Every finding on record at Birchwood Health Care Center

Based on interview and document review, the facility failed to verify and obtain on admission a resident's need for bipap (bilevel positive airway pressure machine which delivers pressurized air through a mask over the nose or mouth to provide improvement in breathing) equipment and failed to notify the provider after prescribed breathing interventions were ineffective for 1 of 1 resident (R90) reviewed for hospitalization. This resulted in an Immediate Jeopardy situation when R90 continued to have respiratory decompensation leading to the need for transfer to the emergency room, intubation, and admission to the intensive care unit. The IJ began on 6/4/26, when R90 was hospitalized , intubated, and admitted to the intensive care unit. Administration was notified of the IJ on 6/11/26, at 3:40 p.m. The IJ was removed on 6/11/26 at 8:38 p.m., however non-compliance remained at a lower scope and severity, level 2, isolated scope, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R90's admission Record dated 6/12/26, identified R90 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (COPD, a condition where lung tissue is damaged), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream) and hypoxia (not enough oxygen in the bloodstream), malignant neoplasm (cancer) of bronchus or lung, pulmonary hypertension, dependence on supplemental oxygen, and heart failure.R90's care plan dated 6/3/26 identified a focus statement for altered respiratory status with difficulty breathing and shortness of breath (SOB) and included interventions to observe, document, and report any signs or symptoms of SOB, provide oxygen as ordered, observe and record pulse oximeter (SpO2) readings, and report abnormalities to provider.R90's provider orders dated 6/3/26 identified: Facility standing orders without exception. Standing orders identified to initiate and titrate supplemental oxygen from one to four liters per minute (LPM) via nasal cannula for dyspnea, hypoxia (oxygen saturation less than 90% or less than 88% for COPD) or acute angina to keep oxygen saturations (a measurement of blood oxygen gases quantified in a percentage) less than 90%; immediately update provider with nursing assessment. May wean supplemental oxygen per nursing judgment to maintain oxygen saturation greater than 90%; monitor SaO2 three times per day for three days after oxygen is discontinued, including once during night-time sleep.Budesonide inhalation suspension 0.5 MG/2M, inhale 2 milliliters (mL) by inhalation in the morning.Formoterol fumarate inhalation nebulization solution 20 MCG/2ML, inhale 2 mL via nebulizer two times per day.Sodium chloride inhalation nebulization solution 3%, inhale 4 mL via nebulizer two times per day.Ipratropium-albuterol inhalation solution 3MG/3ML, inhale 3 mL orally as needed (PRN) four times per day for wheezing or SOB. Use second after albuterol inhaler.Ventolin (albuterol) inhalation aerosol solution 108 micrograms per actuation (MCG/ACT), give two puffs by inhalation as needed for wheezing or SOB. Use first prior to ipratropium-albuterol. Continuous oxygen at 1 LPM via nasal cannula or mask to keep Sa02 greater than 90%. Ensure tubing patency and proper flow rate.Obtain and record SaO2 every shift.R90's progress notes identified the following:6/3/26 at 2:37 a.m., a respiratory status note: A respiratory evaluation was performed 06/03/2026 for R90. Resident currently sleeps in recliner. Resident currently sleeps with HOB elevated when lying in bed. Resident has needed rest breaks d/t shortness of breath with ADLs (activities of daily living) and/or Mobility. Resident uses oxygen. Lung sounds with wheezes. Respirations were shallow. Dry, non-productive cough present.6/3/26 at 4:15 p.m., a social services note: Met with resident's wife regarding her concern that the resident did not have a bipap in the facility. The wife expressed concerned with his breathing. SS reviewed resident's orders and hospital notes. SS followed up with the wife informing her that there were no orders for a bipap, just oxygen. SS informed that that the nursing team will work with the doctor here to see if a bipap can be ordered. SS directed the nurses to monitor the resident's breathing.6/4/26 at 2:15 a.m., progress note: R90 having a difficult time breathing, SpO2 mid-80's on 3 LPM oxygen. Lung sounds diminished on left with crackles and wheezes on right. PRN albuterol inhaler utilized with little effect. Nebulizer then utilized. SpO2 remaining in upper 80's. Oxygen turned up to 4 LPM and head of bed (HOB) at 65 degrees to maintain SpO2 above 90% at this time. SpO2 92% upon completion of interventions. R4 remains uncomfortable and SOB.6/4/26 2:20 a.m., a medication administration note: Ipratropium-Albuterol Inhalation Solution 3 MG/3ML, 3 ml inhale orally as needed for wheezing or SOB. Use 2nd after Albuterol inhaler. PRN Administration was: Ineffective R90's SpO2 88-89% on 3 LPM. Turned oxygen up to 4 LPM at this time.6/4/26 at 2:58 a.m., vital signs: oxygen saturation 85%, blood pressure 164/89, pulse 78, respirations 246/4/26 at 3:10 a.m., a medication administration note: Ventolin inhalation aerosol solution 108 MCG/ACT, 2 puffs every 4 hours as needed for wheezing or SOB. Use first prior to duoneb. PRN administration was ineffective R90's SpO2 remains in upper 80s.6/4/26 at 3:46 a.m., an oxygen administration note: R90 cannot tolerate one LPM, patient on four LPMs oxygen at this time to maintain saturations above 90%. 6/4/26 at 8:13 a.m., greeted resident for morning and R90 was sitting on the edge of bed. Nurse asked if resident was alright, resident shook head, indicating no. Checked SpO2, and was 80 percent. Got resident sitting up in bed and checked other vitals. Respirations were 50 (typical rate 12 to 20). Provided both scheduled nebulizer treatments, but no improvement. Called 911, after emergency medical system (EMS) arrived, R90 became nonresponsive to all stimuli. EMS transported R90 to the emergency department.R90's Discharge summary dated [DATE], identified during cardiology course of care dated 5/16 to 5/19/26, R90 had become increasingly somnolent (sleepy) and tachypneic (fast breathing) when bipap had not been worn consistently overnight. During the pulmonary course of care dated 5/26/26 to 6/1/26, R90 was seen by sleep medicine for a bipap prescription with settings of inspiratory positive airway pressure (IPAP) of 22, expiratory positive airway pressure (EPAP) of 10, and a backup rate of 16. A sleep medicine follow-up visit was arranged in three to six months. Referrals were sent for a skilled nursing facility which accepted 6/1. A discharge medication list included line items for disposable medical equipment (DME) oxygen with the message to see Order Report for details.R90's electronic medical record (EMR) included an ExuCare Summary Report (an AI-powered platform designed to analyze full admission packets) for R90, identified the hospital referral source was the same hospital as the discharge summary and included equipment and assistive devices to include nighttime bipap with settings documented in hospital discharge.During an interview on 6/11/26 at 8:27 a.m., licensed practical nurse (LPN)-B, who identified as the clinical coordinator for R90, stated she would have expected the provider to be updated or call 911 if interventions were not helping him improve. The risk of not doing so was respiratory failure and up to death. Raising the oxygen flow on someone with COPD could be detrimental to the patient and would expect nursing staff to have that knowledge.During an interview on 6/11/26 at 9:06 a.m. social services staff (SS)-A stated R90's wife had come to her on 6/3 asking why R90 didn't have a bipap. At the hospital she was told a bipap was important for his care. SS-A stated she talked to the administrator at that point, and he reached out to the admissions team, and it was found there were no orders for R90 to have bipap here, just oxygen. SS-A stated she then talked with R90's wife and explained they would try get orders for a bipap. SS-A didn't know if the provider was notified, but she did tell nursing staff to keep an eye on his breathing and let them know of his wife's concern.During an interview on 6/11/26 at 10:44 a.m., LPN-C, who identified as a long-term care clinical coordinator, stated their process was to have an outside admissions team receive the referral, the history and physical, discharge orders and any other pertinent orders and then accept or deny the referral. Before the residents came to the facility, they received finalized admit orders, looked into equipment needs, any oxygen or bipap needs, and they confirmed Northwest Respiratory has received the orders. LPN-C further stated they also review the ExuCare report that summarizes the care and equipment used in the hospital course and what the resident may need for care and equipment here. LPN-C pulled up R90's report in the EMR and a bipap was identified on the report.During an interview on 6/11/25 at 10:59, registered nurse (RN)-B stated he worked the morning shift of 6/4/26 and noted R90 to be in respiratory distress, he initiated help from an LPN, so that he could stay with the resident while the LPN called 911 and started to get the paperwork ready.During an interview on 6/11/26 at 11:29 a.m., customer service lead (CS)-D at Northwest Respiratory stated they had received orders for oxygen for R90 on 6/1/26, but they hadn't received an order for a bipap until yesterday when he was discharged from the hospital to a different facility.During an interview on 6/11/26 at 11:35 a.m., RN-A identified as the nurse caring for R90 on the night of 6/3 to 6/4/26, stated she hadn't updated another RN, DON, or provider that R90 continued to decompensate after provided interventions.During an interview on 6/11/26 at 12:23 p.m., the director of nursing (DON) stated when oxygen needs required increasing oxygen, or if the initial treatments were not helping, then the staff should notify the provider.During an interview on 6/11/26 at 12:37 p.m., corporate admissions coordinator (AC)-E stated there wasn't anything that indicated R90 needed a bipap but did remember the facility administrator asking her if R90 was supposed to have a bipap, and she had told them it didn't flag on the discharge note from the provider. AC-E stated she sent the paperwork to the respiratory company to get a machine delivered after talking with the facility.During an interview on 6/11/26 at 12:42 p.m., LPN-A stated she remembered working the morning of 6/4/26 and helping RN-B with R90. LPN-A stated that she and RN-B both felt that R90 needed to be sent in when they assessed the resident on the morning of 6/4/26.R90's hospital record dated 6/4/26 at 9:32 a.m., identified patient was obtunded and in respiratory failure on arrival requiring intubation to protect airway. Provider noted they suspected patient developed increasing carbon dioxide retention since discharging as he does not have home bipap machine that was recommended. During an interview on 6/11/26 at 1:40 p.m., the medical director stated he would have expected the nurse to call a provider if the patient didn't look good and interventions were not successful. This patient really needed a BIPAP to wash out the carbon dioxide, all the oxygen wouldn't help. With sooner intervention, he may have avoided intubation. The facility needs more education for nursing staff about when to call the provider.The immediate jeopardy was removed on 6/11/26 at 8:38 p.m., when it was determined the facility had completed the following:-Identified any residents that had unmet respiratory needs-Implemented education to licensed nursing staff regarding the admission process, assessments, and how to utilize oxygen administration orders in conjunction with oxygen standing orders-Implemented education on when to notify the provider and other nursing staff when a resident is experiencing a change of condition-Reviewed and revised necessary policies pertaining to admission process and assessments, oxygen or equipment needs, provider notification, management of COPD for residents with hypercapnia Policies regarding oxygen use and respiratory equipment needs, and the admission process were requested but not received.

Based on observation, interview and document review the facility failed to ensure residents were given an opportunity to wash their hands prior to eating. This had the potential to affect any resident who chose to eat in the main dining room.Findings include:During an observation on 6/8/26 at 12:06 p.m., dining was in progress in the main dining room. Tables had hand wipes on the tables. Staff were not observed to offer residents an opportunity to clean their hands as they were brought in and seated at the tables.During an observation on 6/9/26 at 4:13 p.m., in the main dining room staff were bringing residents to the tables, staff were not observed offering any residents hand wipes to clean their hands. There were hand wipes on each table.During an observation on 6/9/26 at 4:25 p.m., in the main dining room staff were bringing residents into the dining room, staff were not observed offering hand wipes to residents as they brought them in.During an observation on 6/9/26 at 4:40 p.m., another resident was brought into the dining room and placed at a table, they were not offered a hand wipe to clean their hands.During an observation on 6/11/26 at 7:17 a.m., a resident was brought into the dining room and situated at the table she was not offered an opportunity for handwashing, she was however offered something to drink.During an observation on 6/11/26 at 7:19 a.m., R24 was brought into the main floor dining room and was assisted to her table, she was not offered an opportunity to wash her hands but was brought some juice.During an observation on 6/11/26 at 7:22 a.m., R47 was brought into the dining room and seated by R12, he was not offered an opportunity to wash his hands but was brought some juice.During an observation on 6/11/26 at 7:26 a.m., R69 and R51 were seated at a table in the dining room coloring and looking at magazines at the table where they eat.During an observation on 6/11/26 at 7:26 a.m., R12 was observed getting juice on his own.During an observation on 6/11/26 at 7:31 a.m., R69 was brought her breakfast, no handwashing was offered. R51 had not been offered handwashing and she was eating toast with her hands.During an observation on 6/11/26 at 7:44 a.m., R13 was brought into the dining room, they were not offered hand washing but they were offered a beverage.During an observation on 6/11/26 at 7:45 a.m., R24 was observed eating peanut butter toast with her hands.During an observation on 6/11/26 at 7:51 a.m., R16 was brought to a table, no offer was made for handwashing.During an observation on 6/11/26 at 7:51 a.m., R13 entered and did not perform handwashing but helped herself to items from the counter. During an observation on 6/11/26 at 7:57 a.m., R34 was brought into the dining room, she was given a clothing protector but not offered handwashing.During an interview on 6/11/26 at 10:23 a.m., nursing assistant (NA)-F stated it was the nursing assistants' job to make sure residents received assistance to wash their hands prior to eating. During an interview on 6/11/26 at 10:25 a.m., NA-E stated they should be offering residents a chance to use the hand wipes before meals.During an interview on 6/11/26 at 10:31 a.m., registered nurse (RN)-F stated all staff should be helping residents with hand washing before meals. RN-F stated it was important to do this to prevent the spread of germs.During an interview on 6/1/26 at 10:43 a.m., the director of nursing (DON) stated when the NAs brought residents into the dining room they should be offering them the hand wipes to clean their hands. The DON stated this would be important to prevent the spread of germs. The DON further qualified any staff who brought a resident to the dining room should be offering handwashing. Hand Hygiene dated 8/2025, identified proper hand washing should be used to protect the spread of infection. The policy did not address hand hygiene related to residents and meals.

Based on observation, interview, and record review the facility failed to ensure that assessments and orders were in place for self-administration of medication and bedside storage for 1 of 1 resident (R40) who was reviewed for safe self-administration and storage of medications. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 was cognitively intact with diagnoses of diabetes, chronic kidney disease, and peripheral vascular disease.R40's care plan last reviewed 3/22/26, included Focus area Med Self Administration dated 9/30/25, which indicated R40 was able to keep at besides, and self-administer Voltaren gel. The associated intervention section instructed: (9/30/25) facility to administer medications as resident is not safe to independently administer medications at this time.R40's Order Summary Report, Active Orders as of 6/11/26, included okay to have over the counter medications for nerve pain in room. The order summary lacked administration parameter orders and/or orders to keep at bedside for the following medication/supplements: Amala super fruit extract, aged garlic extract, Alphacure, total pain relief supplement, Lymphavive, vision supplement, triple complex magnesium, coq10 complex, Antartic [NAME] oil, and Moringa.A medication assessment completed on 7/17/25, indicated R40 was safe to keep at bedside and self-administer the medication Nerve Renew Supplement two times a day. The chart lacked evidence of completion of subsequent self-administration assessments for oral medication administration.During an interview on 6/8/26 at 12:40 p.m., it was noted R40's bedside table in their room had multiple over the counter medication bottles on it.During an observation on 6/9/26 at 4:29 p.m., multiple over the counter bottles of medications remained on R40's bedside table in their room.During an interview on 6/10/26 at 2:50 p.m., R40 stated they had ordered the bottles of medication from advertisements they had seen. R40 confirmed the following medication/supplement bottles were located on their room bedside table: Amala super fruit extract, aged garlic extract, Alphacure, total pain relief supplement, Lymphavive, vision supplement, triple complex magnesium, coq10 complex, Antartic [NAME] oil, and Moringa. R40 confirmed they had been keeping the bottles on their bedside table. R40 did not think that any of the nursing staff had taken a list of the bottles for the doctor or the pharmacist to review. R40 did not think they had been tested on taking the pills either.During an observation on 6/11/26 at 7:27 a.m., R40 was in bed with eyes closed. Multiple over the counter medication bottles remained on R40's bedside table.During an interview on 6/11/26 at 9:08 a.m., the bottles of over-the-counter medication were present on R40's bedside table.During an interview on 6/11/26 at 10:22 a.m., the director of nursing stated (DON) if a resident would like to self-administer medications or supplements, nursing would do an assessment to see if they could safely do so. If safe, an order from the doctor for the resident to be able to self-administer the medications would be requested. Most medications kept at bedside should have an order and a completed assessment to ensure the medication(s) could be safely kept at bedside. When staff become aware a resident has medications at bedside, they should notify the nurse so the nurse can make sure the resident has orders and an assessment in place for the medications. If nothing is in place the nurse should initiate the process.The facility policy Medication Self Administration Safety Screen and /or Self Administration dated 9/2023, included evaluation and approval of self-administration will be based on the medication self-administration safety screen which is to be completed prior to a resident self-administering medication. A physician order will be obtained with indication of which medications the resident may self-administer with or without staff supervision. Repeat self-administration safety assessments will be completed at minimum quarterly and with medication changes, changes in function/condition that might impact ability to self-administer.

