expectation was R174's baseline care plan would have contained all the components to care for R174 and would have been completed within 48 hours of R174's admission. DON indicated it was important to ensure baseline care plans were developed timely to ensure staff were aware how to care for the residents. Review of a facility policy titled Care Planning revised 1/6/22, identified a baseline plan of care would be developed within 48 hours of admission to ensure that the resident's immediate basic needs were met and maintained. Indicated, in accordance with state and federal regulations, each resident would have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs.

Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect oxygen usage and hospice status for 1 of 1 resident (R28) reviewed for hospice services. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2023, outlined an overview which included, Intent: The intent of the items in this section is to identify any special treatment, procedures, and programs that the resident received or performed during the specified time periods. Facilities may code treatments, programs, and procedures that the resident performed themselves independently or after set-up by facility staff. The RAI had directions to check all the following treatments, procedures, and programs that were performed during the last 14 days: Section O0100C oxygen therapy, and section O0100K, hospice care. During a review of R28's facesheet, diagnoses information included, COPD, unspecified onset date of 12/13/23, encounter for palliative care onset date of 12/13/23, and dependence on supplemental oxygen onset date of 5/18/18. Review of the admission MDS dated [DATE], section O100C oxygen therapy had not been checked. In addition, section O100K, Hospice, had not been checked. Review of the quarterly MDS dated [DATE], section O100C special treatments and programs: oxygen therapy had not been checked. In addition, section O100K Hospice had not been checked. Review of the care plan dated 12/14/23, identified R28's hospice care was provided by [NAME] County Hospice. Indicated R28 had an alteration in oxygen/ gas exchange. Staff were to monitor oxygen saturations as ordered, and PRN. Staff were to administer oxygen as ordered. Review of the Medical director (MD) progress note dated 1/10/24, identified R28 had been admitted to the facility on hospice care for COPD and R28 had supplemental oxygen for COPD. Orders were in place for oxygen, two liters per minute (LPM) continuously (since about 2014). In addition, diagnosis of Hospice Care (primary encounter diagnosis) COPD, severe and dependence on supplemental oxygen. During the review of [NAME] County hospice physician certification of terminal illness dated 11/9/23, identified R28 had a diagnosis of COPD. R28 had shortness of breath and used oxygen. Dyspnea related to COPD was identified as a problem. The hospice goal was for R28 to remain free of signs of respiratory distress and/or report dyspnea was managed at an acceptable level. The hospice MD order: two LPM via nasal cannula (NC). During the review of R28's signed orders from MD dated 5/13/24, R28 had an order for two to four LPM of oxygen via NC to keep oxygen sats greater than or equal to 88-92% every shift related to chronic obstructive pulmonary disease, unspecified, order active as 2/21/24. In addition, an order for Hospice of [NAME] County active since 12/13/23. During an interview on 6/5/24 at 10:50 a.m., registered nurse (RN)-B stated R28 had been admitted to the facility on hospice and with orders for oxygen. During an interview on 6/5/24 at 8:40 a.m., the director of nursing (DON) stated she had been the MDS coordinator and completed R28's quarterly MDS. DON stated R28 had been admitted on hospice. DON confirmed the MDS should have been marked for hospice. DON believed oxygen not being marked on the MDS was accurate as R28 did not wear 02 consistently and had oxygen for comfort. DON's expectation would be for staff to accurately complete the resident assessment. DON indicated the MDS would be updated to reflect an accurate assessment of R28. A policy regarding completing an MDS accurately was requested however, was not provided. The facility provided a copy of The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019, which the facility stated they followed.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 1 resident (R176) observed for medication administration. Findings include: R 176's admission Minimum Data Set (MDS) dated [DATE], identified R176 had intact cognition and had diagnoses which included asthma, end stage renal disease, and chronic obstructive pulmonary disease (COPD). R176's comprehensive care plan dated 6/3/24, identified R176 required staff assistance with dressing, hygiene and transfers. Indicated R176 had a diagnosis of COPD, and instructed staff to give aerosol or bronchodilator (medication that relaxes and opens the airways, or bronchi, in the lungs) as ordered, with goals which included would be free of symptoms of respiratory infections. R176's Order Summary Report signed 5/31/24, identified Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Advair is a combination medicine used to prevent asthma attacks) one inhalation inhale orally every 12 hours related to COPD. Rinse mouth after each use. During an observation on 6/3/24 at 7:30 p.m., licensed practical nurse (LPN)-A entered R176's room, handed an inhaler which included the Advair medication to R176 and instructed R176 to take one puff of the inhaler. R176 took one puff of the inhaler as instructed and handed the inhaler back to LPN-A who took the inhaler and exited the room. R176 was not observed to rinse her mouth out as ordered after taking the Advair inhaler. During an interview on 6/3/24 at 7:34 p.m., R176 indicated she received the Advair inhaler twice a day. R176 confirmed she had not rinsed her mouth out after receiving the inhaler. R176 was not aware she was expected to rinse her mouth after each use of the inhaler and stated only once in a while staff would instruct her to rinse her mouth out however, not every time she used the inhaler. During an interview on 6/3/24 at 7:36 p.m., LPN-A confirmed she had not instructed R176 to rinse her mouth after receiving the Advair inhaler. LPN-A stated she had not seen the order instructions to rinse mouth after use. LPN-A indicated it was important to rinse the mouth after use of a steroid inhaler to prevent any infections. During a phone interview on 6/5/24 at 8:59 a.m., pharmacy consultant (PC)-A stated it was important to rinse the mouth after receiving Advair inhaler as it contained steroid medication. PC-A indicated it could cause thrush, a fungal infection inside the mouth. PC-A stated it was her expectation nursing staff would instruct the resident to rinse their mouth after each use. During an interview on 6/5/24 at 10:47 a.m., director of nursing (DON) confirmed R176's Advair inhaler was a steroid medication. DON stated it was important for residents to rinse their mouth after use of a steroid inhaler to prevent infections in the mouth. DON stated her expectation was for nursing staff to instruct R176 to rinse mouth after receiving the Advair inhaler. R176's Advair inhaler box instructions indicated take one puff twice daily and rinse mouth out after using the inhaler. Review of a facility policy titled Oral Inhalation Administration dated 8/22, indicated the facility would allow for safe, accurate, and effective administration of medication using an oral inhaler (with or without a spacer/chamber). Indicated for steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup.

Based on observation, interview, and document review, the facility failed to provide maintenance services to ensure a clean and safe kitchen for 1 of 2 kitchenettes and the main kitchen observed during the kitchen tour. This deficient practice had the potential to affect all 76 residents currently residing in the facility and staff who worked in the kitchen. Findings include: During the initial tour of the kitchen on 4/24/23, at 6:32 p.m. with the dietary cook (DC)-A the following was observed: The three compartment sink located in the back kitchen area had a heavy build up of white/green lime scale on the inside of the sink half way up the sidewalls of the third sink area and all around the faucet area. The water leaked from the sink area and ran onto the water heater located below the sink area and into a gray plastic basin located on the floor. The water heater and the gray basin had a heavy build up of white lime scale which ran onto the entire floor area underneath the sink area and towards the back of the wall. - the counter area next to the three compartment sink and the plastic drying rack with pots and pans on it had a moderate amount of lime scale build up present and was unclean. DC-A confirmed the facility used the three compartment sink on a daily basis to soak pots, pans, knives and such utensils. - the ice machine located in the front of the kitchen area had a moderate amount of white lime scale build up on the sides of the ice machine and above the cover area. The flooring located under the ice machine towards the back of the wall area had a moderate amount of white lime scale build up present and was unclean. - at 6:51 p.m. a tour of the kitchenette on the first floor was completed with licensed practical nurse (LPN)-A. The sink area was noted to have a moderate amount of white lime scale on the inside of the silver sink and on the entire faucet area. During the follow-up kitchen tour on 4/26/23, at 11:05 a.m. with the dietary manager (DM) the following continued to be observed: The three compartment sink located in the back kitchen area had a heavy build up of white/green lime scale on the inside of the sink half way up the sidewalls of the third sink area and all around the faucet area. The water leaked from the sink area and ran onto the water heater located below the sink area and into a gray plastic basin located on the floor. The water heater and the gray basin had a heavy build up of white lime scale which ran onto the entire floor area underneath the sink area and towards the back of the wall. - the counter area next to the three compartment sink and the plastic drying rack with pots and pans on it had a moderate amount of lime scale build up present and was unclean. - a heavy build up of white lime scale was noted underneath the convection oven and several Combi (combination of steam and convection) ovens and was present on the shelves below the ovens and on the flooring behind the oven area. - the ice machine located in the front of the kitchen area had a moderate amount of white lime scale build up on the sides of the ice machine and above the cover area. The flooring located under the ice machine towards the back of the wall had a moderate amount of white lime scale build up present and was unclean. The DM indicated her staff were expected to wipe down the ice machine nightly and maintenance did a complete cleaning every week. The DM indicated the facility had de-[NAME] that they used to clean the areas with lime scale on it and indicated she had asked the maintenance supervisor (MS) what she could use to remove the lime scale from these areas and had not heard back. The DM indicated she did not have any documentation of when or how often the kitchen areas were being cleaned in the kitchen. During an interview on 4/27/23, at 9:44 a.m. the DM confirmed the above findings and indicated her expectation of staff were to clean these areas daily when they were able to. The DM stated she used to have staff designated to clean these areas and no longer had someone to clean the lime scale due to staffing issues. The DM indicated she expected all staff ensured the kitchen areas were clean. During a tour of the kitchen on 4/26/23, at 12:04 p.m. the MS confirmed the above findings and stated the build up of lime scale was an infection control issue. The MS indicated staff were expected to clean the ice machine every other week. The MS stated the ice machine was professionally cleaned once a year. The MS indicated staff were expected to clean the three compartment sink and water heater weekly. The MS confirmed there was no documentation to reveal the equipment and areas had been cleaned as directed. The MS indicated he was not aware the lime scale had built up to the level as described above. The MS stated he expected staff to ensure the equipment and areas were cleaned on a regular basis and further expected staff to follow facility policy. Review of the facility policy titled, Lime Scale Build Up revised on 4/2023, indicated the culinary director and maintenance director would ensure all areas would be clean and free from lime scale build up. The culinary director would contract professional cleaning of lime scale build up as needed. Review of facility policy titled, Ice Machine Cleaning revised on 4/2023, indicated the maintenance director would ensure all ice machines were clean and fully operational per manufactures guidelines bi-weekly and cleaned professionally yearly.

Based on interview and document review, the facility failed to immediately report, no later than 2 hours, an allegation of abuse to the State Agency (SA) for 1 of 1 residents (R1) reviewed for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnosis which included chronic obstructive pulmonary disease (COPD), anxiety disorder, and hypertension (elevated blood pressure). Indicated R1 had intact cognition and required extensive assistance with activities of daily living (ADL's) which included bed mobility,transfers, and toileting. R1's care plan dated 12/19/22, revealed R1 was at risk for altercations in behavior related to trauma, including verbal and physical abuse. The care plan directed staff to consider past trauma when engaging in work with R1. The facility SA report dated 12/19/22, at 12:21 p.m. identified R1 had reported on the evening of 12/16/22, R2 swore at her from across the hall and R2 responded by swearing at R1 After the verbal altercation R1 began to cry. During an interview on 1/3/22, at 1:00 p.m. R1 stated some time during the evening this past month. R2 had cussed at her which really hurt her feelings and made her cry. R1 indicated this had made her afraid of R2. During a telephone interview on 1/4/23, at 10:15 a.m. nursing assistant (NA-A) stated on the evening of 12/16/22, she entered R1's room to assist R1 with bedtime cares when she noticed R1 was crying. NA-A asked R1 what was wrong and R1 informed NA-A she was scared and very upset because R2 had cussed at her. R1 stated she was afraid R2 may enter her room and hurt her while she was sleeping. NA-A stated she had immediately reported R1's concerns to registered nurse (RN-A) In addition, NA-A indicated she had sent administration an email on the evening of 12/16/22, regarding R1's concerns with R2. During an interview on 1/4/23, at 10:25 a.m. RN-A confirmed NA-A had reported R1's allegation of abuse to her on the evening of 12/16/22. RN-A confirmed she had not notified administration or filed a report with the SA since she was aware NA-A had emailed administration and assumed they would have reported the allegation. RN-A stated the facility's expectation was a report to the SA would have been filed within two hours of the allegation of abuse. During an interview on 1/4/23, at 10:35 a.m. social worker (SW) stated when she arrived to work on 12/19/22, she had received an email from NA-A dated 12/16/22, which identified R1 had become upset when R2 cussed at her. SW indicated her and clinical manager (CM) spoke with R1 regarding the allegation of abuse on the morning of 12/19/22, and then filed a report to the SA. SW stated her expectation was the allegation of abuse would have been reported to the SA within two hours. During an interview on 1/4/23, at 10:44 a.m. director of nursing (DON) stated when she arrived to work on 12/19/22, she had received an email from NA-A dated 12/16/22, which identified R1 had become upset with R2. DON stated while SW and CM were talking with R1 she indicated she suffered emotional abuse and that is when a report was filed to the SA. DON confirmed the SA report had been filed late. DON stated her expectation was any allegation of abuse would have been reported to the SA immediately but no more than two hours after learning about the allegation of abuse. During a telephone interview on 1/4/23, executive director (ED) stated he had been made aware of the allegation of abuse on the morning of 12/19/22. ED stated his expectation was for RN-A to contact the DON and a report would have been filed to the SA immediately but no more than two hours after the allegation of abuse. A facility policy titled Abuse Prohibition/Vulnerable Adult Plan revised 4/11/22, indicated all staff were responsible for reporting any situation that was considered abuse or neglect. and immediate notification to the administrator was required for any incidents of resident abuse, alleged or suspected abuse. The policy indicated suspected abuse should have been reported to OHFC online reporting not later than two hours after forming the suspicion of abuse. . .

