Every finding on record at Colonial Manor Nursing Home

Based on interview and document review, the facility failed to implement immediate protective measures for resident protection after staff witnessed a co-worker subject 1 of 1 resident (R1) to alleged abuse in the form of derogatory verbiage and actions that caused R1 to fall backwards onto the bed. As a result of this failure, the alleged perpetrator continued to provide care to R1, along with other residents, for approximately four hours after the witnessed allegation with the potential to affect all residents who resided in the facility. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency on 7/7/26 at 5:13 p.m., alleged caregiver abuse when registered nurse (RN)-A verbalized profanity at and abruptly stopped supporting R1's weight, causing him to fall backward into the bed. A previous report was submitted to the Minnesota Adult Abuse Reporting Center on 7/4/26 at 12:20 p.m., which identified the same information. R1's entry Minimum Data Set (MDS) identified R1 was admitted to the facility on [DATE]. R1's Continuity of Care document identified diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke); anxiety disorder; obesity; delirium (mental state that results in confusion, disorientation, and lack the ability to think or remember clearly); and spinal stenosis. R1's brief interview for mental status (BIMS) dated 7/1/26, indicated R1 had severe cognitive impairment. During an interview on 7/9/26 at 10:37 a.m., with R1 and his son, R1 indicated he was new to the facility and although he could not remember the day or time, he did describe an incident when an unidentified staff was volatile and the situation got out of control. R1 stated he did not ever want her to care for him again. During an interview on 7/9/26 at 4:05 p.m., licensed practical nurse (LPN)-A stated she witnessed the incident of abuse on 7/4/26 at 6:30 a.m., and left a voicemail for the director of nursing (DON) at 6:45 a.m. She then left the facility at 6:45 a.m., in which RN-A was the lone charge nurse. During an interview on 7/9/26 at 2:48 p.m., nursing assistant (NA)-A indicated she witnessed the alleged abuse incident on 7/4/26 at 6:30 a.m. NA-A indicated RN-A raised her voice and used foul language, like the F-word, towards R1, which made R1's behaviors worse. NA-A stated RN-A continued caring for residents until approximately 10:30 a.m. and described the work environment during that period as extremely uncomfortable as RN-A remained responsible for resident care after the alleged abuse. During an interview on 7/9/26 at 1:11 p.m., RN-B stated she was notified of the allegation of abuse on 7/4/26 at 10:04 a.m. by the DON. The DON had requested RN-B replace RN-A due to the abuse allegation. RN-B stated she arrived at approximately 10:30 a.m. and RN-A left the building at that time (four hours after the alleged abuse incident). During an interview on 7/9/26 at 2:05 p.m., the DON stated she did not hear her phone call from LPN-A at 6:45 a.m. but did receive the voicemail at approximately 10:00 a.m. The DON received reports that NA staff feared for resident safety as RN-A continued working and they felt uncomfortable working with RN-A. The DON called RN-B to replace RN-A and notified the administrator. The DON stated RN-A should have been immediately suspended and removed from resident care pending the investigation and acknowledged RN-A remained the acting charge nurse until RN-B arrived at approximately 10:30 a.m. The DON explained the facility had yet to complete abuse training with staff related to facility expectations and the identified failures in light of the allegation; however, had a meeting scheduled for later in July and would discuss it at that time. During an interview on 7/9/26 at 3:29 p.m., the administrator identified the DON notified her of the alleged abuse incident on 7/4/26 at 10:44 a.m. (over four hours after the allegation of abuse). Further identified the alleged abuse incident occurred on 7/4/26 at 6:30 a.m.; LPN-A left the facility at 6:49 a.m.; RN-B had arrived at 10:30 a.m. which resulted in RN-A continuing to care for R1 and all the residents in the facility unsupervised for approximately four hours. The administrator indicated it was her expectation that staff would notify the DON or administrator immediately; RN-A should have been immediately suspended and removed from duty; and LPN-A should have stayed until RN-B arrived. The facility's Abuse Prevention Plan last updated 1/12/2011, identified it is the policy of Colonial Manor, in accordance with the Vulnerable Adults Act of the State of Minnesota and Centers for Medicare and Medicaid Services (CMS), that all residents residing in the facility will be protected from maltreatment. Residents, the alleged perpetrator, and other staff will be protected from harm during an investigation. The facility will ensure the residents' psychosocial well-being as related to the incident under investigation. Although the Abuse Prevention Plan stated residents would be protected during an investigation, the policy failed to provide operational guidance for immediate implementation of protective measures, including removal of the alleged perpetrator from resident care when supervisory staff were unavailable. The absence of clear direction was consistent with staff uncertainty demonstrated during this event.

Based on interview and document review, the facility failed to ensure an allegation of abuse was reported timely to the State Survey Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse. In addition, the facility's Abuse Prevention Policy contained outdated reporting requirements that were inconsistent with current federal regulations and did not provide staff with accurate direction regarding required State Agency reporting timeframes.Findings include A Facility Reported Incident (FRI) submitted to the SA on 7/7/26 at 5:13 p.m., alleged caregiver abuse when registered nurse (RN)-A verbalized profanity at and abruptly stopped supporting R1's weight, causing him to fall backward into the bed. A previous report was submitted to the Minnesota Adult Abuse Reporting Center on 7/4/26 at 12:20 p.m., which identified the same information. During an interview on 7/9/26 at 4:05 p.m., licensed practical nurse (LPN)-A stated she witnessed the incident of abuse on 7/4/26 at 6:30 a.m., and left a voicemail for the director of nursing (DON) at 6:45 a.m. and then left the facility. LPN-A stated she did not notify the administrator and did not submit a report to the SA. During an interview on 7/9/26 at 1:11 p.m., RN-B stated she was notified of the allegation of abuse on 7/4/26 at 10:04 a.m. by the DON. The DON requested RN-B replace RN-A due to the abuse allegation. RN-B stated she submitted a report to the MAARC system and not to the SA at 12:20 p.m. RN-B stated she was new and did not know the proper process for filing a FRI to the SA. During an interview on 7/9/26 at 1:37 p.m., RN-A stated she was late for work the morning of 7/4/26 and had a bad morning. She explained R1 had attempted to self-transfer, was not cooperative, and wanted to go home. RN-A responded to assist and stated to R1, I can't wait until you can get the f*** [foul language]out of here either. RN-A stated she knew it was not professional but R1 was belligerent and although unprofessional, did not feel that it was abusive. R1 indicated her employment at the facility was terminated because of the incident. During an interview on 7/9/26 at 2:05 p.m., the DON stated she did not hear her phone call from LPN-A at 6:45 a.m. but did receive the voicemail at approximately 10:00 a.m. and called the facility for more information. The DON called RN-B to replace RN-A and notified the administrator. The DON stated it was her expectation that if staff cannot reach her directly, they are to call the administrator immediately and file a report to the SA. During an interview on 7/9/26 at 3:29 p.m., the administrator identified the DON notified her of the alleged abuse incident on 7/4/26 at 10:44 a.m. (over four hours after the allegation of abuse). The administrator indicated it was her expectation that staff notify the DON or administrator immediately and file a report to the SA according to the facility abuse prevention policy. The facility's Abuse Prevention Plan, reviewed January 12, 2011, directed staff to report suspected maltreatment to the Common Entry Point and the Office of Health Facility Complaints (OHFC) and defined immediately as within 24 hours after discovery. The policy did not reflect current federal reporting requirements requiring allegations involving abuse to be reported to the State Survey Agency no later than two hours after discovery. The outdated policy failed to provide staff with accurate guidance regarding current reporting obligations.

Based on record review and interviews, the facility failed to have a registered nurse (RN) on duty 8 consecutive hours a day, 7 days a week for 3 of 18 days reviewed.Findings include: Review of the 18 sampled days between 7/1/25 through 1/1/26 identified:On 11/15/25 the RN had only worked 4.5 hours that day.On 7/4/25 there was no RN coverage for that day.On 8/2/25, the RN had only worked 6.25 hours that day. Interview on 1/28/26 at 3:51 p.m., with the health unit coordinator who identified he was responsible for the schedule and to ensure there was an RN working 8 consecutive hours a day. If there was a call-off it was the responsibility of the case manager to work that shift for the RN coverage. He confirmed no RN had worked on 7/4/25. Interview on 1/29/26 at 2:50 p.m., with director of nursing identified that the health unit coordinator was responsible for the schedule and was very good at letting her know if there was not an RN scheduled to work. When that occurred, she revealed that the case manager or herself would provide that RN coverage. The expectation was that the facility would have an RN work 8 consecutive hours a day, 7 days a week. Review of April 2025, Departmental Supervision, Nursing policy identified that the facility would have a licensed nurse (registered nurse, or licensed practical or vocational nurse) on duty 24 hours a day 7 days per week. The policy further identified that an RN would be scheduled to work 8 consecutive hours in a 24-hour period, 7 days a week.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness dependent upon their symptoms for 3 of 3 months reviewed. This has the potential to affect all 26 residents who resided at the facility.Review of the facility staff illness surveillance identified the following1.On 10/13/25 licensed practical nurse (LPN)-A called in for his shift with symptoms of glassy eyes, sore throat, and feeling sick. The surveillance did not identify the last day worked, the date symptoms resolved, or when LPN-A returned to work.2.On 10/20/25 nursing assistant (NA)-A called in with symptoms of a sore throat and a temperature of 100.1. Her last day worked was 10/19/25. The staff illness log did not identify when NA-A was eligible to return to work or her actual return to work date. Under a column labeled notes it said she had been gone a few days, and she brought in a physician note.3.On 11/25/26 the facilities health unit coordinator (HUC) called in with symptoms of nausea, vomiting, chills, fever, headache, and body aches. The symptom onset date was 11/25/25. The log did not identify when his symptoms were resolved, when he was eligible to return to work, or what day he returned to work.4.On 12/19/25, NA-A called in with symptoms of sick. The log did not identify any other symptoms, no onset date, no resolution date, no eligible to return to work date, and no actual date that NA-A did return to work. The notes column identified that she was out for multiple days until signs and symptoms stopped. Interview on 1/28/26 at 8:24 a.m., with the facility designated infection preventionist identified that when staff call in for their shift, the department head fills out a form that is given to the facility health unit coordinator (HUC) and he was responsible for tracking staff illnesses. She identified that he would let her know if staff called in with symptoms that may be related to an infection. She identified she had not included any information on staff illness in her monthly infection control summaries, and she was unable to provide any documentation or actions to indicate she was involved in overseeing staff illnesses. She identified that she was not overseeing staff illness to the extent she should have been. Interview on 1/28/26, at 8:45 a.m., with the HUC identified he takes the call in forms from the department heads and adds the information to the staff illness logs, he then uses the work eligibility form to identify how long staff have to stay out of work and tells staff they have to stay out 48 hours post signs and symptoms. Interview on 1/29/26 at 3:15 p.m., with the administrator and the regional administrator identified the facilities designated infection preventionist was not certified. The infection preventionist was originally contracted to be the interim director of nursing. They agreed that when she took over the infection preventionist role she should have been enrolled in an approved infection prevention certification course. In addition, they would have expected the facility infection preventionist would oversee the staff illness surveillance to ensure the safety of the resident living at the facility. Review of the facility provided Infection Prevention Surveillance policy identified its purpose is to identify possible communicable diseases or infections before they can spread to other people in the facility. Surveillance of both residents and staff is needed in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, determine need for changes in current practices, identify education needs, and identify individual resident problems in need of intervention. The infection preventionist/designee will develop and maintain systems to gather surveillance data for both residents and staff, compile and analyze the data, utilize the findings to direct all Infection Prevention and Control activities within the facility, and report to the QAPI (Quality Assurance Performance Improvement) committee, monthly and as needed. When a staff member exhibits signs and symptoms of a suspected infection while at work or when they call off due to illness, the nurse or department leader made aware of the illness will:1.Refer to the Recommendations for Exclusion from Work. After illness tool and provide direction to the employee accordingly.2.Route the Colonial Manor Absence Report to the nursing department coordinator or HUC for tracking. Should the information provided indicate a potential infection, or should there be additional information needed to make this determination and/or a safe return date, the HUC will make contacts with the employee as needed.3.The infection preventionist should be apprised of all staff illnesses that are potentially infectious, as must be considered when determining the facility outbreak status. A request was made for the designated Infection Preventionist certification; however, nothing was provided by the end of the survey period.