Based on observation, interview, and document review, the facility failed to ensure staff was properly educated on how to monitor a dialysis access site for 1 of 1 resident (R1) reviewed for dialysis.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, with diagnoses that included end stage renal disease (ESRD), and required dialysis.R1's care plan dated 6/9/26, indicated R1 required hemodialysis with potential for (arteriovenous) AV fistula malfunction. Instructions included to check for a thrill/bruit at the AV fistula/graft left arm access site every shift and as needed.R1's orders dated 6/11/26, indicated hemodialysis three times weekly, and instructed:Monitor hemodialysis vascular access AV fistula on left arm for signs and symptoms of infection every shift.Dialysis -Thrill/Bruit: Check Thrill (palpate) & Bruit (listen with stethoscope) every shift.Dialysis Post Run: Obtain full vital signs (VS) post dialysis run every evening shift every Tuesday, Thursday, Saturday.During an observation on 6/9/26 at 3:12 p.m., R1 returned from dialysis and licensed practical nurse (LPN)-D checked R1's vitals and AV fistula site. LPN-D looked at the AV fistula dressing and placed a gloved hand at the site. LPN-D did not use a stethoscope to auscultate the AV fistula site.During an interview on 6/9/26 at 3:38 p.m., LPN-D stated they did not know what a thrill or bruit was but indicated it was related to the AV fistula. They stated they thought the thrill and bruit should be checked when a resident returned from dialysis, but they needed to look it up. During an interview on 6/9/26 at 3:41 p.m., LPN-D returned and stated the thrill was what they felt at the AV fistula when they rested their hand on the site, and the bruit was a sound to listen for at the site. LPN-D confirmed they had not listened for the bruit and stated they would grab their stethoscope to listen now.During an interview on 6/11/26 at 8:37 a.m., director of nursing (DON) stated that when a resident returns from dialysis, nurses were to obtain vitals, check port site for bleeding, thrill and bruit, and monitor for lethargy. They stated they expected nurses to know how to check for a thrill and a bruit and stated it was important to auscultate for a bruit to ensure patency of the AV fistula. If it were not patent, they would have concern for a possible blood clot.Dialysis Care Plan and Treatment Sheet guideline instructed staff to monitor for complications following dialysis and monitor the shunt site by checking for the bruit and thrill.

Based on interview and document review, the facility failed to meet the requirements for a bed hold notification for 1 of 2 residents (R90) reviewed for hospitalization.Findings include:R90's admission Record dated 6/12/26, identified R90 was admitted on [DATE] and had diagnoses of chronic obstructive pulmonary disease (COPD, a condition where lung tissue is damaged), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream) and hypoxia (not enough oxygen in the bloodstream), malignant neoplasm (cancer) of bronchus or lung, pulmonary hypertension, dependence on supplemental oxygen, and heart failure.R90's electronic medical record (EMR) didn't contain evidence of a bed hold offered to R90 or his spouse when he was transferred to the hospital.During an interview on 6/11/26 at 8:27 a.m., licensed practical nurse (LPN)-A stated the usual process for bed hold was when they go out ask if they want to hold the bed and provide them with bed hold policy at the time of their need to transfer or if the resident was unable to say, they will call the family. LPN-A stated she saw social work had put in a note this morning, stating bed hold policy was sent with resident to the hospital on 6/4. LPN-A's expectation would be the resident or family were asked if they wanted to hold the bed and that it is documented at that time, which was important because there could be a private pay responsibility and the hospital needs to know if they have a bed hold.During an interview on 6/11/26 at 9:06 a.m. social services person (SS)-A stated when a resident was sent out, they were sent with a copy of the bed hold and transfer form and then she would follow up with the family and find out if they want to hold the bed. SS-A stated she attempted to call R90's wife on 6/9, who then called SS-A back on 6/10 stating they didn't wish to hold the bed. SS-A further stated she usually would want to make that call the next day or once they knew if the resident had been admitted , unfortunately time got away from her on this one.A bed hold policy was requested but not received.

Based on observation, interview and document review the facility failed to ensure a resident's call light was answered timely to prevent a bladder accident for 1 of 1 resident (R53) reviewed for bowel and bladder. Findings include:R53 was admitted on [DATE], his admission Minimum Data Set (MDS) was in progress. R53's Face Sheet dated 6/11/26, identified R53 had diagnoses which included post-polio syndrome (a progressive neurological condition that causes new or worsening muscle weakness, fatigue, and pain decades after an initial polio infection), benign prostatic hyperplasia without lower urinary tract symptoms (non-cancerous enlargement of the prostate gland that commonly occurs as men age, obstructing urine flow and causing bothersome lower urinary tract symptoms like frequent urination, weak flow, and the inability to fully empty the bladder).R53's care plan dated 6/9/26, identified R53 was at risk for falls, interventions included to have his call light accessible and within reach. R53's care plan identified incontinence and interventions included to have urinal available.R53's admission note dated 6/8/26, identified R53 was oriented to time, place, and person. His speech was clear and he was able to make himself understood and usually understood others. In addition, R53 was identified as continent of bladder.On 6/8/26 at 2:32 p.m., someone was heard shouting and saying, quickly I need the urinal. The call light was on for R53's room.On 6/8/26 at 2:32 p.m., therapy staff were observed outside of R53's room, no actions were taken for R53 by therapy staff.On 6/8/26 at 2:34 p.m., the call light banner was scrolling and flashing for R53's room.On 6/8/26 at 2:41 p.m., R53's call light remained on, a staff member walked past R53's room but no actions were taken.On 6/8/26 at 2:42 p.m., a staff member from activities found a nursing staff and informed them R53's call light was on. The staff member knocked and went into R53's room and shut the door.On 6/8/26 at 2:49 p.m., nursing assistant (NA)- B left R53's room and returned with a urinal for R53.During an interview on 6/8/26 at 2:51 p.m., R53 stated his call light had been on for a h*** of a long time, he stated he'd had an accident waiting for someone to answer his call light. R53 stated after the call light had been on for 20 minutes he started calling out loud for help. He said he had been in the facility for about an hour. R53 stated he was not given a urinal when he was admitted and stated he'd had to use drinking cups to urinate in. He stated his clothes had gotten wet and also the floor got wet. He pointed to two bags on the floor as evidence of the accident and the long wait for help.On 6/8/26 at 3:10 p.m., R53 wanted the administrator to come to the room, R53 told the administrator his chair was not working and pointed out the two bags on the floor, the drinking cups were visible in the bag. The administrator stated he was aware that R53's motorized wheelchair was not working when he arrived, and he then took a picture of the control screen.During an interview on 6/8/26 at 3:27 p.m., NA-C stated when she entered R53's room he had urinated in the drinking cups, she stated there was also urine on the floor, the overbed table, and the bed. She stated she cleaned it all up and sanitized the table. NA-C stated R53 would not allow her to remove the bags with the linen and the garbage.During an interview on 6/10/26 at 2:41 p.m., NA-D stated when a new admission arrived it was nursing's job to ensure they had supplies which for some residents would include a urinal.During an interview on 6/10/26 at 3:42 p.m., the unit coordinator (UC)- F stated she had heard later that when R53 arrived his motorized wheelchair was not working. UC-F stated the hospital had not communicated anything about his wheelchair not working.During an interview on 6/11/26 at 8:29 a.m., the social service director (SS)-A stated they found out the day he arrived that his motorized wheelchair wasn't working but had heard registered nurse (RN)-E and the administrator had figured out how to fix it (it had been in a manual mode setting).During an interview on 6/11/26 at 9:15 a.m., the administrator verified when R53 arrived his motorized wheelchair was not working properly, and it took three staff to get the motorized wheelchair out of the van. He stated RN-E figured out the problem and corrected it. The administrator volunteered R53's call light had been on 14 minutes before it was answered.During an interview on 6/11/26 at 10:26 a.m., NA-E stated part of getting a new resident settled would include asking a male resident if they needed a urinal.During an interview on 6/11/26 at 10:41 a.m., the director of nursing (DON) stated it would be important to ensure a resident was provided with items they needed upon admission, including a urinal for male resident to prevent accidents and to promote dignity.Call Lights Accessibility and Timely Response Policy dated 4/2025, identified the purpose of the call light was to allow residents to call for assistance. The policy included the call light would be relayed directly to a staff member. The policy also included All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on interview and document review the facility failed to provide residents the Skilled Nursing Facility Advance Beneficiary notice of Non-coverage (SNF ABN) CMS-10055 when Medicare part A services were being discontinued and the resident stayed in the facility. This affected 4 of 4 (R1, R5, R8, R11) residents reviewed for beneficiary notices. Findings include:R1's Notice of Medicare Non-Coverage (CMS-10123) dated 4/21/26, indicated R1's last covered day of Medicare A would be 4/23/26. R1's electronic medical record (EMR) lacked indication the SNF ABN was provided.R1's Census list and progress notes indicated R1 remained at the facility after 4/21/26 (Medicare Part A discharge date ).R5's CMS-10123 dated 3/12/26, indicated R5's last covered day of Medicare A would be 3/13/26. R5's electronic medical record (EMR) lacked indication the SNF ABN was provided.R5's Census list and progress notes indicated R5 remained at the facility after 3/12/26 (Medicare Part A discharge date ).R8's CMS-10123 dated 2/2/26, indicated R8's last covered day of Medicare A would be 2/5/26. R8's electronic medical record (EMR) lacked indication the SNF ABN was provided.R8's Census list and progress notes indicated R8 remained at the facility after 2/5/26 (Medicare Part A discharge date ).R11's CMS-10123 dated 5/14/26, indicated R11's last covered day of Medicare A would be 5/23/26. R11's electronic medical record (EMR) lacked indication the SNF ABN was provided.R11's Census list and progress notes indicated R11 remained at the facility after 5/23/26 (Medicare Part A discharge date ).During an interview on 6/9/26 at 5:21 p.m., the licensed social worker (LSW) stated she was not aware the SNF ABN needed to be given to residents. The facility had been using from CMS-R-131 (the ABN form for home health and hospices) instead. The LSW reviewed all medical records and confirmed R1, R5, R8, and R11 remained in the facility after discharge from Medicare-A. During an interview on 6/9/26 at 5:34 p.m., the administrator stated the facility had been told by corporate staff to use CMS-R-131 when all residents were discharged from Medicare-A and stayed in the facility. Facility policy Advanced Beneficiary Notices dated 4/1/26, indicated residents would receive form CMS-10055 when residents were discharged from Medicare-A services. Form CMS-R-131 would be utilized for residents under Medicare-B services.

Based on observation, interview and document review the facility failed to thoroughly investigate and failed to comprehensively assess in an effort to identify risks and hazards associated with an elopement for 1 of 3 residents (R1) reviewed after R1 removed his wander alert bracelet and left the facility unsupervised by staff. In addition, the facility failed to ensure a system for all staff to identify who was at risk for elopement. Findings include:R1 quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and mental status had not acutely changed from baseline. No behaviors were indicated. R1 was independent with transfers and used a wheelchair. R1's diagnoses included hypertension, arthritis, aphasia (language disorder affecting ability to communicate effectively), CVA (stroke), Non-Alzheimer's dementia, and seizure disorder.Facility Incident Audit Report dated 4/12/26, indicated on 4/12/26, R1 had been seen around 4:00 p.m., by staff seated by the reception desk and had been observed again around 4:30 p.m. in the lobby. Staff noted R1 was missing around 4:45 p.m. R1 was located at 5:00 p.m., outside, just down from the assisted living. R1 stated he had been chasing the dead bodies in the ambulance. R1 was re-assessed for elopement, and a wander alert device was placed. IDT met and reviewed on 4/15/26. R1 had been exhibiting increased confusion, had gone outside and was on the sidewalk when staff found him. R1's progress note dated 4/12/26, indicated R1 was anxious and wandering, believed there were dead bodies being escorted out of the facility and he needed to help the police solve the crime.R1's Elopement Risk Evaluation dated 4/12/26, indicated R1 was ambulatory or able to self-propel his wheelchair, had a habit/history of wandering or attempts to leave the building and asked to go home or to other specific destinations.R1's care plan revised 4/13/26, identified cognitive loss/dementia and elopement/wander risk and identified the use of a wander alert bracelet. The care plan directed staff to check wander device function daily and ensure proper placement observe and document potential triggers to increased attempts at wandering/ elopement. The care plan identified limited physical mobility and indicated R1 required supervision/touching assistance for ambulation and required staff to propel him to and from all destinations in his wheelchair. R1's progress note dated 4/13/26, indicated IDT met and reviewed R1 exhibiting increased confusion. R1 went outside and was located on the sidewalk when staff located him. R1 had delusion thoughts and stated he was helping the police. R1 had cognitive impairment but had not previously displayed exit seeking behaviors. Past assessments indicated no risk for elopement. New assessment completed with increased risk. Wander alert device was placed.Facility resident sign out sheet indicated on 4/25/26, R1 signed himself out at 9:33 a.m.R1's Elopement Risk assessment dated [DATE], indicated R1 was ambulatory or able to self-propel his wheelchair, had a habit/history of wandering or attempts to leave the building and asked to go home or to other specific destinations.Facility Incident Audit Report dated 4/26/26, indicated R1 eloped from the facility on 4/25/26. Nursing description written 4/26/26, indicated Dietary aide (DA)-A notified registered nurse (RN)-A he had seen R1 outside in the parking lot. RN-A alerted staff members who searched the parking lot. R1 was seen with a bystander with his vehicle. R1 was not wearing his wander alert bracelet. R1 was brought back to the facility and told facility staff he had been going to the farm and had signed himself out. When asked where his bracelet was, R1 stated he had removed it in his room and threw it away. Interdisciplinary team (IDT) met to review the incident 4/26/26. R1 was located across the street from the facility with a bystander who was placing R1 in his car for safety. Staff replaced R1's wander alert bracelet upon return to the facility and placed him on 15-minute checks.R1's quarterly MDS dated [DATE], identified severe cognitive impairment, indicated he was independent with the use of a manual wheelchair and indicated he displayed wandering behaviors. The MDS identified the use of a wander alarm.R1's progress note dated 5/4/26, indicated IDT met and reviewed R1's attempt to remove wander alert bracelet from wrist. R1 had been redirected and continued on 15-minute checks. R1 had a plan for what he wanted to do and where he wanted to go but was confused.During observation on 5/5/26 at 2:45 p.m., R1 was seated at the front entry in wheelchair talking with a visitor. R1 had a black wander alert bracelet on his right wrist.During interview on 5/5/26 at 4:20 p.m., licensed practical nurse (LPN)-A stated when she worked the station at the front of the facility, she did a lot of walking back and forth to monitor the residents. LPN-A said unless a resident was new, she knew who to watch and stated there was a binder at the front desk with the residents who were at risk for wandering. During interview on 5/5/26 at 4:51 p.m., RN-B stated they kept an eye on the residents who were known to wander. RN-B stated on the evenings and weekends it was really hard to keep an eye on the people going in and out of the facility but stated if a resident was wearing a wander alert bracelet the door would alarm if they were near the door.Video surveillance was viewed on 5/6/25 at 11:29 a.m., The surveillance video dated 4/25/26, showed R1 talking to another resident by the front door of the facility at 10:01 a.m. At 10:11 a.m., R1 left through the front door. R1 appeared again on the sidewalk at 10:16 a.m. and began propelling himself in his wheelchair to the parking lot on the south side of the building. At 10:20 a.m., R1 headed toward two dumpsters at the far end of the parking lot, stood up and left his wheelchair between the dumpsters and continued on foot. At 10:28 a.m., Staff headed to R1's location. R1 was observed on the video across the street and in front of an apartment building near an intersection of the street and the highway.Social services progress note dated 5/6/26, indicated social services spoke with R1's family regarding potential move to a facility with a secured unit due to increased wandering and attempts to remove wander alert device.During interview on 5/6/26 at 7:54 a.m., RN-B stated on 4/25/26, when R1 had left the facility he had been his usual self, wheeling around in his wheelchair. RN-A said DA-A had approached her and said he saw R1 outside by the apartments across the street. RN-A stated she went outside and R1 was with a bystander who had pulled over and was assisting R1 into his car. RN-A noted R1 did not have a wander alert bracelet on and when he was brought back to the building R1 told her he had taken it off and thrown it away and said he had signed out of the facility. RN-A stated the facility had discussed moving R1 to a facility with a secure unit because they didn't feel the facility was appropriate due to R1 having a plan to leave and removed the wander alert bracelet. RN-A stated R1 broke the clasp off of the bracelet. RN-A said they were keeping an eye on R1 but said he's definitely looking for stuff he can get it off with.During interview on 5/6/26 at 8:52 a.m., LPN-B said R1 was on 15-minute checks and said it was hard because he was all over the place. LPN-B said if R1 was hanging out up front, she would go check on him. LPN-B said, we have a lot of people.During interview on 5/6/26 at 8:585 a.m., DA-A said on 4/25/26, he had been on break and when he returned to the facility he saw R1 by the stop sign at the highway. DA-A said he had recognized R1 but said he did not have a wander alert device, so DA-A was not sure if R1 was at risk or not. DA-A said he notified nursing and had gone with to get R1. DA-A said they found R1's wheelchair in the parking lot by the trash. DA-A said if a resident was wearing a wander alert bracelet, that meant the resident was not safe to be outside unsupervised. DA-A said he was almost certain there was a list of residents who required supervision outside of the facility but did not know where to find it.During interview with the director of nursing (DON) and the administrator on 5/6/26, at 9:04 a.m., the DON said all staff were educated during monthly meetings regarding the missing resident protocol. DON said the wander alert bracelet alerted staff to who was at risk. The administrator said they had wander alert binders but said, I would not think every staff would memorize everyone, and said if a resident was new, staff may not know the person was at risk.During interview on 5/4/26 at 10:10 a.m., The DON stated on 5/5/26, when R1 was observed attempting to remove his wander alert bracelet, she did not know which staff had seen it. She said it may have been reported on one of the 15-minute check sheets but was not sure. The DON said R1 would try to find something to remove the wander alert bracelet and said he was on 15-minute checks because he was still actively trying to remove it. The DON said they did not know what he was using to attempt to remove the bracelet but said he has activities, pens, his own nail clipper, etc. in his room and said there were many different tactics R1 could take. The DON indicated they had not made any efforts to removed objects from R1's room and not specified the need to staff to monitor R1 for removal of items accessed in the dining room or activities which could be used to remove the bracelet. The DON stated currently they felt the 15-minute checks were successful. DON stated R1's case was different and said R1 had knowledge to know what to do. The DON said staff interviews were not a part of the investigation when R1 removed and/or attempted to remove the bracelet and said she did not know when he had last been seen prior to the elopement on 4/25/26.Facility policy Elopements and Wandering Residents dated 4/16/26, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 2 of 3 (R2, R3) residents who were on enhanced barrier precautions (EBP), required personal cares and ordered treatments and staff did not maintain proper hand hygiene practices or use of gowns while performing cares and treatments.Findings include: R2's Face Sheet dated 2/16/25, indicated R2 had neuromuscular dysfunction of bladder and was a carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had a suprapubic catheter in place, and was on EBPs. R3's Face Sheet dated 10/18/25, indicated R1 had retention of urine and was a carrier or suspected carrier of MRSA. R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 had memory problems, had an indwelling catheter, had a feeding tube was dependent on staff for hygiene, and was on EBPs. Enhanced Barrier Precautions signage on R2 and R3's door undated, indicated providers and staff would wear gloves and gown for the following High-Contact Resident Care Activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toilet use, and when caring for wounds or device cares. During an observation on 12/18/25 at 9:54 a.m., registered nurse (RN)-A sanitized her hands, applied gloves, and entered R2's room. RN-A told R2 she was going to change her suprapubic catheter dressing. RN-A did not have a gown on, she removed the drainage sponge from R2's abdomen and indicated purulent tan medium amount of drainage, and discarded the soiled dressing in the garbage. RN-A removed her gloves, applied new gloves without preforming hand hygiene, and cleansed the catheter site. RN-A applied a clean dressing to catheter site with same gloves she cleansed site with. RN-A removed her gloves and sanitized her hands. During an interview on 12/18/25 at 10:13 a.m., RN-A stated it was expected that staff wear personal protective equipment for residents on EBPs when they come into contact with the resident. RN-A stated she forgot to wear a gown when completing R2's treatment. RN-A stated staff were expected to wash or sanitize hands after removing soiled gloves and when going from dirty to clean areas. RN-A stated she should have sanitized her hands after removed her gloves and after cleansing R2's suprapubic site but the sanitizer and gloves were on the other side of the room so she did not do either step. During an observation on 12/18/25 at 11:18 a.m., nursing assistant (NA)-A and NA-B sanitized hands applied gown and gloves and entered R3's room. NA-A and NA-B assisted R3 to bed and lowered his pants. NA-B held R3 on his right side and NA-A cleansed bowel from R3's buttocks with wipes. NA-A removed the bowel soiled brief and placed it in the garbage and removed her gloves. NA-A applied clean gloves without sanitizing hands, applied barrier cream to R3's buttocks, applied a clean brief on R3, and placed clothes back on. NA-A emptied urine out of R3's catheter bag, removed her gloves, and applied clean gloves without sanitizing hands. NA-A and NA-B assisted R3 back to his wheelchair, took off gown and gloves, and sanitized hands. During an interview on 12/18/25 at 1:14 p.m., NA-A stated staff were expected to sanitize hands when taking gloves off. NA-A stated she did not sanitize her hands because she got nervous. During an observation on 12/18/25 at 3:48 p.m., licensed practical nurse (LPN)-A and NA-A sanitized hands, applied gown and gloves, and entered R3's room. LPN-A gathered supplies and explained to R3 that she was going to change his feeding tube dressing. LPN-A removed her gloves, washed her hands, and applied clean gloves. LPN-A removed R3's dressing with no drainage on it and placed it in the garbage, removed her gloves, sanitized her hands, and applied clean gloves. LPN-A cleansed the insertion site and applied a clean dressing without changing her gloves or sanitizing her hands. LPN-A removed her gloves, dated a piece of tape, sanitized her hands, applied a clean pair of gloves, and put the tape on the clean dressing. During an interview on 12/18/25 at 4:01 p.m., LPN-A stated she should have changed her gloves and sanitized her hands after cleansing R3's feeding tube insertion site but she did not because she was nervous. On 12/19/25 at 11:55 a.m., the director of nursing (DON) stated staff were expected to perform hand hygiene per policy. When residents are on EBPs staff were expected to wear a gown and gloves with cares and when completing dressing changes. On 12/19/25 at 11:57 a.m., the administrator stated staff were expected to follow the hand hygiene policy. Staff were expected to follow EBP guidelines when preforming dressing changes on a resident on EBPs. The facility Hand Hygiene policy revised 8/2025, indicated staff would cleanse hands before putting on gloves, after removal of gloves, and before moving from a soiled body site to a clean body site. The facility Personal Protective Equipment Selection and Use policy reviews 9/2023, indicated staff would apply a gown and gloves prior to high contact care, which may apply to indwelling medical devices regardless of MDRO colonization. EBPs would be used during high contact resident activities such as hygiene, incontinence cares, and devices or wound care.