Based on observation, interview and document review, the facility failed to provide proper preparation and tracking of food temperatures in order to provide nourishing foods in a safe manner to prevent the potential for food-borne illness. This had the potential to affect all 72 residents who ate food prepared by the facility kitchen. Findings include: During an observation on 9/27/21, at 5:18 p.m. culinary services (CS)-B pushed a cart into the kitchenette with four large pans of pizza and additional special diet hot foods which were covered with aluminum foil. During an observation on 9/27/21, at 5:25 p.m. CS-C checked the temperature of all hot foods prior to being served to residents with the following results noted: Mashed potatoes 176 degrees Fahrenheit (F), ground pizza 161 degrees F, Pureed pizza 172 degrees F, gravy 164 degrees F, Pizza 162 degrees F. An observation on 9/27/21, revealed the following: -at 5:30 p.m. CS-C served pizza to the residents from the first pan located on the steam table. The three additional trays of pizza remained on the cart, unheated and covered with foil. -at 5:42 p.m. CS-B placed the second tray of pizza on top of the first empty pan on the steamer and removed foil from the top and served the pizza to the residents. The two additional trays of pizza remained on the cart unheated and covered with foil. The food temperature had not been rechecked since 5:25 p.m. -at 5:50 p.m. CS-B placed the third tray of pizza on top of the empty pans located on the steam table and continued to serve the pizza to the residents. The food temperature had not been rechecked since 5:25 p.m. -at 5:55 p.m. Maintenance director (MD) approached the cart and loosened, lifted the foil off of the fourth pan of pizza, looked underneath it, and did not secure the edges. -at 6:01 p.m. CS-B placed the fourth tray on top of the empty trays stacked on the steam table, removed the foil and continued to serve the residents. The food temperature had not been rechecked after 5:25 p.m. -6:18 p.m. The meal service ended. On 9/27/21, at 6:07 p.m. during an interview, CS-B stated it had been her first-time serving pizza. A request was made to take the temperature of the last 10 remaining pieces of pizza left on the fourth pan. CS-B checked the temperature and confirmed the results of 96 degrees F. CS-B stated the temperature should have been over 165 degrees F in order to prevent foodborne illness. At 6:15 p.m. CS-B served another piece of pizza to a resident and made no attempt to warm it up. CS-B confirmed she had not re-heated the piece of pizza prior to serving the resident. CS-B stated the facility expected staff to re-heat in the microwave prior to serving residents. On 9/28/21, at 11:10 a.m. during an interview, R64 stated the pizza had been served cold last night and R64 would have preferred it to be served hot. R64 indicated the facility had difficulty keeping food hot while serving meals. On 9/30/21, at 9:45 a.m. during an interview, culinary director (CD) stated hot foods temperatures were taken prior to sending them up to the kitchenettes and the temperature of the food should have been maintained at least 160 degrees F. CD indicated the staff were expected to maintain the temperature of at least 140 degrees F while the food was on the steam table. CD stated the pizza had been difficult to keep hot and should have been batched cooked instead of cooked all at once. CD confirmed the fourth pan of pizza's temperature was around 90 degrees F when re-checked and should not have been served to the residents. CD stated the pizza should have been sent back to the kitchen and a new pizza should have been made. CD indicated the residents could have developed foodborne illness from the cold pizza. Review of a facility policy titled Food Temperatures dated 2005, identified the temperatures of the food items would be taken and properly recorded for each meal. The procedure identified all hot food items must be served at a temperature of at least 140 degrees Fahrenheit (F). Hot food items were not to fall below 140 degrees F after cooking. Cooking temperature must be reached and maintained according to regulations, laws, and standardized recipes while cooking. Temperatures were expected to be taken periodically to ensure hot foods stayed above 140 degrees F.

Based on observation and interview, the facility failed to ensure appropriate personal protective equipment (PPE) including N95 masks were disposed of after each use for 1 of 1 resident (R56) reviewed for infection control practices who was on droplet precautions. Findings include: R56's Minimum Data Set (MDS) dated [DATE], indicated R56 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, eating and toileting. R56's admission record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/21, at 7:47 a.m. during an observation, occupational therapist (OT)-A entered R56's room and followed instructions posted on the door for droplet precautions. An isolation caddy hung on the door which contained gowns, gloves, and instructions for appropriate donning and doffing of PPE. Additionally, a sign was posted on the door which read Must wear N95 Mask. OT-A closed the door to assist R56 with morning cares. At 8:11 a.m. OT-A opened the door with gown and gloves already removed. OT-A had N95 mask on when leaving a room designated for droplet precautions and proceeded to walk down the hallway past several doors until she reached her office. OT-A removed the N95, placed it in a brown paper bag and donned a surgical mask. OT-A sanitized hands. On 9/29/21, at 8:11 a.m. during an interview OT-A stated she had been instructed to wear an N95 when working in rooms on droplet precautions and to reuse the mask up to 5 times. OT-A indicated they were asked to store the N95 mask in the brown bag between uses. On 9/29/21, at 8:25 a.m. during an interview, infection preventionist (IP) stated staff were expected to wear N95 masks when working with residents on droplet precautions and to reuse the N95 mask up to 5 times unless soiled. IP stated the facility was not experiencing a shortage of masks, nor would it cause a hardship to convert to single use N95. On 9/29/21, at 1:19 p.m. nursing assistant (NA)-D indicated the staff had received education and training multiple times on personal protective equipment (PPE) use since COVID began. NA-D stated staff were expected to always wear a surgical mask and eye protection. NA-D indicated they had been fitted for N-95 masks, and were to wear them in a residents room who had potential COVID-19 or were positive for COVID-19. NA-D stated the usual facility practice was to remove the N-95 mask after cares were provided, place it in a brown paper bag, and wear the same mask up to 5 times. NA-D indicated they stored the brown paper bags in the closet by the medication room. The facility's COVID-19 Respiratory Protection Plan, revised 5/3/21, directed N95 were disposable, however lacked direction for multi-use or single use. CDC COVID guidance, Interim Infection Prevention and Control Recommendations for healthcare personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/10/21 directed when N95 masks were used during the care of a patient on droplet precautions, it was to be discarded after the patient care encounter and a new one was to be donned.

Based on observation, interview and document review the facility failed to provide nail care, routine shaving, and timely incontinence care for 3 of 5 residents (R33, R20, R59) reviewed for activities of daily living (ADL). Findings include: R33 R33's annual Minimum Data Set (MDS) dated [DATE], identified R33 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R33 required extensive assistance with personal hygiene, dressing, and transfers. R33's care plan revised 9/8/21, identified R33 had an ADL self-care performance deficit related to stroke with left sided weakness and diabetes. R33's care plan interventions included: extensive assistance with bathing, dressing and personal hygiene. The care plan indicated R33 preferred to keep his fingernails longer to assist with picking up objects, staff offered to trim nails, however R33 often refused date initiated 5/16/21. R33's care plan identified at times resident fingers and nails were dirty, staff offered to assist to clean, if resident declined, staff would re-offer and explain why they should be kept clean, revised on 9/30/21. On 9/27/21, at 2:30 p.m. R33 sat in his wheelchair in his room. R33's fingernails were long, and his right fingernails had a brown substance under the nails, with a darker larger amount of substance noted under his thumbnail. R33 indicated he liked to keep his fingernails long and stated they had trimmed them about a week ago. On 9/28/21, at 9:20 a.m. R33's fingernails continued to have a brown substance under the nails on his right hand. R33 stated he liked his fingernails a little long however they had not been cleaned in a long time. On 9/29/21, in a follow-up interview at 11:54 a.m., R33 confirmed his nails were dirty and it appeared there was dirt present under them. R33 stated he was not able to recall the last time his nails had been cleaned. On 9/29/21, at 12:38 p.m. NA-D stated R33 received an evening bath and he refused his bath at times. NA-D indicated R33 preferred to keep his nails long and were trimmed by the nurses due to R33 had Diabetes Mellitus. On 9/29/21, at 12:46 p.m. NA-D checked R33's nails and confirmed they were dirty. NA-D asked R33 if she could clean his nails and he agreed. On 9/29/21, at 1:16 p.m. during a follow up interview, NA-D stated she had cleaned R33's fingernails and registered nurse (RN)-A had trimmed them. NA-D indicated R33's fingernails were soiled on his right hand and his left thumb. On 9/30/21, at 9:17 a.m. clinical manager (CM)-B confirmed she expected nursing staff to offer to clean R33's nails when soiled, or assist R33 to clean them himself. CM-B indicated when R33 refused to have his nails cleaned, she expected staff to explain why his nails required cleaned and to re-approach. On 9/30/21, at 10:41 a.m. director of nursing (DON) indicated she expected staff to offer to clean R33's fingernails on his bath days and in between as needed. DON stated when R33 refused to have his nails cleaned, she expected other staff members to offer and if the resident continued to refuse, staff were to notify the nurse. DON indicated R33 allowed certain staff members to assist him. DON stated it was important to keep residents' nails clean for infection control purposes and to maintain dignity. A facility policy was requested however not provided. R59 R59's quarterly Minimum Data Set (MDS) dated [DATE], identified R59 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R59 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's) of bed mobility, dressing, personal hygiene, and bathing. R59's care plan updated 9/28/21, revealed R17 had an ADL self-performance deficit related to dementia and [CONDITION(S)], and required extensive assistance with grooming. R17's care plan lacked identification of R59's shaving preference. R59's nursing assistant care guide printed 09/30/21, lacked R59's preference for shaving. On 9/27/21, at 5:30 p.m. R59 was observed seated in her wheelchair at a table in the main dining room. Dozens of white, wispy facial hairs were noted on R59's chin ranging from two (2) to six (6) millimeters (mm) in length. On 9/28/21, at 8:54 a.m. R59 was observed in her room seated in her wheelchair at a table eating breakfast. A half dozen long, wispy white facial hairs were noted to the left side of her chin which ranged from five (5) to six (6) mm in length and dozens of dark facial hairs were noted to the right side of her chin which ranged 2-four (4) mm length. - at 3:15 p.m. R59 was observed seated in wheelchair in her room and the facial hair remained on her chin. On 9/29/21, at 7:03 a.m. R59 was observed seated in her wheelchair in her room, R59 was dressed for the day and the facial hair remained on her chin. On 9/30/21, at 9:15 a.m. during an interview, licensed practical nurse (LPN)-A identified residents would have been shaved once weekly on their bath days if that were their preference. On 9/29/21, at 9:52 a.m. R59 returned to her room in her wheelchair from beauty shop. R59 continued to have dozens of dark facial hairs 2-4mm in length present on right side of chin with half dozen long, wispy white facial hairs 5-6mm in length on left side of chin. On 9/30/21, at 9:56 a.m. R59 was observed seated in her wheelchair in her room and the facial hair remained on her chin. On 9/30/21, at 10:00 a.m. during an interview, LPN-B stated R59 required extensive assistance with grooming. LPN-B indicated R59 had her own razor, staff were expected to shave her on her bath day and checked every morning during cares to determine if she R59 needed to be shaved. On 9/30/21, at 10:10 a.m. during an interview, nursing assistant (NA)-A identified R59 required extensive assistance with ADL's. NA-A stated R59 had her own razor in her room and would shave herself with staff assistance. NA-A indicated staff were expected to shave R59 on her bath day (Tuesday) and if staff noted any long hairs they were expected to offer to shave her. On 9/30/21, at 10:51 a.m. during an interview, R59's family member (FM)-A identified her mom had worked as a beautician and stressed it was very important for her to have her hair styled and makeup on her face. FM-A indicated it had been very important to R59 to have her facial hair removed. On 9/30/21, at 1:45 p.m. during an interview, clinical manager (CM)-A identified R59 required extensive assistance with dressing and grooming. CM-A stated staff were expected to shave R59 on her bath days. CM-A confirmed R59 had an electric razor in her drawer in her room and further confirmed R59 had dozens of dark facial hairs 2-4mm in length present on right side of her chin along with a half dozen long wispy white facial hairs 5-6mm in length on the left side of chin. On 9/30/21, at 2:10 p.m. during an interview, the director of nursing (DON) stated she expected staff to offer and trim both male and female facial hair as long as the resident agreed. Review of facility policy titled Shaving the resident policy last revised in February 2018, identified the facility promoted cleanliness and indicated staff would review the residents care plan to assess any special needs. R20 R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R20 had intact cognitive abilities and required extensive to total assistance with activities of daily living (ADL's) of bed mobility, dressing, personal hygiene and bathing. R20's care area assessment (CAA) dated 2/4/21, identified R20 required extensive assist and was always incontinent of urine. The CAA indicated R20 was at risk for infection related to incontinence and required assistance with toilet needs. R20's care plan updated 8/8/21, revealed R20 had an ADL self-care performance deficit related to limited mobility related to weakness and [CONDITION(S)]. R20's care plan revealed she required an extensive assist for personal hygiene and staff are to provide incontinent products and assist to change as needed. R20's bowel and bladder evaluation dated 2/4/21, identified R20 was incontinent related to urge and functional deficient and had uncontrolled urgency. R20's nursing assistant care guide printed on 9/30/21, identified staff were to offer R20 the bedpan prior to meals. On 9/27/21, at 2:30 p.m. R20 laid on her back in her bed with head of bed (HOB) elevated 80 degrees. Noted to be covered by a blanket with the over the bed table was in front of her. During continual observation conducted on 9/29/2021, from 7:07 a.m. to 9:55 a.m. revealed the following: - at 7:07 a.m. R20 laid on her back in her bed with her eyes closed and HOB elevated to 30 degrees. R20 had a wedge positioned under the left side of lower back. - at 7:30 a.m. R20 continued in the same position. No staff had entered room from first observation at 7:07 a.m. - at 8:05 am. R20 continued in the same position and no staff were observed to enter R20's room. - at 8:22 a.m. licensed practical nurse (LPN)-C entered R20's room with medications. - at 8:24 a.m. LPN-C exited R20's room. - at 8:40 a.m. nursing assistant (NA)- A entered R20's room with her breakfast tray and exited the room. NA-A had not offered to toilet or reposition R20. - at 8:43 a.m. R20 continued in the same position and no staff entered her room to offer to toilet R20. R20's breakfast tray was on her overbed table in front of R20. - at 9:01 a.m. NA-A entered R20's room. - at 9:09 a.m. NA-A exited R20's room. NA-A had not offered to toilet or reposition R20. - at 9:11 a.m. R20 continued in the same position and no staff entered her room to offer to toilet R20. - at 9:32 a.m. NA-B entered and exited R20's room. NA-B had not offered to toilet or reposition R20. - at 9:50 a.m. NA-C entered and exited R20's room. NA-C had not offered to toilet or reposition R20. - at 9:55 a.m. R20 remained in her bed in the same position when NA-A and NA-C entered R20's room to provide cares. NA-A lowered R20's HOB and R20's brief was noted to be saturated with urine and bowel movement (BM) which extended up to her lower abdomen. NA-A and NA-C rolled R20 to her right side and redness was noted to her buttocks. A slit to R20's coccyx was noted with a scant bloody drainage observed. LPN-C entered R20's room and identified the slit as moisture associated skin damage (MASD). R20 was boosted in bed by LPN-C, NA-A and NA-C. NA-A and NA-C rolled R20 to her right side and placed the wedge under her left side. NA-C elevated R20's HOB to 50 degrees. R20 went two hours and 43 minutes without being checked or changed, a full 43 minutes over the two hour time frame identified on R20's care plan. On 9/29/21, at 10:30 a.m. during interview, NA-A confirmed prior to the care that was performed at 9:55 a.m., R20 had last been checked and changed at a little after 7:00 a.m. On 9/30/21, at 10:00 a.m. during interview, LPN-B identified R20 required total assistance for all cares which included grooming and hygiene. LPN-B indicated R20 had a MASD area on her coccyx and should have been checked and changed every 2 hours to prevent further breakdown. On 9/30/21, at 10:45 a.m. during interview, LPN-C identified R20 required total assistance from staff for all ADL's which included hygiene cares. LPN-C indicated R20 was confined to her bed, had bowel and bladder incontinence and should have been checked and changed every 2 hours. On 9/30/21, at 1:45 p.m. during interview, clinical manager (CM)-A stated R20 required extensive assistance with basic ADL's and peri cares. CM-A noted R20 was frequently incontinent of both bowel and bladder and was aware of her MASD. CM-A indicated staff were expected to check and change R20 every 2 hours and confirmed based on observation from 9/29/21, R20 had not been checked and changed every 2 hours. On 9/30/21, at 2:10 p.m. during interview, director of nursing (DON) identified she expected staff to check and change R20 every two hours per her care plan and confirmed based on observation from 9/29/21, R20 had not been checked and changed every 2 hours Reviewed resident examination and assessment policy last revised February 2014. Policy identified procedure to examine and assess abnormalities in health status.

