Every finding on record at Cook Hospital & Care Center

Based on interview and document review, the facility failed to ensure care planned fall interventions were implemented for 1 of 4 residents (R29) reviewed for falls. This resulted in actual harm for R29 who fell and sustained a laceration to the forehead, requiring sutures. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. Findings include:R29's admission Minimum Data Set (MDS) dated [DATE], indicated significant cognitive impairment. Diagnosis included dementia with behaviors. Fall history indicated falls 2 to 6 months prior to admission along with a fall with fracture.R29's care plan dated 6/3/25, identified a risk for falls related to a history of falls at home and since admission, impaired balance, impaired mobility, impaired cognition, and psychotropic medication usage. Care planned interventions dated 6/10/25, included not to leave alone in wheelchair in her room. Care planned interventions dated 6/23/25, included bed sensors, Velcro alarmed seat belt, and chair clip alarms on at all times.R29's Care Plan Summary for South Neighborhood dated 8/13/25, indicated R29 needed bed, chair and Velcro belt alarms on always and not to be left alone in her room when in the wheelchair. R29's nurses notes identified the following: - 8/15/25 at 6:30 p.m., R29 was physically aggressive with nurse assistant (NA) this afternoon. R29 was grabbing and pushing NA against wall and scratching NA's arm and chest. R29 received medications for behaviors and became calmer and more cooperative.- 8/16/25 at 10:01 a.m., two family members on the unit requesting information related to R29's fall the night prior.- 8/18/25 at 2:05 p.m., there was a late entry for the date of 8/15/25, that R29 had returned from the emergency room (ER) after receiving 10 stitches to a laceration on the right forehead.The facilities fall investigation and root cause analysis identified the following:R29 had an unwitnessed fall in her bathroom on 8/15/25 at 7:05 p.m., and received a laceration to her forehead, a scratch on the bridge of the nose, and a skin tear to the left wrist.R29's alarms were not sounding at the time of the fall.R29 had behavior problems and had refused to let staff place her seatbelt back on.In conclusion R29 self-transferred from the wheelchair to the bathroom in her room and the alarms were not on at the time of the fall as care planned.Registered nurse (RN)-A interview note dated 8/15/25 indicated R29 was calling out for her husband. R29 was found in her room lying on the floor in her bathroom with a puddle of blood under R29's forehead. The laceration was deep enough to see R29's skull. The note did not state if staff were with R29 in her room prior to the fall. During an interview on 5/27/26 at 2:42 p.m., nurse assistant (NA)-A stated on 8/15/25, evening shift had just started and R29 was having increased behaviors. R29 kept trying to get out of the chair and was setting off the lap belt alarms. She would not let me put the lap belt on her and R29 scratched my arms while I was trying to get the lap belt on her. I was finally able to get the lap belt on her after several minutes but do not remember if the alarm was on when I reattached the alarm.During an interview on 5/27/26 at 2:52 p.m., NA-B stated She was assigned to the south hall, the hall R29 was on. On 8/15/25 at approx. 6:00 p.m., NA-B saw R29 wheel herself into her room. The lap belt was in place but did not know if the alarm was turned on. NA-B stated she attempted to go into R29's room so R29 would not be alone in her room but the registered nurse (RN) stopped her and had NA-B go into another resident room to assist the RN with cares. No other staff were around to go be with R29 in her room, so R29 was in her room alone in the wheelchair. When they had finished the cares on the other resident the screams from R29's room were heard and staff entered the room and found R29 on the floor in the bathroom with blood on the floor.NA-A stated the staff were aware R29 could not be left alone in her room due to her high risk of falls and self-transfers in the past.On 5/28/26 at 10:44 a.m., RN-A, the PM nurse working on 8/15/25, was called but did not answer and was unable to leave a voicemail due to mailbox being full.On 5/28/26 at 10:54 a.m. RN-B, the AM nurse working on 8/15/25, was called nut did not answer. There was no voicemail to leave a message to call back.During an interview on 5/28/26 at 1:22 p.m., RN-C stated the fall investigation found that the care plan was not followed because the alarms were not turned on while R29 was in the wheelchair and alone in her room.During an interview on 5/29/26 at 9:09 a.m., the director of nursing (DON) stated staff should make sure the care plan is always