Based on interview, observation, and document review the facility failed to provide adequate supervision resulting in the likelihood of serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement, had exit seeking behavior, and wore a WanderGuard (security device that prevents residents at risk of wandering from a designated area). The facility's failure resulted in an immediate jeopardy when R1 exited the building without staff knowledge and was returned to the facility by a community member (CM)-A.The immediate jeopardy began on [DATE] when R1 exited the facility chapel door at 6:25 p.m. The facility was made aware of R1 missing after CM-A arrived at the facility at 6:44 p.m., with R1 who was found two blocks away. The facility director of nursing (DON), administrator, regional nurse consultant (RNC), and regional director of operations (RDO) were notified of the immediate jeopardy on [DATE] at 5:02 p.m. The facility had implemented corrective action and therefore being cited as past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 had severe cognitive impairment, diagnoses of dementia, muscle weakness, required a wheelchair for locomotion, and had wandering behavior 1-3 days in the 7-day look back period. The facility Office of Health Facility Complaint (OHFC) report dated [DATE] at 9:00 p.m., indicated CM-A was driving and saw R1 on [DATE] at approximately 5:45 p.m., sitting in a wheelchair on the side of the road two blocks from the facility, in the dark, waving her hands frantically. CM-A indicated in the report R1 stated she was from another town, and didn't know how she got to her current location. CM-A noticed a sticker on R1's wheelchair identified the facility name, CM-A walked R1 back to the facility. A staff came to the door to let R1 in and stated they had no idea R1 was out of the facility. R1's care plan dated [DATE], indicated R1 was an elopement risk and used a WanderGuard. The care plan further indicated R1 had impaired physical mobility and required a wheelchair for locomotion and had cognitive loss/dementia with deficits in memory/recall ability, judgement, decision-making and thought process related to anoxic brain damage (brain loses oxygen supply) with an intervention to supervise and assist with all decision-making. R1's orders dated [DATE], indicated check WanderGuard on right wrist every night. R1's progress notes dated [DATE] at 9:11 p.m., indicated R1 eloped out of the chapel doors and neighbors brought R1 back. 1:1 supervision was implemented when resident was out of bed, and 15-minute checks when in bed. R1's Elopement Risk assessment dated [DATE] indicated a score of 6. A score of 4 or greater indicates the potential for elopement. On [DATE] at 11:35 a.m., review of facility surveillance revealed on [DATE] the following occurred:-6:26:40 p.m. R1 was observed exiting the chapel door, activating WanderGuard alarm-6:27:03 p.m. R1 was observed to push on keypad button and then pushed on secured exit door handle-6:29:38p.m. R1 was observed to push secured exit door greater than 30 seconds, engaging fire safety feature and exited the building.-6:29:58 p.m. (3 minutes, 18 seconds from first alarm activating) NA-A appeared, silenced alarm, briefly looked through the door outside (did not step outside).-6:30:35 p.m. NA-A proceeds back to work. -6:40:10 p.m. (11 minutes 12 seconds) R1 returned to the facility by CM-A to front entry way.- In the video footage, R1 was noted in the video to be wearing a flannel shirt with gray undershirt, black sweatpants, slippers and socks. Additionally, R1 had what appeared to resemble a throw or light blanket covering her thighs to just below her knees.Review of the weather on [DATE] from the Weather Channel revealed the daily temperature in Forest Lake was 29 degrees Fahrenheit with possibility of some snow flurries. During an observation on [DATE] at 1:12 p.m., R1 was observed in a wheelchair, wearing a WanderGuard on her right wrist, and used her arms to propel the wheelchair to move around the facility hallways and moved very quickly. R1 attempted to wander into the kitchen, but staff intervened before R1 could enter. During an interview on [DATE] at 1:45 p.m., registered nurse (RN)-B stated she was notified on [DATE] at 6:56 p.m., of R1's elopement after R1 returned, and RN-A informed her a neighbor brought R1 back to the facility. RN-B notified the director of nursing (DON) at 7:01 p.m., and the administrator at 7:39 p.m. The DON called RN-B at 9:14 p.m., and instructed RN-B to educate staff to not turn off the alarms until all risks (residents who wore WanderGuard bracelets) were accounted for. RN-B started the education on [DATE], as instructed. RN-B stated most of the time when the alarm was activated, the resident was nearby. RN-B was not sure why a Code [NAME] was not initiated. Further, RN-B stated R1 was very quick, and very impulsive. During an interview on [DATE] at 3:22 p.m., R1's family member (FM)-A stated he was notified of R1's elopement on [DATE] at 7:15 p.m., and staff had notified him four days ago, on [DATE], the facility needed to move R1 to another facility because R1 kept trying to get out of the facility. R1 was not injured, but if she had kept going straight she would have gotten behind the church and they wouldn't have found her. FM-A said that Sunday night ([DATE]) it was very windy and cold. During an interview on [DATE] at 3:35 p.m., RN-A stated she was working on [DATE] when R1 eloped. RN-A stated she was on break and received a call from staff when R1 was brought back to the facility by a neighbor. RN-A checked her phone and saw R1's Wander Guard alarm activated at 6:29 p.m. and R1 exited through the chapel doors. RN-A interviewed staff and found nursing assistant (NA)-A disabled the alarms, and did not go outside to look for a missing resident. RN-A stated NA-A acknowledged he turned off the outside door alarm but not the chapel door alarm, but both would have required a code to deactivate. RN-A further acknowledged a Code [NAME] (missing resident) was not initiated because staff was not aware R1 was missing. RN-A stated she met with all five NAs working, explained elopement was serious and if it had been colder and she had not been found, R1 would have died. RN-A instructed the NAs to check for missing residents with each activated alarm. During an interview on [DATE] at 10:01 a.m., NA-A acknowledged he was working when R1 eloped. NA-A was coming out of a room when he heard the alarm, deactivated the alarm, looked around, and looked out the door to the parking lot but didn't see anyone. NA-A stated he deactivated the alarm to the door that led to the parking lot, but not the chapel door alarm, as it had not activated. NA-A stated he did not call a Code [NAME] because he didn't know anyone was gone. During an interview on [DATE] at 11:29 a.m., the administrator stated video footage indicated NA-A deactivated the WanderGuard alarm for R1 on [DATE]. During an interview on [DATE] at 11:38 a.m., the DON stated NA-A turned off both alarms, looked for a resident without going outside, did not alert any other staff, and NA-A failed to call a Code [NAME] (missing resident) per the facility policy, and should have. The facility staff learned R1 was missing after a community member brought R1 back. The DON stated R1 was not safe to be outside alone, which was why she wore a WanderGuard. The DON stated staff education started on [DATE], after the elopement, to ensure staff would account for each resident who wore a WanderGuard prior to deactivating a WanderGuard alarm. During an interview on [DATE] at 1:37 p.m., NA-B stated staff education started on [DATE], to leave the alarm on until all the residents who wore Wander Guards were accounted for, and that had always been the policy. We are supposed to call a code green when the alarm goes off and a resident is not accounted for near the alarm. The Elopement Risk policy dated 5/24, indicated residents who scored 4 or more on the Elopement Risk Assessment required interventions that may include using a Wander Guard. Residents who had an attempted elopement required a new review, and all residents who wore the WanderGuard were not to be outside the building without staff or family members. The past non-compliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions:Upon R1 returning to the facility, R1 was assessed for injuries.R1 was placed on 1:1 staffing upon return. 15-minute observations following.Nursing assistant (NA)-A was suspended, was verbally retrained but remains on suspension until he gets a full retraining.All Wander Guard systems (exits and bracelets) were tested and found to be in working condition. (Testing continues to meet Manufacturer's recommendations).Training started [DATE], to ensure alarms are not shut off before residents at risk for elopement and wearing a Wander Guard are accounted for.R1's care plan was updated to include 1:1 initially, then 15 min checks when R1 went to bed.Activity staff increased activity options for R1 to assist with distraction.Doors to R1's unit to be shut at night to limit R1's movement to her own unit for increased supervision.Staff was educated on the care plan revisions.

Based on interview and document review, the facility failed to accurately assess elopement risk for 1 of 3 residents (R1) reviewed for elopement. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, diagnoses that included dementia, and had wandering behavior 1-3 days in the 7-day look back period. R1's orders dated 10/29/25, indicated check Wander Guard on right wrist every night. R1's progress notes dated 11/9/25 at 9:11 p.m., indicated R1 eloped out of the chapel doors and neighbors brought R1 back. R1's Elopement Risk assessment dated [DATE], indicated R1 was at risk for elopement with a score of 6 because R1 was able to self-propel her wheelchair, had a history of wandering, exhibited pacing or agitated behavior, was asking to go home, had a diagnosis of dementia, and was currently taking medications which may cause confusion. R1's Elopement Risk assessment dated [DATE], indicated R1 was at risk for elopement with a score of 5 because R1 was able to self-propel her wheelchair, had a history of wandering, exhibited pacing or agitated behavior, was asking to go home, and had a diagnosis of dementia. The assessment lacked indication R1 had just eloped from the facility, family had just voiced concern about R1's elopement, and R1 was taking a medication that may cause confusion. R1's care plan dated 10/29/25, indicated R1 was an elopement risk and used a Wander Guard (security device that prevents residents at risk of wandering from leaving a designated area). The care plan further indicated R1 had impaired physical mobility and required a wheelchair for locomotion and had cognitive loss/dementia with deficits in memory/recall ability, judgement, decision-making and thought process related to anoxic brain damage with an intervention to supervise and assist with all decision-making. During an interview on 11/12/25 at 3:35 p.m., registered nurse (RN)-A stated after R1 eloped on 11/9/25, she performed an updated Elopement Risk assessment with R1, per policy after an elopement. RN-A stated R1 scored a 5, indicating elopement risk. RN-A acknowledged she had not reviewed the previous assessment, in which R1 scored a 6. Upon review of the assessment, RN-A stated she should have indicated R1 was taking a medication that was sedating because R1 was taking Seroquel which could contribute to an altered mental state. RN-A further acknowledged she should have scored a point for the elopement that just occurred, and should have scored a point for family who voiced concerned as R1's husband voiced concerns when RN-A notified him of R1's elopement. RN-A acknowledged it was not an accurate assessment, and stated she would update it. During an interview on 11/13/25 at 11:38 a.m., the director of nursing (DON) stated R1's elopement triggered RN-A to perform a new Elopement Risk Assessment, so RN-A should have known to assign a point for the elopement. The DON stated RN-A should have reviewed R1's medication list when it was completed to ensure accuracy of the assessment. The DON acknowledged the assessment was not accurate and had not been updated yet. The Elopement Risk policy dated 5/24, indicated residents who scored 4 or more on the Elopement Risk Assessment required interventions that may include using a Wander Guard, and further stipulated a new assessment would be completed every 90 days and with attempted elopement.

Based on interview and record review the facility failed to ensure an antibiotic was monitored, tracked and had an end date for 1 of 1 residents (R75) who was prescribed a topical antibiotic. Findings include: R75's admission Minimum Data Set (MDS) dated indicated R75 had severe cognitive impairment and diagnoses of dementia and heart failure. R75's interdisciplinary team (IDT) progress note dated 3/1/25 at 8:08 a.m., R75 had a small amount of blood in brief. R75 stated their foreskin gets stuck at times and they pulled on it to get it back up. The provider was notified and an order for bacitracin twice daily for 7 days and then daily was received. R75's provider order dated 3/1/25, indicated R75 required bacitracin external ointment 500 units/gram (antibiotic ointment) applied to foreskin topically every day and evening for 7 days and then daily for foreskin care. The order lacked an end date. R75's Treatment Administration Record (TAR) dated 3/1/2025-4/8/2025 indicated R75 had received the bacitracin ointment as ordered. R75's electronic medical record (EMR) lacked indication monitoring of R75's foreskin occurred between 3/15/25- 4/9/25, to ensure R75's bacitracin was still needed. The facilities 3/2025- 4/2025 antibiotic tracker and skin tracking log was requested and was not received. However, an email communication dated 4/10/25, verified R75 was not listed on the antibiotic and skin tracking log. When interviewed on 4/9/25 at 11:28 a.m., registered nurse (RN)-A stated residents who were on antibiotics would have their vital signs monitored and any assessments related to why they were on antibiotics. RN-A further stated there was no specific order or note template used. RN-A verified R75's order for bacitracin had no end date. RN-A was not aware of any infection or skin concerns with the foreskin and did not know why R75 required the bacitracin daily. When interviewed on 4/10/25 at 10:37 a.m., the clinical pharmacist stated all antibiotics were reviewed during monthly medication reviews, including topical antibiotics. The CP verified R75's order for bacitracin had no end date. CP stated the facility monitored the conditions for any topical antibiotics and would discontinue the antibiotic when it was no longer needed. The CP further stated if R75 was noted to be on it for a second monthly review, they would then notify the facility to determine if it was still required. When interviewed on 4/10/25 at 11:28 a.m., the Director of Nursing (DON) who was also the Infection Preventionist verified there was no end date for R75's topical antibiotic and believed since it was recently changed to an as needed medication on 4/9/25, it was monitored. The DON needed to follow up with the provider and determine what the order was and should be. A follow up interview on 4/10/25 at 11:35 a.m., the DON verified R75 was not on the facilities antibiotic tracker as bacitracin did not require a 72-hour time out. DON stated any topical antibiotics required actual monitoring of their condition that required the topical ointment and this was tracked separately. When the skin condition resolved, the antibiotic should be discontinued. The DON verified R75 was not tracked on their skin tracker and verified the bath audits since 3/14/25 did not mention any concerns with R75's foreskin. The DON further acknowledged R75's skin condition was not being tracked or monitored to ensure appropriate use and necessity of the bacitracin. A facility policy titled Antibiotic Stewardship revised 6/2021, directed all providers to follow the 5 D's of basic antimicrobial stewardship practices which include duration of use. Furthermore, the policy directed staff to assess residents for the appropriateness of the antibiotic use and duration.