Based on observation, interview and document review the facility failed to assess for safe administration for 1 of 1 resident (R45) who had medications left at the bedside. Findings include: R45's Face Sheet listed various [DIAGNOSES REDACTED]. R45's admission Minimum Data Set (MDS), dated [DATE], indicated R45 had [DIAGNOSES REDACTED]. The MDS indicated R45 had intact cognition, and required extensive assistance with all activities of daily living (ADL.) The MDS indicated R45 had coughing or choking during meals or when swallowing medications, had delusions, verbal behaviors directed towards other and other behaviors such as hitting, scratching self and disruptive sounds. On 1/22/20, at 8:42 a.m. R45 was observed alone her room, seated in bed, with a food tray of food items on her bedside table. The food tray had a plastic cup on it,which held 4 pills (one white pill, one red, one dark pink and one light pink pill) resting on the tray. At approximately 8:50 a.m. license practical nurse (LPN)-C entered R45's room and asked R45 if she had taken her pills. R45 responded not yet. Review of R45's Self- Medication Administration Record [REDACTED]. The record lacked documentation of any oral medication to be self adminsitered. Review of R45's Self Adminsitration of Medication Evaluation form, dated 1/16/20, indicated R45 was safe to administer topical medication/treatment and opthalmic, nasal and/or [MEDICATION NAME] medication. However, the evaluation did list R45 was safe to administer oral medications. On 1/24/20, at 11:02 a.m. LPN-C confirmed she had left R45's oral medications at her bedside, for her to take on her own on 1/22/20. She confirmed R45's Self Adminsitration evaluation had not included assessment of oral medications and confirmed she had updated the evaluation to include oral medications just that day(1/24/20.) She confirmed R45's R45's self adminsitration record lacked documentation she could self administer oral medications. On 1/24/20, at 1:15 p.m. the consulting pharmacist (CP) stated she would expect the nurses to complete an assessment, and obtain a physican's order for the resident to self administer. She indicated if the resident did not have an assessment or order to self administer, she would expect the nurses to watch the resident take their medications. On 1/24/20 at 2:32 p.m. the director of nursing (DON) stated she would expect the nurses to assess each resident for safety with self adminstration of oral medications and confirmed R45's most current Self Administration had been updated on 1/24/20. She indicated she would expect the nurses to complete an assessment and get an order from the physican prior to the resident self administering any medications. Review of the facility policy titled Self-Adminstration of Medications, revised, 4/14, directed the resident's ability to to self-administer medications is done by means of a skill assessment done periodically and the results of the assessment was recorded in the resident's medication record.

Based on observation, interview, and document review, the facility failed to ensure a system for accurate reconciliation of controlled medications for 2 of 2 residents (R10, R66) to prevent potential loss or diversion who received controlled drugs and resided on the Maple Lake and Turtle Beach unit in the facilty. Findings include: On 1/23/2020, at 6:37 p.m. a tour of the Maple Lake/Turtle Beach medication storage room was conducted with Registered Nurse Unit Coordinator (RNUC)-[NAME] In the locked refrigerator, a bottle was noted to be partially full, labeled with R10's name. -R10's bottle of [MEDICATION NAME]/[MEDICATION NAME] 2 milligrams (mg) per milliliter (mL), with instructions to give 0.25 mL orally at hour of sleep. The bottle was observed to have 6 mL remaining in the bottle. RNUC-A verified the findings and verified the narcotic log book listed there should have been 10.75 mL in the container. At that time, RNUC-A verified the narcotic log book count indicated 2 staff had counted the [MEDICATION NAME] that day at 1/23/2020, at 8:30 a.m. and signed off that the medication count was accurate at that time. RNUC-A indicated the nurses should have reported the discrepancy immediately, and verified that had not been done. On 1/24/2020, at 9:31 a.m. a count of the Maple Lake medication cart controlled drug count was conducted with RNUC-A and reconciled with the facility narcotic log book at that time and revealed the following: Maple Lake Medication Cart: - R66's [MEDICATION NAME] 100 mg/5 mL liquid medication was observed to have 2.4 mL, and the log book indicated 4.25 mL should be in the container, a 1.85 mL discrepancy was verified by RNUC-[NAME] On 1/24/2020, at 10:30 a.m. the RNUC-A stated she had conducted an investigation for R10's medication discrepancy in which she compared the controlled drug log with R10's Medication Administration Record [REDACTED]. RNUC-A indicated the investigation had identified 14 doses had not been documented in the controlled drug log book. In addition, RNUC-A had identified 1 spilled dose documented in R10's progress note on 1/21/2020, had also not been documented in the controlled drug log book. RNUC-A indicated the investigation of R66's [MEDICATION NAME] sulfate discrepancy of 1.85 mL had compared the log book documentation to the MAR from 10/16/19, to 1/24/2020, and revealed 7 doses had not documented in the log book, and 1 calculation error was identified. RNUC stated staff had not documented administration of the controlled medication in the controlled drug log book, and had not accurately reconciled at the end of each shift by looking carefully at the medication in comparison to the log book to promptly identify discrepancies. RNUC-A stated staff needed re-education and closer monitoring to ensure understanding and accuracy of controlled drug documentation and reconciliation. On 1/24/2020, at 1:07 p.m. the facility Pharmacy Consultant (PC) stated she would expect the facility to conduct an accurate count of all controlled medications each shift to ensure the amounts are accounted for and accurate, and follow their policy and procedure with any medication discrepancies identified. The pharmacy consultant stated any discrepancy identified should be investigated to ensure drug diversion had not occurred, and to ensure accurate dosing and documentation of medication given was done each shift. The pharmacy consultant indicated she would expect nursing staff to identify any discrepancies during shift count to be recognized, reported, investigated, and reconciled immediately. On 1/24/2020, at 12:02 p.m. LPN-B working on the Maple Lake medication cart stated a controlled drug count was completed with another nurse at the beginning and end of each shift. LPN-B indicated one nurse looked at the medications and the other nurse looked at the log book. LPN-B indicated that signing the log book verified the count was completed and found to be accurate. LPN-B stated if a liquid controlled drug is a little low she would notify the supervisor, but indicated sometimes she gets busy and forgets to do so. LPN-B stated she had not noted any discrepancies or reported anything recently. On 1/24/2020, at 1:40 p.m. during a group interview with the RNUC-A and DON, RNUC-A stated she had been investigating the discrepancies identified during the Maple Lake/Turtle Beach controlled drug medication review and indicated she had identified many doses given and not entered into the controlled drug log book. The DON indicated if a controlled drug was given she would expect nursing staff to document it in the narcotic log book. The DON stated she would expect staff to compare the bottle to the log book and set it on the cart to verify the amount. The DON and RNUC stated they would expect staff to have noticed the discrepancies identified and verified no discrepancies had been identified or reported during the shift change count by their staff. On 1/24/2020, at 2:18 p.m. during a follow up interview, the DON verified she would expect staff to look to have noticed discrepancies that were identified during observations made of the controlled drug medications on Maple Lake/Turtle Beach medication storage room and medication carts so an investigation of the discrepancies could have been done to prevent potential drug diversion. The DON stated she would expect staff to follow the policy and procedure and report any discrepancies immediately. The DON verified the policy was not followed and the discrepancies should have identified, reported, investigated, and reconciled. A review of the facility provided policy and procedure titled Controlled Medication Storage, revised on (MONTH) 2014, indicated the Drug Enforcement Agency (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal and state regulations. The procedure section E. instructed staff at each shift change conduct a physical inventory of all controlled medications 2 authorized staff at the end of each shift as a means of reconciliation. Section F. indicated any discrepancy in controlled substance medication counts is reported to the DON immediately, and the DON or designee reconcile the discrepancy. In addition, the policy indicated the consultant pharmacist or designee monitored medication storage and records during quarterly medication storage inspection.