Based on interview and document review the facility failed to ensure the acting infection preventionist (IP) (who is the facility's interim director of nursing (IDON)) had completed specialized training in infection prevention and control. This had the potential to affect all 26 residents residing in the facility. Findings include: Review of the facility assessment identified the designated facilities infection preventionist was the IDON. Infection prevention and control program (System to prevent, identify, report, investigate, and control infections) has a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease (IPCP), for all residents, staff, volunteers, visitors and other individuals receiving services under contractual arrangements based upon the facility assessment, and following accepted national standards. Our facility uses multiple tools to control and prevent infection, including 'support from outside organizations, interactions and training with the MN department of health ICAR team, having a designated infection prevention and control officer (IPCO), bringing identified IPCP issues to the QAPI committee for root cause analysis, implementing an antibiotic stewardship program, reporting required diseases to public health authorities, has hand hygiene procedures in place, utilizes standard and transmission based precautions, screen, education and offer immunizations to residents, staff and volunteers, has a training program for residents, families, volunteers and staff, interacts with community Medical Practitioners for continuity of care. Interview on 1/28/26 at 8:24 a.m., with the IDON identified she oversees the infection control program at the facility. She stated she completed training on infection control while working in another state but was unable to provide any information or a certificate of completion of an approved infection prevention course. Interview on 1/28/26 at 2:13 p.m., with the administrator and the regional administrator identified the IDON/IP was originally hired for the director of nursing role, when the facilities infection preventionist abruptly left her employment, the IDON took on the IP responsibilities. The regional administrator was aware that the IDON was not certified for infection control. She agreed that anyone working at the facility as the infection preventionist should either be certified by an approved infection preventionist training program or be enrolled in a program to become certified as an infection preventionist. Review of the facilities infection preventionist job/MDS description identifies the IP must obtain and/or maintain a registered nurse (RN) license by the state of Minnesota and be registered with the Minnesota Board of Nursing. Must possess leadership skills, have the ability to make sound decisions, and work under pressure. Must have a thorough knowledge of federal and state guidelines, Medicare, Tardive Dyskinesia Screening, and Case Mix reimbursement or the willingness to obtain training in these areas. A high school diploma or general education development (GED), graduate of an accredited school of nursing, and experience working in a geriatric setting is preferred. The job description makes no mention that the infection preventionist shall have an IP certification or be enrolled in an IP certification program upon hire.

Based on interview and document review the facility failed to ensure the infection preventionist (IP) brought a thorough report to the Quality Assurance Performance Improvement (QAPI) meetings on the infection control program. Findings include: Review of the 2/18/25, 5/15/25, 8/19/25, and 12/16/25 quarterly QAPI information provided, was a sign in sheet and an agenda for the meeting. There were no minutes provided. Interview on 1/28/26 at 8:24 a.m., with the interim director of nursing (IDON) who was the facility designated infection preventionist identified when staff called off for their shift the manager for their department filled out a form that was sent to the health unit coordinator (HUC) and he was responsible for tracking staff illness. The IDON revealed that she did not track, analyze or include staff illness in her QAPI reports and that staff illness was not discussed at QAPI. She was responsible for overseeing the infection control program. She reported she was certified in another state; however, she was unable to provide any information on completion of a program or certificate to confirm that. Interview on 1/28/26 at 2:13 p.m., with the regional administrator identified that the IDON was originally hired for the director of nursing role. When the facilities IP abruptly left her employment the IDON took on the IP responsibilities. She was aware that the IDON was not certified for infection control. She agreed that anyone working at the facility as the IP should either be certified by an approved infection preventionist training program or be enrolled in a program to become certified as an IP. Review of the undated, Infection Prevention Surveillance policy identified the IP would develop and maintain systems to gather surveillance data for both residents and staff, compile and analyze the data, utilize the findings to direct infection control activities and report those findings to the QAPI committee. Review of the 2/18/25, 5/15/25, 8/19/25, and 12/16/25 quarterly QAPI information provided, was a sign in sheet and an agenda for the meeting. There were no minutes provided. Interview on 1/28/26 at 8:24 a.m., with the interim director of nursing (IDON) who was the facility designated infection preventionist identified when staff called off for their shift the manager for their department filled out a form that was sent to the health unit coordinator (HUC) and he was responsible for tracking staff illness. The IDON revealed that she did not track, analyze or include staff illness in her QAPI reports and that staff illness was not discussed at QAPI. She was responsible for overseeing the infection control program. She reported she was certified in another state; however, she was unable to provide any information on completion of a program or certificate to confirm that. Interview on 1/28/26 at 2:13 p.m., with the regional administrator identified that the IDON was originally hired for the director of nursing role. When the facilities IP abruptly left her employment the IDON took on the IP responsibilities. She was aware that the IDON was not certified for infection control. She agreed that anyone working at the facility as the IP should either be certified by an approved infection preventionist training program or be enrolled in a program to become certified as an IP. Review of the undated, Infection Prevention Surveillance policy identified the IP would develop and maintain systems to gather surveillance data for both residents and staff, compile and analyze the data, utilize the findings to direct infection control activities and report those findings to the QAPI committee.

Based on interview and document review the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee for improvements had a developed measurable goal, action plan identified to reach the goal and analysis of the data collected on the improvement activities. This had the potential to affect all 26 residents residing in the facility.Findings include: Review of the quarterly QAPI meeting minutes provided identified:1) QAPI meeting minutes from 2/18/25, identified agenda for February, March, and April, included dietary review, diagnosis of malnutrition, at-risk of malnutrition, supplements, fluid restrictions, modified diets, low body mass index (BMI), high BMI's, and weight loss. Included with the documentation was a weight variance report from 1/18/25 through 2/18/25, which listed the residents' name and their weights, their BMI, and any change in weight. There was no identified goal, no action plans, or analysis of the data that was brought forth.2) QAPI meeting minutes from 5/15/25, identified agenda for February, March, and April, included dietary review, diagnosis of malnutrition with 3 residents listed, at-risk of malnutrition with 1 resident listed, supplements with 8 residents listed, fluid restrictions with 1 resident listed, modified diets with 7 residents listed, low BMI's with 2 residents listed, high BMI's with 10 residents listed, and weight loss with 1 resident listed. There was no identified goal, no action plans, or analysis of the data that was brought forth.3) QAPI meeting minutes from 8/19/25, identified agenda for May, June, and July included infection control updates, COVID-19 updates, current audits, accident/incident reports, pharmacist consultant reports, medication error, antibiotic stewardship, quality improvement projects, social service report, dietary report and environmental services. There was no documentation of any new concerns brought forth nor was there any indication that the committee reviewed or analysis the previously identified concerns. 4) QAPI meeting minutes from 12/16/25, identified agenda for December, included infection control updates, COVID-19 updates, current audits, accident/incident reports, pharmacist consultant report, medication errors, pressure ulcer, antibiotic stewardship, quality improvement projects, dietician report, and environmental services. There was no documentation of any new concerns brought forth nor was there any indication that the committee reviewed or analysis the previously identified concerns. Review of the quality improvement project for 2025 through 2026 identified: 1) The goal was to decrease the call light response times. Data would be collected from residents, the call light system and to identify any trends. 2) The goal was to decrease the number of skin concerns. The team will implement new wound strategies, educate staff on skin breakdown and prevention along with partnering with an outside wound care company. There was no measurable goal identified for either the call light times, or the skin issues identified. Interview on 1/29/26 at 4:00 p.m., with quality assurance director, regional administrator, and the administrator identified that concerns were brought forth to the QAPI committee via resident surveys, staff reports, grievances, and resident council. When concerns were identified the committee would come up with a plan to correct the concerns. The regional administrator confirmed that the facility had information related to concerns brought forth to the QAPI committee however, that information was not identified in the QAPI minutes. The facility was currently working on 2 areas, skin and call light times. She confirmed neither concern had a measurable goal identified however, the facility was working on reducing skin issues and long call light wait times in general. They reported the facility had interventions in place but did not do any documentation in the QAPI minutes or that the information had been reviewed by the committee. The quality assurance director identified that the facility had been through 5 nurse directors in the last year, there had been a turnover of management and that she was aware the QAPI committee was lacking documentation and structure. She had been trying to attend some of the QAPI meetings and planned to complete audits to give to the committee for some feedback. She also had reached out to the facilities consulting provider for some guidance on what needed to be documented in the QAPI meeting minutes. The quality assurance director, regional administrator and administrator agreed that the QAPI meeting minutes for improvement projects lacked documentation of an identified measurable goal, interventions, and analysis of any data brought forth. Review of the July 2025, Quality Assurance & Performance Improvement plan (QAPI) identified the facility would take a proactive approach to improve the way they cared for residents. The organization made decisions based on data from input from caregivers, residents, health practitioners, families and other stakeholders. Data may be gathered from a data collection system such as Trend Tracker, Matrix Care, and surveys. The facility would set goals and measure progress towards those goals. The administrator was responsible for overseeing the QAPI committee. The committee will decide on what data to monitor with priority given to QA committee project recommendations. The QAPI team will review information from sources to determine if gaps or patterns exist in the facility systems of care that could result in quality problems and if there were opportunities to make improvements. Once a concern or issue was identified the QAPI team would prioritize and determine which problem will become the focus for a performance improvement project (PIP). The facility will then outline who would be entrusted with a mission to investigate and produce plans for correction and/or improvement to be implemented. At a minimum PIP team members would be given resources and guidance on how to develop and process improvements. The improvement team will report monthly to the QA committee/QAPI committee via a report or in person if requested or additional information was needed. The facility would take a systematic approach to determine when an in-depth analysis was needed to understand the problem, its causes, and implications of a change. The facility was to comprehensively assess all involved systems to prevent future events and promote sustained improvements. Staff were encouraged to use root cause analysis to identify the core of the system breakdown. The facility would at a minimum report the progress on the established QAPI goals, PIP plans and current data trends to the leadership, staff, and resident and family council. The team would thoughtfully and thoroughly consider the progress made in the last year toward achieving the QAPI goals and status of sustaining the performance indicators.