followed, and alarms were turned on when R29 was out of bed and in the wheelchair.Facility policy Care Plan-Comprehensive Nursing dated 1/15/26, indicated a comprehensive car plan would be developed for each resident that included measurable objectives, and a timetable to meet a resident's medical, nursing, emotional, mental and psychosocial needs. The care plan was kept in the electronic health record and needed to be always followed.The noncompliance that began on 8/15/25 was corrected prior to the start of survey when the facility implemented a corrective action plan on 8/16/25. Actions taken included education related to the importance of following the care plan and education related to the use of lap belt alarms. Shift checks were initiated to verify alarms were on properly along with frequent checks of the residents and alarms. The education and audits were verified through interview and document review. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on interview and document review, the facility failed to ensure the nurse staff posting was posted daily and was updated to reflect the current staffing. This had the potential to affect all 24 residents residing in the facility. Findings include:On 5/27/26 at 2:15 p.m., the nurse staff posting was dated 5/26/26.On 5/27/26 at 4:10 p.m., the nurse staff posting was dated 5/26/25.On 5/28/26 at 6:58 a.m., the nurse staff posting was dated 5/26/26.On 5/29/2026 at 8:13 a.m., the nurse staff posting was dated 5/28/26.During an interview on 5/28/26 at 9:08 a.m., nursing assistant (NA)-A verified the nurse staff posting was dated 5/26/26. NA-A stated it was important for families and visitors to see how many staff were working.During an interview on 5/28/26 at 2:24 p.m. staffing coordinator (SC)-B stated she changed the nurse staffing hours on Thursdays for the coming week. SC-B stated she did not update the changes on the posted sheets but would make the changes in the computer after they occurred when she returned on Mondays. A review of the next week's schedules (5/28/26, 5/29/26, 5/30/28, 6/1/26) all had the census as 24. The schedule dated 5/30/26, had zeros for all staff listed and a census of 24.During an interview on 5/29/26 at 8:35 a.m., the director of nursing (DON) verified the nurse staff posting should be posted daily so anyone could see how many residents were in the facility and how many staff were working. The DON stated it was important so families could have confidence there was enough staff to take care of their family members.The Staffing - Care Center policy dated 1/26/26, identified the intent was to ensure sufficient staffing was in place to meet the needs of residents. The policy identified staffing hours would be posted on the bulletin boards in each household and the bulletin board located in the hallway leading to the Care Center from the Business Office. The policy identified the location was for residents, families, visitors, and staff but did not address how frequently the information Daily Staffing would be posted.

Based on interview and document review, the facility failed to develop a baseline care plan to ensure immediate resident needs were identified and addressed for 1 of 5 residents (224) reviewed for comprehensive care planning and new admissions. Findings include: R224's face sheet indicated an admitted [DATE], with a diagnosis of cerebral vascular accident. R224's paper baseline care plan indicated a completion date of 4/7/25. During an interview on 4/10/25 at 10:39 a.m., registered nurse (RN)-A stated the initial care plan was filled out in paper form and started at the time of admission. It took about 5 days for the initial care plan to be completed. During an interview on 4/10/25 at 11:48 a.m., the director of nursing stated the care plan needed to be done within 24-48hrs after admission. Facility policy Charting last reviewed 11/18/24, indicated a baseline care plan would be developed within 24hours of admission addressing pertinent problems/needs of the resident

Based on interview and document review, the facility failed to provide appropriate side effect monitoring with antipsychotic medication consumption related to residents who did not have an Abnormal Involuntary Movement Scale (AIMS) for 1 of 5 residents (R14) reviewed for unnecessary medication use. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had intact cognition. Diagnoses included psychotic disorder and post-traumatic stress disorder. R14's active order list undated, indicated R14 received Zyprexa, an antipsychotic medication that can cause involuntary muscles movements of the body, 5 milligrams (mg) by mouth in the evening. R14's medical record lacked documentation an AIMS assessment was performed prior to the start of the medication or since the medication was started. During an interview on 4/9/25 at 12:45 p.m., registered nurse (RN)-B stated when a resident was put on an antipsychotic medication an order was entered to monitor for side effects such as nausea, vomiting, hallucinations and TD. The Nursing staff had to check each shift the side effects were monitored. We did not actually do any kind of AIMS assessment before an antipsychotic medication was started as a baseline or while on the medication. During an interview on 4/10/25 at 9:48 a.m., the consultant pharmacist (CP) stated they do not look for AIMS assessments when doing the chart reviews because of the monitoring interventions are in place and documented on. The CP stated the facility probably should do a baseline AIMS prior to start of a new antipsychotic so there is a documented baseline and then would then know when a change occurred. During an interview on 4/10/25 at 11:48 a.m., the director of Nursing stated AIMS assessments specifically were not performed as part of assessments, but the monitoring interventions did list TD effects that were monitored and documented on during each shift. Facility policy Psychotropic Medications last revised 4/5/23 indicated side effect monitoring would be entered into the care plan and reviewed quarterly. Refer to state and federal regulations for long term care for a list of psychotropic dose specifics and adverse consequences of psychotropic medications

Based on interview and document review, the facility failed to comprehensively assess each fall to ensure interventions were followed; and failed to ensure fall interventions were care planned timely and implemented to prevent falls for 1 of 1 resident (R5) reviewed for falls. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], identified R5 had moderate cognitive impairment and diagnoses that included dementia, depression, osteoporosis and neurogenic bladder (as medical condition that causes bladder control issues). R5 had a history of fall without injury in the last 90 days. R5 had a bed alarm and chair alarm in place to monitor R5's movement and alerted staff when movement was detected. R5's care plan started 9/28/24, identified R5 was at risk for fall as evidenced by a history of falls, wandering, dizziness, impaired balance, impaired cognition and a history of self-transferring. Interventions included a post fall root cause analysis, bed sensor pad, fall risk assessment and vital signs. The care plan lacked any other interventions to attempt to protect the resident from falls. R5'S Post Fall Documentation (PFD) form last updated 12/12/24, indicated on 3/29/25 at 10:20 p.m., R5 was found on the floor by the bed after trying to transfer from the wheelchair to the bed. There were no behaviors documented as contributing to the fall other than resident had self-transferred. Nursing assessment indicated no injury occurred. Diagnoses listed as contributing factors included dementia, hypertension, anemia, and neurogenic bladder. The PFD lacked documentation related to last toileted or self-catheterized. Fall precautions in place in place included bed and chair sensors. The form indicated precautions such as floor mats, anti tippers, gripper socks or call signage were in place. The form indicated a post fall root cause analysis was competed, the resident was a high fall risk, and no immediate interventions were implemented. The conclusion indicated current interventions appropriate due to dementia and unable to follow recommendations. The PFD lacked documented information related to if appropriate footwear was on, if the call light was available, and when the resident had last been seen. R5's Post Fall & Root Cause Analysis (PFRCA) dated 3/29/25 at 10:32 p.m. indicated the same information as the Post Fall Documentation form. Interventions of frequent checks was also added. The PFRCA lacked any other information related to a comprehensive assessment/investigation into the fall was performed or what was reviewed as part of the PFRCA. R5'S Fall Worksheet dated 3/29/25, indicated no new interventions were added to R5's care to attempt to prevent falls. During an interview on 4/8/25 at 9:45 a.m., nurse assistant (NA)-A stated residents would be put on frequent checks after fall for an undisclosed amount of time to keep a close observation of them to prevent further falls. Frequent falls meant they would be observed every 30 minutes and then documented on a paper form where we wrote down when they were checked, who did the check and where they were located at the time of the check. NA-A stated R5 had not been on frequent checks for several months. During an interview on 4/8/25 at 10:03 a.m., licensed practical nurse (LPN)-A stated when a resident fell there was a fall assessment that