Based on interview and record review the facility failed to ensure an antibiotic ointment was still necessary for 1 of 1 residents (R75) reviewed for antibiotic use. Findings include: R75's admission Minimum Data Set (MDS) dated indicated R75 had severe cognitive impairment and diagnoses of dementia and heart failure. R75's provider order dated 3/1/25, indicated R75 required bacitracin external ointment 500 units/gram (antibiotic ointment) applied to foreskin topically every day and evening for 7 days and then daily for foreskin care. The order lacked an end date. R75's Treatment Administration Record (TAR) dated 3/1/2025-4/8/2025 indicated R75 had received the bacitracin ointment as ordered. R75's interdisciplinary team (IDT) progress note dated 3/1/25 at 8:08 a.m., R75 had a small amount of blood in brief. R75 stated their foreskin gets stuck at times and they pulled on it to get it back up. The provider was notified and an order for bacitracin twice daily for 7 days and then daily was received. R75's electronic medical record (EMR) lacked indication monitoring of R75's foreskin occurred between 3/15/25- 4/9/25, to ensure R75's bacitracin was still needed. The facilities 3/2025- 4/2025 antibiotic tracker and skin tracking log was requested and was not received. However, an email communication dated 4/10/25, verified R75 was not listed on the antibiotic and skin tracking log. When interviewed on 4/9/25 at 11:28 a.m., registered nurse (RN)-A stated residents who were on antibiotics would have their vital signs monitored and any assessments related to why they were on antibiotics. RN-A further stated there was no specific order or note template used. RN-A verified R75's order for bacitracin had no end date. RN-A was not aware of any infection or skin concerns with the foreskin and did not know why R75 required the bacitracin daily. When interviewed on 4/10/25 at 10:37 a.m., the clinical pharmacist stated all antibiotics were reviewed during monthly medication reviews, including topical antibiotics. The CP verified R75's order for bacitracin had no end date. CP stated the facility monitored the conditions for any topical antibiotics and would discontinue the antibiotic when it was no longer needed. When interviewed on 4/10/25 at 11:28 a.m., the Director of Nursing (DON) who was also the Infection Preventionist verified there was no end date for R75's topical antibiotic and believed since it was recently changed to an as needed medication on 4/9/25, it was monitored. The DON needed to follow up with the provider and determine what the order was and should be. A follow up interview on 4/10/25 at 11:35 a.m., the DON verified R75 was not on the facilities antibiotic tracker as bacitracin did not require a 72-hour time out. DON stated any topical antibiotics required actual monitoring of their condition that required the topical ointment and this was tracked separately. When the skin condition resolved, the antibiotic should be discontinued. The DON verified R75 was not tracked on their skin tracker and verified the bath audits since 3/14/25 did not mention any concerns with R75's foreskin. The DON further acknowledged R75's skin condition was not being tracked or monitored and R75 was potentially receiving the Bacitracin unnecessarily. A facility policy titled Antibiotic Stewardship revised 6/2021, directed staff to ensure optimal antibiotic therapy included the recommended duration of the therapy. Furthermore the policy directed all providers to follow the 5 D's of basic antimicrobial stewardship practices which include duration of use.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 2 residents (R48, R75) reviewed for call lights. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R78 had severe cognitive impairment and diagnoses of dementia. R48's care plan revised 7/2/24, indicated R48 had limited mobility related to weakness and dementia. R48 was dependent on 1-2 staff for bed mobility and required a soft touch call light in reach. An observation on 4/7/25 at 1:26 p.m., R48 was sitting up in their broda wheelchair next to the bed. The wheelchair was slightly reclined and R48 was sleeping with their arms bent laying on their torso. The chair was next to their bed. R48's soft touch call light was laying flat in the middle of the bed. An observation on 4/8/25 at 9:37 a.m., R48 was sitting in their broda wheelchair next to their bed. R48's arms were bent and laying on their torso. R48's soft touch call light was laying flat on the bed. An observation on 4/8/25 at 1:31 p.m., R78 was laying in bed sleeping. R48's soft touch call light appeared to be placed under R78. At 1:41p.m., Nursing assistant (NA)-C pulled back R48's blanket and determined R48's call light was under the blanket and laying on the side next to R48. R48's arms and hands were lying on their stomach. When interviewed on 4/8/25 at 1:31 p.m., NA-C stated a soft touch call light was used when residents were not able to push a button. NA-C stated R48 has not used the call light regularly, but has used it a few times and further stated even if not used regularly, still needed to be in reach to allow the opportunity. NA-C further stated R48 had some contractions and needed the call light to be on them near her hands to use. R75's admission Minimum Data Set (MDS) dated indicated R75 had severe cognitive impairment and diagnoses of dementia and heart failure. R75's care plan revised 2/22/25, indicated R75 had limited physical mobility and required partial to moderate assistance of one staff member to transfer for chair/bed mobility. R75's care plan lacked indication R75 was not able to use the call light or preferred not to use the call light. An observation on 4/8/25 at 12:29 p.m., R75 was seated in his chair with his lunch tray in front of him. R75 stated they may need to use the bathroom and requested help. Writer asked R75 to place call light on and R75 stated I don't know where it is. While looking around. R75 had a call light looped over a bedside table drawer that was behind him and out of reach. Another call light was wrapped around the grab bar and hanging down towards the floor. Writer left room and alerted registered nurse (RN)-A R75 needed assistance. RN-A went into R75's room to help and verified R75's call light was hanging on the grab bar and not in reach. When interviewed on 4/9/25 at 10:37 a.m., NA-B stated R75's call light needed to be in reach, however, doesn't want to use it and gets up on his own at times. NA-B further stated R75's family wants him to be more active and not in bed. When interviewed on 4/9/25 at 11:26 a.m., RN-A stated R75 was confused at times and would get up on their own. RN-B wasn't sure if R75 didn't want to use the call light and stated all residents should have the call light in place, even if they didn't choose to use it and we encourage residents to ask for help. When interviewed on 4/9/25 at 12:30, the Director of Nursing (DON) expected staff to ensure call lights were in reach with all residents. This was important to help residents communicate their needs. DON further stated there were many residents who did not touch their call lights and it was a gray area if needing to be in reach if never used. A facility policy for call light use was requested however the facility does not have one.

Based on observation, interview and record review the facility failed to ensure preferences for drinks and food choices was followed for 2 of 2 residents (R38, R75) reviewed for food choices. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE] indicated R38 was cognitively intact with diagnoses of diabetes. R38's care plan revised 2/22/25, indicated R38 had a potential nutritional problem related to acute gallbladder infection. Interventions included review food preferences with resident and family. R38's meal ticket dated 4/8/25, indicated R38 wanted milk. R38's meal ticket dated 4/9/25 was requested however was not received. An interview on 4/7/25 at 1:09 p.m., R38 stated staff give items someone with diabetes shouldn't have. R38 stated they always get juice with breakfast and has told them she prefers milk, tea or coffee. The juice causes blood sugar to elevate. R38 further stated she had talked to the registered dietician (RD) but still gets the wrong items. An observation on 4/8/25 at 8:11 a.m., R38 was sitting up for breakfast. R38 had oatmeal. On the tray was a glass of apple juice. Review of R38's meal ticket indicated milk should have been served. An interview on 4/9/24 at 8:25 a.m., R38 was sitting up at bedside for breakfast. R38 had a muffin, a hard-boiled egg and no coffee on their breakfast tray. R38 was upset and stated I talked to the RD yesterday and I was supposed to get fried eggs, toast, and coffee. This was not what I wanted and not what I requested. R38's breakfast meal ticket stated muffin and hard-boiled egg. R75's admission MDS dated indicated R75 had severe cognitive impairment and diagnoses of dementia and heart failure. R75's care plan revised 2/24/25, indicated R75 had a nutritional problem related to heart failure and weakness. Interventions included for meals to be served as ordered and to review preferences with resident/family. R75's meal ticket dated 4/8/25, indicated R75 wanted decaf coffee at all meals. An observation on 4/8/25 at 8:15 a.m., R75 was sitting on their bed with the bedside table in front of them eating breakfast. R75's meal ticket indicated Decaf coffee at all meals. R75's breakfast tray did not contain coffee. R75 stated I guess I didn't get any. An observation on 4/8/25 at 12:29 p.m., R75's lunch was delivered. R75 was seated up in their wheelchair. R75's meal ticket indicated decaf coffee at all meals. Registered nurse (RN)-A verified R75's lunch did not have coffee and R75 stated I like coffee. An interview on 4/9/25 at 8:30 a.m., the registered dietician (RD) stated when residents were admitted and at least quarterly, residents were assessed for food and drink preferences. RD stated I discussed food preferences yesterday and R38's breakfast ticket was updated to fried eggs, toast and coffee. RD verified R38's ticket did not have the correct items listed for breakfast and further stated they were not sure how an old ticket was provided. RD expected residents to get the items matched on their meal ticket. When interviewed on 4/9/25 at 8:36 a.m. dietary aide (DA) stated meal tickets were printed each day around 11:00 a.m. for the next day. DA further stated if RD made any changes after that time, either the RD would need to print a new ticket or communicate to the dietary staff what the change was. When interviewed on 4/10/25 at 11:20 a.m., the Administrator expected the RD to meet with residents upon admission and as needed to review meal preferences. Furthermore, resident meal preferences should be on the meal tickets and served as written. A facility policy for food choices was requested however was not received.

Based on observation, interview, and document review the facility failed to ensure feeding assistance and routine personal hygiene cares i.e., nail care, facial hair removal, was provided for 2 of 4 residents (R23, R28) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares. Findings include: R23 R23's Optional State Assessment (OSA) dated 2/19/25, indicated severe cognitive impairment, rejected cares one to three days, required extensive assist with toilet use and limited assistance with transfers. R23's annual Minimal Data Set (MDS) dated [DATE], indicated severe cognitive impairment, rejected cares one to three days, required substantial maximal assistance with toileting hygiene, showering and bathing, and personal hygiene including shaving. Further, R23 had the following diagnoses: heart failure, Alzheimer's disease, and muscle weakness. R23's care plan dated 11/26/24, indicated R23 had an ADL self-care performance deficit due to Alzheimer's disease and required substantial maximal assist of one for shaving at regular time or when R23 was most willing. R23's care plans were reviewed and lacked information R23 required nail care. R23's nursing assistant (NA) care sheets indicated R23 had a bath on Sunday p.m., shift and required stand by assistance with shaving as needed. The care sheet lacked information R23 required nail care. R23's physician's orders indicated the following order: 9/22/24, Complete body audit assessment in the electronic medical record. R23's Behaviors task form 30-day lookback 3/12/25, thru 4/10/25, indicated R23 did not reject cares. R23's Bathing 30-day lookback from 3/16/25, thru 4/6/25, indicated R23 did not reject cares. R23's Bathing Shower, Bath and Skin Condition task form 30-day lookback from 4/10/25, indicated No Data Found. R23's Body Audit form dated 3/16/25, indicated R23 received a shower, and allowed his fingernails to be trimmed and were clean and trim. R23's Body Audit form dated 3/23/25, indicated R23 received a shower, fingernails were clean and trim and did not need to be trimmed. R23's Body Audit form dated 3/30/25, indicated R23 received a shower, fingernails were clean and trim, and did not need to be trimmed. R23's Body Audit form dated 4/6/25, indicated R23 received a shower, fingernails were clean and trim, and did not need to be trimmed. R23's progress notes were reviewed from 3/16/25, to 4/8/25, and lacked information R23 refused shaving or nail care. R23's progress note created 4/8/25 at 3:51 p.m., and effective 4/8/25 at 3:48 p.m., indicated licensed practical nurse (LPN)-A assisted R23 to shave facial hair and trimmed, filed, and cleaned under R23's fingernails and R23 stated he was refreshed and felt like a brand new man. R23's aide tasks lacked information for documentation of completion of shaving. During observation on 4/7/25 at 3:22 p.m., R23 had gray sweatpants and a black t-shirt with crusty yellow particles on the upper pants and R23 had facial hair that was approximately 1/4 inch long. R23's fingernails had brown debris located under the nails. During observation on 4/8/25 at 11:16 a.m., R23 was in the dining room participating in a balloon activity. R23 had brown checkered pajama type pants on and a gray t shirt. During observation on 4/8/25 at 11:27 a.m., R23's fingernails were still long with debris under the nails and R23 was still unshaven. During observation on 4/8/25 at 2:25 p.m., R23 was still unshaven and had long nails with debris under them. During interview and observation on 4/8/25 at 2:26 p.m., licensed practical nurse (LPN)-A stated the evening nurse started at 2:00 p.m., and the day nursing assistants and nurses left at 2:30 p.m. At 2:27 p.m., R23 started to bring himself to the bathroom and LPN-A assisted R23 into the bathroom. During interview and observation on 4/8/25 at 2:31 p.m., nursing assistant (NA)-A stated they had care sheets to know what cares a resident required. NA-A stated if a resident refused cares she would reapproach and would document refusals and let the nurse know and stated the nurse would document refusals as well. NA-A stated shaving was completed after showers and as needed and stated she completed nail cares and trimming in the evenings. NA-A verified R23 had facial hair and stated they hadn't shaved R23 in a while and verified R23 had long nails adding, it did not look like R23 was shaved on 4/6/25, and nails did not look like they had been trimmed either and stated it had been a couple weeks since shaving and nail care had been provided. Further, NA-A stated R23 did not refuse cares and stated R23 loved to get washed up and R23 states, Oh yay and won't typically refuse. During interview and observation on 4/8/25 at 2:42 p.m., LPN-A stated the aides knew what cares a resident required based on the care sheets. LPN-A stated if a resident refused cares, aides reapproach and document refusals in point of care and the nurses documented refusals in a behavior note or in a progress note. LPN-A stated residents were shaved as needed and encouraged on shower days and nail cares was completed on shower days and also as needed and if a resident had diabetes was referred to podiatry due to thicker nails and would be documented in a body audit form. LPN-A verified care sheets provided on 4/7/25, were current and verified R23's bath day was on Sunday evenings and verified R23 did not refuse nail care or shaving and expected staff complete nail care and shaving on bath days and as needed when nails were long and dirty and when facial hair was getting long. At 2:53 p.m., LPN-A verified R23 had long nails with debris under the nails and was unshaven. LPN-A stated if R23 was provided a razor he could possibly shave himself, but nurses should trim R23's nails because R23 had diabetes. LPN-A stated it did not look like nail care was completed on 4/6/25, and stated it was important for skin and with dirt sitting under the nails and trying to avoid skin tears and R23 would need supervision to make sure R23 could thoroughly shave. During observation on 4/9/25 at 7:09 a.m., R23 was in the dining room and nails were trim and clean and was clean shaven. During interview on 4/9/25 at 9:57 a.m., the director of nursing (DON) stated she expected staff try nail care and shaving on shower days and added R23's care plan indicated as willing. The DON verified R23's tasks lacked documentation R23 refused and viewed the progress notes which also lacked documentation R23 refused cares and stated nails should be cleaned on shower day and as needed and added they washed hands with Sani wipes and R23 used the restroom often so his nail care should be done on a daily basis adding it was important how residents felt in general and for personal hygiene. R28 R28's Optional State Assessment (OSA) dated 2/25/25, indicated R28 rejected care 1 to 3 days, required extensive assist with bed mobility, and toileting, and required set up support for eating, and was totally dependent on staff for transfers. R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, required set up assistance with eating, was dependent on staff for transfers, had non-Alzheimer's dementia, cancer, malnutrition, depression, Alzheimer's disease, gastroesophageal reflux disease (GERD), and generalized muscle weakness. Additionally, R28 was on hospice care. R28's physician orders dated 12/23/24, indicated R28 Needs to be up in chair and in dining room for meals. R28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2025 and printed 4/9/25 at 10:53 a.m., indicated nine times a 9 was documented under the order R23 needed to be in in the chair and in the dining room for meals. A 9 was documented in the 7:30 a.m., time slot on 4/1/25, 4/2/25, 4/4/25, 4/6/25, 4/7/25, 4/8/25, and 4/9/25. A 9 was documented in the 11:00 a.m., time slot on 4/2/25 and a 9 was documented in the 4:00 p.m., time slot on 4/5/25. A chart code in the MAR and TAR identified a 9 indicated Other/See Progress Notes. R28's progress notes were reviewed from 4/1/25 to 4/9/25, and R28's orders administration progress note dated 4/2/25 at 12:04 p.m., indicated R28 refused to be up in the chair for meals. No other refusals to be up in the chair were documented. R28's care plan dated 6/21/24, indicated R28 had depression and interventions included encouraging dining in the dining room to improve socialization. R28's care plan dated 9/25/24, indicated R28 had limited physical mobility and required a Broda wheelchair. R28's care plan dated 12/22/24, indicated R28 required set up and clean up assistance from one staff to eat. Additionally, R28 had a terminal prognosis requiring hospice involvement due to dementia. R28's care plan dated 1/13/25, indicated R28 had severe cognitive impairment and interventions included to cue and supervise as needed. R28's care plan dated 4/8/25, indicated R28 had GERD (gastroesophageal reflux disease) and interventions included to observe document and report to the medical practitioner as needed signs and symptoms of GERD: belching, coughing, choking when lying down. R28's care plan was reviewed and lacked information R28 was required to be up in the chair for meals. R28's care sheet undated, indicated R28 was on hospice, required assist of one for dressing, grooming, and bathing, was incontinent, was on a regular diet, required set up assist with meals and lacked information R28 was to be up in the dining room for meals. R28's Amount Eaten/Eating question 2 Task form indicated R28 needed to be up in the chair and in the dining room for meals. Additionally, R28 required supervision, oversight, encouragement, and cueing on 4/9/25. R28's Amount Eaten/Eating question 3 Task form indicated R28 generally required setup help and on 4/9/25, required one-person physical assist. R28's Amount Eaten/Eating question 4 Task form indicated R28 needed to be up in the chair and in the dining room for meals. Additionally, R28 did not refuse. R28's Behaviors task form from 3/12/25, printed on 4/10/25, indicated R28 did not have any behaviors of refusals. A form, Dining Hours, indicated the facilities mealtime schedule was as follows: Breakfast 7:30 a.m., to 8:30 a.m., lunch 11:30 a.m., to 12:30 p.m., and supper was from 4:30 p.m., to 5:30 p.m. R28's meal ticket dated 4/9/25, indicated R28 was on a regular diet and instructions included to setup and cut up meat into bite sized pieces and included 8 ounces of milk, 4 ounces of juice, 1 serving of choice of cereal, 1 hard cooked egg, 1 muffin, and 6 ounces of milk. During observation on 4/8/25 at 12:08 p.m., R28 was in the dining room and was assisting herself with her meal. During continuous observation on 4/9/25 from 7:59 a.m., to 9:28 a.m., dietary aide (DA)-A brought breakfast to R28 in her room. DA-A did not uncover the meal tray or take the lids off the juice and milk. R28's meal ticket indicated setup and cut up meat into bite sized pieces. R28 was in bed and sleeping. At 8:11 a.m., staff entered the room to assist R28's roommate. At 8:16 a.m., R28's head of the bed was observed to be elevated approximately 45 degrees. At 8:26 a.m., no staff came in to assist R28 with her breakfast. At 8:29 a.m., R28's eyes were closed, and her head was tilted towards the window. At 8:30 a.m., a staff person entered the room to assist R28's roommate. R28's meal was still covered with the lids on. At 8:33 a.m., R28's breakfast was still covered and R28's eyes were closed. At 8:35 a.m., nursing assistant (NA)-D went to the closet and R28's roommate told NA-D to get out and NA-D turned the light off and did not come to assist R28. At 8:42 a.m., an unknown staff person entered the room checked on R28 and stated R28 was snoozing and did not try to assist with setting up breakfast and did not try to offer food and left the room. At 8:43 a.m., NA-D entered the room and tried to wake R28 and told R28 her breakfast was in front of her. NA-D did not offer to get R28 up. NA-D took the cover off the plate and R28 had oatmeal and a muffin and assisted to take off the liquid covers. NA-D gave R28 a bite of oatmeal and R28 stated it was yummy. NA-D asked R28 if she wanted her head of the bed elevated but did not elevate the bed more and left the room. NA-D did not cut up the egg. At 8:47 a.m., R28 put a spoon in the oatmeal and then closed her eyes and her spoon dropped into her bowl of oatmeal and did not attempt to further feed herself. NA-D returned to R28's room at 9:00 a.m., and asked if R28 had finished eating and began feeding R28. NA-D took a spoon and a fork and cut up the egg and gave R28 a bite of eggs. NA-D stated R28 ate breakfast in bed and went out for lunch because R28 had pain in her legs and further stated someone should always be with R28 because R28 may choke and stated R28 did not need help to eat and ate well when fully awake and further stated if residents refused cares they reapproached residents and added she never approaches R28 because R28 eats and sleeps at the same time and was wasting her time reapproaching R28. At 9:13 a.m., R28 closed eyes, but reopened them when NA-D assisted with feeding and readily accepted breakfast. At 9:18 a.m., R28 pointed to her oatmeal for a bite and required assistance with eating the entire time. By 9:21 a.m., R28 ate approximately 50% and drank most of her milk and half of her orange juice. At 9:28 a.m., R28 stated she was all done and NA-D stated R28 ate 80% of her meal. During interview on 4/9/25 at 9:33 a.m., licensed practical nurse (LPN)-A stated R28 had to get up in order to encourage her to eat and stated R28 does refuse in the mornings and will sometimes help herself eat in bed but was more likely to eat when sitting up in the chair and expected staff to offer to get R28 up. LPN-A stated if R28 doesn't eat in the dining room, dietary staff deliver meals to the room and added R28 didn't need help but lacked motivation in bed and did not need physical help to eat and further stated if R28 was not eating it was not acceptable for a meal to be left for 40 plus minutes and the dietary aides should remove covers and place drinks close to residents and alert them their food was there and if unable to alert the resident, should place the tray back on the cart and update nursing. LPN-A verified R28 had an order to be up in the dining room for meals, but did not know why R28 had to be in the dining room. During interview on 4/9/25 at 9:42 a.m., the director of nursing (DON) reviewed R28's order that R28 had to be up in the chair and stated she recalled stuff happening with R28. The DON stated she had conversations with a family member and R28 needed to come out to meals because she was not eating as much in bed and added if R28 declined staff should reapproach and added it was the dietary department's responsibility to help with setting up trays and stated she completed education R28 needed to be upright and to follow the meal ticket. LPN-A stated R28 could eat on her own after meal set up but that was with items within reach and the covers off. The DON stated that was why R28 ate in the dining room because she ate better and thrived on stimulation. Further, the DON stated R28 needed encouragement and expected staff to offer to get up and verified the care sheet lacked information to get R28 up and stated it would be helpful to the aides to have the information on the care sheet. During observation on 4/10/25 at 8:23 a.m., R28 was in bed and her meal appeared untouched. R28 had biscuits and gravy that had not been cut up and a bowl that looked like malt o meal cereal. At 8:25 a.m., NA-D came in the room and asked R28 if it was time to get up and R28 dipped her knife in the bowl and took a bite of the cereal with her knife. At 8:27 a.m., NA-D told R28 she wanted to help her to eat, and readily accepted help and NA-D gave R28 a bite of biscuits and gravy and R28 stated it was cold. NA-D asked if she could reheat the plate and R28 started speaking nonsensically and NA-D gave R28 another bite of the biscuits and R28 furrowed her eyebrows and stated it was cold and NA-D gave R28 another bite of biscuits and R28 started speaking nonsensically. NA-D did not know how long R28's meal had been in the room because she was assisting another resident and added the kitchen delivered the meals and does not inform staff working and further stated R28 had a disability, and somebody needed to assist R28 to eat. A policy on ADLs was requested, however the interim executive director sent an email on 4/10/25 at 10:44 a.m., they did not have a policy related to aide or staff responsibilities regarding assistance with nails, shaving, or meal assistance.