Based on observation, interview, and record review, the facility failed to ensure proper wheelchair positioning for 1 of 1 resident (R64) observed with positioning concerns. Findings include: R64's quarterly Minimum Data Set (MDS) an assessment dated [DATE], identified R64 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R64 required total dependence of staff for all activities of daily living (ADLs), had a functional limitation in range of motion in upper and lower extremities, and utilized a wheelchair. R64's care plan last reviewed 9/17/18, identified R64 was on Hospice services and had limited physical mobility related to [MEDICAL CONDITION], contractures, and [MEDICAL CONDITION] as evidenced by requiring total assist with all mobility. R64's care plan interventions included: unable to ambulate, total dependence on staff for locomotion using wheelchair, use of pressure relief cushion to prevent skin breakdown related to a history of pressure ulcer and inability to reposition self, has reclining wheelchair, able to sit in wheelchair in room fully reclined to promote proper posture. Further, R64's care plan identified R64 was unable to independently extend and relax neck muscles as evidenced by muscle rigidity, and needs assist to recline chair to promote neck stretches. Review of R64's signed Order Summery Report dated 10/3/18, indicated R64's wheelchair was to be tipped back at all times when in use for neck and spine extension. Review of R64's Care Conference Form dated 9/18/18, indicated R64's wheelchair positioning was assessed. The section on the form titled positioning device, indicated not applicable. The section titled team review of risk and benefits, indicated not applicable. Wheelchair positioning comfortable for resident, indicated yes. Resident had satisfactory body alignment, indicated yes. Occupational therapy referral, indicated no. On 10/1/18, at 5:32 p.m. R64 was observed seated in an upright, black reclining wheelchair located at the dining room table. R64's head/neck was stretched out and to the right. Her head was approximately four inches away from the wheelchair's headrest, and a curved neck pillow was placed behind her head, but did not support R64's head or neck. At 6:22 p.m. R64 was observed seated in her wheelchair by the nursing station against the wall near the elevator door. Her chair remained in an upright position. R64 had leaned to the right to the point that her head rested directly on the wall's handrail. At 6:25 p.m. licensed practical nurse (LPN)-A pushed another resident out of the dining room and past R64. R64's head remained on the handrail. At 6:27 p.m. nursing assistant (NA)-A walked directly past R64, whose head remained on the handrail, and NA-A did not offer R64 repositioning assistance. At 6:34 p.m. trained medication aide (TMA)-A walked directly past R64, whose head remained on the handrail. At 6:37 p.m., NA-B walked up to R64's wheelchair. Another staff member called NA-B's name and NA-B walked away from R64 without offering to reposition R64. R64's head remained on the handrail. At 6:38 p.m., NA-B approached R64 and pushed R64's wheelchair back to her room. R64 remained leaning to the right. On 10/2/18, at 9:40 a.m. R64 was seated in her wheelchair, with her upper body leaned to the right. The middle of R64's head was aligned with the right wheelchair handle. A neck pillow was loosely positioned behind her head and was not assisting with positioning. On 10/3/18, at 7:16 a.m. R64 was seated in her upright wheelchair outside of the dining room doors. R64's head was turned to the right with her chin pointing up and to the right. R64's neck was stretched out and appeared rigid with her neck vessels and tendons stretched tight. R64 was without a neck pillow. At 7:39 a.m., R64 was seated in her wheelchair at the dining room table. LPN-B approached R64, used her left hand to push R64's right shoulder, until R64 was seated straight in the wheelchair. LPN-B then sat in an empty chair next to R64 and administered medication and a small amount of nutritional supplement and then left. At 7:41 a.m., R64 had returned to the original right side-leaning position. On 10/3/18, at 12:09 p.m. R64 was seated in her upright wheelchair at the dining room table. R64's shoulders leaned to the right with her right shoulder approximately three inches lower than the left, and R64 was without a neck pillow. LPN-B approached R64 from her right, stood next to R64 and used her open left hand to push R64's head until her shoulders, neck, and head were straight. LPN-B left her left hand on the side of R64's head, which held R64 in a straight position, as she had R64 drink small sips of nutritional supplement. At 12:11 p.m., LPN-B removed her hand from the side of R64's head and R64's head returned to the original right leaning position. At 1:09 p.m., R64 remained in the right side leaning position after completing her meal. No staff attempted to reposition R64 during the meal. On 10/4/18, at 8:58 a.m. R64 was seated outside the dining room doors in her wheelchair. R64's right shoulder was approximately three inches lower than the left. R64's arms were contracted and pulled to her chest. R64's chin was again outstretched and head approximately 4-5 inches away from the wheelchair's head rest. R64's neck pillow was not observed. On 10/4/18, at 1:29 p.m. NA-C stated R64 required total staff assistance for ADLs. NA-C stated R64 could not adjust or move herself in her wheelchair. NA-C stated R64 leaned to the right side in her wheelchair and staff sometimes used a pillow for positioning help in the wheelchair. NA-C indicated she had to reposition R64 in the wheelchair due to leaning to the right about once per shift as R64 did not spend much time up in the wheelchair. On 10/4/18, at 1:40 p.m. NA-D stated R64 required total assist from staff for all ADLs. NA-D stated R64 was unable to make any meaningful movements. NA-D stated R64 leaned over to the right about 90 percent of the time she was in her chair, and stated, I would not want to lean that much. NA-D stated staff at times used pillows to assist R64's position in her wheelchair. On 10/4/18, at 2:11 p.m. LPN-B stated R64 required total staff assistance with ADLs, had contractures, was weak, and was losing weight. LPN-B stated staff could place R64 in her wheelchair perfectly, and R64 would still lean to the right. She indicated staff utilized either a bendable neck pillow behind R64's neck for head support, or staff would bend it straight and place it on R64's right side to help her sit straight in the wheelchair, or use pillows for positioning. LPN-B indicated R64 had the same wheelchair for the last three years and therapy had worked with R64 and her wheelchair multiple times in the past due to R64's contractures and positioning. LPN-B stated she would push on R64's upper body to get her to sit up straight to drink her nutritional supplements every breakfast and lunch. On 10/4/18, at 2:45 p.m. the director of rehab (DOR) stated R64 had not been assessed by therapy for her wheelchair positioning this year and added therapy typically do not see residents that are on hospice services. The DOR stated hospice provided wheelchairs for residents on their services. On 10/4/18, at 2:52 p.m. during a phone interview, the hospice registered nurse case manager (HCM)-A indicated R64 was on hospice services and she would see R64 weekly and as needed. HCM-A stated when she visited R64 she would either be lying in bed, or seated in her wheelchair with the wheelchair tilted back. HCM-A stated when R64 was tilted back in the wheelchair; she was in good alignment and had no positioning concerns. HCM-A stated she was not aware of R64 leaning in the wheelchair, but indicated hospice was capable of seeing if a different wheelchair would support R64. On 10/4/18, at 3:03 p.m. nurse manager (NM)-A stated if staff had to consistently reposition a resident in their wheelchair, due to positioning concerns, then staff would get a therapy assessment to help with wheelchair needs or assistive devices. NM-A stated, if staff had to push on R64's arms to position her, then R64 should have been repositioned properly. NM-A stated staff could get therapy to adjust R64's headrest. On 10/4/18, at 3:14 p.m. the director of nursing (DON) indicated staff try to keep residents positioned evenly in their wheelchairs. The DON stated hospice could bring in specialty wheelchairs if hospice felt a resident needed one. The DON stated therapy looked at R64's wheelchair in the past, but do not screen residents on hospice services. The DON indicated the facility could talk to hospice about a different wheelchair for R64. A policy for wheelchair positioning was requested, however none was provided.

Based on observation, interview and document review, the facility failed to provide range of motion (ROM) exercises to prevent further decline in ROM for 1 of 4 residents (R53) reviewed for limited ROM. Findings include: R53's admission Minimum Data Set (MDS) an assessment dated [DATE], identified R53 was cognitively intact and required total assistance with activities of daily living (ADL). R53 had diagnoses, which included [MEDICAL CONDITION] (impairment in motor or sensory function of the lower extremities) and [MEDICAL CONDITION] disorder. R53's MDS further identified R53 had functional limitation in ROM bilaterally in her upper and lower extremities. R53's ADL function care area assessment (CAA) dated 8/23/18 identified R53 was totally dependent of staff needs. Her CAA also identified she was receiving PT/OT (physical therapy/occupational therapy) to help with deconditioning from recent hospitalization . R53's care plan dated 9/12/18, for ADLs had identified interventions with check marks for mobility/safety and included PT to evaluate and treat and to follow PT instructions. During an observation on 10/3/18, at 8:52 a.m. R53 was lying in her bed on her back, pillow under her right elbow, with sheep skin on her right shoulder under her chin. At 11:35 a.m. R53 was dressed in a pink top, dark slacks and she was reclined in an electric high back wheel chair. R53's head and chin were supported by a head rest which curved from her right side of her head to her chin. R53 demonstrated how she could adjust the tilt of her wheelchair with the electric controls on her wheelchair with her left hand. At 11:54 a.m. NA-E indicated during interview that the facility had a staff member who completed restorative nursing for the residents. On 10/4/18, at 9:09 a.m. R53 was in her bed, dressed, with covers up to her chest. She had a sheepskin on her right shoulder. R53 indicated with her communication board that she was comfortable, and denied pain at that time. R53's current physician orders [REDACTED]. R53's PT Evaluation and Plan of Treatment form dated 8/10/18, signed by physician 8/13/18, identified R53's RLE (right lower extremity) and LLE (left lower extremity) ROM = WFL (within functional limit). The form also identified R53 had impaired strength to her hips, knees and ankles of both RLE and LLE. The form indicated R53 did not have functional limitations due to contractures. R53's Clarification Order form, undated, signed by physician, instructed staff to provide a restorative program, PT eval (evaluation) only and to continue with functional maintenance program focusing on BLE (bilateral lower extremity) ROM exercises. R53's Documentation Survey Report forms, which identified R53's Restorative ROM Program: 3 times a week to maintain BLE ROM. Review or R53's forms from 8/13/18, to 10/4/18, revealed the following: -August (YEAR): R53 received restorative ROM program ROM 5 times out of a possible 9 times. -September (YEAR): R53 received restorative ROM program 1 time out a possible 12 times. One entry indicated NA (Non-applicable). -October (YEAR), R53 received restorative ROM program 0 out of possible 2 times. One entry indicated NA. R53's progress notes reviewed from 8/13/18, to 10/4/18, lacked any documentation of why R53 did not receive her restorative ROM program. On 10/4/18, at 1:28 p.m. R53 indicated with her communication board that she did not remember when she had last received ROM exercises. R53 indicated she did not know how often she was to receive ROM, but she indicated she did remember receiving them in the past. R53's family member (FM)-A was in the room during interview and stated that it has been awhile since R53 had received ROM exercises. On 10/4/18, at 2:10 p.m. during an interview with physical therapy assistant (PTA)-A, who indicated R53 had received only an evaluation from therapy. PTA-A reviewed R53's therapy documentation and stated R53 was put on a functional BLE ROM exercise program. PTA-A indicated R53's left and right lower extremities were within functional limits with strength impaired. PTA-A indicated no contractures were present at the time of the evaluation. PTA-A indicated she would expect nursing staff to complete the ROM exercise program as recommended. PTA-A indicated if the nursing staff were unable to complete the ROM exercises for any reason she would expect them to notify the therapy department who would perform a screening if necessary to determine if any changes were needed to the program. On 10/4/18, at 2:37 p.m. NA-F stated she had provided cares for R53 many times. NA-F stated she felt R53 had no change in her ability or ROM when performing cares, movement or dressing her. NA-F stated R53 required total assistance with ADLs, and was unable to move herself. NA-F stated R53 was able to straighten her legs out with assistance and she felt R53 had no change. NA-F stated the facility had staff who performed ROM exercises for residents during the day. NA-F indicated she assisted residents with a little ROM with cares, but she did not complete the actual ROM exercise program. On 10/4/18, at 2:58 p.m. clinical manager (CM)-B indicated restorative nursing staff were at the facility 7 days a week. CM-B indicated she would expect R53 to receive her ROM exercises 3 times a week as scheduled. CM-B indicated if the restorative nursing staff member was unable to complete the ROM exercises, she would expect the nursing assistant staff to complete them. CM-B confirmed R53 was at risk of contractures, which could occur if ROM exercises were not completed. On 10/4/18, at 3:26 p.m. the director of nursing (DON) stated the usual facility practice was for restorative nursing to begin when a resident was taken off of therapy. The DON stated the therapist would give recommendations, but the nurse in the restorative program could adjust the program. The DON stated the goal of the restorative program was to maintain or improve, but indicated most were for maintenance. The DON stated a nurse overseen the restorative nursing program, who worked with the nursing aides to make sure the program was working, for the resident or make changes or therapy referrals if needed. The DON stated the facility had two restorative nursing assistants who worked part time and they documented in the resident's electronic health record. The DON stated restorative programs should be completed as scheduled to prevent decline. The DON stated she would expect R53 to have her ROM exercise program completed 3 times a week as scheduled or adjust if not able to complete it. The DON stated if staff were unable to complete the resident's restorative programs, then the facility would need to work on programming and staffing. The DON stated if a resident refused restorative services, they should mark refused. The DON stated if the staff were unable to complete restorative services, they probably didn't chart anything. The DON stated NA (not applicable) documentation could mean either the resident was not present or busy. The Administrator, who was also present during the interview, also gave examples of NA documentation, which could mean they were not present, such as when at bingo. The DON confirmed R53 could decline if ROM exercises were not performed. The DON indicated she would expect the restorative staff to complete the ROM exercises or document if unable. The facility policy titled Goals and Objectives, Restorative Services revised (MONTH) 2013, identified specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments. The policy further identified rehabilitative goals and objectives were developed for each resident and were outlined in his/her plan of care relative to therapy services.