The facility failed to submit accurate staffing information for payroll-based journal (PBJ) for 1 of 4 quarters (quarter 4) reviewed.Findings include: Review of 2025, quarter 4 PBJ staffing Data Report 1705D identified the facility failed to have licensed nursing coverage 24 hours a day. The report identified the following dates 7/4/25 Friday, 7/5/25 Saturday, 7/6/25 Sunday, 7/19/25 Saturday, 7/20/25 Sunday, 8/2/25 Saturday, 8/3/25 Sunday, 8/9/25 Saturday, 8/10/25 Sunday, 8/17/25 Sunday, 8/30/25 Saturday, 9/13/25 Saturday, and 9/27/25 Saturday. Review of the above dates and facility staff timecard punches for the dates identified, showed that the facility did have licensed staff on duty each shift on each day identified. Interview on 1/27/26 at 3:15 p.m., with the regional director of skill operations identified there had been PBJ issues at each of the facilities she consulted. She reported the facility had not been without 24 hours licensed nursing staff and she was unsure why that had triggered for the facility. The business office manager was responsible for submitting the PBJ data and she also completed audits on the data she submitted. Interview on 1/29/26 at 1:30 p.m., with business office manager confirmed she was responsible for submitting the facility PBJ data. She revealed she had not previously reviewed the 1702D report until it had been requested during this survey. She found with the review that one of the full time licensed practical nurses (LPN)-B was not pulling from their payroll system into the PBJ report. LPN-B worked most of the days in question. She was still investigating why the report had been triggered on the other days. She confirmed that there had been inaccurate PBJ reporting completed. Review of the undated, Payroll Based Journaling (PBJ) policy identified the facility would regularly compile and submit PBJ reports that provided data on staffing levels. The facility would use attendance software databased to assist with reporting. The facility would verify submission by checking the validation report once submitted. The facility could take steps to streamline workflow to help track staffing-related data. Use automated payroll processes, implement processes for staff to clock-in and clock-out for hourly tracking, adopt in-house systems that automatically generate reports, regularly audit PBJ files and data prior to submitting reports, and train and educate staff involved in PBJ data collection and submission.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen with appropriately clean food preparation equipment identified as a buildup of dust and grease on exhaust vents and food residue on food preparation equipment. This had the potential to affect all 26 residents who received food prepared in the facility kitchen.Findings include: Based on observation and interview on 1/27/26 at 9:30 a.m. with the dietary manager (DM) the following areas of concern were identified:1) 2 of 2 rectangular exhaust vents located above the doors on the dining room side of the kitchen were covered with a black, thick, furry appearing substance. The vents were pointed toward the stove and food preparation areas.2) Vents on the refrigerator and freezer on the dining room side of the kitchen, were covered with a thick layer of dust, and the dust was noted to be moved by the circulating air.3) A chest type (milk) cooler positioned between the refrigerator and freezer on the dining room side of the kitchen, had a red liquid dried on the inside seal, in addition to a buildup of dirt and food residue.4) Dried red liquid was noted on the floor, along the base of the refrigerator and splattered on the lower portion of refrigerator. The DM identified the dried liquid as juice that had spilled on 1/26/26 and not been cleaned up.5) A stand mixer on the counter had orange colored residue splattered on the frame and head of the mixer, which the DM identified as food residue. She was not able to identify the residue, and she stated she was not aware of when the mixer had last been used.6) A metal rack was positioned on the back side of the electric range and hood with a plexiglass barrier behind it which contained spatters of grease and dust from the range. The rack contained steam table pans, and cooking equipment. The DM identified the barrier had a buildup that should have been cleaned daily but had not been done.7) Exhaust vents facing the rack behand the range, and over the doors on the opposite end of the kitchen also had an accumulation of dust and grease that had the potential of blowing onto food being prepared.8) A table mounted can opener had black buildup surrounding the blade of the opener and would have come in contact with the inner surface of a can being opened. The DM identified the substance as food residue and reported she had not noticed this previously and reported it needed to be put in the dishwasher for cleaning. The DM reported she had begun preparing cleaning schedules, but she had not noticed the areas identified and confirmed they needed to be cleaned. She stated she was new to the position and was finding she needed to have cleaning schedules for daily, weekly, and monthly tasks to be completed because the cleaning was not being done. She identified she had not implemented her cleaning schedules as of the date of survey and would be contacting maintenance to clean the vents, and to put on a schedule for cleaning. Observation and interview on 1/27/26 at 11:15 a.m. with the administrator noted the areas of concern and confirmed the need for development of cleaning schedules and maintenance would be notified of the need to clean the vents in the kitchen on a regular basis. A policy was requested for cleaning of the kitchen and equipment but not provided by the end of the survey period.

Based on observation, interview and document review, the facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department in the absence of a full time dietitian. This had the potential to affect all 26 residents, visitors and staff who consumed food from the kitchen.Findings include: Interview on 1/27/26 at 9:30 a.m. with the dietary manager (DM), identified she was not yet certified and was waiting for direction as to what courses she needed to complete to obtain her certification. She reported she did have her SERV Safe certification and had previously worked as the main cook, prior to taking the position as DM. She reported the facility had a contracted registered dietitian that came to the facility once a week on Tuesdays and was available via phone or email between visits. She identified when the RD came to the facility, she completed the assessments, reviewed dietary items with her, and assigned leaning topics she was to complete online. She reported she had not had anyone work alongside her to provide training in her new role, but she was committed to taking the courses and obtaining her certification. Interview on 1/28/26 at 3:40 p.m. with the RD reported she came to the facility once a week, on Tuesdays to complete the Minimum Data Set (MDS) assessments, review menus, and assist the DM. She reported the DM completed the initial interview with residents to determine preferences, and general information that was documented in the record. Interview on 1/28/26 at 4:09 p.m. with the administrator and the regional director reported they were under the impression that the DM's years of experience met the requirement for the certified dietary manager position. They both confirmed the intent for the DM to complete the required certification coursework, but she had not started as of the date of survey. Following discussion and review of the regulation identified in the State Operation Manual (SOM) they voiced agreement that the facility was not currently in compliance with the regulation. A policy for management of the dietary department was requested but not provided by the end of the survey.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 3 of 3 residents (R3, R4, and R16). This deficient practice had the potential to affect all 26 residents who resided in the facility. Findings include: R4's 10/15/25, physician order identified the facility was to administer cefdinir 300 milligrams (MG) by mouth twice daily for 7 days for a diagnosis of a urinary tract infection (UTI). R4's October 2025, administration record identified he received cefdinir 300mg by mouth twice daily for 7 days starting on 10/15/25. R3's 10/29/25, physician order identified the facility was to administer Augmentin 875mg, twice daily for 7 days for a diagnosis of aspiration pneumonia. R3's October 2025, administration record identified he received Augmentin 875mg, twice daily for 14 days starting on 10/29/25. R16's 11/17/25, physician order identified the facility was to administer Keflex 500mg by mouth twice daily for 7 days for a diagnosis of UTI. R16's November 2025, administration record identified she was administered Keflex 500mg by mouth twice daily for 7 days starting on 11/18/25 Review of the October 2025, November 2025, infection control (IC) antibiotic stewardship log made no mention that an antibiotic time out had been completed for R4, R3, or R16. Interview on 1/28/26 at 8:24 a.m., with the infection preventionist identified they were not completing an antibiotic time out for residents who were prescribed antibiotics. Interview on 1/28/26 at 2:13 p.m., with the administrator and the [NAME] administrator identified they would have expected the infection preventionist to ensure the facility policy is followed and antibiotic time outs were completed. The facility provided Infection Control-Antibiotic Stewardship policy identified the facility may consider protocols to address improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and an antibiotic review process, also known as Antibiotic Time-Out for all antibiotics prescribed in the facility. Antibiotic Time Out's prompt clinicians to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available. An Antibiotic Time Out can be considered a stop order of an antibiotic when diagnostic test results or symptoms of the resident do not support the diagnosis of infection.

Based on interview and document review, the facility failed to ensure 2 of 5 sampled residents (R6, and R14) were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).Findings include: Review of the current Centers for Disease Control (CDC): Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV 21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV 21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV 21) at any age and a PPSV23 at or after the age of [AGE] years old. R6's 8/18/25 comprehensive Minimum Data Set (MDS) assessment identified he was [AGE] years old. He had diagnosis of renal failure, thyroid disorder, and dementia. Section O-Special Treatments and Programs identified R6's pneumococcal vaccinations were not up to date, and the facility did not offer him pneumococcal vaccinations while he was a resident at the facility. R6's current immunization report provided by the facility identified he received a pneumo-PPSV23 on 1/4/11 and a Pneumo-PCV13 on 3/19/15. R6's medical record had no indication that the facility had offered to administer a PCV20 or PCV21 upon admission or during his stay. R14's 12/16/25, quarterly Minimum Data Set (MDS) assessment identified she was [AGE] years old. She has a diagnosis of anemia, renal failure, and diabetes mellitus. Section O-Special Treatments and Programs identified R14's pneumococcal vaccinations were up to date. R14's current immunization report provided by the facility identified she received a pneumo-PPSV23 on 7/8/11, and a Pneumo-PCV13 on 1/20/16. R14's medical record had no indication that the facility had offered to administer a PCV20 or PCV21 upon admission or during her stay. Interview on 1/2/26 at 8:24 a.m., with the designated infection preventionist identified she was not aware that the residents mentioned above were eligible to receive additional vaccinations per the CDC guidance. Review of the facility provided Vaccination Policy identified the facility would offer all residents vaccinations per the Centers for Disease Control (CDC) recommendations. The RN Case Manager and Infection control Coordinator would be responsible for researching resident medical records and history to determine if the vaccinations have been given.

Based on observation, interview and document review the facility failed to include the facility census in their daily posting of nursing staff for 29 of 29 days reviewed.Findings include: Observation on 1/27/26 at 6:52 a.m., in the front entry of the building prior to entering the main door of the facility was a daily staff posting hanging up on the bulletin board titled Colonial Manor Nursing Home. The form included the facility name, a place to document the date, the census, and a list of positions for each shift. The form was dated 1/27/26 and the positions for each shift were circled with a total number of hours for that position for that shift. The census section of the form was blank. Interview on 1/27/26 at 6:55 a.m., with registered nurse (RN)-A who was working as the charge nurse upon entry to the facility was unaware of the current facility census and she asked the trained medication aid (TMA)-A working on the medication cart if she knew the census. The TMA-A reported she was not sure and then proceeded to look up in the facility electronic record and reported that the facility census was currently 26. Observation on 1/28/26 at 2:53 p.m., of the Colonial Manor Nursing Home daily staffing posting identified there was no facility census documented on the form. Observation on 1/29/26 at 12:24 p.m., of the Colonial Manor Nursing Home daily staffing posting identified there was no facility census documented on the form. Interview on 1/29/26 at 3:00 p.m., with the business office manager identified that the night nurse filled out the daily staffing posting form. The form was to include the facility current census. Review of the daily staff postings from 1/1/26 through 1/29/26 revealed that the census section had been left blank on each day. Review of the undated Nurse Staffing Information and Daily Census policy identified that the facility must post daily the following information: the facility name, current date, total number and actual hours worked by title and license, and the resident census. The posting must be placed in a prominent place and be easy to read.