Based on observation, interview, and document review, the facility failed to perform timely and accurate comprehensive skin assessments, follow prescribed wound care orders and implement interventions to promote healing for 2 of 3 residents (R2, and R51) who were admitted to the facility without pressure ulcers. This resulted in harm for R2 and R51 when R2 developed a pressure ulcer and the pressure ulcer worsened and R51 developed an unstageable pressure ulcer. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. An unstageable pressure ulcer is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage should be assigned. R2's Diagnosis form indicated the following diagnoses: other displaced fracture of upper end of right humerus (upper arm), chronic combined systolic congestive and diastolic congestive heart failure, unspecified dementia, chronic kidney stage 3, and postural kyphosis (an excessive forward curve of the spine). R2's admission Minimum Data Set (MDS) Optional State Assessment (OSA) dated 10/8/23, indicated R2 required extensive assist for bed mobility, transfers, eating, and toileting. R2's admission MDS dated [DATE], indicated R2 was at risk of developing pressure ulcers, had hallucinations, did not reject care, and did not have unhealed pressure ulcers. R2's significant change MDS OSA dated 12/5/23, required extensive assistance with bed mobility, transfers, and toileting. R2's significant change MDS dated [DATE], indicated R2 had moderate cognitive impairment, rejected cares 1 to 3 days, had one stage three pressure ulcer. The MDS further indicated skin and ulcer treatments included a pressure reducing device for the chair, bed, nutrition or hydration interventions to manage skin problems, pressure ulcer care and applications of ointments or medications other than to feet. R2's Braden Scale for Predicting Pressure Sore Risk form dated 12/1/23, indicated a score of 15, indicating R2 had a mild risk for pressure ulcer development. R2's pressure ulcer/injury Care Area Assessment (CAA) dated 10/8/23, indicated R2 had a potential for pressure ulcers and contributing factors included activities of daily living (ADL) and mobility impairment, and incontinence. Further, nurses assess skin weekly and initiated proper interventions to prevent skin breakdown if needed and the care plan would be reviewed to decrease the risk for pressure ulcers. R2's pressure ulcer/injury CAA dated 12/19/23, indicated pressure ulcer objective was for improvement, due to an actual pressure ulcer and contributing factors included ADL and mobility impairment, cognitive loss, incontinence, and pain. A licensed nurse assesses skin each week and skin was also assessed by caregivers with each bath and each time the resident was dressed. Caregivers assist with repositioning at least every two hours and as needed for comfort and a care plan would be initiated to improve actual pressure ulcer by decreased size and condition and decrease further pressure ulcer risk. R2's Dashboard in the electronic medical record (EMR) indicated R2 was 69 inches tall and weighed 130.2 pounds on 1/9/24. R2's care sheet dated 2/2/24, indicated R2 required assist of two for bed mobility, repositioning, had an air mattress, and a Tilt N Space wheelchair, was incontinent and was to be toileted upon rising, before and after meals, at bedtime and as needed. The care sheet lacked information that resident had a pressure ulcer on her sacrum and lacked interventions how to reposition, and how often to reposition and offload when in the wheelchair. Additionally, the care sheet lacked information on how to determine whether the air mattress was on. R2's care plan revised 12/5/23, indicated R2 refused repositioning, cares, and medications and an intervention included to attempt redirection. R2's care plan revised on 1/24/24, indicated R2 required partial to moderate assistance of 1 for bed mobility to roll left and right. R2's care plan revised on 1/24/24, indicated R2 had a stage three pressure injury to the coccyx (tailbone). Interventions included keeping linens dry, observing skin during cares and reporting changes to the nurse, pressure relieving support surfaces in bed and chair, air mattress on the bed alternating, and weekly skin inspections. Interventions were later added on 2/6/24, that included: attempt to reposition off area and not position on area when possible, daily wound monitoring in place, educate, cue and assist with repositioning and offloading, see skin and wound tab for current skin measurements and interventions. Additionally, an intervention was later added on 2/7/24, to ensure the alternating air mattress was plugged in and in working order and report to the nurse if it was not working. R2's Air Mattress task form obtained 2/8/24, indicated staff were to ensure an alternating air mattress was plugged in and in working order and report to the nurse if not working. During a 30 day look back period, no data was found to indicate staff were checking the air mattress. R2's Behaviors task form obtained on 2/6/24, from 1/8/24, to 2/6/24, indicated R2 did not have any behaviors of refusals, or rejection of care or treatments in the last 30 days. R2's Bed Mobility Self Performance task form obtained on 2/6/24, indicated from 1/8/24, to 2/6/24, R2 required mostly extensive assist with bed mobility, but did not refuse. R2's Skin Observation form from 1/8/24 to 2/6/24, indicated R2 did not refuse. R2's Transfer Support Provided form from 1/9/24 to 2/7/24, indicated R2 did not refuse transfers and mostly required two person physical assist. R2's Amount Eaten form from 1/8/24 to 2/6/24, indicated R2 mostly ate 51 to 75% of meals. Nurse practitioner's (NP)-A's nursing home regulatory progress note dated 12/6/23, indicated R2 had a stage two pressure injury to the sacral region that was improving per staff reports and approved an order for an air mattress. Medical director's (MD) progress note dated 1/15/24, indicated R2's pressure injury had increased in size per nursing report, and under the heading, Exam indicated a large wound over the buttock just behind anal canal, soiled with watery stool. There was a thick band of necrotic tissue attached at 1 o' clock. The wound base had good granulation tissue. The progress note further indicated the wound was a stage three pressure wound over the sacral area and oxycodone (a narcotic used to treat pain) 2.5 mg was ordered prior to wound change due to unbearable pain. NP-A's nursing home progress note dated 1/24/24, indicated R2 had a stage three pressure injury and did not see the wound the week prior. Additionally, the note indicated NP-A had ordered Vashe (a wound cleanser that inhibits microbial contamination, loosens exudate, slough, and other foreign materials from the wound bed) for the wound but was not available per the nurse and had also ordered Iodoform (used to drain exudate from tunneling wounds that are open and or infected) to pack the wound, which was also not available. The wound had a moderate amount of foul smelling drainage present on the wound and R2 could benefit from calcium alginate and planned to continue with a wet to dry dressing and change twice daily and may need to increase the frequency of the dressing changes. NP-A's progress note indicated R2 should off load as much as possible. R2's physician's orders dated 11/28/23, indicated a body audit was completed every week on Tuesdays. Additionally, physician orders on 1/18/24, indicated the following wound care orders for R2's coccyx wound: clean wound with Vashe, wet to dry dressing with normal saline, Iodoform gauze in areas of tunneling, then gauze, then ABD (abdominal gauze pad) and apply skin prep around wound change twice daily. R2's Comprehensive Skin and Positioning Evaluation note dated 12/1/23, indicated R2 had immobility/contractures and was confined to her bed or the chair all or most of the day and had a pressure reducing device for the chair and bed and application of ointments or medications other than to feet. R2's Comprehensive Skin and Positioning Evaluation form dated 2/6/24, indicated R2 had immobility/contractures, refused cares and or treatments, was confined to the bed or chair all or most of the day, was on an antidepressant, narcotics, and opioids, had a pressure ulcer over a bony prominence, had thin fragile skin, and approaches included: a pressure reducing device for the chair, turning and repositioning program, pressure ulcer injury care, and application of a nonsurgical dressing other than to feet. R2's Occupational Therapy (OT) note dated 1/24/24, indicated the following recommendations were made to nursing: two hour repositioning for pressure relief, two hour check and change to reduce infection risk, air mattress with alternating current air pattern, wound debridement and custom seating if family will pay. The note further indicated R2 was cooperative but in pain during wound care and R2 stated she would try anything to alleviate the pain. Additionally, the note indicated nursing reported R2 was non compliant with two hour repositioning when supine in bed and preferred to lay on her back and would roll over pillows placed for side lying in order to lay on her back. R2's OT note dated 1/30/24, indicated repetitive repositioning was not effective due to moderate-severe dementia, and was non-compliant with positioning recommendations preferring to be upright when seated in w/c and on her back when in bed. R2's Assessment tab in the EMR indicated R2 had a skin and wound evaluation on the following dates and indicated: 10/19/23: R2 had a new facility acquired stage two pressure ulcer to the sacrum that measured 1.8 cm (centimeters) long by 1.3 cm wide and depth indicated not applicable. Additionally, the note indicated the wound was healable and had a foam dressing with no additional care such as a turning and repositioning program, mattress with a pump, incontinence management, or a cushion. R2's nursing progress note dated 10/29/23, indicated R2's dressing to the coccyx was changed and the wound was 90% covered in slough. The note did not include any measurements of the wound or appearance of surrounding tissue. 11/10/23: R2 had a stage two pressure ulcer to the sacrum that measured 2.1 cm long by 2.0 cm wide and the depth indicated not applicable. The wound bed did not contain eschar or slough, did not have an odor, the surrounding tissue had redness, did not have pain and the wound was healable, had a foam dressing, and no additional care such as a turning and repositioning program, mattress with a pump, incontinence management, or cushion was indicated under the heading, Additional Care. Further, the note indicated the wound stalled, and under the heading, Notifications there was no check marks next to practitioner notified, resident/responsible party notified, dietician notified, or therapy notified. 12/14/23: R2 had a stage two pressure ulcer to the sacrum that measured 1.5 cm long by 1.6 cm wide and the depth indicated not applicable. The note further indicated the wound was healable, had incontinence management, moisture barrier, and a turning and repositioning program and the wound progress was stalled. Under the heading, Notifications there was no check mark next to practitioner notified, resident/responsible party notified, dietician notified, or therapy notified. 12/22/23: R2 had a stage two pressure ulcer to the sacrum and was unknown how long the wound was present, and measured 2.3 cm long by 2.4 cm wide and the depth indicated not applicable. The goal of the wound was healable and under the heading, Additional Care indicated incontinence management, moisture barrier, moisture control, and a turning and repositioning program and the wound was documented as stable, however, 100% of the wound was filled with slough. Under the heading, Notifications there was no check mark next to practitioner notified, resident/responsible party notified, dietician notified, or therapy notified. 12/28/23: R2 had a stage two pressure ulcer to the sacrum that measured 2 cm long by 1.6 cm wide the depth indicated not applicable, and 90% of the wound was filled with slough. Under the heading, Additional Care incontinence management, moisture barrier, moisture control, and turning and repositioning program was checked, and the wound was stalled. Under the heading, Notifications there was no check mark next to practitioner notified, resident/responsible party notified, dietician notified, or therapy notified. A late entry nursing progress note was entered on 2/5/24, for 1/4/24, indicated R2 refused to lay down and allow the nurse to assess the coccyx and the nurse would attempt the following week. A late entry nursing progress note was entered on 2/5/24, for 1/10/24, indicated R2 would not allow the nurse to take pictures of the wound, but allowed wound care. The note indicated the wound had 80% slough, was cleansed with wound cleanser and a hydrocolloid dressing was applied. Further, the wound measured 7 cm by 3 cm with no known depth. A late entry nursing progress note for 1/15/24, indicated the physician assisted with wound care and debrided the wound, but R2 would not allow a picture of the wound and the wound measured approximately 9 cm by 4 cm with an unknown depth. A late entry nursing progress note for 1/24/24, indicated R2's wound was assessed with the provider and a photo was captured but did not upload to wound rounds. The wound had 80% slough and measured approximately 12 cm by 4 cm with an unknown depth. 2/5/24: R2 had a stage 4 pressure ulcer to the sacrum that measured 4.4 cm long by 4.5 cm wide with a depth of 2 cm. Under the heading, Undermining and Tunneling was documented as not applicable. Additionally, 50% of the wound bed was filled with slough and the goal indicated R2's wound was slow to heal, and was deteriorating. Under the heading, Additional Care, incontinence management, and moisture barrier was checked. Under the heading, Notifications there was no check mark next to practitioner notified, resident/responsible party notified, dietician notified, or therapy notified. R2's Assessment tab in the EMR indicated R2 had a body audit on the following dates: 10/18/23: R2 did not have a pressure ulcer. 12/5/23: R2 did not have pressure ulcers. 12/12/23: R2 had an open area on coccyx and a dressing was applied. The documentation lacked a wound assessment. 12/26/23: R2 had an alteration in skin integrity to the coccyx and wound care was already being completed. The documentation lacked a wound assessment. 1/2/24: R2 had an alteration in skin integrity to the coccyx and wound care was done according to orders and staff was monitoring an ongoing issue. The documentation lacked a wound assessment. 1/10/24: R2 had an alteration in skin integrity to the coccyx and a new dressing was applied. The documentation lacked a wound assessment. 1/16/24: R2 did not have evidence of an alteration in skin integrity, did not have a pressure ulcer, however documentation additionally indicated wound treatment on the coccyx. 1/30/24: R2 had an alteration in skin integrity and had a pressure wound on R2's sacrum that was cleansed and dressed per orders. The documentation lacked a wound assessment. 2/6/24: R2 had an alteration in skin integrity that was documented as unstageable to the sacrum. The documentation lacked a wound assessment. During continuous observation on 2/5/24 from 5:47 p.m. to 6:24 p.m., R2 was seated in a four wheeled chair across from social services office, and an unnamed staff person stated the residents just finished supper about 30 minutes prior. At 6:05 p.m., a staff person walked by R2. At 6:12 p.m., a staff person spoke with R2, but did not reposition R2. At 6:21 p.m., R2 was in the four wheeled chair and her head was tilted forward. At 6:24 p.m., R2 was asked if she wanted to lay down and R2 told the unnamed staff person she did not want to lay down because it was too early. During interview and observation on 2/6/24 from 12:33 p.m. to 12:39 p.m., nursing assistant (NA)-D, and NA-C entered R2's room and brought in a full body mechanical lift. R2 stated she did not want to lie down. NA-C stated once R2 gets into bed, she falls asleep and explained to R2 that she had a sore on her bottom. NA-C instructed R2 to roll towards the wall and R2 was agreeable to staying in bed. At 12:37 p.m., NA-C helped R2 with her incontinence brief and positioned R2 on her back and did not offer to position R2 off her bottom and did not use pillows to help position R2. R2's air mattress settings on the powered controlled unit were located on the foot of the bed, there was an orange light on with no additional lights on. During interview on 2/6/24 at 1:48 p.m., occupational therapist (OT)-C stated she was going to reposition R2, but R2 was sleeping and verified R2 was laying supine and sometimes would see if she would lie on her side. OT-C stated staff should try to ask R2 if she will position on her side. At 1:49 p.m., OT-C explained to R2 what she was doing and placed a pillow and R2 agreed to turn on her left side and a pillow was placed along R2's back and in between R2's legs. R2 stated she was ok with the repositioning. OT-C stated sometimes R2 can be resistive and if she became agitated, you calmed her down and tried to convince R2 to reposition. OT-C stated R2 can be redirected. OT-C further stated she expected staff to keep R2 off her bottom because she had a pressure ulcer on her bottom. During interview on 2/06/24 at 1:57 p.m., NA-C stated they looked to see what cares a resident required on the care plan and added it was a paper form they looked at. NA-C further stated if a resident refused, you had to reapproach and refusals were documented in the charting and further stated R2 had a big wound on her bottom and if she wasn't turned it would get really bad and stated R2 was afraid of the lift. NA-C verified she did not offer to position R2 on her side and verified she laid R2 down on her back. During interview on 2/6/24 at 2:37 p.m., licensed practical nurse (LPN)-B stated they looked to the care plan and the aides looked at the care sheets to know what kind of cares a resident required. LPN-B stated if a resident refused, they would reapproach and refusals were documented in a general progress note. If it was a treatment or medication that was refused, the refusal was documented on the medication administration record (MAR) or treatment administration record (TAR). When a resident develops a pressure ulcer LPN-B stated they would contact the nurse manager on duty and call the physician. LPN-B stated R2 had a pressure ulcer on her coccyx area and thought it looked cleaner and did not think the wound had gotten shallower. LPN-B further stated interventions for treating the pressure ulcer included: repositioning, off loading and encourage R2 to lay down instead of being in the chair, and hydration. LPN-B verified the care plan lacked interventions to offload or reposition and stated they should offload every hour if in the chair and be repositioned every 2 hours and further stated he would have to direct to the nurse manager regarding interventions on the care plan. LPN-B viewed R2's care sheet and verified the interventions were not located on the care sheet. LPN-B further stated wounds were measured weekly by the nurse manager and if the wound was not resolving he would contact the nurse manager. LPN-B stated it was important R2 not be positioned on her back because you need to relieve pressure and prevent further breakdown and laying on her back could cause increased breakdown in the area and be uncomfortable. LPN-B further verified there was nothing on the EMR to indicate how often to reposition and stated the standard was to get the resident off the pressure area and verified there were no new dressing change orders since January. During interview on 2/6/24 at 3:49 p.m., registered nurse (RN)-A stated when a wound started to open, it was monitored every shift and once it got to a certain point, the resident was placed on wound rounds. Once they see a stage two or stage three wound and the wound continues to get worse RN-A stated they knew something more was going on. If the wound gets worse, the physician is notified by leaving a nursing concern in her binder. RN-A stated R2 had a pressure ulcer located on her coccyx and the nurse practitioner's (NP)'s goal was to start doing weekly rounds. RN-A stated R2's wound was not improving and when the NP visits on 2/7/24, RN-A was going to talk with the NP about a new treatment plan. RN-A stated wound assessments were completed once a week and added her staff completed twice daily dressing changes and verified measurements were done weekly and stated it was a new program their NP wanted to start completing weekly wound rounds with the nurses. RN-A stated when a resident refused they try to accommodate the resident and she would try to get to R2 before she got out of bed the following day. RN-A stated she documented refusals. RN-A stated when R2's pressure ulcer is at this point, interventions included getting an air mattress, attempt repositioning every two hours and R2 should be on her side and expected staff to reposition R2 on her side and if R2 was in her chair and refusing it would be ideal to try to offload by tilting the chair back or up. RN-A stated it was important for R2 to be off her tailbone because of pain and the increased pressure would cause the wound to get worse and they want to prevent the wound from getting deeper than it was. RN-A stated the aides know what cares a resident requires because it was on their care sheets. RN-A viewed the care sheet and verified there were no instructions for repositioning or offloading on the care sheet, and added interventions to the care plan that morning. RN-A further stated she expected staff to encourage R2 to turn side to side and hoped the air mattress would help, but best practice was to roll side to side. RN-A stated the NP came to the facility Monday, Wednesday, and Thursday and verified there were no notes to update the NP on the wounds in the binder. RN-A further stated the wound was documented the day prior and was unstageable because of the amount of slough. RN-A verified there were gaps in R2's wound assessments, and R2 should have had wound assessments completed from 10/19/24 to 11/10/23, 11/10/23, to 12/14/23 and added R2's wound had not had improvement since it first was noted on 10/19/23, and has gotten significantly worse since it started. During observation on 2/7/24 at 7:10 a.m., R2 was in bed mostly on her back and had a pillow partially under her right side under her shoulders to her hip area. R2 was sleeping and her bed was positioned lengthwise along and against the wall with the head of the bed facing the doorway and when entering the room on the left side of the room. During observation on 2/7/24 at 7:59 a.m., R2 had a pillow under her right shoulder and was partially under R2. The orange light was on, on the powered control unit, at the foot of the bed and the mattress felt soft, but not deflated. During interview on 2/7/24 at 8:01 a.m., NA-D stated she thought maintenance set the air mattress settings on the powered control unit and verified there was an orange/yellow light on next to the power button on the powered control unit. During interview and observation on 2/7/24 at 8:03 a.m., licensed practical nurse (LPN)-A stated the air mattress had a hard yellow light on the powered control unit for the bed that indicated the bed was on, and further added it was difficult to check if it was on because the powered control unit was up against the wall and stated she could tell if the bed was on by hearing if it was on or by feeling the bed. LPN-A stated it was hard to know what setting R2's bed was on, and further stated they just knew it was on and would have to ask maintenance what setting the bed was on. LPN-A further stated when they received an order, it just indicated air mattress. The instructions on the powered control unit of the bed indicated the Pressure Guard Custom Care, when plugged in, an amber light indicated the unit was drawing a current; press button until the light changes to green indicating unit is powered on. The power control unit, attached to the bed, illuminated an orange/ yellow light next to the words on/off. LPN-A verified the power control unit was not illuminating a green light. Additionally, there was no audible sound coming from the bed. During interview on 2/7/24 at 8:23 a.m., NA-D stated she couldn't hear a sound indicating the mattress was on and stated all the air mattresses were different and checked that the mattress was plugged into the outlet and stated it was plugged in. NA-D stated whoever comes to check R2 would check the mattress. During observations on 2/7/24, between 8:01 a.m. and 8:23 a.m., R2 did not try to reposition herself. During interview on 2/7/24 at 8:42 a.m., the maintenance director stated the settings for the air mattress was left up to nursing staff when he brought the mattress up and stated he turned on the mattress, but did not know what setting was needed for each individual resident and did not know resident's wound statuses and additionally stated things could change. The maintenance director stated the mattress was turned on when all the green lights come on and stated he just turned on R2's bed and verified the mattress was previously not turned on. The maintenance director further stated the green indicators need to be on and nursing staff make the proper adjustments and stated the mattress had pressure relieving properties if the bed was not powered on, however was not in the alternating air mattress mode. During interview on 2/7/24 between 8:52 a.m. and 8:59 a.m., the director of nursing (DON) and regional consultant (RC), the RC stated R2's mattress on the bottom was a standard mattress and the top was an air mattress, and added even if the mattress was off or malfunctioned, it still had a mattress underneath and nursing was responsible to monitor it and make sure it was on and functioning every shift. RC stated just because the motor was not on didn't mean the mattress was not functioning. RC further stated they determined whether a mattress was an alternating air or a standard, but was not sure of R2's mattress settings. RC stated the interdisciplinary team determined the air mattress setting and would be reflected on the care plan, orders and MAR for the nurses to follow and document. RC stated R2's mattress was on an alternating setting when she was in the room. The DON stated turning and repositioning every two hours or an alternating mattress was best practice but R2 refused and liked to be in her chair. DON further stated refusals should be documented and care planned, but expected staff continue to offer and encourage as R2 allowed and expected staff turn R2 on her side. The DON further stated she expected staff to complete weekly skin assessments and update the provider. DON further stated she expected staff to complete weekly skin assessments to assure the wound was not getting worse and they wanted to get ahead of the game and talk to the provider adding they may not have updated the provider as often as they should have. The DON stated she thought the wound had gotten worse, and added it was larger and therefore they were going to talk with the provider today. During interview on 2/7/24 at 10:53 a.m., RN-A stated they had Vashe a substance that promoted healing, no sting to R2's peri wound, tape measures, and added she would be doing a wet to dry moistened with Vashe and pack in and cover with and ABD pad and tape. RN-A stated she brought in a Mepilex dressing in case the provider changed her mind and also had wound cleanser. During interview and observation on 2/7/24 at 11:47 a.m., RN-A stated R2 was forgetful and asked if R2 had any pain. R2 initially said no, but then shouted Ow, Ow, Ow, it hurts R2 used the grab bars and pulled her upper body over to the left and staff assisted to turn R2's lower body over. At 11:49 a.m., RN-A removed the ABD dressing and removed gloves and grabbed an additional set of gloves and did not sanitize hands in between and donned gloves and pulled packing out of R2's wound bed. An odor was noted when the dressing was removed and the nurse practitioner (NP)-A stated there was more odor than the last time she saw R2. RN-A stated the wound was 6.5 cm long by 5.5 cm wide and stated from 2 p.m., to 5 p.m., the wound was deeper. RN-A cleaned wound with gloves on and then took more gauze out of the clean package and sprayed the 4 by 4 gauze with wound wash and packed the 4 by 4 gauze into the wound. R2 stated it hurt, and RN-A verified she started with the Vashe and sprayed the gauze with wound wash. At 11:59 a.m., R2 stated she didn't want to hurt and NP-A stated R2 was uncomfortable when positioned on her back. During interview on 2/7/24 at 12:02 p.m., NP-A stated R2's wound has gotten worse and stated the lack of routine wound assessments, R2 lying on her back, lack of care planning on repositioning and offloading, and the air mattress in the off position may have contributed to R2's wounds getting worse. NP-A stated R2's pain didn't seem as bad as this week and clarified for at least a week, but not more than two weeks, the facility did not have the Vashe and Iodoform gauze per her progress note dated 1/24/24. NP-A further stated the wound assessment was completed to see if the wound is healing or if changes were needed and stated standard of practice for pressure ulcers included repositioning off the area, OT, and continence cares. During interview on 2/7/24 at 12:08 p.m., RN-A stated R2's wound depth was 3.7 cm and had undermining (destruction of tissue or ulceration extending under the skin edges so the pressure ulcer is larger at its base than at the skin surface. Undermining often develops from shearing forces) of 2.7 cm from 3 p.m., to 7 p.m., and the length measured 6.5 cm by 5.5 cm wide. During interview on 2/8/24 at 8:07 a.m., RN-A stated she should have made sure before putting new stuff in the wound that gloves were changed and hands were sanitized and added hands should be sanitized between glove changes. RN-A further stated R2's wound care was Vashe and saline soaked gauze in the wound and cover with an ABD and tape. RN-A stated she did not pull out the saline bottle in order to put something wet in, RN-A used the wound cleanser which she noticed after she found the saline. RN-A verified the wound care was not conducted according to orders and added it wo [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure sufficient staffing were available to ensure 1 of 1 resident (R18), reviewed for weight monitoring, had weights completed. Ensured a comprehansive skin assessment, following prescribed wound care orders and implemented intervention to promote healing for 2 of 3 residents (R2, and R51) admitted to the facility without pressure ulcers, ensure that 1 of 1 resident (R18) with continuous oxygen via nasal cannula had current physician orders for oxygen use and failed to assess oxygen saturation levels consistently reviewed for sufficient staffing, ensure adequate supervision was provided to prevent attempted elopement for 1 of 1 (R3) resident reviewed for wandering. Furthermore, the facility failed to evaluate and analyze R3's attempted elopements to develop targeted interventions to reduce the risk for elopement and ensure dignified conversation was maintained for 1 of 1 (R48) residents who was observed during morning cares. This had the potential to affect all 64 residents who resided at the facility. Findings include: Refer to F684 for weight monitoring Refer to F686 for comprehensive skin assessment and wound care Refer to F695 for continuous oxygen therapy and assessment Review of the facility assessment updated 6/2/23, indicated the general staffing plan was to adjust staffing according to census and acuity. The executive director had discretion to adjust staffing to respond to census changes, acuity, emergency and other extenuating circumstances. Number of licensed nurses providing direct care (six to 10), nurse aides (12-20); in addition to nursing staff, other staff needed for behavioral healthcare and services (three to five). The facility utilized and reviewed on a regular basis daily assignment sheet, care plans, individual plans of care and daily census to determine appropriate assignments to ensure continuity of care. Required trainings and competencies were identified. Review of facility January 2024, master schedule indicated: Day shift-6:00 a.m. to 2:30 p.m. Evening shift-2:00 p.m. to 10:30 p.m. Night Shift- 10:00 p.m. to 6:30 a.m. -1/1/24-one nurse staff called in on the evening shift; replaced with staff coming in at 4:00 p.m. -1/10/24- one nurse called in on the evening shift with no replacement. -1/15/24- one nursing assistant (NA) called in on the day shift with no replacement and one NA scheduled from 6:30 a.m. to 2:30 p.m., left at 11:15 a.m., and not replaced. -1/19/24- one NA called in on the evening shift with no replacement -1/21/24- one NA called in day shift with no replacement; one NA left at 1:00 p.m., scheduled on the 6:30 a.m. to 2:30 p.m., shift with no replacement -1/22/24-one NA called in on evening shift; with no replacement -1/23/24- one nurse scheduled on the day shift left at 1:30 p.m., one NA called in on the day shift with no replacements. -1/24/24- one NA called in on the day shift with no replacement; one NA called in on the evening shift with no replacement. -1/29/24- one NA called in on the evening shift, with no replacement. Review of July 2023, master schedule: Day shift-6:00 a.m. to 2:30 p.m. Evening shift-2:00 p.m. to 10:30 p.m. Night Shift- 10:00 p.m. to 6:30 a.m. -7/1/23-one nurse left earlyat 7:20 p.m., on the evening shift; no staff replacement indicated. -7/3/23- one nurse called in on the day shift; one NA called on the day shift; one NA left at 12:00 p.m., on day shift; no staff replacement indicated. -7/5/23- one nurse came in at 8:00 a.m., on the day shift; one NA called in on the day shift; one NA left at 9:30 p.m., on the evening shift; one NA left at 9: 00 p.m., on the evening shift. one NA called in on the night shift; no staff replacement indicated. -7/7/23- one nurse called in on the day shift; two NAs left early on the evening shift; no staff replacement indicated. -7/8/23- one nurse called in on day shift; no replacement; two NAs came in late (4:00 p.m.) on the evening shift; no staff replacement indicated. -7/9/23-one NA called in on the day shift; one NA called in on the evening shift; one NA came in at 4:00 p.m., on the evening shift and left 1/2 hour early; no staff replacement indicated. -7/10/23- two NAs called in on the day shift; one NA left at 9:00 p.m., on the evening shift; one nurse called in on the night shift; no staff replacement indicated. -7/11/23- one NA called in on the day shift; one NA came in late at 4:00 p.m., on the evening shift; one NA left early at 9:00 p.m., on the evening shift; one NA called in on the night shift with no staff replacement indicated. -7/12/23- one nurse called in on the day shift; one NA called in on the evening shift; one nurse called in on the night shift; no staff replacement indicated. -7/13/23- one nurse called in on the evening shift; no staff replacement indicated. -7/14/23- one NA called in on the day shift; one NA called in on the evening shift; no staff replacement indicated. -7/15/23- one NA called in on the day shift; one NA called in on the evening shift; one nurse no call/no show on the night shift; no staff replacement indicated. -7/17/23- one NA called in on the day shift; one NA called in on the evening shift; no staff replacement indicated. -7/21/23- one NA called in on the evening shift; no staff replacement indicated. -7/22/23- one NA called in on the day shift; one NA called in on the evening shift; no staff replacement indicated. -7/23/23- two nurses called in on the day shift; two NA's marked late; one NA's called in on the day shift; one NA came in late on the evening shift at 4:00 p.m., and one NA called in ; no replacement noted. -7/24/23- one TMA called in on the day shift and one NA called in on the day shift; one NA called in on the evening shift; no staff replacement indicated. -7/25/23- there NAs called in on evening shift; one nurse called in on the night shift; no staff replacement indicated. -7/26/23- two NAs called in on the day shift; one NA called in on the evening shift; no staff replacement indicated. -7/27/23-one nurse called in on the day shift; no staff replacement indicated. -7/28/23- one NA called in on the evening shift; no staff replacement indicated. -7/30/23- two NAs called in on evening shift. no staff replacement indicated. During interview on 2/5/24 at 3:17 p.m., nursing assistant (NA)-J stated staff were not always available due to the facility using agency staff that did not show up. NA-J also stated the weekends were usually more challenging due to pool agency call-ins and difficulty in finding replacement. NA-J explained they got frustrated when assigned 1:10-15 residents per NA on the transitional care unit (TCU). NA-J also stated with only two NAs staffed on the unit it was very busy and it was frustrating since they were unable to meet resident's needs timely. NA-J further explained a meeting was held recently with upper management and had expressed staffing concerns. During interview on 2/6/24 at 1:40 p.m., universal worker (UW)-I stated was assigned to help with activities, 1:1's with residents, answering call lights, and worked 40 hours a week, however, did not provide any personal cares to residents. UW-I stated the weekends were usually short staffed since there was only one manager on duty who came in at varied times and worked about four hours. When there was a call-in, typically the agency staff called in more frequently, it was difficult to find staff replacement and the staff typically would work short. During interview on 2/7/24 at 7:53 a.m., licensed practical nurse (LPN)-E stated it was stressful when one nurse was assigned with a trained medication assistant (TMA) as they had to administer medications on one cart till around 10 a.m., then administer insulin and provide other resident treatments. LPN-E stated the weekends were more challenging due to call-ins. LPN-E also explained the manager on duty was often unable to find a replacement and since the manager on duty was at times not a nursing staff, they were unable to provide direct patient care. During interview on 2/7/24 at 10:02 a.m., registered nurse (RN)-B stated they often had to stay late after working assigned shifts. RN-B explained when assigned with a TMA, they had to work on both halls and could have up to 40 residents assigned to their care, to pass medications, complete treatments, gave insulins, and other nursing related responsibilities the TMA was unable to perform for the residents. RN-B stated the weekends were more challenging with staffing due to call-ins mostly from agency staff and the manager on duty often adjusted staff assignments on the weekends. RN-B also clarified when short-staffed, residents were left soaked for long periods, there were more falls and incidents, it was more challenging for residents who had skin and wounds issues to be turned and repositioned timely and residents had to wait longer periods when they put on their call lights to receive assistance. During interview on 2/7/24 at 1:14 p.m., LPN-D stated felt overwhelmed most days due to working short staffed and having to work with a TMA with 27-30 residents. LPN-D stated when they worked with a TMA, they would have to complete morning medication pass till around 10 a.m., when the TMA would take over the two medication carts. LPN-D then completed resident treatments, and nursing cares for residents on tube feeding, intravenous antibiotics, insulins and wound cares, etc. LPN-D also clarified the facility had residents who were assigned restorative nursing programs, but staff were unable to complete the walking or exercise program because they did not have time. 44647 Refer to 684 quality of care: elopment When interviewed on 2/8/24 at 9:19 a.m., RN-F stated R3's behaviors escalate on evenings more than days. RN-F stated there are just less people and R3 wants to go home like many of the staff are doing. RN-F further stated If staff noticed the behaviors early, R3 was able to be redirected but a lot of 1:1 time was needed. The amount of 1:1 time was challenging as usually there were only three staff on the wing and if staff were in other rooms, R3's behaviors and wandering may not be seen right away. Refer to F550 resident rights When interviewed on 2/7/23 at 8:50 a.m., NA-B stated R48 usually will get out of bed but sometimes will not want to. NA-B further stated R48 needed assistance eating needed encouragement to get out of bed. NA-B was not sure if the comment spoken in front of the R48 offended them, and further stated in 5 minutes R48 will want to be up for breakfast .it's frustrating as there are so many residents to get up. During interview on 2/8/24 at 10:17 a.m., director of nursing (DON) and regional nurse consultant (RNC)-E stated staffing was based on acuity and census and adjusted as needed. Nursing staff had complained about working short-staffed and the facility leadership tried to explain to them, staffing was based on census and acuity. DON also stated the leadership would often have staff clarify what they meant by working short-staffed when the required number of staff had been scheduled. DON further stated there were no identified concerns related to resident cares not being completed due to nursing staff working short. The facility policy titled Nursing Services and Staffing Requirements revised 12/2022, indicated the facility shall provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.