Based on observation, interview and document review, the facility failed to accurately assess and failed to appropriately implement interventions to promote healing and prevent worsening for 1 of 1 resident (R58) reviewed with 2 current unstageable (anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed) pressure ulcers on the left foot. In addition, the facility failed to educate R58 on the risks versus benefits of wearing pressure relieving boots against manufacturer's recommendations. R58 sustained actual harm when the facility failed to identify/address the inappropriate application of protective boots, which resulted in worsening of a unstageable pressure ulcer and development of a second unstageable pressure ulcer and increased pain. Findings include: R58's annual Minimum Data Set ((MDS) dated [DATE], identified R58 had [DIAGNOSES REDACTED]. The MDS identified R58 had intact cognition, required extensive assistance from staff for bed mobility, dressing, personal hygiene and toileting and required total assistance with transferring. R58's MDS indicated he was at risk for developing pressure ulcers and had a current unstageable pressure ulcer (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The MDS also indicated R58 had a pressure reducing device for chair and bed. Further, R58's MDS identified he had almost constant pain that made it hard to sleep at night that was rated at a 6 out of 10 on a pain scale. R58's Care Area Assessment (CAA) dated 1/16/18, indicated R58 required assist with activities of daily living (ADLs), declines were expected related to [MEDICAL CONDITION] disease and [DIAGNOSES REDACTED]. The CAA indicated R58 had a current pressure ulcer on left heel, did not move his feet freely and did not always like to reposition and would refuse. Further, the CAA indicated R58 had refused to elevate feet when staff offered, had a rigid routine and made his own decisions. Further, the CAA indicated R58 utilized a pressure relieving mattress to prevent skin breakdown, and would be educated about the risk of pressure ulcers and them healing properly but respect resident decision. R58's care plan printed 1/22/18, identified R58 had [DIAGNOSES REDACTED]. The care plan listed various interventions which included: encourage R58 to lay down to off load pressure, pressure relieving wheelchair cushion, assistance with repositioning and wear padded foot protectors to both feet while up in chair. However, R58's care plan did not address the incorrect placement of R58's Prevalon boots, or alternative interventions to utilize for pressure relief of his feet while he was in the wheelchair. R58's untitled, undated form, identified by the facility as a nursing assistant care guide form listed various directions which included wears large blue heel protector when in wheelchair and bed, and **PLEASE FOLLOW TASK LIST ON WALL WHEN DOING CARES*** On 1/30/18, at 1:10 p.m. R58 was seated in a power wheelchair next to his bed facing the windows. Present on R58's feet were yellow non-skid socks and covering the feet and lower legs were blue Prevalon heel protector boots. The Prevalon boots were placed on R58's feet with the intended calf portion of the boot on the bottom of R58's feet with the manufacturer's tag present behind R58's ankle. This positioning had the Prevalon boot's intended bottom of foot portion on the back of R58's ankle and calf. The black and white straps were wrapped loosely around the heel protector and the corners of the Velcro ends were turned up and loosely held in place. This incorrect positioning of the Prevalon boot caused the intended heel cut out portion of the boot to fold down onto itself, which did not allow for the heel to be fully visible, and floated as intended. The edges of R58's boot were compressed, and approximately 1 inch of R58's left heel was visible at the opening and his heel rested directly on the footboard (direct pressure to the pressure ulcer), in the blue boot. R58's left foot was turned medially so the left lateral, outer edge and the foot rested directly on the wheelchair's footboard. During interview at that time, R58 rocked his body back and forth in his wheelchair, breathing through pursed lips while repeatedly grimacing. R58's body jolted with pain at times, which caused his left foot to rub on the surface of the wheelchair footboard. R58 stated he had pain in his left leg from the knee down to the foot and this pain occurred every few days. He stated lying down in bed gave him the most relief of the pain. On 1/30/18, at 1:47 p.m. R58 remained seated in his wheelchair with Prevalon boots applied incorrectly and registered nurse (RN)-A present in R58's room. R58's feet rested directly on the footboard. She confirmed his Prevalon pressure relief boots were not applied as directed by manufacturer's instructions. RN-A knelt next to R58's feet, unfastened the boot's straps and adjusted R58's left foot. R58 winced as RN-A lifted his left foot to adjust it in the boot. She fastened the straps and placed his foot back on the wheelchair's footboard. RN-A stated she felt the opening of the heel was in the correct position for the most part. RN-A briefly exited R58's room and returned with a new Prevalon boot in packaging and stated she was going to replace R58's left boot because the Velcro straps were worn. RN-A confirmed the Prevalon boot packaging indicated the manufacturer's instructions for correct placement of boot and confirmed the way R58 preferred to wear the boots were identical to the picture on the manufacturer's instructions which had a red circle around the picture and line thru the picture, which indicated incorrect placement. RN-A stated, We always put it on this way. On 1/31/18, at 7:39 a.m. R58 was seated in his power wheelchair in his room, the blue boots on his feet resting directly on the footboard, with licensed practical nurse (LPN)-A present. LPN-A bent down and tightened the straps of the boots and left the boot on with the intended calf portion on the bottom of R58's foot. A gray wedge sleeve was observed on the outside aspect of the left boot without the foam wedge present and the right boot had a wedge sleeve with a foam wedge on the medial side of the boot. At 7:42 a.m., LPN-A stated she had adjusted R58's Prevalon boots because the boots must have slipped down R58's feet during a transfer in the mechanical lift. LPN-A indicated she had not attempted to apply the boots correctly and stated R58 had always worn his boots that way and preferred to wear them that way for comfort and to protect his toes. On 1/31/18, at 8:31 a.m. R58 was seated in his power wheelchair next to the bed with nursing assistant (NA)-A present. A white paper sign was observed posted to the left of R58's bathroom door. The sign was titled R58's AM (morning) routine with a revised date of 11/17/2017 listed on the sign. The sign included steps in R58's morning routine and included: step 14. Make sure socks are on all the way and place blue padded boots on feet a. Long portion of boot should be on the bottom of the foot. b. velcro strips should be pointing in the same direction, gray straps on outside. R58's Prevalon pressure relief boots were observed to continue to be applied incorrectly, with the intended calf portion of the boot on the bottom of R58's feet with the manufacturer's tag present behind R58's ankle. His left lateral edge of left foot made contact with padded wheelchair footboard and right foot bottom of foot making contact with footboard. NA-A and another staff member transferred R58 into bed with a mechanical lift. Once R58 was in bed, NA-A asked R58 if he would like his Prevalon boots removed, R58 refused and stated the boots were to remain on when he was in bed. NA-A proceeded to place left Prevalon boot directly on a pillow with left heel making direct contact with the pillow. R58 told NA-A his heel was not supposed to rest directly on the bed or pillow. NA-A proceeded to move the pillow higher up R58's left leg so that the left Prevalon boot was floated off the pillow and mattress. At 8:38 a.m., NA-A stated R58 had been breathing in and out heavily, with grimacing and R58 indicated he had pain in his left leg. She stated it was weird but staff put R58's Prevalon boots on backwards and that is how he liked them, so the calf part will cover the bottom of R58's feet. NA-A stated if staff put the boot on the correct way, he would ask to have it changed. NA-A stated she had never seen R58 in that much pain and grimacing, and stated his pain was worse since he developed sores on his foot. On 1/31/18, at 10:32 a.m. R58 was observed lying in bed, with his left leg up on a pillow, with nurse manager (NM)-A present. NM-A removed a gauze dressing from R58's left foot and measured the two pressure ulcers as follows: left lateral foot pressure ulcer 0.5 centimeter (cm) x 0.5 cm brown scabbed area with hardened edges and slight redness that measured 2.0 cm x 2.0 cm. NM-A stated she felt the area was a stage 3 (three) pressure ulcer. NM-A measured R58's left heel pressure ulcer 3.0 cm x 3.0 cm and described the heel as hard eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) with a boggy center. NM-A stated she felt the deep tissue injury on R58's left heel was from pressure while lying on the bed. She stated R58 had some pain with the left lateral stage 3 pressure ulcer and none with the heel ulcer. NM-A wrapped R58's left foot with white gauze bandage roll and floated the heel off the bed. On 2/01/18, at 9:13 a.m. R58 was observed seated in his power wheelchair with the Prevalon boots in the same incorrect position on both feet, with the manufacturer's tag in back of his ankle. Both of R58's feet in the boots rested directly on the footboard of the wheelchair. His left foot was medially rotated with left lateral outer edge of foot resting on the wheelchair footboard. On 2/01/18, at 1:25 p.m. R58 was seated in power wheelchair in his room reading a piece of mail. The blue Prevalon boots remained in the same incorrect position. R58's feet in the boots rested directly on the footboard of the wheelchair. His left foot continued to be medially rotated and resting on left edge of left foot. Review of R58's Skin Assessments from 12/30/17 to 2/1/18, revealed the following: -12/30/17, indicated first observation of a blister to left heel that measured 1.0 inch x 0.75 inch that was firm, dark purple deep tissue injury with a blood blister type appearance. R58 denied pain to the area. R58's heels would be elevated at all times when lying in bed. The assessment did not identify R58's incorrect placement of the Prevalon boots, and did not address alternative pressure relief interventions for R58's heel while in his chair. -1/6/18, left lateral foot dry blister present 1.0 centimeter (cm) x 1.0 cm , skin pink, no drainage. Skin dry around area and tender to touch. R58's current Braden score (a scale to predict pressure ulcer risk) indicated R58 was at risk for pressure ulcers due to immobility, unable to reposition independently. R58 was to wear foam boots at all times to prevent pressure to heels due to pressure area on left heel. The assessment form listed various interventions including: pressure relieving mattress and cushion, pressure relieving boots on at all times to prevent further pressure to heels, reposition every two hours and R58 to lie down to elevate feet. The evaluation lacked assessment of the left heel pressure ulcer. Also, the assessment did not address R58's incorrect application of the pressure relief boots or alternatives to pressure relief to use for his feet while R58 was in the wheelchair. -1/13/18, R58's left heel had a black non-blanchable area. 3.5 cm x 3.5 cm circular in shape. Skin was tough and intact, cool to the touch. Surrounding skin pink and warm. R58 complained of pain rated a 10 out of 10 on a pain scale (0 meaning no pain, and 10 meaning the worst pain) in the area with pressure. R58's left lateral foot outer edge: 1/15/2015, (sic) measured 0.4 cm x 0.4 cm scabbed area, surrounded by blanchable red skin that is flaky. The assessment listed various interventions including: pressure relieving boots at all times, pillows under legs to float heels while in bed and encourage to lay down 9-11 a.m. to elevate feet. A note indicated the previous analysis 1/6/18, indicated site was pink and 1 cm x 1 cm and NM-B notified. The overall impression indicated worsening of ulcers. -1/15/18, Complex Wound Observation Tool (CWOT) indicated a suspected deep tissue injury related to pressure on the left heel measuring 3.5 cm x 3.5 cm and an unstageable pressure ulcer to the left lateral foot measuring 0.4 cm x 0.4 cm. R58's CWOT indicated the physician was notified and assessed the ulcers on 1/16/18, with a referral made to Sanford Clinic wound care nurse. R58's CWOT indicated that the pressure ulcers were acquired at the facility on 12/30/17. R58's visible tissue of the left foot was dry with the left heel having 0.3 cm of dark red/black (old blood looking) outer edge of circular wound and the left lateral foot was dry, white scab. R58's pressure ulcers had no drainage and were without odor. Both pressure ulcers were well defined and circular without suspected infection or inflammation. R58's CWOT indicated various interventions including: pressure relieving mattress in bed and cushion in wheelchair, padded foot boots while up in his wheelchair and elevation of legs and float heels on pillows while in bed. R58's evaluation included a Braden score of 15, which indicated a risk for pressure ulcer development related to immobility and diabetes mellitus. R58 was unable to move his legs on his own and the left heel was tender to touch. Staff reported R58 had been refusing to have pillows under his feet for several days due to some pain in feet prior to finding the wound. Education given to R58 and is in agreement to continue to float heels. R58 had always worn padded foot protectors to bilateral feet since admission for comfort. However, the information provided to R58 lacked education on incorrect placement of pressure relief boots to provide pressure relief to R58's feet. -1/27/18, Skin Assessment: R58's left heel was black non-blanchable area with skin intact, measuring 3.5 cm x 2.5 cm. Skin around area pink and warm and complained of pain with pressure. R58's left lateral pressure ulcer measured 0.6 cm x 0.5 cm dark scab with dry skin sloughing off around the scab. Area around the scab was red and R58 had pain with pressure. The assessment indicated R58 was to wear pressure relieving boots at all times to prevent further pressure to heals, float heels on pillow when in bed. However, the assessment did not address the incorrect application of R58's pressure relieving boots, other alternatives for pressure relief for his feet in the wheelchair and did not assess R58's increase in pain in his left foot in correlation to the presence of the 2 unstagable pressure ulcers. On 1/30/18, at 3:24 p.m. during a group interview with the administrator and the director of nursing (DON), the DON stated she was aware R58 wore the Prevalon boots incorrectly, and stated R58 had always worn the Prevalon boots incorrectly since he had been admitted to the facility with Prevalon boots in use. DON stated R58 wore the Prevalon boots for comfort and not for pressure relief. The administrator stated R58 refused to wear the Prevalon boots the recommended way and he felt NM-A had explained the risk versus benefit of wearing the device incorrectly to R58. DON stated she would expect staff to know what the manufacturer's guidelines for application of the boots were, and to follow the guidelines. DON indicated she felt there was an aspect of resident choice to consider. On 1/30/18, at 3:39 p.m. NM-A stated R58 had been admitted with Prevalon boots, the same as he was currently wearing. She stated R58 had always worn them the incorrect way, for his comfort. NM-A stated R58 used to not wear the Prevalon boots in bed, but on 1/18/18, when R58 went to the wound nurse, she recommended wearing the boots at all times. NM-A stated she had not explained the risk versus benefits of wearing the Prevalon boots against the manufacturer's recommendation since the development of the new pressure ulcers on R58's left foot. NM-A stated she asked R58 after the wound nurse appointment on 1/18/18, if the wound nurse said anything about R58 wearing the Prevalon boots incorrectly and R58 indicated he could not remember. NM-A stated she had not yet clarified with the wound nurse if wearing the Prevalon boots incorrectly would be an appropriate pressure relief device. On 1/31/18 at 8:49 a.m., during a following up interview with NM-A, she stated she had not gotten in contact with the wound nurse yet, and indicated she was contacting the doctor to see if there was alternative to boot for elevating heels off the bed and request a occupational therapy screening to assist with this. NM-A confirmed she was aware of the sign posted in R58's room for the nursing assistants to follow when applying the Prevalon boots and confirmed the instructions included the incorrect application of the boots per manufacturer's directions. On 1/31/18, at 1:26 p.m. NA-B indicated R58 had worn the blue Prevalon boots for years, indicated she was not aware of the incorrect placement and stated she applied the boots for R58 the same way she does for anyone else in the facility. On 1/31/18, at 11:46 a.m. a call was placed and message left for R58's primary physician. A return call was not received during survey. Review of physician notes from 1/16/18 to 1/18/18, revealed the following: -1/16/18, R58 was seen for an assessment of a worsening area on left heel. A physical assessment revealed a 4.0 cm diameter pressure ulcer to left posterior heel, unable to assess stage as surface tissue is still intact. Skin appears black in this area, concerned of necrosis (death) of tissue, unable to assess the depth of the pressure ulcer. Also with a callous over lateral surface of fifth metatarsophalangeal joint (the joint between the metatarsal bones of the foot and the proximal bones (proximal phalanges) of the toes). A referral was given for R58 to a wound nurse at Sanford Clinic for further assessment. - 1/18/18, R58 had a pressure ulcer on his left heel. R58's ulcer was tender to palpation and gets pain in the heel that comes on during the night. R58's caregiver stated he complains of pain quite a bit. The note indicated R58 was in his power wheelchair most of the day. He had a blood filled blister on the plantar surface of the left heel about 2.0 cm x 2.5 cm in diameter with mild surrounding redness. Review of CWON-A's wound care nurse visit note dated 1/18/18, indicated R58 was seen for an assessment of R58's pressure ulcers. R58 had a history of [REDACTED]. R58 had a left foot deformity with medial rotation and wore a foam bootie bilaterally to his feet. R58's left heel was a pressure ulcer, unstageable deep tissue injury that was 2.5 cm long and 3.0 cm wide. CWON-A recommended to wear the Prevalon boots 24 hours a day, elevate the feet/legs as much as possible during the day and monitor for positioning of foot to avoid pressure against the foot rest etc. On 1/31/18, at 11:30 a.m. during a telephone interview, the Prevalon Heel Protector III manufacturer Sage Products LLC representative stated the Prevalon boot was manufactured to be worn per the package instructions. She stated the tag on the boot should be up by the toes on the bottom of the boot, not near the heel. The large black strap is used to keep the foot in a neutral position. The long end of the brace is to go against the calf to create the hole for the heel. The thicker portion of the boot is designed for the calf and helps keep the foot in an upright position. The representative confirmed the placement of the boot the way R58 wore the Prevalon boot was incorrect. She indicated to ensure pressure relief the Prevalon boot should only be worn per package instructions and stated the company had not tested the Prevalon boot for the placement seen on the package with the red no sign. On 1/31/18, at 11:55 a.m. during a telephone interview, certified wound ostomy nurse (CWON)-A confirmed she had seen R58 on 1/18/18, and stated the area on R58's left lateral foot was most likely a protrusion in the foot and shear, friction or irritation caused breakdown of the skin. She had recommended wear his Prevalon boots 24 hours per day and elevate his left leg to keep as much pressure off of foot as possible. CWON-A stated she would expect R58 to wear the Prevalon boots per manufacturer's recommendations. On 2/01/18, at 10:45 a.m. NA-D stated R58 had worn the Prevalon boots incorrectly the two years she had worked at the facility. She stated he wore them backwards to protect his feet. NA-D stated R58's left heel pressure ulcer started the size of a quarter and now is huge. She stated R58's pain in his left leg/foot was worse since the development of the ulcer on his heel. On 2/01/18, at 1:41 p.m. LPN-B stated R58 had worn the Prevalon boots incorrectly for the two years she had worked at the facility. She stated if the Prevalon boots were placed the correct way, he would tell staff they put them on wrong. LPN-B stated R58 spent much of the day in the wheelchair, and laid down for a couple hours in the morning. LPN-B stated R58's pain in the left foot had been worse in the last month and had utilized more pain medication for the pain. LPN-B stated the only intervention in place for pressure relief when R58 is in his wheelchair was the use of the Prevalon boots. On 2/01/18, at 1:47 p.m. LPN-C stated R58 had worn the Prevalon boots for years and was aware the boots were worn incorrectly. She indicated the boots were placed incorrect for comfort due to his sensitive feet. She stated R58 preferred them worn backwards and if staff applied them correctly R58 would tell them the boots were on wrong. She indicated R58 was at risk for pressure ulcers and that he has had an increase in pain since the left foot pressure ulcers. LPN-C stated R58's heels were floated on pillows at night in the bed and had the pressure relief boots for when in the wheelchair. LPN-B stated R58 had no other pressure relief interventions while in wheelchair. Review of R58's progress notes from 12/30/17, to 1/29/18, revealed the following: - 1/3/18, blister on the left side of left foot during skin check after bath. - 1/11/18, resident to lay down 9 a.m. - 11 a.m. each morning for left foot pain in the morning for left foot pain. - 1/12/18, resident to lay down 9 a.m. - 11 a.m. each morning for left foot pain in the morning for left foot pain: resident was only able to lay down for a short period of time due to an appointment with doctor. -1/14/18, completed skin assessment today, and 3.5 centimeter (cm) x 3.5 cm black area discovered last assessment on 1/6/18. Stated site was pink and 1 cm x 1 cm (see assessment). Overall impression worsening, site black 3.5 x 3.5 circular in shape, unblanchable, intact and tough. Black area cool to the touch, surrounding skin pink and warm. R58 complained of pain rated 10 out of 10 when pressure applied to site. Current interventions are pressure relieving boots worn at all times, pillows under legs to float heels while in bed, and encouraging R58 to rest 9 a.m. - 11 a.m. to get feet up. Nurse manager (NM)-B notified and per her instructions: physician referral is written and interventions are continued. As needed [MEDICATION NAME] ([MEDICATION NAME]) given to control pain. - 1/15/18, writer assessed area to left heel: area is intact, appears to have a blister like appearance. Outer edge of the area is dark red/blackish in color (0.2 cm - 0.3 cm) then area is more clear in appearance, center has a dark area under the intact skin. Also noted a scab on the outer edge of the left foot, 0.4 cm x 0.4 cm surrounded by blanchable red flaky skin. Referral made for physician to address. Resident recently was refusing to place pillow under his feet while lying in bed, writer provided some education and he stated his understanding. Resident also wore pressure relieving boots (have a cutout for his heels) to both feet while up in his power wheelchair. - 1/15/18, writer added task to Point of Care (P(NAME)) charting to float heels while in bed; every shift will need to chart if completed or if refused. Also, added task to P(NAME) charting for wearing padded foot protectors while up in chair for staff to chart on. Education provided to staff on proper placement of pillow to float heels and provide comfort for the resident. Per staff interview, resident had been refusing to float heels on and off for the last couple of weeks (would occasionally agree to float heels) due to increased pain in feet. -1/16/18, R58's primary physician here and has seen R58's left heel dark purple blister. Physician wanted R58 to see certified wound nurse at Sanford clinic and keep pressure off heels. - 1/16/18, left heel ulcer charting: See charting book every shift. R58 was experiencing a lot of pain to ulcer area. Black in color. Floating heels on pillows while in bed. -1/17/18, nurse practitioner saw R58 regarding pressure wound to the left heel. Prostat (protein supplement) ordered every day for wound healing. -1/17/18, outer edge of the blister looking area is dark red/blackish in color, size unchanged, had a scab on the outer edge of the left foot 0.4 cm x 0.4 cm, surrounded by blanchable, red flaky skin. -1/17/18, wound to left heel measured 4.0 cm x 3.5 cm and was black/dark purple in color. Skin prep applied to area, no open areas noted and no drainage. -1/18/18, R58 went out to see physician regarding left heel pressure ulcer. [MEDICATION NAME] ordered daily to left heel, wear foam boot to left heel 24 hours a day 7 days a week, elevate as much as possible while avoiding pressure to left heel and monitor lateral side of left foot. -1/19/18, wound not witnessed this shift, R58 had pillow boot in place and was elevated on pillow, no complaint of pain or discomfort. - 1/19/18, left heel remains unchanged. Does complain of pain and laid down most of shift with heels floated and boots on. - 1/19/18, received order: [MEDICATION NAME] swab to the heel area and the lateral midfoot site once daily. Wear bootie 24 hours a day, elevate feet/legs as much as possible during the day, and monitor for positioning of foot to avoid pressure against the foot rest, etc. Call in 10 days (1/29/18) with an update, and sooner if becomes moist. -1/20/18, left heel wound remained unchanged and intact, not open. At midnight rounds, pressure relieving boot was not on foot. Placed on foot and elevated on pillows. Will need to re-educate evening staff to place boots on when resident goes to bed. - 1/20/18, left heel wound remains unchanged, dark purple in color, intact and not open. Wound on left distal side of foot is protruding and gray and white in color. R58 complained of slight discomfort when area treated with ordered [MEDICATION NAME]. Heels floated and boots applied as ordered. -1/21/18, R58 had been admitted to the hospital intensive care unit with [DIAGNOSES REDACTED]. -1/26/18, R58 returned from hospital. - 1/27/18, left heel ulcer charting: see charting book every shift: did not observe this shift. -1/27/18, R58 had left heel ulcer, purple in color and painful to resident when pressure applied to area. -1/28/18, left heel ulcer charting: See Charting book every shift: foot is elevated on pillow, sock on. -1/28/18, ulcer to left heel, feet floated off bed with boots on. -1/28/18, Monthly Charting Note: pressure ulcer present to left heel and foam boots are to be on at all times to prevent further pressure. R58 complained of pain to feet and occasionally legs. Tylenol three times a day and [MEDICATION NAME] twice a day and as needed ordered, see skin assessment. -1/28/18, resident ulcer on heel is dark purple and tender to touch. Protruding skin with hole in center on distal outer portion of left foot observed as well, no noted drainage. On 2/01/18, at 2:54 p.m. DON stated she did not know what caused R58's unstageable pressure ulcer on R58's lateral heel, but did not feel it was from the the padded wheelchair footboard. DON stated she felt it was R58's choice for wearing the Prevalon boots incorrectly for comfort prior to the development of the unstageable pressure ulcers, but would have expected NM-A to discuss the risk versus benefits of wearing the Prevalon boots against manufacturer's recommendation once the facility identified the pressure ulcers and the Prevalon boots became a pressure reduction intervention. The DON stated she did not feel the incorrect Prevalon boot use caused the development or impeded the healing of the pressure ulcers. DON confirmed R58 has had more pain since his readmission from the hospital, and that R58 had no other interventions in place to relieve pressure to the left foot while R58 was in the wheelchair. Review of the plastic Prevalon Heel Protector III packaging from R58's Prevalon boot included manufacturer's guidance for use on it's exterior. Below the brand name on the packaging was a red no sign over a picture of the Prevalon boot being worn with the intended calf portion of the boot on the bottom of a foot, with the manufacturer's tag present behind the ankle. The manufacturer's guidance indicated to off load the heel: 1. Put heel protector on. The heel protector is shipped inside out. Position heel over opening on the gray side. Pull sides up around foot and toes. 2. Position wedge on the outside of leg (lateral side). Push wedge tight against the side of heel protector. Reposition as appropriate. 3. Tighten straps. Wrap straps around the heel protector and adjust. Do not over tighten. 4. Make sure heel is floated. Review of facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated March 2014, indicated a pressure ulcer would be assessed including cause identification and treated per physician orders. Pressure ulcers would be monitored for progression of wound healing and care plans would be reviewed and modified as appropriate.