Based on observation, interview and document review the facility failed to prevent potential accident hazards for 1 of 1 resident (R5) due to wandering behaviors into an unsecured area with steep cement stairs down to a cement floor.Findings include: R5's accepted 1/2/26, Significant change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and wandered throughout the facility including into other resident spaces. R5 had diagnoses which included: Alzheimer's disease, dementia with agitation, history of falls, and anxiety. Observation on 1/27/26 at 3:16 p.m. noted R5 wandering in her wheelchair as she went up and down each of the halls and attempted to open closed doors in the short hall across from the director of nursing (DON) office. She then turned to the right and went down the hall toward the main door and dining room area,. An unknown staff member intercepted R5 and took her to an activity that was in progress. Observation on 1/27/26 at 6:30 p.m. noted R5 transporting herself in her wheelchair down the [NAME] Hall where she attempted to enter a resident room and was redirected by staff back to the area in front of the nursing station. Observation on 1/28/26 at 10:30 a.m. noted R5 again going down the hall toward the exit door at the end of the hall, and toward the door that led to the therapy room. She was observed attempting to open doors as she proceeded down the hall.Observation on 1/28/26 at 4:30 p.m. R5 was at the end of the NW wing where she opened the door to the conference room and was attempting to enter when an unknown nursing assistant (NA) redirected her back toward the nursing station. Observation on 1/29/26 at 10:30 a.m. identified R5 pulling herself down the hall toward the hall past the DON office attempting to open doors as she proceeded. Observation on 1/29/26 at 1:45 p.m. R5 wandered down the NW hall and opened the door to the conference room, when staff redirected her back down the hall toward the nursing station. R5 had a wander guard device on her wheelchair that alarmed when she traveled close to an alarmed area. The area which extended to the right when going past the DON office had an exit door with a mural of a bookcase on the door. To the right of this door was an unsecured door that accessed the entry area for therapy. Straight ahead and to the right, was an unsecured door that allowed access to the back of the kitchen, to the left the hall went to the assisted living and to the right was a wire mesh gate, with a hook and eye closure which accessed 15 steps going to the basement. The hook and eye closure was mounted on the inside of the gate but was within reach of a person in a wheelchair and there was no resistance when the hook was lifted. The wander guard system activated when a resident got close, and sounded an alarm, but did not secure the doors. The long hall with the main entrance door on one end and the exit door with the mural at the other end, in addition to the access to the therapy were not within the line of sight of the nursing station. It was also noted if after regular business hours for therapy, management and dining, no staff would likely be in that area. There was no camera or form of monitoring identified these areas during the off hours' time periods. Interview on 1/27/26 at 10:19 a.m. with registered nurse (RN)-A identified R5 had end stage dementia, used a wheelchair for mobility, and was very active. She reported she wandered through out the facility, repeatedly going to exit doors and attempting to enter other resident spaces. RN-A identified R5 was discovered between the unsecured door that led to therapy and beside the unsecured door that allowed access to the stairway leading to the basement at least weekly. She identified R5 could open doors and did not believe the hook and eye closure on the gate at the top of the stairs would prevent her from accessing the area. Interview on 1/27/26 at 1:35 p.m. with nursing assistant (NA)- B reported R5 wandered throughout the facility and did go to exit doors and attempted to enter other resident spaces. NA-B identified R5 had a Wander Guard device and staff responded quickly when it sounded as it was frequently R5 setting off the alarm. She also reported R5 had been found in the area between the unsecured door and the therapy door, but she was not certain how often it occurred, but reported it was at least weekly. Observation and interview on 1/28/26 at 1:45 p.m. with the maintenance supervisor, administrator, and regional director of skilled operations of the area near the exit door, unsecured door entering the hall leading to the therapy room and the unsecured door to the hall accessing kitchen, basement stairs, and the assisted living area. They confirmed there was no locking or security measure in place for the identified areas. They confirmed when the renovation was recently completed the potential for access by unauthorized persons had not been identified and presented a potential hazard if a wandering resident were to access the area before staff were able to respond to the sounding alarm. Review of the February 2017 policy Elopement identified it was the responsibility of all staff to assist in investigation of a reported missing resident,. The policy failed to include any reference to monitoring a resident who attempted to access unauthorized areas, or response to residents utilizing a wander guard device and attempting to access alarmed exits or restricted areas. No additional policies or procedures were provided during the survey period.

Based on interview and document review the facility failed to have a discharge summary for 1 of 1 (R31) sampled residents. Findings include: R31's 12/12/25, accepted discharge Minimum Data Set (MDS) assessment identified R31's cognition was moderately impaired. R31 was independent with care, and participated in speech, occupational and physical therapy. R31 had been discharged to home/community. R31's 11/20/25, progress notes identified that R31 was excited to return to the assisted living facility. Staff reviewed the discharge summary with R31 and faxed R31's discharge orders to the pharmacy. R31's 11/21/25, progress note identified R31 discharged via private vehicle accompanied by caregiver. There was no recapitulation of R31's stay documented in the progress notes. R31's 11/21/25, Transition of Care/Discharge Summary form identified a section on the form to document a recapitulation of R31's stay which was left blank. Interview on 1/29/26 at 1:08 p.m., with director of nursing (DON) identified there was a place on the facilities Transition of Care/Discharge Summary form to document the resident's recapitulation of stay. She confirmed that the section on R31's discharge form titled recapitulation of stay had not been completed. She further revealed that there had not been a discharge summary documented for R31's stay while at the nursing home on the discharge form or in the progress notes. She was unaware that the facility needed to complete a summary of the resident's stay in addition to the discharge information provided to the accepting facility on the discharge form.A policy was requested but not provided by end of survey.

Based on interview and document review the facility failed to provide timely beneficiary notice to 1 of 3 (R31) sampled residents.Findings include: R31's last day of Medicare part A skilled services ended on 11/18/25. R31 was provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) on 11/18/25 at which time R31 had signed the notice. R31 was provided with the CMS-10123 Notice of Medicare Non-Coverage on 11/18/25 at which time R31 had signed the notice. R31 was not provided with adequate time to appeal the decision and make a request for an independent reviewer authorized by Medicare to review the decision to end the services if R31 had wanted to. Interview on 1/28/26 at 3:13 p.m., with the regional administrator identified that residents were to be given 2-day notice before Medicare part A skilled services were to end. Her expectation was that the facility would provide timely notices to residents who were ending Medicare part A skilled services to ensure the resident had time to appeal the decision if they wanted to. A policy was requested but not received.

Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 25 residents who resided in the facility. Findings include: During an interview on 11/18/24 at 12:25 p.m., dietary manager (DM)-J stated she had been employed at the facility since 12/18/23 and was not a certified dietary manager nor had she started any classes. DM-J stated she was notified today the administrator was going to get her signed up for the certification class. DM-J stated she does have a Food Safety Certificate, which she completed in 2019. During an interview on 11/20/24 at 10:45 a.m., the administrator was aware DM-D was not certified as a dietary manager. The administrator stated she understood the registered dietician coming once a week would be adequate until DM-J got her certification. The administrator stated, DM-J has not been signed up for her dietary certification classes. Dietary manager job description undated, skills/qualifications included, knowledge of state and federal food regulations, Serv-Safe Certified, current certification as a Certified Dietary Manager (CDM) or dietician preferred or willing. If not licensed as CDM will encourage the candidate to get obtain their CDM certificate.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report for quarter 3 of 2024, which included dates from 4/1/24, to 6/30/24, triggered for: Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage. The following infraction dates were identified: 5/25/24, 6/8/24, 6/9/24, 6/16/24, 6/1/24, 6/22/24, 6/23/24, 6/24/24, 6/29/24, and 6/30/24. Review of nursing staff schedules for each infraction date indicated a licensed nurse had been scheduled each of the three shifts (days, evenings, and nights). The daily staffing postings for each infraction date indicated a licensed nurse was scheduled on each shift. During an interview on 11/20/24 at 11:10 a.m., nursing department coordinator (NDC)-A who was responsible for scheduling nursing staff, stated there was always a licensed nurse working every day, on each shift - days, evenings, and nights. Together with business office manager (BOM)-G, timecards were reviewed for each infraction date. All shifts were identified as having been worked by a licensed nurse, either an employed nurse or an agency nurse. During an interview on 11/20/24 at 3:15 p.m., BOM-G stated she was responsible for entering data for the PBJ report and was not able to identify why the report triggered for four or more days within the quarter with <24 hours/day licensed nursing coverage. All nursing staff, including management and/or agency were entered into the report. During an interview on 10/20/24 at 4:00 p.m., the administer could not determine the reason the PBJ report triggered for four or more days within the quarter with <24 hours/day licensed nursing coverage. Facility PBJ policy was requested, and the administrator stated the facility followed the CMS PBJ - LTC (long term care) policy manual.

Based on interview and document review the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 25 residents residing in the facility. Findings include: On interview on 11/19/24 at 10:29 a.m., the director of nursing (DON), indicated she started her employment at the facility in July 2024 and started doing the infection control role in October. The DON indicated she is enrolled in the Centers for Disease Control (CDC) infection preventionist course but has only completed one module so far and isn't very far into the training course. The DON added the role was going to be split between her and RN-A, also identified as Minimum Data Set (MDS) coordinator. On interview 11/19/24 at 10:23 a.m., RN-A indicated she is new to the infection preventionist role and has had no training at this time. RN-A stated she started at the facility at the end of June 2024 and was told to focus on MDS training first. RN-A indicated she is enrolled in a Boot Camp for Infection Control class the first week in December and is enrolled in the CDC infection preventionist course, but hasn't started it yet. On interview 11/19/24 at 10:59 a.m., the administrator stated she is aware the facility currently has no trained infection preventionist, but both the DON and the MDS coordinator are enrolled in the CDC course. Facility Infection Prevention and Control Program, dated 12/2022, included the early detection, prevention and management of infections are accomplished through effective oversight of the Infection Prevention and Control program that must include at a minimum, the following elements: To recognize and manage infections at the time of the resident's admission to the facility and throughout the stay; to follow recognized infection prevention and control practice while providing care that includes transmission based precautions and isolation; to provide program oversight including planning, organizing, implementing, operating, and monitoring; to maintain all of the elements of the program and ensuring the facility's interdisciplinary teams is involved in infection prevention and control practices; to develop and revise policies, procedures, and practices that promote consistent adherence to evidence-based infection control practices; to plan organize, implement, operate and maintain all the program elements; to define roles and responsibilities during routine implementation of practice and during unusual occurrences or times of potential risk of spread of infection or outbreak; to define and manage resident and employee health initiatives. The infection Prevention and Control Program components include the establishment of surveillance standards and frequency .; the development of the education component including the training in infection prevention and control practices that ensures compliance with facility requirements as well as State and Federal regulations.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance for 4 of 5 residents (R9, R19, R20, R25) reviewed for antibiotics. This had the potential to affect any of the 25 residents who resided in the facility who might use antibiotics. Findings include: Review of the monthly infection control log dated 7/2024, 8/2024, 9/2024, 10/2024 and 11/2024, identified residents who had been identified as having an infection and had been administered an antibiotic and had included the floor plan of the facility. Review of 7/2024, surveillance log identified R20 had a urinary tract infection (UTI). R20 was admitted [DATE]. R20's face sheet had diagnoses of dementia with anxiety and traumatic brain injury. She was prescribed an antibiotic Macrobid that was started on 7/28/24. The surveillance log lacked indication of the antibiotic dosages and when or if the infection had resolved. Review of 9/2024, surveillance log identified R19 had a UTI infection. R19 was admitted [DATE]. R19's face sheet had diagnoses of dementia, UTI, obstructive reflux uropathy and benign prostatic hyperplasia (enlargement) with lower urinary tract symptoms. R19's 10/02/24, significant change Minimum Data Set (MDS) identified he had an indwelling catheter. R19 was prescribed an antibiotic ampicillin 500 milligrams (mg) on 9/16/24. The surveillance log lacked indication when or if the infection had resolved. Review of 9/2024, surveillance log identified R9 had a UTI infection. R9 was admitted [DATE]. R9's face sheet had diagnoses of functional urinary incontinence, retention of urine and chronic kidney disease. R9's 11/01/24, significant (MDS) identified he had an indwelling catheter. R9 was prescribed an antibiotic cefdinir 300mg on 9/24/24. The surveillance log lacked indication when or if the infection had resolved. Review of 10/2024, surveillance log :identified R25 had a UTI infection. R25 was admitted [DATE]. R25's face sheet had a diagnosis of joint replacement surgery, right artificial knee joint, and pruritis. R25 was prescribed an antibiotic macrobid on 10/28/24. The surveillance log lacked indication of the antibiotic dosages, as well as, when or if the infection had resolved. Review of 11/2024, surveillance log identified use of antibiotics for residents who had a UTI, however, the surveillance log lacked indication of what the infection were, did not identify if a time out had been completed, and did not indicate when or if the infection had resolved. During interview on 11/20/24 at 2:19 p.m., with registered nurse (RN)-A hired June 2024, and had not started her Infection preventionist (IP) training and was recently assigned to the duty as the facility's IP in September. RN-A stated the director of nursing (DON), who no longer worked at the facility, had a process in place for identifying antibiotic use for residents and would need to collaborate with the current facility administration to enforce consistency with the antibiotic stewardship program of tracking and logging all antibiotics. During interview on 11/20/24 at 3:27 p.m., with administrator would expect the nursing team to identify, track and maintain monthly log updates of all residents who had received antibiotics. Review of April 2023, Antibiotic Stewardship Policy identified the facility licensed nurses would follow up on pending cultures within 48 hours and would contact lab services at 72 hours to verify culture results, as well as antibiotics used to treat infections or to prevent unnecessary antibiotic use. Review of April 2023, Infection Control-Antibiotic Stewardship Program policy identified the facility would promote appropriate use of antibiotics to treat infections and reduce adverse effects related to antibiotic use under evidence based practice guidelines aligned with Centers for Disease Control and Prevention (CDC).Secondly, the facility would monitor antibiotic usage patterns on a regular basis, review the antibiotic stewardship policy annually, would evaluate clinical signs and symptoms of residents who was suspected of having an infection and would use antibiotic time out forms to assess the ongoing need for antibiotics. Lastly, the IP would oversee the infection surveillance and would provide monthly reports, as indicated.