Based on interview and document review, the facility failed to complete an annual performance review for 5 of 5 nursing assistants (NA-E, NA-F, NA-G; NA-H, NA-I) whose employee files were reviewed. This had the potential to affect all 64 residents who resided at the facility. Findings include: The facility Annual Performance Review documentation provided for NA-E, NA-F, NA-G; NA-H and NA-I, were all undated and unsigned by employee and evaluator. During interview on 2/9/24 at 9:12 a.m., regional nurse consultant (RNC)-E stated it was the expectation that performance evaluations were completed accurately and thoroughly, dated and signed by employee and evaluator annually. During interview on 2/9/24 at 10:04 a.m., RNC-E also clarified performance reviews were to be completed annually, however, after checking facility records, RNC-E verified performance reviews had not been completed for NA-E, NA-F, NA-G; NA-H, and NA-I who were due for one. RNC-E stated the facility began a new process where performance reviews would be completed quarterly but the new process had not been implemented. Facility policy titled Performance Reviews dated 1/1/24, indicated the employer's goal is to provide a written performance review at the end of a new employee's first 90 days of employment (the introductory period) and annually at the end of the 4th quarter. Performance reviews should provide clear, direct, accurate evaluations of performance. The employee may make comments on the evaluation form. All performance evaluations will be signed by the employee after the performance management evaluation has taken place. The employee's signature does not indicate that the employee agrees with the evaluation, but that the evaluation has been completed and discussed. The employee should be given a copy of the completed evaluation form. Should the employee elect not to sign the evaluation form, the immediate supervisor must note in the comments section Employee Refuses to Sign, and, if convenient, have another supervisor also sign this comment.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours per day. This deficient practice had the potential to affect all 64 residents who resided in the facility. Review of staff schedule postings for the months of July, August, September and December 2023, on the following dates there was no RN coverage for eight consecutive hours per day: 7/4/23, 7/15/23, 7/16/23, and 12/17/23. The facility was unable to provide verification (such as sign in sheets, documentation completed, email communication, etc.,) of RN in facility on 7/3/23, and 8/12/23. There were no RN's scheduled on the nursing master schedule on 7/3/23, and 8/12/23. During email communication from administrator on 2/8/24 at 12:47 p.m. RN coverage clarification were as follows: 7/3/23- one RN (director of nursing) was in building (per administrator) but did not provide direct resident care 7/4/23- No RN in building 7/15/23-one RN worked 5.85 7/16/23- No RN was in the facility 8/12/23-one RN in building (per administrator) but did not provide direct resident care 12/17/23- one RN worked 6.52 hours During email communication on 2/7/2024 at 2:41 p.m., administrator indicated I know we always scheduled eight hours or above per day for RN coverage, but it appears due to call in's we may have missed the total of hours in a day on a few occasions. During interview on 2/8/24 at 12:16 p.m., administrator stated the facility needed to have coverage for RN's at least eight hours per day and seven days a week and typically the facility had staffed way above that. The administrator further explained that when the staffing coordinator (SC)-I completed the nursing staff schedules, the DON, human resources and the administrator got a copy in their emails and this schedule was reviewed during the weekly staffing meetings every Wednesday. The administrator identified the lack of RN coverage for eight consecutive hours indicated on the days above were missed by the facility during staff schedule reviews. During interview on 2/8/24 at 2:30 p.m., SC-I stated they had not been trained regarding the requirement for eight consecutive hours of RN coverage daily and had just became aware when surveyor was requesting documentation and clarification for eight consecutive hours of RN coverage on the schedule. The facility policy titled Nursing Services and Staffing Requirements revised 12/22, indicated licensed nursing staff provided 24 hours a day, 7 days per week. Provide Registered nurse services at least 8 consecutive hours a day, 7 days per week. The facility shall provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.