is filled out and then given to the director of nursing (DON). I do not know what happens after that point. LPN-A also stated residents after falls would be placed on frequent checks. Frequent checks could be anywhere from every hour to every fifteen minutes. Documentation of frequent checks were done on a paper form and entered in the computer. During an interview on 4/8/25 at 10:39 a.m., registered nurse (RN)-A stated when a fall occurred the fall paperwork was given to the DON and then the DON would give RN-A the paperwork to review. Part of the review process would be to talk with staff about the incident, look at the resident's medical record, and evaluate causes for the fall. A root cause analysis would be performed by myself to decide the cause of the fall and what if any changes need to occur. RN-A reviewed R5's fall paperwork from 12/12/24 and stated a lot of information was missing related to the fall and what occurred at the time of the fall. Interviews with the staff to investigate the fall did not occur so there were unanswered questions related to the fall and why it occurred. RN-A knew R5 and knew she would just keep getting up on her own, so I just copied the information from the nursing documentation onto my review and started frequent checks. RN-A was unable to show the frequent check documentation and stated frequent checks were never started by the staff. During an interview on 4/8/25 at 11:10 a.m., the DON stated a complete investigation and root cause analysis should be performed to evaluate why a fall occurred and how to attempt to prevent further falls. Interventions should be care planed and started based on recommendations found through the investigation process. The facility policy Falls Program-Care Center last reviewed 4/11/25, indicated the licensed nurse would perform a post fall huddle/root cause analysis to determine any potential contributing factors to a fall. Post fall interventions would be put into place based on the RCA. The nurse manager or DON would then review the fall with reenactment if there were questions or concerns related to the fall.

Based on interview and document review the facility failed to follow care planned interventions for transfers for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 fell when transferred with a mechanical standing lift and sustained a right clavicle (a break in the thin bone that connects the shoulder blade to the breastbone) fracture. This deficient practice was corrected prior to the start of the survey, therefore, was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment. R1's care plan dated 1/24/25, included diagnoses of Alzheimer's with agitation, diabetes, congestive heart failure (CHF), coronary artery disease (CAD), insomnia, and osteoarthritis. Care Plan Summary updated 1/8/25, indicated R1 was a stand pivot transfer or ceiling lift transfer. A Fall Risk assessment dated [DATE], indicated R1 was a high risk for falls. A facility 24 hour Nursing Report sheet dated 1/23/25, indicated R1 had a fall at 12:30 p.m. Post Fall Documentation dated 1/23/25, indicated nursing assistant (NA)-A had assisted R1 to the ground from the mechanical stand lift after R1 had fallen asleep. The report indicated R1 fell asleep instantly while she was raising R1 up and had sustained a right clavicle fracture. Prefall R1 was a pivot transfer or a full body lift transfer. The report indicated NA-A used the mechanical stand lift and R1 was not care planned for the type of lift. A progress note dated 1/23/25 at 4:30 p.m., indicated the provider came to see R1. R1 had a right clavicle fracture. R1 had pain medication ordered and now required a ceiling lift for all transfers. During an interview on 1/27/25 at 1:30 p.m., R1 was lying in bed watching television. R1 stated he did not have a fall last week but was not sure why he was wearing an immobilizer on the right arm. During an interview on 1/27/25 at 1:43 p.m., NA-A stated R1 needed assistance to the bathroom and was using the mechanical stand lift to assist R1 into the wheelchair and bring R1 to the bed. NA-A then used the mechanical stand lift to assist R1 from wheelchair to bed. NA-A indicated once R1 had been lifted up R1 began sliding and NA-A could not get R1 into bed. NA-A stated R1 had fallen asleep. R1 slid down to NA-A's knees and R 1 slid to the floor through the harness for the mechanical stand lift. NA-A stated the harness was secure on R1. R1 was lowered to the floor and rolled off NA-A's lap to the floor. NA-A stated she left R1 and went to get assistance from staff. Registered nurse (RN)-A assessed R1 and the ceiling lift was used to get R1 off the floor and into bed. NA-A stated R1 was a two person pivot transfer or a ceiling lift transfer. NA-A stated R1 was not