Based on interview and document review, the facility failed to ensure a fall risk intervention was implemented in order to minimize the risk for falls and injury for 1 of 3 (R1) residents identified at risk for falls. This deficient practice caused actual harm to R1 when resident was not provided access to call-light, self-transferred, and sustained a fracture resulting from a fall. The facility had implemented corrective action on 6/9/20 and the deficient practice is being issued at harm level, past non-compliance. Findings include: R1's current diagnoses according to the facesheet printed 6/15/20, included fracture to left lower leg, obesity, muscle weakness and difficulty walking. A fall risk analysis dated 3/30/20, indicated R1 had a past history of falls, medical conditions, symptoms and medications which may attribute to falling, as well as R1's physical impairments such as problem with balance, lower extremity weakness and needing toileting assistance. R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified R1 was cognitively intact, with clear speech, able to make herself understood and was able to understand others. In addition, the MDS indicated R1's hearing was adequate and her vision was adequate with eye glasses. R1 required extensive assistance of two staff for bed mobility, transfers, and toileting. R1's care plan revised on 5/27/20, indicated R1 required assistance with activities of daily living related to impaired mobility due to left ankle fracture, and her call light was to be kept within reach when in her room unattended. Further, the care plan indicated R1 required extensive assistance of staff for transferring and was to be reminded not to transfer without assistance. A progress note by registered nurse (RN)-B on 6/9/20, at 4:13 p.m. indicated at 7:20 a.m., R1 yelled out and upon entering her room, was found on the floor. R1 stated to staff she was going to the bathroom. Staff noticed R1's call light was not within her reach at the time of the fall. R1 was lifted back into bed and staff noted her right ankle was turned outward. R1 was transferred to a local hospital by ambulance. According to a progress note by RN-B on 6/9/20, at 2:42 p.m., the facility received a call from the local hospital stating R1 sustained several fractures to right ankle and leg, including medial malleolus (prominence on the inner side of the ankle) fracture and a fibular (calf bone) fracture. R1 was then transferred to a tertiary care center (large hospital with specialists) for further evaluation and treatment. A progress note dated 6/10/20, at 1:39 a.m. indicated the facility received a call from the tertiary care center to report R1 passed away. During an interview on 6/15/20, at 4:10 p.m., director of nursing (DON) stated R1 ultimately passed away from acute [CONDITION(S)]. During an interview on 6/15/20, at 12:20 p.m. (NA)-A stated nursing assistants did not utilize resident care worksheets; that everything a nursing assistant needed to know about the care of a resident was on the paper care plan, located in a residents chart at the nurses desk. R1's care plan, last reviewed on 6/9/20, indicated as of 4/17/20, to keep call light within reach when in room unattended. This affected all disciplines, including nursing assistants. During an interview on 6/15/20, at 2:00 p.m. nursing assistant (NA)-B stated before he put R1 to bed on 6/8/20; he did her evening cares and gave R1 her call light. NA-B stated he had training on call lights and stated that is the last thing you do when you leave the room. During an interview on 6/15/20, at 2:05 p.m. the DON stated she was on her way to the facility when she received the call about R1's fall. When she arrived and went into R1's room, she noted two call lights. The DON stated this was the staffs initial intervention; to put an additional call light in R1's room. The DON stated she then implemented an audit to verify location of each resident call light, each shift. The DON further indicated the call light auditing had continued. Viewed call light audits from 6/9/20 to 6/15/20. On the first day of audit on 6/9/20, for the 10 p.m. to 6 a.m. shift, call light for resident in room NW8 was noted to be attached to a stationary chair while the resident was in the recliner. Staff from that shift were telephoned and reeducated to ensure location of call light prior to exiting a residents room. The remainder of the audit indicated proper placement of call lights for all residents each day; all three shifts. According to the DON, the facility investigation and staff interviews following R1's fall concluded that NA-B failed to leave R1's call light within reach when he left her room after doing evening cares. NA-B was counseled and corrective action taken. During a telephone interview on 6/15/20, at 2:28 p.m. NA-C stated she found R1 on the floor on 6/9/20, at 7:20 a.m. and noted R1's call light was across the room on the recliner. NA-C stated R1 had been in bed and got up because she had to use the bathroom. During an interview on 6/15/20, at 2:30 p.m. with RN-A who worked the night on the date of R1's fall, stated he did not go into R1's room during the night because her door was closed and she did not put her call light on. During an interview on 6/15/20, at 3:15 p.m. DON stated that following this incident, she spoke to staff who worked during the night preceding R1's fall and informed them they needed to go into each resident room during the night to check on them; even when they don't put their call light on. DON stated these conversations where not documented. The nurse's aide orientation checklists were reviewed, and during an interview on 6/15/20, at 3:55 p.m. the DON verified there was nothing about resident call lights on the checklists. The facility policy titled Abuse Prevention Plan, dated 3/25/19 indicated: 1. Centers for Medicare and Medicaid Services (CMS) definition: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 2. Minnesota Department of Health (MDH) definition: The failure or omission by a caregiver to supply a resident with the care or services, including but not limited to food, clothing, shelter, health care or supervision which is reasonable and necessary to obtain or maintain the residents physical and mental health or safety; considering the physical or mental capacity or dysfunction of the resident which is not the result of an accident or therapeutic conduct. 3. The absence or likelihood of absence of care or services, or supervision necessary to maintain the physical and mental health of the resident and which a reasonable person would deem essential to obtain or maintain the resident's health, safety, or comfort, considering the physical and mental capacity or dysfunction of the resident.

Based on observation, interview and document review, the facility failed to ensure the safety of 1 of 1 resident (R8) who smoked unsupervised while inhaling oxygen supplied from a compressed oxygen (O2) canister attached to his wheelchair, resulting in an immediate risk of serious harm, injury or death from [MEDICAL CONDITION] R8. The IJ began on 5/29/18 at 4:45 p.m., when R8 was observed to be smoking a cigarette unsupervised, while receiving oxygen from a small oxygen tank and it was determined the facility failed to ensure the safety R8 from this highly flammable situation. The Administrator (A) and Director of Nursing (DON) were informed of the IJ on 5/29/18 at 6:18 p.m The IJ was removed on 5/30/18 at 5:00 p.m., when the facility took steps to remove the immediate situation, however non-compliance remained at the lower scope and severity level of a D, which indicated no actual harm with potential for serious harm, injury or death. Findings include: During observation on 5/29/18, at 4:45 p.m. R8 was observed to be smoking in the parking lot of the facility's east entrance. The resident was observed to be smoking while wearing an oxygen nasal cannula and tubing that was connected to a 36 inch E-style oxygen compressed air tank, affixed to a holder on his wheelchair. During interview at 5/29/18, at 4:50 p.m. nursing assistant (NA)-A confirmed the observation of R8 smoking. She she stated he was known to smoke while wearing oxygen and while he was near the O2 tank. NA-A stated, He signed a form stating it was o.k. to smoke with O2 (oxygen). During interview on 5/29/18, at 4:55 p.m. A and the DON stated R8 was smoking in the parking lot and stated they were both aware he smoked while wearing his nasal cannula and tubing in the presence of his O2 tank. The administrator remarked, Well is it even on? The DON proceeded to go outside and check R8. During observation and interview on 5/29/18, at 4:57 p.m. R8 was still in the parking lot smoking. R8 stated he was just beginning to put out his cigarette on the ground when the DON and surveyor arrived. A loud hissing could immediately be heard coming from the proximity of the tank on the back of R8's wheelchair. The DON immediately turned the handle of the regulator switch on top of the canister and stated, There, it's off now. The DON confirmed the oxygen tank had been running, and loudly hissing (indicating release of oxygen from the canister) upon arrival. The DON asked R8 why he didn't shut off his oxygen. R8 reported he thought he had, but commented he had problems getting it to completely shut off. R8's admission record indicated he'd been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of R8's medical record indicated a current Brief Interview for Mental Status (BIMS) dated 3/30/18, indicated a score of 9, indicating moderate cognitive impairment. Previous BIMS scores were 8 on 12/29/17, and 7 on 9/29/17, indicating coginitive fluctuations between severe and moderate cognitive impairment. The record also included a signed attestation statement from R8 dated 10/24/16, which included: (1) Colonial Manor is a tobacco free campus as of (MONTH) 1, (YEAR). (2) I agree to not have cigarettes, lighters, matches, or any form of tobacco in my possession. (3) I agree not to use tobacco products on or off the facility grounds, including inside the facility. (4) As discussed at admission, due to my medical condition and medications, I agree to refrain from smoking at all times. Review of R8's current care plan included a note dated 6/22/17, indicating R8 had a history of [REDACTED]. Found to be placing cigarette butts under his w/c (wheelchair) cushion because he was told not to throw them out on peoples property in the community. A smokeless butt ashtray was to be given to R8 independently when he leaves the facility grounds and brought back when he's finished. Resident aware that he needs to give ashtray to nurse when he returns and is not taken to room. Another note on the care plan dated 10/6/16, included: The resident smokes daily. States he shuts off his oxygen when he smokes. Aware of the risk factors. Resident is independent with setting O2 liters (L) on his portable O2 tank. Puts liters (2-4 L) at whatever he feels he needs at the time. Review of a faxed physician (pulmonologist) response on 10/23/17, indicated R8's [MEDICAL CONDITION] stable on current program. recommend smoking cessation. F/U (follow up) only as needed. Review of R8's 9/29/17, Assessment for Self Administration of Smoking indicated the criteria for smoking were: (1) (R8) has no cognitive impairment: No. See BIMS. Resident alert. Signs self out of facility when he smokes. (2) (R8) does not use oxygen. Residents are never allowed to smoke with oxygen on: Yes. resident reports visually noted to shut off O2 when he smokes. (3) (R8) can identify appropriate areas to smoke- off property: Yes. (4) (R8) can effectively demonstrate safe smoking habits including safe and proper disposal of ashes and cigarettes: Yes. Needs to take smokeless ashtray with him when he smokes. (5) Resident has no history of unsafe smoking practices (No evidence of burn holes in clothing, finger burns, etc.): No. H/O (history of) placing cigarette butts under w/c cushion. Safety discussed with resident. A note in the middle of the form indicated, Any area marked NO may disqualify the resident from independently smoking. On the back of the form, comments were added for the next two quarterly assessment dates as follows: (1) On 12/28/17: No changes with plan of care (P[NAME]). (2) On 3/30/18: Staff have discussed with resident tobacco free campus policy. resident verbalized understanding. Continue with P[NAME]. During interview on 5/29/18, at 5:25 p.m. the DON was asked how staff verify safety of R8 while smoking in the presence of O2. The DON stated R8 did not smoke on the property. He goes uptown. (The social worker) (SW) does spot checks on him to verify he has his O2 shut off. She does it on an annual basis. The DON clarified R8 was known to smoke on or near the property. When asked if the SW followed R8 uptown to do smoking assessments, the DON stated the SW performed the assessments out front on the street. The DON was unsure how the resident had been determined to be safe while he smoked in the presence of O2, and an O2 tank, with a history of unsafe smoking, and cognitive impairment. Review of R8's 4/5/18 Care Conference Summary, indicated R8 had a BIMS of 9 indicating moderate cognitive impairment. Safety measures were identified as: Making sure O2 is shut off with smoking. R8 was noted to be on continuous O2, and was Reminded about smoking safety. During interview with R8 at the time of the observation on 5/29/18 at 5:45 p.m., R8 stated he was aware he had an O2 canister on the back of his w/c. R8 stated he normally went across the street off the property to smoke, but stated, today it was so hot I wanted to sit under the tree. If I get close to the corner, the cars will take me out. He recalled facility staff discussing risks of smoking in the presence of O2 with him and stated, I usually shut it off but I've had some trouble with this new tank regulator. R8 also stated the tanks run empty a couple times per day but said he has no set times of day when he is allowed out to smoke. R8 stated he sometimes went uptown, and if the weather was bad he just didn't go out. R8 also stated the nursing staff keep his cigarettes and stated he field stripped his cigarettes when smoking, meaning he smoked them all the way down to the filter. R8 stated he was not the only resident who smoked but stated he wasn't going to tell. He again stated, There is something wrong with the regulator (on the O2 tank). I've been after them for a month (to fix it). During interview on 5/29/18, at 6:00 p.m. registered nurse (RN)-A verified R8's O2 regulator needed to be changed as she thought it was leaking. Review of R8's 2/6/18, therapy progress note indicated nursing staff reported R8 was caught over the weekend smoking inside the facility in the therapy entrance. R8 opened the door and was blowing smoke outside. A progress note from 5/5/18 indicated R8 had returned from the store with a yellow plastic bag. The note indicated the contents were not checked by licensed practical nurse (LPN)-A . R8 handed his lighter, ashtray and an empty pack of cigarettes to LPN-[NAME] LPN-A asked R8 if he was aware there were no cigarettes left in the box. R8 agreed. After supper, R8 requested his cigarettes from LPN-A and became angry that she had no cigarettes. LPN-A asked R8 if he checked the yellow bag. R8 returned to his room. Upon returning to the nurses' station, R8 denied having found his cigarettes, but LPN-A observed R8 smoking outside the window. A social worker (SW) note documented 5/16/18, indicated it had been reported to her R8 was smoking on the sidewalk outside her office. The SW had documented she'd told R8 he had to leave the property to smoke. (R8) believed he was off property since he was on the edge of the sidewalk. (R8) went to the edge of the property to finish his cigarette. During interview on 5/30/18, at 4:30 p.m. dietary aide (DA)-C stated she had seen R8 downtown smoking with his O2 on before and had reported it to the nursing staff. During interview with physical therapist (PT)-F on 5/30/18, PT-F stated she was aware R8 had a history of [REDACTED]. During interview on 5/31/18, R8's medical director (MD)-A stated he was not aware R8 had been smoking while using O2, near his O2 canister, or that R8 had a history of [REDACTED]. smoking or he shouldn't be on oxygen. Review of the facility's 1/1/15 Tobacco Free Campus policy, indicated the facility was tobacco free and residents were to be notified upon admission. There was no mention how residents were going to be assessed for safety, or if the facility would allow residents who smoked prior to admission to continue to smoke off the property. <BR/[NAME]R. Hall, Jr., The Smoking Material Fire Problem, NFPA (National Fire Protection Association) Fire Analysis and Research Division, (MONTH) 2013 indicates: 7% of fatal victims of smoking-material fires who were themselves the smokers whose smoking materials started the fires were under treatment with medical oxygen. The combination of smoking and use of medical oxygen is so dangerous that it became the subject of one of the seven recommnded educational messages from the project: Smoking should not be allowed in a home where medical oxygen is used. Additionally, the article states In an NFPA analysis of fires [MEDICAL CONDITION] home medical oxygen, smoking materials were inivolved in 73% of 2003-2006 [MEDICAL CONDITION] to hospital emergency room s and involving home medical oxygen. The immediate jeopardy that began on 5/29/18 was removed on 5/30/18, at 5:00 p.m., when the facility took action to ensure R8's safety with smoking including requiring R8 to remove the oxygen tank prior to him leaving the campus, educating R8 and staff related to safe smoking practices, requring nursing to monitor and document R8's compliance with removing his oxygen prior to smoking, as well as assessing other residents who may smoke to ensure safe smoking practices. Noncompliance remained, however, at the lower scope and severity level of a D, which indicated no actual harm with potential for serious harm, injury or death.