Based on interview and record review, the facility failed to reduce the risk of accidents to prevent falls for one of one resident (R1) reviewed for falls with injuries. The facility failed to assess and add interventions following a positive Covid diagnosis with symptoms increasing the potential R1's risk for falls and did not comprehensively analyze and update the care plan with appropriate interventions following a fall that resulted in new fractures. Findings include: R1's progress noted dated 11/21/23 indicated R1 was admitted to the facility from a hospital 11/21/23 with a primary diagnosis of a spinal surgery following a fracture in his back in the 11th and 12th lumbar vertebra that resulted from a fall at home. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 11 indicating R1 had moderate cognitive impairment. R1 required moderate assist with toileting, upper body dressing and transferring. R1 required maximum assistance with showering, and lower body dressing and putting on shoes. R1's progress note dated 11/29/23 at 1:09 p.m. indicated R1 tested positive for Covid-19. R1's progress note dated 11/30/23 at 5:25 a.m. indicated R1 was having dry heaves and later had emesis. R1 had a nonproductive cough and a light pink color in his urinal. R1's progress note dated 11/30/23 at 9:21 a.m. indicated R1's oxygen saturation rate was 93% on room air. R1 exhibited a cough and gastrointestinal symptoms. R1's progress note dated 12/1/23 at 5:25 a.m. indicated R1's oxygen saturate rate was 90% on room air. R1 gastrointestinal symptoms and a cough. R1's progress note dated 12/2/23 at 4:53 a.m. indicated R1's rate was 90% on room air and R1 continued to exhibit a cough and body aches. R1's progress note dated 12/3/23 at 1:37 p.m. indicated R1 complained of pain with movement, repositioning and transfers. R1's incident report dated 12/4/23 at 4:41 indicated R1 was heard yelling down the hallway, R1 was found on the floor in his room lying on the floor next to his bed. R1 was confused, making groaning sounds and complaining of lower abdominal pain. The note indicated R1 was mechanically lifted to bed and assessed for injury. At that point he did not complain of pain. He had full range of mouth in his neck, arms, and legs. R1's temperature was 100.6 with all other vital signs stable. R1 was not sent to the hospital. He had a head strike with a laceration on the back of his head. In addition, the incident report indicated R1's room had poor lighting, R1 had a recent change in condition, was confused and had a recent illness. R1 was ambulating without assistance. The incident report did not indicate any new fall prevention interventions. R1's progress note dated 12/4/23 at 4:41 a.m. (a late entry) indicated R1 had an unwitnessed fall. R1 was witnessed to have hit his head with a laceration. There were no further notes on the laceration. R1's mental staff was oriented to person, place, and time. R1 was attempting to transfer without using his call light. There were no recent changes to may have contributed to the fall. No new interventions were put into place and no potential of root cause was identified. A Post Fall Data Collection document dated 12/4/23 indicated that R1 fell and was found on the floor in his room with a laceration to the back of the head. It was indicated that R1 did not activate his call light for assistance, and R1 was capable and had historically used the call light. The report indicated that R1 was not transferred to the hospital. The Post Fall Data Collection Assessment did not indicate or include any environmental factors that may have contributed to the fall, vital signs, blood sugars, or last urination/bowel movement. The interventions that were indicated was for R1 to always have gripper socks on, and other fall interventions but was not specified on the report. The report indicates that the care plan and nursing care sheets were reviewed, and no changes were indicated. R1's progress note dated 12/4/23 at 9:43 a.m. indicated R1 was transferred to the hospital. There was no documentation as to the reason he was sent to the emergency department. R1's progress note dated 12/4/23 indicated the hospital called and stated R1 was being admitted with Covid and a fracture of the 5th vertebra. R1's hospital discharge date d 12/7/23 indicated R1 reported he was trying to transfer from his wheelchair to another chair and fell to the floor hitting his head. Spine imagining identified a fracture at through L4 and L5. In addition, R1 was admitted for hypoxia secondary to Covid, with suspected superimposed bacterial pneumonia and borderline/early sepsis. R1's care plan dated 12/7/23 did not indicate any indications on how R1 was to be transferred. In addition, the care plan did not indicate R1 was positive for Covid with any interventions and did not indicate any fall preventions prior to or to the recent fall on 12/4/23 with the new fracture. R1's Post Fall Data report dated 12/17/23 indicated that R1 fell and was found on the floor in his room. The report stated that R1 lost his balance while trying to reach for his pillow that fell on the floor. The report indicated no apparent injuries. The report indicated R1 had an overall decline in his health in the past few months. R1 was not transported to the hospital. The specified intervention was to remind R1 to use his call light. The report indicated the care plan and nursing care sheets were reviewed and no changes indicated. R1's fall report dated 12/17/23 indicated the immediate intervention was to ensure items are within reach for R1. R1's progress note dated 12/17/23 at 11:56 p.m., indicated that R1 had a fall and to see the care plan for interventions put into place. R1's care plan dated 1/9/24 did not indicate that R1 had recent falls or that R1 should be always wearing gripper socks, to keep items within reach or how to transfer R1. During an on 1/10/24 at 9:57 a.m. Physical Therapist (PT)-A the director of rehabilitation services stated that when a resident falls the staff will reach out to him for interventions during the interdisciplinary team (IDT) meeting and ask if he has any suggestions on interventions. He stated he did not recall what interventions were put into place after R1 had his fall on 12/4/23 or 12/17/23. PT-A denied reassessing R1 following his Covid diagnosis for any increased interventions due to the pain, gastrointestinal symptoms, and weakness. During an interview on 1/10/24 at 11:30 a.m., RN-D stated that after R1 fell on [DATE] she had sent him to the hospital for further evaluation. RN-D stated that PT and Occupation Therapy (OT) did not give the nursing staff any interventions for R1 and stated she was uncertain how R1 was to have been transferred. She was unaware that R1 had another all on 12/17/23. During an interview on 1/10/24 at 12:19 p.m., LPN-D stated that she did not know of any interventions that were in place after R1's fall on 12/4/23. LPN-D stated that she does not remember anyone telling her about R1's fall from 12/4/23 or 12/17/23. During an interview on 1/10/24 at 2:33 p.m., the director or nursing DON stated that when a resident falls, she will be notified by the nurse on duty, or the on-call nurse and they will then put add new interventions following an assessment to the care plan. The DON stated that it is ultimately the responsibility of the nurse on duty or the nurse manager to put the interventions into the residents' care plans. She stated after a fall a new intervention should always be placed on the resident. The DON stated she was uncertain of any increased interventions were set in place for R1 following the Covid-19 diagnosis. A policy provided by the facility called Fall Risk and Prevention Policy and Procedure effective 11/2014 and revised on 8/2022 indicated it is the responsibility of the director of nursing services (DNS)/ director of health services (DHS) and/or delegate to monitor these preventative measures to assure they are in place. The policy indicates that all interventions are to be listed on the skilled nursing facility (SNF) Care Plan and the NAR Care Plan/home health aide (HHA) Care Plan. The policy indicates an immediate action post fall procedure is that post fall interventions are implemented.