Based on observation, interview and document review, the facility failed to comprehensively assess, ensure adequate supervision and implement interventions, to decrease the risk of further falls for 1 of 3 residents (R87) reviewed who sustained multiple falls. R87 experienced an injury while utilizing a Merry walker (a walker/chair combination type device), resulting in an immediate jeopardy (IJ) situation. The facility failed to investigate and comprehensively assess the resident's falls while utilizing the Merry walker to determine whether new interventions should have been implemented, and the facility failed to ensure interventions currently in place were adequate and consistently implemented to minimize the risk for further falls. The immediate jeopardy (IJ) began on 10/24/15, when R87 sustained a fall with injury while walking in the Merry walker. The facility's administrator and director of nursing (DON) were notified of the immediate jeopardy (IJ) situation on 7/19/16, at 7:05 p.m. The IJ was removed on 7/20/16, however, noncompliance remained at a lower level of G, isolated scope, with severity of actual harm that is not immediate jeopardy. Findings include: R87 was observed on 7/18/16, at 5:31 p.m. with a gait belt fastened around her waist, standing in a Merry walker made of PVC pipe. Cloth weights had been fastened with zip ties to the bottom of the walker on three sides and a cloth type strap was attached to the seat of the walker. The strap attached to the front of the walker and was located between R87's legs. R87 independently wandered about the Darling Springs unit utilizing the Merry walker. R87 was observed to walk with a shuffling gait and was noted to have an abrasion near her right eye. When she got to the doorway to the dining room, R87 couldn't move the Merry walker forward. R87 remained stationery in the doorway to the dining room until nursing assistant (NA)-D assisted R87 to turn around in the Merry walker so R87 could ambulate in the opposite direction. R87 continued to move around the area of the Darling Springs nurses' desk, bumping into walls and doorways. R87 was again observed on 7/18/16, at 6:48 p.m. walking in the Merry walker in the Darling Springs hallway with a shuffled gait. R87 was observed bumping into walls, doorways and residents in wheelchairs while walking down the hallway in the Merry walker device. The administrator was observed at that time to grasp a corner of the Merry walker to straighten R87's navigation. A few minutes later, R87 was observed to walk/bump into the right front corner of the Merry walker, bounced backward and came to rest on the seat of the Merry walker with half of her buttock positioned on the seat of the walker. R87 then stood and continued to wander throughout the hallway while attempting to navigate the Merry walker. On 7/19/16, at 10:42 a.m. NA-E was observed to guide R87, who was in the Merry walker, out of her room to the hallway. NA-E then left R87 to independently walk in the Merry walker. R87 was observed to walk with a shuffled gait. She was located in the short hall outside of her room, but not within staff view. While in the Merry walker in the corner of the short hall, R87 was able to grasp the door handle to the bathroom door labeled B-13 and jiggle the handle. R87 then turned her body to the right side of the Merry walker, moved the walker in a sideways direction out from the corner and moved toward the nurses' desk located on the opposite side from the dining room. At 10:46 a.m. R87 continued to move about in the Merry walker with a shuffled gait. She navigated to and from the short hallway located near her room which was located on the side of the nurses' station desk without staff in the area. At 10:47 a.m. a lab (laboratory) tech (technician) and two facility staff walked near the side of the nurses' station facing the dining room. None of these three staff looked in the direction of R87 as they walked past this area. At 10:47 a.m. licensed practical nurse (LPN)-C returned to the nurses' station area and approached the medication cart which faced the opposite direction from R87. LPN-C did not move to an area where R87 could be supervised. During this time, R87 was observed to have turned herself within the Merry walker to face backwards, and was observed to have lifted her right knee onto the Merry walker seat. On 7/19/16, at 10:50 a.m. two NAs were observed in the hallway to propel a cart while water mugs were removed from resident rooms. Neither NA looked in the direction of R87 as she once again maneuvered the Merry walker into the corner of the hall and was unable to propel it forward. At 10:51 a.m. R87 stood backwards in the Merry walker. The front and one side of the Merry walker were located against the corner walls in the short hallway. No staff were in the vicinity nor in view of R87 to provide supervision. At 10:55 a.m. R87 remained unable to move from the corner with the Merry walker. R87 raised her feet, one at a time, placing them onto the bottom bar of the Merry walker. She then placed her right knee onto the seat of the walker. At 10:57 a.m. R87 shuffled the Merry walker towards the location of the nurses' desk, leaned over the Merry walker bar, spit on the floor and continued forward with little shuffled steps in the direction of the corner located near the bathroom. NA-E was observed in the hall to be delivering water mugs to resident rooms but did not walk in R87's direction. At 11:00 a.m. R87 continued to ambulate with small steps, navigating the Merry walker toward the nurses' station. R87 stopped the movement of the walker when it butted up against the nurses' station desk. At 11:08 a.m. R87 stood up in the Merry walker while it was caught against the nurses' station. Staff were noted on the dining room side of the desk. At 11:11 a.m. on 7/19/16, R87 and another female resident seated in a wheelchair were in the vicinity of the nurses' desk. At 11:14 a.m. R87 pushed her Merry walker into the other female resident's wheel chair. When R87 could not propel forward, she grasped the top bar of the walker and shook it back and forth. At 11:17 a.m., while R87 continued to shake the Merry walker, the resident located in the wheel chair grasped R87's left wrist and stated go tell your mother. R87 made no response but continued to shake the walker. At 11:18 a.m. facility staff walked through the area pushing a housekeeping cart onto the elevator, without looking in the direction of R87. At 11:19 a.m. R87 finally seated herself in the Merry walker with only the right side of her buttock seated on the Merry walker seat. The Merry walker remained in contact with the other resident's wheel chair. At 11:19 a.m. R87 stood from the seat, and again began shaking the walker. The resident in the wheelchair stated, do you want me to spank you? and grasped R87's wrist. At that time, the surveyor summoned staff. At 11:22 a.m. registered nurse (RN)-A separated the two residents. R87's annual Minimum Data Set ((MDS) dated [DATE], identified R87 had long and short term memory problems with no recall ability, was rarely to never understood, and required extensive assistance for all activities of daily living (ADL). A facility form, Order Summary Report signed by the physician 6/27/16, indicated R87's medical [DIAGNOSES REDACTED]. R87's Care Area Assessment (CAA) dated 5/11/16, included: Cognitive loss /Dementia: severe impairment w(with)/cognition triggered CAA r/t (related to) dx (diagnosis) of dementia with Lewy bodies, Parkinson's and depression ADL functional /Rehabilitation Potential: Requires assist with ADL's and mobilities r/t Parkinson's Disease, Dementia with Lewy Bodies, HTN (hypertension), osteoarthritis and Hx (history of falls). See CP (care plan) for details. Safety interventions are in place to prevent falls/injuries. Noted to have 2 falls since previous MDS. Will monitor and implement safety interventions PRN (as needed). Resident does wander about unit. At times will wander into other resident's rooms. Wander guard is in place to alert staff if resident attempts to wander outside. Velcro sashes are put across other residents' doorways to detour resident of entering room. Does help detour at times. Is at risk for impaired communication r/t (related to) Dementia and Parkinson's Disease. Speech is mumbled and has difficulty finding the right words. Response does not always make sense. Is sometimes understood and sometimes understands communication. No referral needed at this time. Behavioral Symptoms: Observed to have behaviors of physical abuse towards others and wandering. Staff will provide (R87) with PRN pain meds (medications) when is showing aggression in her face. (R87) will also ram into things with her Merry walker repetitively. PRN pain meds have shown to redirect this behaviors. R87's care plan reviewed 7/13/16, indicated the resident was at risk for falls due to dementia with Lewy Bodies, and Parkinson's disease. Interventions included: Ensure (R87) is wearing appropriate footwear when ambulating or mobilizing in wheel chair. Follow facility fall protocol. Physical therapy eval (evaluation) and treat as ordered or as needed. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Educate resident/family/caregivers/ IDT (interdisciplinary team) as to causes. Safety interventions: (1) Low bed and safety mats when in bed. (2) Shoes or gripper slippers to be worn when in Merry walker. (3) Close dining room and activity doors in the evening when (R87) is in Merry walker. Bathroom door to be closed when resident is not using the bathroom. (4) Weights on base of Merry walker to increase stability. (5) Keep an extra set up (SIK) slippers in Merry walker in case one falls off. (6) 1:1 staff assist/ supervision when in the dining room. (7) Clip call light to resident at NOC (night) to alert staff when she moves or gets up (has soft touch call light). (8) Staff will monitor whereabouts every 30 minutes and PRN. (9) Bring to bathroom before sitting in recliner. R87's NA care sheet (a reference NAs used regarding specific care for residents) undated, identified safety interventions for R87 to include: (1) to ensure to take R87 to the bathroom before assisting to the recliner, (2) keep bathroom door closed, (3) clip call light on R87 at bed time, (4) low bed and safety mat (put mat against wall when not in bed), (5) keep gait belt on walker (close to resident), (6) Follow with wheel chair when ambulating, one to one assist when in dining room, use body pillow to position in bed, wanderguard worn. The NA care sheet also indicated in the comment section: Merry Walker (see purple sheet in NA book). The purple sheet directed staff to observe frequently. Although the NA care sheet directed staff to observe R87 in the Merry walker, no specific time frame was given even though the care plan indicated staff to monitor R87's whereabouts every 30 minutes and PRN. When interviewed on 7/19/16, at 11:22 a.m. RN-A stated R87 was safe to be unsupervised in the Merry walker and stated, we check on her every half hour. On 7/19/16, at 1:35 p.m. NA-E indicated it was usual practice to allow R87 to walk around while in the Merry walker unsupervised. NA-E stated, We try to keep her safe, the nurses do a good job of keeping her close. NA-E verified that although she had not witnessed R87's falls involving the Merry walker, she'd heard that R87 had stepped on the bottom of the walker causing it to fall over and causing a cut to R87's face. NA-E pointed to the temple area. A review of R87's clinical record identified the following 27 documented fall incidents which involved the use of the Merry walker since R87 was admitted on [DATE]: (1) 5/10/15- found on floor underneath Merry walker; No apparent injuries Care plan and multiple safety interventions were being followed at time of fall. Spoke with family member (F)-A. Discussed the risk vs. benefits of the Merry walker, F-A feels at this time, the merry walker continues to benefit greatly and feels is at a greater risk of injury if she was not using the Merry walker and self transferring without it. Staff will continue with 30 minute checks and follow Merry Walker guidelines as listed in CP (care plan). (2) 5/17/15- found on floor, had tipped over Merry walker; head up against the wall on right side; bruising on RUE (right upper extremity) from previous fall; No other noted injuries. Resident was crying but able to voice if she was hurt. Unwitnessed. Will place safety mat against wall when not in bed to prevent resident from tripping on mat or wheeling over it with Merry walker. Will also continue Q (every) 30 minute checks. (3) 5/20/15- found by a staff member laying on the floor with one leg still around the strap of Merry walker around 4:00 p.m. Resident assisted back into Merry walker with 2 staff and EZ (mechanical device) lift. No further documentation of IDT (interdisciplinary team) review of fall. (4) 5/30/15- found on the floor in her Merry walker with one leg around Merry walker strap. No injuries noted. Will continue current interventions. (5) 6/20/15- found sitting opposite direction in Merry walker. Sitting on floor. No apparent injuries. (6) 6/23/15- found on floor in Merry walker. When staff removed Merry walker to assist off the floor, resident began scooting on her butt on the floor. No injuries noted. CP being followed. (7) 6/28/15- in Merry walker, stumbled to the left and right leg crossed over left leg and resident grabbed for medication cart to catch herself and this caused (R87) and Merry walker to fall to the left. Right hip pain and right foot rotated inward. Lump on left side of head and above left eye. Pupils sluggish. Guarded movement to the right leg. Ice applied to head abrasion and lump. Sent to the emergency department (ED). (8) 6/30/15- in Merry walker when lost her balance and fell to the floor, tipping Merry walker over. Was sent to ER (emergency room ) and returned with no fractures or injuries. CP being followed. Action: Weights added to base of merry walker to add stability. (9) 8/1/15- found on floor in Merry walker in room. Got up with assist of 2 staff. Resident was uninjured. (10) 8/3/15- found on the floor of bedroom in Merry walker. No injuries noted from fall. CP was being followed. Will continue current interventions. (11) 8/4/15- found on floor at 11:30 a.m. in another resident's room with no injuries or hitting head. Was wearing slippers and in Merry walker at time of occurrence. Action: Up off floor and back in Merry walker. (12) 8/4/15- found on floor in front of nurses' station in Merry walker and slipper on. No injuries noted. Continue current CP. (13) 8/5/15- had 2 falls in one day. Resident appears to be more restless and has facial grimacing. Is not always able to communicate pain with staff. No injuries from either fall. CP was being followed. Action: Physician referral out to schedule pain meds to see if this helps with restlessness. (14) 9/15/15- found sitting on floor backwards in Merry walker in her room, leg strap still attached between legs; shirt off at this time, gripper socks in place; R87 agitated at the time. Staff last checked in on R87 shortly before, less than hour prior to fall. (15) 9/16/15- found on the floor, in Merry walker, Merry walker did not tip over. No injuries noted from fall. CP being followed. (16) 9/19/15- observed on floor next to bed in room, was lying under the Merry walker. The Merry walker was intact, was assisted to the toilet and into the Merry walker at 2:20 p.m. No lumps bumps or bruising noted to her head. (17) 9/21/15- found on floor, in Merry walker at the time of fall. No injuries noted. CP being followed. Resident has been showing increased signs of pain and has been more anxious, likely related to pain. Fentanyl patch was increased today; Will also continue with current interventions. (18) 9/22/15- found in room on the floor underneath Merry walker at 7:00 p.m. The strap was hooked around R87's foot and was lying on her back. A small quarter sized bruise was found on right buttock. Brought to the bathroom and returned to bed. (19) 9/23/15- found on the floor in room per staff interview, (R87\ assisted just prior to fall. Received a small bruise to buttocks as a result of the fall. Action: Fentanyl patch (pain medication) was recently increased on 9/21. Will continue to monitor pain and effects of Fentanyl patch as pain causes (R87) to be more anxious and increased her risk for falls. (20) 10/24/15- Resident tipped merry walker over sideways and was found face down on floor, unable to move. (R87) hit head/mouth on floor; mouth bleeding from losing a tooth. No one seen (sik) the incident so don't know what resident was trying to do at the time. Action: resident was lifted up from the floor w/ assist of 3 and EZ lift. A follow up nursing note dated 10/26/15 at 11:41 a.m. included, IDT reviewed fall from 10/24/15. Resident tipped over merry walker and landed on her face. Received a small abrasion under nose and lost a tooth as a result of the fall. Seroquel (antipsychotic medication) was recently decreased last Wednesday, (R87) more active