Based on observation, interview and document review, the facility failed to ensure the safety of 1 of 1 resident (R8) who smoked unsupervised while inhaling oxygen supplied from a compressed oxygen (O2) canister attached to his wheelchair, resulting in an immediate risk of serious harm, injury or death from [MEDICAL CONDITION] R8. The IJ began on 5/29/18 at 4:45 p.m., when R8 was observed to be smoking a cigarette unsupervised, while receiving oxygen from a small oxygen tank and it was determined the facility failed to ensure the safety R8 from this highly flammable situation. The Administrator (A) and Director of Nursing (DON) were informed of the IJ on 5/29/18 at 6:18 p.m The IJ was removed on 5/30/18 at 5:00 p.m., when the facility took steps to remove the immediate situation, however non-compliance remained at the lower scope and severity level of a D, which indicated no actual harm with potential for serious harm, injury or death. Findings include: During observation on 5/29/18, at 4:45 p.m. R8 was observed to be smoking in the parking lot of the facility's east entrance. The resident was observed to be smoking while wearing an oxygen nasal cannula and tubing that was connected to a 36 inch E-style oxygen compressed air tank, affixed to a holder on his wheelchair. During interview at 5/29/18, at 4:50 p.m. nursing assistant (NA)-A confirmed the observation of R8 smoking. She she stated he was known to smoke while wearing oxygen and while he was near the O2 tank. NA-A stated, He signed a form stating it was o.k. to smoke with O2 (oxygen). During interview on 5/29/18, at 4:55 p.m. A and the DON stated R8 was smoking in the parking lot and stated they were both aware he smoked while wearing his nasal cannula and tubing in the presence of his O2 tank. The administrator remarked, Well is it even on? The DON proceeded to go outside and check R8. During observation and interview on 5/29/18, at 4:57 p.m. R8 was still in the parking lot smoking. R8 stated he was just beginning to put out his cigarette on the ground when the DON and surveyor arrived. A loud hissing could immediately be heard coming from the proximity of the tank on the back of R8's wheelchair. The DON immediately turned the handle of the regulator switch on top of the canister and stated, There, it's off now. The DON confirmed the oxygen tank had been running, and loudly hissing (indicating release of oxygen from the canister) upon arrival. The DON asked R8 why he didn't shut off his oxygen. R8 reported he thought he had, but commented he had problems getting it to completely shut off. R8's admission record indicated he'd been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of R8's medical record indicated a current Brief Interview for Mental Status (BIMS) dated 3/30/18, indicated a score of 9, indicating moderate cognitive impairment. Previous BIMS scores were 8 on 12/29/17, and 7 on 9/29/17, indicating coginitive fluctuations between severe and moderate cognitive impairment. The record also included a signed attestation statement from R8 dated 10/24/16, which included: (1) Colonial Manor is a tobacco free campus as of (MONTH) 1, (YEAR). (2) I agree to not have cigarettes, lighters, matches, or any form of tobacco in my possession. (3) I agree not to use tobacco products on or off the facility grounds, including inside the facility. (4) As discussed at admission, due to my medical condition and medications, I agree to refrain from smoking at all times. Review of R8's current care plan included a note dated 6/22/17, indicating R8 had a history of [REDACTED]. Found to be placing cigarette butts under his w/c (wheelchair) cushion because he was told not to throw them out on peoples property in the community. A smokeless butt ashtray was to be given to R8 independently when he leaves the facility grounds and brought back when he's finished. Resident aware that he needs to give ashtray to nurse when he returns and is not taken to room. Another note on the care plan dated 10/6/16, included: The resident smokes daily. States he shuts off his oxygen when he smokes. Aware of the risk factors. Resident is independent with setting O2 liters (L) on his portable O2 tank. Puts liters (2-4 L) at whatever he feels he needs at the time. Review of a faxed physician (pulmonologist) response on 10/23/17, indicated R8's [MEDICAL CONDITION] stable on current program. recommend smoking cessation. F/U (follow up) only as needed. Review of R8's 9/29/17, Assessment for Self Administration of Smoking indicated the criteria for smoking were: (1) (R8) has no cognitive impairment: No. See BIMS. Resident alert. Signs self out of facility when he smokes. (2) (R8) does not use oxygen. Residents are never allowed to smoke with oxygen on: Yes. resident reports visually noted to shut off O2 when he smokes. (3) (R8) can identify appropriate areas to smoke- off property: Yes. (4) (R8) can effectively demonstrate safe smoking habits including safe and proper disposal of ashes and cigarettes: Yes. Needs to take smokeless ashtray with him when he smokes. (5) Resident has no history of unsafe smoking practices (No evidence of burn holes in clothing, finger burns, etc.): No. H/O (history of) placing cigarette butts under w/c cushion. Safety discussed with resident. A note in the middle of the form indicated, Any area marked NO may disqualify the resident from independently smoking. On the back of the form, comments were added for the next two quarterly assessment dates as follows: (1) On 12/28/17: No changes with plan of care (P[NAME]). (2) On 3/30/18: Staff have discussed with resident tobacco free campus policy. resident verbalized understanding. Continue with P[NAME]. During interview on 5/29/18, at 5:25 p.m. the DON was asked how staff verify safety of R8 while smoking in the presence of O2. The DON stated R8 did not smoke on the property. He goes uptown. (The social worker) (SW) does spot checks on him to verify he has his O2 shut off. She does it on an annual basis. The DON clarified R8 was known to smoke on or near the property. When asked if the SW followed R8 uptown to do smoking assessments, the DON stated the SW performed the assessments out front on the street. The DON was unsure how the resident had been determined to be safe while he smoked in the presence of O2, and an O2 tank, with a history of unsafe smoking, and cognitive impairment. Review of R8's 4/5/18 Care Conference Summary, indicated R8 had a BIMS of 9 indicating moderate cognitive impairment. Safety measures were identified as: Making sure O2 is shut off with smoking. R8 was noted to be on continuous O2, and was Reminded about smoking safety. During interview with R8 at the time of the observation on 5/29/18 at 5:45 p.m., R8 stated he was aware he had an O2 canister on the back of his w/c. R8 stated he normally went across the street off the property to smoke, but stated, today it was so hot I wanted to sit under the tree. If I get close to the corner, the cars will take me out. He recalled facility staff discussing risks of smoking in the presence of O2 with him and stated, I usually shut it off but I've had some trouble with this new tank regulator. R8 also stated the tanks run empty a couple times per day but said he has no set times of day when he is allowed out to smoke. R8 stated he sometimes went uptown, and if the weather was bad he just didn't go out. R8 also stated the nursing staff keep his cigarettes and stated he field stripped his cigarettes when smoking, meaning he smoked them all the way down to the filter. R8 stated he was not the only resident who smoked but stated he wasn't going to tell. He again stated, There is something wrong with the regulator (on the O2 tank). I've been after them for a month (to fix it). During interview on 5/29/18, at 6:00 p.m. registered nurse (RN)-A verified R8's O2 regulator needed to be changed as she thought it was leaking. Review of R8's 2/6/18, therapy progress note indicated nursing staff reported R8 was caught over the weekend smoking inside the facility in the therapy entrance. R8 opened the door and was blowing smoke outside. A progress note from 5/5/18 indicated R8 had returned from the store with a yellow plastic bag. The note indicated the contents were not checked by licensed practical nurse (LPN)-A . R8 handed his lighter, ashtray and an empty pack of cigarettes to LPN-A. LPN-A asked R8 if he was aware there were no cigarettes left in the box. R8 agreed. After supper, R8 requested his cigarettes from LPN-A and became angry that she had no cigarettes. LPN-A asked R8 if he checked the yellow bag. R8 returned to his room. Upon returning to the nurses' station, R8 denied having found his cigarettes, but LPN-A observed R8 smoking outside the window. A social worker (SW) note documented 5/16/18, indicated it had been reported to her R8 was smoking on the sidewalk outside her office. The SW had documented she'd told R8 he had to leave the property to smoke. (R8) believed he was off property since he was on the edge of the sidewalk. (R8) went to the edge of the property to finish his cigarette. During interview on 5/30/18, at 4:30 p.m. dietary aide (DA)-C stated she had seen R8 downtown smoking with his O2 on before and had reported it to the nursing staff. During interview with physical therapist (PT)-F on 5/30/18, PT-F stated she was aware R8 had a history of [REDACTED]. During interview on 5/31/18, R8's medical director (MD)-A stated he was not aware R8 had been smoking while using O2, near his O2 canister, or that R8 had a history of [REDACTED]. smoking or he shouldn't be on oxygen. Review of the facility's 1/1/15 Tobacco Free Campus policy, indicated the facility was tobacco free and residents were to be notified upon admission. There was no mention how residents were going to be assessed for safety, or if the facility would allow residents who smoked prior to admission to continue to smoke off the property. <BR/(NAME)R. Hall, Jr., The Smoking Material Fire Problem, NFPA (National Fire Protection Association) Fire Analysis and Research Division, (MONTH) 2013 indicates: 7% of fatal victims of smoking-material fires who were themselves the smokers whose smoking materials started the fires were under treatment with medical oxygen. The combination of smoking and use of medical oxygen is so dangerous that it became the subject of one of the seven recommnded educational messages from the project: Smoking should not be allowed in a home where medical oxygen is used. Additionally, the article states In an NFPA analysis of fires [MEDICAL CONDITION] home medical oxygen, smoking materials were inivolved in 73% of 2003-2006 [MEDICAL CONDITION] to hospital emergency room s and involving home medical oxygen. The immediate jeopardy that began on 5/29/18 was removed on 5/30/18, at 5:00 p.m., when the facility took action to ensure R8's safety with smoking including requiring R8 to remove the oxygen tank prior to him leaving the campus, educating R8 and staff related to safe smoking practices, requring nursing to monitor and document R8's compliance with removing his oxygen prior to smoking, as well as assessing other residents who may smoke to ensure safe smoking practices. Noncompliance remained, however, at the lower scope and severity level of a D, which indicated no actual harm with potential for serious harm, injury or death.