Based on interview, and document review, the facility failed to provide adequate supervision and interventions to prevent ongoing sexual abuse of 1 of 3 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1 who received unwanted sexual touching by R3 without facility intervention. The IJ began on 5/20/23 at 2:16 p.m., when R3 was observed kissing R1's hand and touching R1's chest (breasts) and neck. The administrator and director of nursing (DON) were notified of the IJ on 6/6/23 at 12:33 p.m. The IJ was removed on 6/7/23 at 11:58 a.m. but noncompliance remained at the lower scope and severity level of a D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnosis List indicated R1 had a diagnosis of hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke) on the non-dominant side. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with the ability to rarely or never make decisions, and had speech that was unclear and rarely understood. The MDS further indicated R1 required extensive assistance of one or two staff for activities of daily living (ADLs), and had impairment bilaterally in both her upper and lower extremities. R1's s care plan dated 5/23/22, indicated R1 preferred to not be alone with male peers. R1's electronic medical record lacked documentation of the allegations of sexual abuse by R3. R3's Diagnosis List indicated R3 had diagnoses which included spondylosis (degeneration of the spinal column) and spinal stenosis (abnormal narrowing of the spinal canal). R3's quarterly MDS dated [DATE], indicated R3 had intact cognition and was independent in moving around the facility in a wheelchair. R3's care plan dated 3/22/23, indicated R3 had behaviors of holding hands and touching faces of peers as a sign of comfort, but lacked mention of interventions to prevent touching other peers. R3's progress notes indicated the following: *On 4/19/23 at 4:30 p.m., R3 was watching TV near the office. Staff noticed R3 hold R1's hand, and touching R1's face in the mouth area. The progress note indicated R3 put his finger in R1's mouth, and stopped after he noticed staff observing him. The nurse manager (NM, registered nurse [RN]-D) and the DON were notified. *On 4/22/23 at 1:43 p.m., R3 was in the dining room holding hands with a female resident (unidentified) who kissed R3. Staff informed R3 he could not touch female residents or kiss them. LPN-A notified the supervisor (RN-D) of the interaction. *On 5/20/23 at 2:16 p.m., R3 was observed kissing R1's hand and touching R1's chest (breasts) and neck. RN-A reported the behavior to RN-D. *On 5/22/23 at 9:00 a.m., R3 was observed in R1's resident's room while R1 was in bed. Staff asked R3 to leave the room. RN-A reminded R3 he had been spoken to about this before. RN-A informed the assistant director of nursing (ADON) and social worker (SW)-A of the incident. *On 5/22/23 at 2:34 p.m., SW-A met with R3 to review how to have proper boundaries with peers. R3 acknowledged understanding. *On 5/25/23 at 11:21 a.m., SW-A observed R3 with a female resident in the hallway. The female resident leaned towards R3 and they kissed. The SW separated the residents. R3 stated, It is okay, and I am not going to stop. *On 6/6/23 at 7:30 p.m., SW-A met with R3 to review behaviors of touching other residents. R3 denied the behavior. R3 was re-educated to not touch other residents, and acknowledged understanding. On 6/5/23 at 12:35 p.m., trained medication aide (TMA)-A was interviewed. TMA-A stated RN-A instructed her to keep R3 out of R1's room. TMA-A further stated she highly doubted R1 wanted R3 to touch her, as R1 was married and R1's husband visited almost daily. TMA-stated if she had witnessed the abuse, she would have reported it to administration. On 6/5/23 at 12:52 p.m., TMA-B stated R3 targets R1. TMA-B stated she has witnessed R3 caress R1's face, run his fingers across R1's lips, and kiss R1's hands three times. TMA-B stated she has reported the abuse to RN-A. TMA-B stated on another weekend a nurse called her from the front of the building to ask her to remove R1 from the area as R3 was touching R1 inappropriately. TMA-B stated, She [R1] gets the furrowed brows when [R3] is touching her. TMA-B further stated, We all watch [R1]. When we move her where we think she is in a visible place, [R3] still does it. I believe it is sexual abuse or assault. She is not capable of being a consenting partner. I reported it to [RN-A]. On 6/5/23 at 1:10 p.m., R1 was interviewed. R1 was not able to answer questions verbally, but could nod her head. When asked if she wanted R3 to stop touching her, R1 nodded yes. R1 slowly lifted her right arm/hand a few inches off the bed to shake hands, but could not lift her left arm. On 6/5/23 at 1:43 p.m., SW-A stated she knew R3 kissed and held hands with a couple of female residents. SW-A stated she reviewed the incident with R1's family member (FM)-A who stated he did not want R1 near R3, and this was updated on R1's care plan. On 6/5/23 at 2:06 p.m., NA-B stated she saw R1 with R3 by the television by the dining room. R3 was touching R1's face. NA-B stated she could not recall what day that was. NA-B stated she thought the behavior was weird because R3's fingers were so close to R1's mouth. NA-B could not recall which nurse she told. On 6/5/23 at 2:14 p.m., nursing assistant (NA)-A stated she found R3 in R1's room once and asked R3 to leave the room. NA-A stated, Nothing has been done to prevent it. [R1] cannot do anything to prevent [R3] from touching her. NA-A further stated, He [R3] took his fingers and rubbed them on her [R1] lips and shoved them in and out of her mouth, and grabbed her breasts. NA-A further stated R1 was visibly upset when R1 was left alone with R3 in a room, and NA-A had to reassure R1 she was not going to be left alone with R3. NA-A further stated she saw R3's hand next to R1's breast when R1 was lying in bed. On 6/5/23 at 2:36 p.m., FM-A was interviewed. FM-A stated a nurse had called him to notify him about R3 touching R1 inappropriately on the breasts, and kissing and caressing R1 on the hands. FM-A stated one day, prior to the conversation with the nurse, FM-A visited R1. FM-A stated when he held R1's hand, she pulled away and gave FM-A, a dirty look. FM-A asked R1 for a kiss when he was leaving for the day as per normal routine, and R1 would not allow FM-A to kiss her. FM-A stated when he heard about the incident the next day from the nurse he understood why R1 was upset, and stated, She would not like that kind of attention from him. She would not like it. Absolutely not. I commented to her that she had a boyfriend and she said no. FM-A further stated he was not informed about action taken to prevent further occurrences, and he expected an action plan, but did not get one. FM-A added, They said they had a meeting and talked about it. She has no ability to fight back. I totally disagree [R1] could fight back or help herself. The bottom line is [R1] couldn't do that. On 6/5/23 at 3:42 p.m., the DON stated she was not aware of R3 touching R1's breasts, but knew there were other behaviors and did not know if the incidents were reported to the state agency. On 6/5/23 at 3:48 p.m., RN-B stated, I saw him [R3] putting his finger into her [R1] mouth. RN-B stated she informed RN-D and SW-A, and felt the facility did not respond to the abuse allegations. On 6/5/23 at 3:49 p.m., the administrator stated he was not aware of the allegations of abuse, but stated the facility adjusted the care plans to ensure R3 was kept from R1, and advised staff to keep them apart. On 6/5/23 at 5:33 p.m., RN-B stated R1 used to sit in the entrance area and look out the windows, but now she stayed mostly in her room. On 6/6/23 at 8:48 a.m. SW-A stated she implemented a notice to staff on 5/23/23 to observe for resident behaviors of kissing, holding hands, and entering other resident rooms. The notice indicated to redirect the resident (R3) when it occurs, record a progress note, and update the nurse manager or social services via phone or in person. On 6/6/23 at 9:18 a.m., RN-C stated she was aware of R3 touching R1 by rubbing her arm in the TV area and stated, It creeped me out and I put her back in her room. She has been staying in her room and he can go anywhere. I was pretty upset about it and said something had to be done; nothing has been done. I said it should have been reported to the State. RN-C stated she reported the incident to RN-D. On 6/6/23 at 9:31 a.m., NA-A stated she observed R3 in R1's room. R3's hand was next to R1's breast, and when NA-A addressed R3, He got all scared and backed up. He knew he shouldn't be in there. [R1] looked very scared, very, very uncomfortable. I tried to ask if something happened and she would look at me and look away. NA-A further stated, There was a sign in the front office to make us aware of it, but we all knew. The DON knew. [RN-D] knew and came into the nursing station and talked to us about it. On 6/6/23 at 9:55 a.m., RN-D stated she was aware of the abuse incidents staff reported to her, she did not keep notes about the reports, and conferred with the director of nursing and administrator. RN-D stated it was decided to monitor R3's behavior and keep R3 away from R1. RN-D further stated she would not find the kind of touching R3 was doing with R1 a comfort and stated the incidents should have been reported and investigated. RN-D acknowledged R3's care plan lacked interventions to prevent the abuse. On 6/6/23 at 11:15 a.m., licensed practical nurse (LPN)-A stated she was aware of an incident where R3 touched R1 in the TV area about two months ago, and reported it to RN-D. LPN-A stated nothing had been done to change R3's behavior, and would expect to see behavioral interventions in R3's care plan. LPN-A acknowledged interventions had not been implemented. The Vulnerable Adult/ Maltreatment policy dated 10/22, indicated Zero Tolerance for resident abuse. The policy defined mandated reporter as each employee, and defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy further indicated the supervisor, DON, or administrator would determine if the incident was reportable, and immediately institute an internal investigation of reported allegations. The facility implemented the following corrective action to prevent reoccurrence on 6/7/23: - Initiated 1:1 supervision of R3 until R3 was moved to a room away from R1. - Moved R3 to a room on different hallway. - Updated R3's care plan to monitor behaviors of touching other residents. - Updated R1's care plan to allow only female staff to provide care. - Performed a Vulnerable Adult Assessment for both R1 and R3. - Implemented orders to monitor for behaviors each shift. - Implemented retraining with a post-test for all staff about R3's behavior monitoring and the VA reporting policy. This was verified through staff interviews, observations and document review on 6//7/23.

Surveyor: Nelson, Sandra Based on observation, interview, and document review, the facility failed to monitor, re-evaluate and revise interventions when R168 first developed pressure ulcers and failed to implement interventions on the plan of care to minize skin breakdown for 1 of 3 residents (R168) in the sample reviewed for pressure ulcers who was admitted with intact skin. This practice resulted in actual harm for R168 who acquired four open areas in the facility after being admitted . Findings include: R168 was admitted on [DATE], and had [DIAGNOSES REDACTED]. R168 did not receive the necessary care and services to prevent development of open areas. As a result, R168 developed four open areas since return from the hospital on [DATE]. On 8/21/12, at 1:15 p.m. R168 stood up with the assist of two staff and a standing lift. The buttocks and coccyx were observed and four open areas were noted with clearly defined edges and visible depth. The bilateral buttocks had deep red skin covered with peeling, dry flakes and the skin was noted to be loose and sagging. The licensed practical nurse (LPN)-A stated the two larger open areas looked like they were caused by pressure. R168 was observed continuously from 7:47 a.m. until 10:00 a.m. on the morning of 8/22/12. R168 was sitting in the wheelchair at 7:47 a.m. No repositioning, off-loading or toileting were provided until the physical therapy staff approached R168 at 9:47 a.m. to start the therapy session. The surveyor intervened and requested to observe R168's skin. At 9:51 a.m. R168 stood up with the assist of two staff members and a walker. The buttocks, coccyx and skin folds appeared dark red in color. The nurse was unable to complete a skin assessment as the resident immediately began to have an episode of bowel incontinence. The admission Minimum Data Set ((MDS) dated [DATE], indicated R168 had moderately intact cognition (brief interview of mental status (BIMS) score of 11). R168 required extensive assist of two for transfers, bed mobility and toileting and was frequently incontinent of bowel and bladder. No alterations in skin integrity were noted on the assessment. The Pressure Ulcer Care Area Assessment (CAA) dated 6/22/12, identified R168's risk factors as; immobility, incontinence, altered mental status, [MEDICAL CONDITION] limits mobility, cognitive loss and poor nutrition. R168 needed a special mattress or seat cushion to reduce or relieve pressure per the CAA analysis. R168 returned to the facility on [DATE] after a hospitalization . A body audit dated 7/19/12, indicated the skin was intact. The Pressure Ulcer Comprehensive Risk assessment dated [DATE], indicated that R168 had high risk factors and high risk [DIAGNOSES REDACTED]. The care plan created on 7/24/12, indicated R168 had the potential for pressure ulcer development related to: impaired mobility, bowel and bladder incontinence, need for assist with transfers and repositioning. The goals for R168 were to "have intact skin, free of redness, blisters or discoloration" and "will remain free from skin breakdown due to incontinence and brief use". Interventions directed staff to use a pressure reduction mattress on bed and pressure reduction cushion in wheelchair, assist to turn/reposition at least every two hours, more often as needed or requested, apply moisturizer to skin with cares, notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, and discoloration noted during bath or cares. However, the care plan did not identify the existing open areas and there was no evidence of new interventions related to new open areas identified on 8/1/12 and 8/3/12. A progress note dated 8/1/12, noted R168 had reddened buttocks and received an order for [REDACTED]. A progress note dated 8/5/12, indicated barrier cream applied to open area on coccyx and [MEDICATION NAME] applied to reddened buttocks. Progress notes dated 8/7/12 and 8/8/12, indicated skin intact. Progress note dated 8/10/12, showed Allevyn (a wound dressing) to coccyx area and right buttocks. There was no evidence of additional measurements after 8/3/12. The nurse manager (NM)-A measured the open areas on 8/21/12, and documented her findings in the progress notes. The progress note dated 8/21/12, revealed the following, "resident has ongoing skin breakdown associated with moisture/incontinence maceration. Currently has 4 superficial open areas. Superficial open area to mid coccyx currently measures 2.0 cm x 0.6 cm surrounding skin pink and blanchable, 2 cm below is another superficial open area currently measuring 0.3 cm x 0.2 cm surrounding skin is intact, pink and blanchable. Superficial open area 1.5 cm above anus currently measures 0.1 cm x 0.1 cm surrounding skin intact, pink and blanchable. Superficial open area to right gluteal fold currently measures 1.8 cm x 0.7 cm surrounding skin intact, pink but blanchable. MD (physician) examined open areas yesterday upon rounds and changed treatment to [MEDICATION NAME] cream BID (twice a day) and diagnosed maceration secondary to moisture. No drainage from open areas. Denies pain or discomfort to the area except when stool comes in contact with the areas." However, the note lacked depth measurements or clear description of the wound beds and evidence of re-assessment (including causative factors) were not present. In addition, there were no new interventions identified. Further record review revealed, the MD progress note dated 8/6/12, indicated, "Skin: inspection of skin and subcutaneous tissue baseline." The NP (nurse practitioner) progress note dated 8/10/12, did not address skin. The MD progress note dated 8/13/12, indicated, "Skin: inspection of skin and subcutaneous tissue baseline." Braden Scales (an assessment used to determine pressure ulcer risk) dated 7/19/12, 8/2/12, 8/10/12, and 8/13/12, indicated R168's skin was rarely moist (skin was usually dry; linen only requires changing at routine intervals). The Pressure Ulcer Comprehensive Risk Assessments dated 7/19/12 and 8/2/12, showed that the resident should be turned and repositioned every two hours while in bed and to reposition, off load (relieving pressure for one full minute) while in chair every one hour. There was no assessment of R168's ability of the skin and its supporting structures to endure the effects of pressure without adverse effects completed for R168. The Pressure Ulcer Comprehensive Clinical assessment dated [DATE], indicated R168 had pressure ulcers identified as open area (o/a) to right buttock and directed to locate all pressure ulcers on the body diagram and complete the Pressure Ulcer Record. However, the body diagram and Pressure Ulcer Record were not completed The NP assessed R168's skin. The NP progress note dated 8/22/12, indicated inspection of skin and subcutaneous tissue on coccyx and buttocks assessed. R168 "Has superficial stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) open area on the mid coccyx line with creamy colored slough in the base. No granulation tissue noted. Also has 3 superficial open areas on left buttock. Surrounding skin is deep pink and blanchable. No drainage. Not consistent with shearing injury." R168's regular nursing assistant (NA)-C was interviewed on 8/22/12, at 11:30 a.m. she stated she got R168 up to the commode after 7:00 a.m. and she transferred R168 to the wheelchair around 7:30 a.m. NA-C verified she had not toileted or repositioned/off loaded R168 between 7:30 a.m. and 9:47 a.m. She stated R168 always wanted to go to the bathroom after breakfast. She further indicated R168 had been on a repositioning schedule since the last return from the hospital. She verified the only repositioning that occurred was with toileting and she was not sure what off-loading meant. In addition, she stated she was aware R168 had "three sores on his bottom" and she thought they looked better now. During interview on 8/20/12, at 5:51 p.m. the NM-A stated R168 had moisture related skin breakdown; however, she was unable to describe the status of the open area. NM-A stated the MD/NP had done wound rounds on 8/20/12, and she was unsure of what they had documented. During interview with the NP on 8/22/12, at 2:00 p.m. she indicated she had last seen R168's skin one and a half weeks ago, it had just been reddened and not open at that time. The NP verified the MD progress note from 8/20/12, did not address R168's skin status. The NP stated she could not say what the wound status and had not received an update from the staff regarding the four open areas. In addition, the NP indicated she should receive updates from the staff after weekly wound rounds. During interview with the director of nursing (DON) on 8/23/12, at 1:49 p.m. she stated pressure would need to be ruled out for any open area on the coccyx or bottom. Any open area would need to be monitored daily on the daily wound monitoring sheet and if measurable should be measured weekly during wound rounds. During interview on 8/23/12, at 3:28 p.m. the DON verified the facility did not complete an assessment of R168's ability of the skin and its supporting structures to endure the effects of pressure without adverse effects. The Wound Assessment Record policy dated January 2011, directed staff to complete a weekly report "on each resident with a wound or skin condition that has not resolved after the standing order protocol has been completed. The Nurses Weekly Wound assessment will be reviewed weekly at the IDT (interdisciplinary team) meetings for wound progress and treatment recommendations." The Daily Wound Monitoring Form Policy and Procedure dated January 2011, instructed the daily monitoring of pressure and non pressure wounds promoted early recognition of problems with wound healing, a dressing failure or unrelieved pain associated with the wound or dressing change. The undated Guidelines for Pressure Ulcer Prevention Guidelines indicated that skin subjected to excess friction, shear and weakened by moisture was at risk for pressure ulcers. R168 went from 8/3/12 until 8/21/12, without the staff documenting the progress of the four wounds, the facility staff did not update the NP on R168's wound, the facility did not operationalize the wound policy for monitoring and assessment, and the facility failed to follow the plan of care for the off-loading hourly while in the chair.