since then. Per daughter's request, she would like Seroquel increased to the previous dose, she states she has seen her mom have more added behaviors and would like her mom to be more tired than anxious and falling. Referral filled out for MD (medical doctor). Also, weights added to the back of the merry walker to balance it. (The intervention of added weights to the base of the merry walker was initiated after R87 had sustained a fall on 6/28/15). A nurses' note dated 10/26/15, at 13:39 (1:39 p.m.) included: .Res. face continues to be swelled and abrasion is scabbed. Call placed to (MD) to inquire about xray to face. RN UC (registered nurse unit coordinator) aware. (MD's) nurse will call back after talking to CNP (certified nurse practitioner). Subsequent nursing notes indicated the physician had ordered a head CT scan (computed tomography X-ray) for that date. Documentation from 16:53 (4:53 p.m.) 10/26/15 indicated CT scan results from that date, indicated the resident had presented with facial pain and more confusion than usual. The report further included: Conclusion: 1. Nondisplaced fracture through the anterior superior most maxilla (upper jaw) at the base of the nose. Additionally, a nurse's note from 10:49 a.m. on 10/27/15 indicated the resident required an oral surgery consult. Despite the number of falls and fracture while utilizing the Merry walker, the facility failed to reassess R87's fall risk and interventions. (21) 1/6/16- found on the floor in the bathroom still in Merry-walker, under the bar with leg strap intact. Resident was found leaning against the wall in the bathroom. No other injuries present. Resident was assisted with 3 and ez-lift (mechanical full body lift) off of the floor and into bed. Then placed in merry walker for meals. No further review of the fall by the IDT. (22) 1/8/16- found on the bathroom floor, still in Merry walker; Merry walker did not tip over. No injuries from fall. CP was being followed. Was assisted to the bathroom less than 2 hours prior to the fall, not attempting to go to the bathroom at the time of the fall. Action: intervention to keep the bathroom door closed when not using it, (R87) wanders into her room through out the day. No further IDT review of the fall documented. (23) 2/2/16- on floor in front of nurses' station at 7:30 a.m. in Merry walker. No injuries noted. Had foot wear on at time of occurrence. Continue CP. (24) 4/16/16- found sitting on the floor in the activity room close to Turtle Beach (resident unit) still in the Merry walker; walker was still upright; assisted back into the Merry walker with the EZ lift and 3 staff assist. Continue with CP; Family continue to feel the Merry walker is safest option and continues to be appropriate. A physician visit form dated 4/18/16, identified R87 was seen for a regularly scheduled visit. Nursing has no concerns with (R87), she has been stable. (25) 5/13/16- found on right side, Merry walker was tipped over on the floor, laying on gray mat next to bed, feet still inside tipped Merry walker. Was trying to get to Herbergers, climbed on Merry walker and flipped Merry walker onto side. Aide found resident on floor. No injuries from fall. Staff educated to make sure the mat is not on the floor when (R87) not in bed. Sign placed on wall to remind staff to pick up the mat when not in bed. (26) 6/26/16- found on floor of other resident's room in Merry Walker on floor with feet on the seat. No injuries noted. Merry walker discussed with family at all care conferences and they feel this is her safest option to avoid injury and also gives her the freedom to ambulate and be more independent. Will continue with current interventions. CP followed. (27) 6/27/16- found lying on floor underneath Merry walker outside of room in hallway, lying on back and holding head up, appeared to be sleeping. No injuries. CP being followed;Will continue with these interventions. When interviewed on 7/19/16, at 2:55 p.m. the director of nursing (DON) identified an IDT reviewed resident falls to identify the cause of the fall, current interventions in place, previous interventions and possible new interventions. This IDT review is added to the nurse's progress notes in the electronic record and documented onto a Falls log. Review of the facility form titled Resident Incidents, printed for the dates of January 2016 to July 2016 included the following falls involving the Merry walker for R87: -2/2/16- witness-none, interventions-Continue current interventions-no injury. -4/16/16- witness-none, interventions-Continue current interventions. -5/13/16- witness- none, interventions-Continue current interventions. -6/26/16-witness-none, interventions-Will continue with current interventions. -6/27/16-witness-none, interventions-No maltreatment, care plan was being followed. Resident has numerous fall interventions in place. Will continue with theses interventions. The Incident Log did not include all the documented falls that occurred during the selected time frame. The log also lacked documentation of a comprehensive re-assessment of R87 and lacked documentation of any additional interventions implemented to prevent re-occurrence of falls. R87's electronic and written records lacked any evidence of physical (PT) or occupational therapy (OT) evaluations and/or treatment. In addition, Morse Fall Scale documents completed on 8/28/15, 10/26/15, 11/20/15, 11/22/15 and 5/9/16, each identified R87's risk for falling, the use of a walker, and identified the resident as having a weak gait, stooped posture and described gait with, steps are short, resident may shuffle. Each of these Morse Fall Scale documents indicated the resident had a score of 80 with anything above 45 indicating a high risk for falls. None of the documents identified any other specific assessment information. On 7/19/16, at 4:19 p.m. registered nurse (RN)-A reviewed the progress notes and verified R87's falls involved the Merry walker and that assessments and new interventions were not consistently completed and/or implemented. RN-A identified the usual process after a fall as follows: (1) review the nurse's progress notes, (2) interview staff to see what (R87) was trying to do, (3) if interviewable, ask the resident, (4) reassess fall risk and whether planned interventions are effective. RN-A indicated these assessment findings would have been documented as a follow-up note after each fall. RN-A verified that R87 was cognitively impaired and that it was difficult to identify a cause for each fall because R87 could not express her needs or actions. RN-A further identified there were so many planned interventions it was difficult to identify any new ones, and RN-A also stated fall assessments were completed quarterly, not after each fall. A facility document was provided titled Restraint/ Physical (Quarterly/Annual Evaluation) dated 2/17/16. RN-A verified this was the most current assessment form and verified there were no other assessment forms related to a fall risk assessment for R87. RN-A stated therapy had been involved with the assessment for the use of a Merry walker and had been assessed when admitted . RN-A also stated the current CP included all of the current interventions and confirmed it was an expectation that staff follow the care plan. RN-A also stated the nurse was responsible to check on R87 every 30 minutes and to document such. RN-A explained the Merry walker currently utilized by R87 had been obtained from storage in the basement of the facility, and stated she did not believe they had a written copy of the manufacturer's instructions/recommendations. RN-A indicated she may have to complete a Google search to obtain the instructions. On 7/19/16, at 4:57 p.m. the DON identified the nurse manager was responsible to complete an assessment for resident use of a Merry walker and explained the assessment involved standing the resident in the Merry walker to see whether it was safe. The DON further explained this was not an actual written assessment, but included more of an observation to see whether the Merry walker was appropriate. The DON verified this was the only Merry walker assessment completed. The DON further explained the staff and family were aware that R87 was not safe and remained at risk for falls while in the Merry walker. The DON confirmed they were honoring the family wishes since R87 was not utilizing a Merry walker, she would have to be placed into a Geri Chair (a reclining wheel chair). The DON also indicated implementation of interventions after a fall would be completed if staff identified problems with the Merry walker, identifying examples such as not walking with it, or not using it properly. The DON further indicated the expectation for care of a resident utilizing a Merry walker included frequent observations by all staff when walking by. The DON said if a resident were trying to crawl out of the Merry walker, staff may lay the resident in bed with a safety mat placed next to the bed. The DON reiterated staff were expected to follow the CP. The DON indicated they had tried numerous interventions but would follow family wishes related to the continued use of the Merry walker. The DON stated the manufacturer's recommendations for use of the Merry walker was located in the storage area. On 7/19/16 at 5:50 p.m. RN-A provided manufacturer's recommendations for use of a Merry Walker print out from the Internet. These printed out recommendations included: The walker is constructed of metal and weighted at the bottom and each one should be individually fitted to the resident. The height of the top frame should be at the height of the pelvis to promote good posture. However, the Merry walker R87 currently utilized was constructed of PVC pipe to which three fabric type weights with zip ties were secured to the bottom bar of the walker. In addition, it was noted the height of the top frame of the Merry walker R87 utilized was not at the height of the pelvis but above the pelvis. On 7/20/2016, at 9:33 a.m. physical therapist (PT)-A was interviewed. PT-A confirmed therapy duties included screening and treatment of [REDACTED]. PT-A stated, (Merry walker) is not something we recommend, we want it to be functional walking with a walker or cane. PT-A identified resident considerations for use of a Merry walker would include: look safe, maintain balance and strength, have a good gait pattern and ability to propel forward without tripping. PT-A also verified that Merry walkers were able to tip over. PT-A indicated that when R87 was admitted to the facility, a quick screen to evaluate if therapy services were required was conducted. PT-A indicated that at that time services had not been determined to be needed so no physician order for [REDACTED]. PT-A confirmed R87 had not been provided therapy services any time since admission (March 2015) and confirmed R87 had not been evaluated by PT for the use of the Merry walker. The facility policy titled, Falls- Clinical Protocol revised September 2012, Assessment and Recognition identified the following: #5 The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, and observations of the events, ect. Treatment/Management: #1- Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The immediate jeopardy that began on 10/24/15, and identified on 7/19/16, at 7:05 p.m, was removed on 7/20/16, at 3:30 p.m. when it could be verified by observation, record review and staff interviews, the the facility had implemented interventions including: -discontinuing the use of the Merry walker for R87 - 1:1 staffing implemented for R87 until appropriate assessments could be completed and a new safety plan initiated - the consultant pharmacist reviewed R87's medications - a PT assessment was conducted and a combination wheelchair/walker with 18 wheels for stability was ordered - PT also planned re-assessment of the new device upon arrival to determine appropriateness for R87 - a physician review was conducted - a comprehensive fall assessment was developed and staff were educated to implement appropriately; a post fall assessment, including required progress note, was created in the electronic chart to trigger a review of the care plan to include modifications and review of interventions; all staff were educated either verbally, via e-mail and/or by written postings at nurses' stations; NAs, RNs, case managers, LPNs, activity staff, and PT staff were interviewed to confirm implementation of the plan. Although numerous interventions were initiated, noncompliance remained at the lower scope and severity of a G, isolated scope with severity of actual harm that is not immediate jeopardy, because the facility had failed to ensure ongoing assessment and staff compliance with identified interventions to maintain resident safety.

Based on observation, interview, and document review, the facility failed to ensure the correct use of a mechanical lift during a transfer for 1 of 2 residents (R1) when R1 sustained a C2 (cervical spine) fracture as a result of a fall during a mechanical lift transfer. Findings include: Hospital documentation reviewed established on February 8, 2012, R1 sustained a head injury and a C2 (cervical spine) fracture at the facility as a result of a transfer with a mechanical lift in which one of the upper loops of the sling became unattached from the mechanical lift. A Resident Incident Report document dated February 8, 2012, established that nursing assistant/ (NA) (F) was assisting R1 to her bed at 1:00 p.m. An interview with NA (F) on March 8, 2012, at 1:10 p.m. established that R1 was in her wheelchair, NA (F) positioned the mechanical lift in front of R1 and opened the base of the mechanical lift for stability. NA (F) hooked the four loops of the sling to the mechanical lift and activated the mechanical lift to lift R1 out of her wheelchair. NA (F) backed the wheelchair out of the way of the mechanical lift and turned R1 to line up with the bed when one of the upper loops of the sling by R1 ' s shoulders came unhooked from the mechanical lift. R1 fell to the floor sustaining a head injury to the back of her head. NA (F) immediately got assistance for R1 and she was immediately assessed by nurse (E). An interview with nurse (E) on March 8, 2012, at 1:30 p.m. established that R1 had no loss of consciousness, an ice pack and pressure was applied to the back of her head, her range of motion was intact, vital signs were blood pressure 100/60, pulse 68, respirations 28, temperature 97.5, and oxygen saturation 92% on room air. R1 had complaints of head pain. R1 ' s physician and family were notified of the fall. Emergency medical services (EMS) were contacted for transport to the hospital. R1 was diagnosed with [REDACTED]. A progress note dated February 8, 2012, established that R1 returned to the facility later that day. Record review established that R1 was admitted to the facility in November 2007. R1 had [DIAGNOSES REDACTED]. R1 ' s plan of care dated December 2011, directed staff to transfer her with a mechanical lift and the assist of one staff for all transfers. NA (F) was interviewed on March 8, 2012, at 1:10 p.m. and stated that she was assisting R1 from her wheelchair to her bed after lunch. NA (F) stated that she hooked up the four loops from the sling to the mechanical lift and activated the mechanical lift. R1 ' s wheelchair was backed away from the mechanical lift. NA (F) positioned R1 to align with the bed and one of the upper body loops came unhooked and R1 fell to the floor. R1 hit her head on the floor and said ouch. NA (F) immediately got assistance from employee (G)/NA to stay with R1 and NA (F) went to get nurse (E) to assist with R1. NA (F) stated that she received training on the mechanical lifts during her orientation at the facility. On March 8, 2012, at 12:30 p.m. nurse (A) and nurse (J) demonstrated a transfer of a staff person in the mechanical lift used at the time of the fall. Employee (A) was on a bed and nurse (J) put the sling underneath her and placed the slings loops on the metal hanger of the mechanical lift. Nurse (J) raised nurse (A) up in the air over the bed. Nurse (A) ' s weight was totally suspended off the bed. The loops of the sling were secured on the mechanical lift and would not move off the hanger of the mechanical lift. Nurse (A) did confirm if the sling was connected to the mechanical lift correctly once the individual resident was suspended the weight would prevent the sling from disconnecting from the lift. The facility provided a copy of the manufactures specifications dated January 9, 2006, titled " E-Z Lift Operating Instructions " for the mechanical lift that was utilized at the time of the fall. Review of this revealed that the EZ-lift was designed to be operated safely by one person, however with some patients it is best to use two people. The manufactures specifications did not specify when to use two people. The manufactures operating instructions indicate to lift the resident until there is tension on the wings of the sling, making sure all the loops on the sling are securely hooked on the sling hanger.