Based on interview and document review, the facility failed to ensure prompt medical care and treatment was obtained for 1 of 2 residents (R3) reviewed for hospitalization . R3 sustained actual harm, prolonged discomfort, due to delayed nursing assessment and medical care for a right tibia/fibula spiral fracture. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS further indicated R3 required extensive assist with bed mobility, transfer, locomotion on/off unit, dressing, eating, toileting, and personal hygiene. The quarterly MDS also indicated R3 denied pain, was not on a scheduled pain medication regimen, and had not received any as needed pain medications during the look back period. R3's care plan last revised 3/29/18, indicated R3 required assist of 2 with full body lift as of 12/25/17. Prior to 12/25/17, the care plan had indicated R3 required extensive assist of 2 staff with use of stand aid for transfers and did not walk due to [MEDICAL CONDITION]. A nursing progress note dated 12/24/17, at 11:58 p.m. (recorded as late entry on 12/29/7 at 12:23 a.m.) indicated: When doing routine nursing tasks at 2230 (10:30 p.m.), writer noted that resident was taking (sic) repeatedly, 'Oh boy, Oh boy,' when asked what was wrong resident was not able to address issues. Per previous encounter writer was aware of residents' behaviors that she could get louder and talk repeatedly in two cases most of the time. She is either thirsty or wet. offered (sic)resident water to drink and resident took couple sips, writer left the room. Kept an eye on resident, resident was still awake at 2300 chanting 'Oh boy, Oh boy'. The progress note also indicated at that time, the writer had checked R3 for incontinence and the resident was slightly wet. The note indicated during the provision of care, as the staff attempted to roll away resident (to change), resident got louder and complained of pain at right leg. Assessed resident lower extremities and noted a little reddened area but no bruise at the time. Resident was unaware of what have (sic) happened to her leg but still c/o (complained of) pain with touch or movement. Offered Tylenol but resident refused. When day shift arrived it was reported that bruises were forming in lower right leg. Assessed resident with day nurse and an incident report was filed . A 12/25/17, Resident Incident Report completed by licensed practical nurse (LPN)-A at 6:00 a.m., indicated there was an unknown incident leading to R3 complaining of right leg pain, with a bruise observed on the right shin measuring 7 centimeters (cm) x (by) 3 1/2 cm which was blue in color. The report indicated R3 had been unable to explain the injury. According to the report, immediate interventions implemented included use of a full body lift due to pain in right lower extremity, APAP ([MEDICATION NAME]) given and ice applied. The report further indicated the on-call physician was notified of the resident's injury by telephone at 11:45 a.m. on 12/25/17, the family was notified at 11:50 a.m. on 12/25/17, the administrator was notified on 12/25/17, at 12:05 p.m. and the DON (director of nursing) was notified 12/25/17, at 12:25 p.m The incident report further indicated a VA (vulnerable adult) report was submitted to the State Agency at 12:39 p.m. on 1/3/18. Further review of R3's nursing progress notes indicated: - 12/25/17, 11:53 a.m. documented by LPN-A, Resident had bruise noted on right shin @ (at) 6 am. Area 7 cm long and 3 1/2 cm wide and blue in color. Right lower extremity warm and swollen with extreme pain noted with movement. On Call MD (medical doctor) called and was informed of resident's pain in right leg. LPN-A had requested an order to transfer R3 by ambulance to the ER (emergency room ) for evaluation. The physician had given an order for [REDACTED]. The note also indicated R3's family was at the facility and had been notified of the bruising, pain and use of the pain medications. LPN-A had checked R3's right leg with the family present. The resident had denied pain in the knee, back of lower leg, and foot, but had acknowledged pain on the right shin area. -12/25/17, at 12:41 p.m. LPN-A documented R3 was laying in bed visiting family with ice applied to right lower extremity. LPN-A had also documented R3 complained of pain in the lower right extremity, but had denied right hip, knee and upper extremity pain. The note also indicated R3 had received an as needed (PRN) [MEDICATION NAME] at 12:20 pm. -12/25/17, at 5:12 p.m. progress note indicated that during supper on 12/24/17, the cook brought R3 out of the dining room prior to completion of the meal. The note indicated R3 informed the cook she needed to use the bathroom. The cook reported the resident was not exhibiting any behavioral symptoms and included, Writer spoke with resident at the NS (nurses station). Asked resident if she needed to use the restroom and resident shook her head no. Writer noticed that resident appeared to have a new pair of velcro shoes on and the right one had its velcro loosened considerably. When asked if she was experiencing any pain or discomfort, resident looked down towards that shoe. Writer offered to remove the shoe as it appeared to be causing her some discomfort, but resident refused. Resident also refused to go back into the dining room, but did agree to go to her room. After reaching the room, writer again offered to remove the shoes and resident again refused and was smiling. Later in the shift after this writer had completed cares with resident's roommate, noticed resident was still awake. Asked if she wanted to keep the TV on to which she said, Yes, TV. Resident again offered no complaints of pain or discomfort. -12/25/17, at 5:23 p.m. a nursing progress note included, This afternoon at approximately 1600 (4:00 p.m.), writer was walking by resident's room and noticed she was awake. Entered the room and asked resident if she was aware what had happened to her leg. She stated, 'I don't know.' When asked if she was experiencing any pain or discomfort, responded, 'some.' Declined offer of pain medication at that time. -12/25/17, at 9:05 p.m., a nursing progress note indicated when R3 had been asked prior to supper whether she had hit her leg, the resident responded 'yes', but was unable to recall what it was. A fax (facsimile) communication to R3's physician dated 12/26/18, included, bruise noted to lower right shin measuring 7 x 3.5 cm - complaining of pain, extreme at times with movement, [MEDICATION NAME] ordered with Tylenol with ice, will continue to monitor, nurse requested an order to continue current interventions and 'please advise if any further direction'. R3's physician had confirmed the current interventions and signed the fax. A nursing progress note dated 12/27/17 9:42 p.m. included: Fax back with YES to request for [MEDICATION NAME], take 1 tablet (50 milligram (mg)) orally 3 times a day and every 4 hours PRN. (family member's name) informed. A nursing progress note dated 12/28/17, at 1:17 p.m. by LPN-A included, Resident c/o pain pain with movement in right leg. [MEDICATION NAME] helps with pain control but resident still expresses pain in right leg. Right leg swollen and warm to touch. No redness noted. No documentation was present in R3's progress for 12/29/17, 12/30/17, or 12/31/17. A nursing progress note dated 1/1/18, at 3:59 p.m. indicated R3 continued to have severe in right lower leg pain, and screamed and cried with pain when it was moved forward. The right lower leg continued to be black and blue and swollen. Call placed to (family member name) and he is agreeable to having a portable X ray done. Message left on (family member's name) phone and fax to Dr. (physician's last name). A faxed physician's communication, dated 1/1/18, at 5:23 p.m. indicated R3's leg had been injured 12/24/17, but it was unknown how. Right lower leg area is black, blue, swollen, and she screams and cries with movement. Family does not want to take her (to the hospital) but would agree to a portable x-ray. Request for a portable x-ray. Physician response included an order for [REDACTED]. A nursing progress note dated 1/2/18, at 4:03 p.m. included: (family member's name) notified of x-ray will be done tomorrow due to inability to do it today. A portable x-ray of R3's right lower right extremity was completed on 1/3/18, at 10:45 a.m., which showed a spiral [MEDICAL CONDITION] to distal tibial shaft that appears acute/traumatic with about 7 degrees anterior angulation and spiral comminuted [MEDICAL CONDITION] noted. X-ray results were faxed to (physician's name) for review at 11:10 a.m. A nursing progress note dated 1/3/18, at 1:25 p.m. written by the director of nursing (DON) indicated that a telephone order had been received for resident to be transferred to the emergency room for further evaluation. R3's nursing progress note dated 1/4/18, at 2:39 p.m. indicated R3 was admitted to the hospital for surgical repair but due to a small brain bleed, surgery was not done and comfort measures ordered. A nursing progress note, dated 1/5/18, at 2:51 p.m. indicated R3 returned from the hospital on [DATE], at 2:15 p.m. with the [DIAGNOSES REDACTED]. The progress note further indicated R3 returned with a soft cast with ace wrap to right lower leg that was to be kept in place until follow up visit with the orthopedic physician on 2/16/18. When interviewed on 4/4/18, at 3:34 p.m. nursing assistant (NA)-A, confirmed R3 had pain in her right leg prior to hospitalization on [DATE]. NA-A stated it had started with R3 wanting to have her right shoe taken off of her foot. NA-A stated he'd told the nurse it seemed like something was bothering R3's right leg and foot. NA-A said R3's right leg had started to swell and she was hospitalized , but verified not knowing what had happened to the leg. NA-A stated during the time when R3 had been injured, R3 had propelled herself about in her wheelchair and may have run into something. NA-A stated that prior to hospitalization the resident was transferred with a standing lift, then upon return from the hospital utilized a Hoyer (mechanical full body) lift. When interviewed on 4/5/18, at 7:22 a.m. registered nurse (RN)-A stated R3 complained of pain in the right leg but had just gotten new shoes and RN-A thought the shoes were causing the pain. R3 denied pain at first, but then started to complain of pain and would want her shoes off. RN-A indicated the pain was hit and miss, and monitored pain after the initial physician notification on 12/25/17. RN-A further stated R3 had increasing pain and swelling, and the facility had obtained an x-ray and found out it was fractured. R3 had a soft cast on the leg which was non-removable. When interviewed on 4/5/18, at 1:08 p.m. NA-C verified being familiar with R3; however, hadn't been working during the time when R3's bruise and leg pain occurred. NA-C stated because R3 had a lot of pain, the Hoyer lift was initiated. NA-C said R3 had expressed pain when she was transferred, when moved, or even when she sat up. NA-C further stated the [MEDICATION NAME] and Tylenol had worked some of the time, but said R3 would yell and cry, We have never seen her like that. NA-C was unsure what had happened to cause the injury to R3 and didn't think the reason for R3's leg injury had ever been determined. When interviewed on 4/5/18, at 1:21 p.m., NA-H stated that R3 had been complaining of pain for about three to four days prior to the bruising showing up. NA-H stated she'd reported to the charge nurse when R3 was crying out in pain. NA-H stated they'd started using the Hoyer lift when the bruise had showed up on R3's leg however, NA-H was unsure what had been done about the bruising. NA-H stated she didn't know what had happened to R3, but stated something must have happened to cause the injury. When interviewed on 4/5/18, at 3:24 p.m. LPN-A stated R3 was in excruciating pain and verified there was no pain noted prior to identification of the bruising on R3's leg. LPN-A described R3 as pretty content unless wanting to go to bed then her demeanor changed. It (pain) was brought to LPN-A's attention by the NA's which revealed that R3 expressed pain and discomfort with cares, and even with the [MEDICATION NAME] would still have pain if moved or even touched. LPN-A had talked to the family about it (bruise) when they were here for the holidays but R3's whole affect changed when family was here and she didn't express pain to them. LPN-A further indicated if nursing thought a resident should be seen by a doctor, the doctor would often order a different intervention to try first. LPN-A stated, depending on severity of pain, we (nursing) should probably let the physician know within 24 hours if interventions were ineffective but not sure what the policy was for notification of the doctor. When interviewed on 4/5/18, at 5:16 p.m. NA-D and NA-E stated they had worked around the holidays when R3 acquired the bruise to her right leg. NA-D and NA-E further indicated R3 had a lot of pain with movement and when her leg was touched. NA-D stated R3 was better if she was just sitting or lying in bed, and further stated R3 did not want to go out to meals or activities because when she got up it would hurt. NA-D and NA-E were unaware of how the resident obtained the bruising/fracture. When interviewed on 4/6/18, at 9:12 a.m. NA-F confirmed she had worked the morning on 12/25/17, and further stated being the staff that initially found/identified the bruising to R3's right shin. NA-F reported the bruise to the night nurse who had stated that it (the bruise) wasn't present the hour prior. NA-F identified there was a huge bruise but didn't know how it couldn't have been there an hour prior. NA-F further stated, It makes me mad, we kept reporting the pain and they had contacted the doctor and they had got an order for [REDACTED]. When interviewed on 4/5/18, at 1:38 p.m. the DON stated she'd been notified and was aware of R3's bruise and pain in her right lower extremity. The DON summarized the series of events to include that R3 had expressed pain during the night shift of 12/24/17, was still having pain the next day, the physician had been notified, [MEDICATION NAME] ordered, and R3's children had been informed. The DON stated R3's pain had been intermittent and nurses were visually monitoring the bruise and pain. The DON stated after a few days they weren't satisfied just giving her pain medication resulting in another physician contact, x-ray, and hospitalization . The DON described her investigation into the bruising as including interviews with everyone who had worked on 12/24/17 and 12/25/17 but had not been able to determine what had happened to cause the bruising and pain. The DON further stated there wasn't an incident to link to the injury. The DON acknowledged the hospital summary note by the physician indicated there had been a fall involved, but stated there hadn't been a fall, because the resident would have not been able to get herself off the floor without assistance. The DON stated an x-ray had been requested on 1/1/18 (via fax), but had not been completed until 1/3/18, because the physician had not received the faxed request until 1/2/18. Further, the DON stated the portable x-ray company hadn't had staff available to do the x-ray 1/2/18, so it had waited another day to 1/3/18. Following the x-ray completed on 1/3/18, a fracture had been diagnosed . The DON stated it was her expectation that any changes in a resident's condition would be documented in a progress note, and the doctor would be notified by phone. When asked why the doctor hadn't been called sooner when R3 was having prolonged pain, the DON stated she didn't know. When interviewed on 4/10/18, at 11:20 a.m. medical doctor (MD)-B, who'd been on call for R3's primary physician at the time of the injury, stated during R3's hospitalization [DATE], there had also been a small brain bleed diagnosed . MD-B said the brain bleed, combined with the spiral-like fracture, indicates there must have been an unwitnessed fall to result in that extensive of injury. MD-B verified having received notifications R3 had pain, but was unable to recall exact details.

Based on interview and record review, the facility failed to provide adequate supervision for 1 of 1 residents (resident #1) reviewed for a fall incident that resulted in injury and failed to ensure evidence of analyzing and addressing possible factors which contributed to a fall for 2 of 3 residents reviewed for falls (resident #1 and #2). Findings include: Resident #1 fell on [DATE]. Resident #1 was in a wheelchair immediately prior to the fall and not in view of staff, as directed by resident #1's care plan. All staff were assisting other residents at the time of the fall. Resident #1 sustained a hip fracture. Record review for resident #1 revealed a [DIAGNOSES REDACTED]. Further record review showed a Nurses' Progress Note dated 9/18/2010 that indicated resident #1 had short and long term memory problems, was oriented to person only, had impaired decision-making ability and demonstrated no change in cognitive status. This progress note further indicated that resident #1 used a wheelchair (w/c) and required extensive assistance of 1 staff for transfers. This note included documentation of problem behavior that included "self transfer attempts." Nurse's Notes for resident #1 revealed falls on the following dates: 4/23/2010, 5/14/2010, 8/10/2010 and 9/20/2010. All of these falls occurred as a result of resident #1's attempts to self transfer from the wheelchair. Review of resident #1's care plan showed a problem of potential for falls, originally dated 2/5/2010 and last reviewed 5/3/2010, that instructed staff to "Keep resident in view of staff while up in w/c. Attempts to self transfer." Review of the Nurse's Notes dated 9/21/2010 at 12:45 a.m. indicated that on 9/20/2010 at 10:45 p.m. resident #1 was sitting in a w/c by the nurse's station. The nurse and nursing assistant (NA) were "(down) halls assisting (residents)." Resident #1's alarm sounded and staff found resident #1 in a right sidelying position on the floor. The fall was not witnessed and resident #1 stated "I don't know" when asked what happened. Review of the staff schedule showed two employees (Employee C/NA and Employee D/Licensed Practical Nurse (LPN)) scheduled to be working at the time of the incident. Employee C was interviewed on 11/30/2010 at 2:37 p.m. and verified that at the time of the incident there were two staff in the building. Employee C reported resident #1 was sitting in the w/c at the nurse's station at 10 p.m. at the start of the shift. Employee C left the nurse's station to assist another resident with toileting. Employee C verified that resident #1 was not in view of Employee C during this time and Employee C was not aware of Employee D's whereabouts at the time of the incident. Employee C verbalized knowledge of resident #1's attempts to self transfer, history of falls and fall prevention interventions on the care plan. Employee C was asked how resident #1 would be kept in view of staff if both employees needed to assist other residents and Employee C stated a staff person would stay with resident #1 when up in w/c or if there was not a staff available to watch resident #1 while up in the w/c, resident #1 would be assisted back to bed. Employee D was interviewed on 12/1/2010 at 2:11 p.m. and also verified resident #1's whereabouts and number of staff in the building as described above. Employee D needed to leave the area of the nurse's station and assist a resident who was having difficulty breathing and required oxygen. Employee D was not certain of Employee C's whereabouts. Employee D stated resident #1's fall was unwitnessed and it is not always possible to keep resident #1 in view of staff when up in the w/c at night. Employee E/Director of Nursing (DON) was interviewed on 12/3/2010 at 9:08 a.m. and stated that with the current care plan interventions and no 1:1 staff supervision, that there were no guarantees that resident #1 could always be in view when up in the w/c. The facility lacked evidence of analyzing possible causes of falls for residents #1 and #2. Record review for resident #1 revealed a [DIAGNOSES REDACTED]. Review of Nurse's Notes and facility internal Resident Incident Report forms showed resident #1 fell on [DATE], 5/14/2010, 8/10/2010 and 9/20/2010. All incidences were related to self transfer and ambulation attempts by resident #1 after known to be up in the w/c. Resident #1's record, nor any of the following incident reports, contained documentation of evaluation or analysis of the possible causes and risk factors related to the falls. The Resident Incident Report dated 4/23/2010 did not list dates of falls or similar incidents and did not indicate if any pattern was noted with fall incidents. This report showed the incident was related to impaired mobility. The report showed resident #1 attempted to ambulate without staff assistance. The Resident Incident Report dated 5/14/2010 did not list dates of falls or similar incidents and showed no patterns were noted. The report did not indicate if an underlying illness/condition could be a possible contributing factor to the fall. Impaired mobility and impaired cognition were listed as risk factors. This report documented that resident #1 "does not use call light." The Resident Incident Report dated 8/10/2010 did not list dates of falls or similar incidents and although the report showed a determination of "no" for pattern noted, it contained documentation that resident #1 makes self attempts to get up from bed or w/c. This form showed risk factors of impaired mobility, balance, impaired cognition (dementia) and judgement/safety awareness deficit. The Resident Incident Report dated 9/20/2010 indicated resident #1 was cognitively able to explain how the incident occurred, however, nurse's notes dated 9/21/2010 reported resident #1 stated "I don't know" when asked how the incident/injury occurred. This report indicated a pattern was noted and risk factors of underlying illnesses/conditions, medications, functional status and psychological status. This report also included a narrative note that documented frequently being awake during the night shift, having insomnia and anxiety, staff having to leave resident's sight to answer call lights, resident not being in view of staff at time of fall and "distractions/activity provided (after) fall (not) effective." Record review for resident #2 revealed a [DIAGNOSES REDACTED]. Continued record review showed resident #2 had a history of [REDACTED]. Review of Nurse's Notes and faxed correspondence to the physician for resident #2 showed falls occurred on 5/10/2010, 7/15/2010, 7/27/2010, 8/25/2010 and 8/30/2010. Review of the facility internal Resident Incident Report form dated 8/30/2010 at 2:40 a.m. showed functional and psychological status as risk factors. The form did not indicate if an underlying illness/condition was a potential cause for the fall and also did not list dates of falls/similar incidents nor if a pattern to the falls was noted. The Resident Incident Report dated 8/30/2010 at 4:45 p.m. indicated there was a pattern noted and an underlying illness/condition of dizziness and syncope were potential causes/risk factors of the fall. This report form also showed functional and psychological status as risk factors. Both of these falls occurred in resident #2's room and were not witnessed by staff. None of the above incident reports showed documentation of evaluation or analysis of the possible causes and risk factors related to the falls. Resident #2's record also lacked such documentation. Employee E/Director of Nursing (DON) was interviewed on 12/3/2010 at 9:08 a.m. and stated that incident reports are reviewed informally by the interdisciplinary team (IDT). Employee E further reported the facility does not have any documentation of the IDT meetings, evaluation or analysis of the potential causes/risk factors of the falls or whether or not any determinations were made for possible changes to prevent further falls.