care planned to use a mechanical stand lift and she had used the mechanical stand lift for R1's transfer. NA-A stated I thought the mechanical stand lift was ok to use for R1. During an interview on 1/27/25 at 2:15 p.m., the director of nursing (DON) indicated R1 was care planned for a stand pivot transfer or a ceiling lift for transferring. The DON stated R1 was not care planned to use a mechanical stand lift. During an interview on 1/27/25 at 2:45 p.m. RN-B stated R1 was care planned for a ceiling lift after the fall and right clavicle fracture. RN-B stated R1 should not have been a mechanical stand lift for transfers. RN-B stated we had R1 care planned for a ceiling lift as R1 did fall asleep at the drop of a hat. RN-B stated the interdisciplinary team and therapy determine how to transfer residents then it is put on the care plan. During an interview on 1/28/25 at 10:18 a.m. NA-B stated staff look at the care plan to see how each resident transfers. NA-B stated there were no residents in the facility who required a mechanical stand lift. NA-B stated that R1 would just close his eyes, fall asleep, and start snoring at any time during the day. During an interview on 1/28/25 at 11:08 a.m. RN-A indicated NA-A had come to get assistance to get R1 off the floor. R1 was on the floor laying on right side. RN-A stated NA-A could have used the call light for assistance instead of leaving R1 on the floor alone. RN-A stated staff are not to leave residents alone on the floor. RN-A stated there were no obvious injuries and no complaints of pain until they rolled R1 onto the back then had pain in the right deltoid (shoulder) area. RN-A stated R1 was assessed with no bruising, no deformity, and full range of motion. They assisted R1 into bed using the ceiling lift where R1 complained of the sling pushing on R1's arms. RN-A called the provider and an X-ray was ordered. RN-A state R1 indicated the pain was better if he was not moving the right arm, R1 declined ice. RN-A revealed R1 would just fall asleep and snore multiple times a day and that it could not be predicted when R1 would fall asleep. RN-A stated NA-A had not followed the plan of care for R1 and she did not have the ok to use the mechanical stand lift for R1. During an interview on 1/28/25 at 12:28 p.m. NA-C stated NA's do not make the determination to use a mechanical stand lift for resident transfer, management makes the determination what lifts are to be used for each resident. NA-C stated we follow the care plan to find what type of transfer each resident was. NA-C denied using a mechanical stand lift for R1. During an interview on 1/28/25 at 2:25 NA-D stated staff were to look at the pocket care plan to see what type of transfers residents required. NA-D stated she had used the mechanical stand lift for R1 in the past as she was just following what other staff had done in the past. NA-D stated R1 was not care planned to use a mechanical stand lift. A facility policy Care Plan-Comprehensive Nursing dated 11/20/23, indicated the care plan needs to be always followed. The current care plans are always accessible to nursing staff through the EMR (electronic medical record) and through the pocket care pan that is provided for each individual in the household to the staff daily. Also, all staff must follow the POC. A facility policy Safe Patient Handling dated 9/30/22, indicated use safe patient handling guidelines, proper techniques and mechanical lifting devices during patient handling as directed by patient/resident care plan, physician order or RN assessment. Notify supervisor of any change in the patient's or resident's physical or cognitive status that may necessitate a reevaluation of their care plan. The facility initiated education related to following the care plan for transfers of residents, and communication via the white board for change of condition in the dictation room. Facility policy's related to Care Plans-Comprehensive Nursing, Change in Condition-LTC, Safe Patient Handling, EZ Stand Lift Procedures were gone over with staff. Informational sheets on Tollos slings and Volaro lift safety notes and assessment forms for both full body lift and EZ Stand were printed off for reference during reeducation. Staff signed off they had received education. R1's care plan was updated with current changes. EZ stands were removed from use as there were no residents assessed to use them currently.

Based on observation, interview and document review, the facility failed to perform appropriate hand hygiene when doing a finger stick for blood sugar. This had the potential to affect all residents that needed finger sticks to check blood sugars. Findings included. R19's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment. Diagnoses included dementia. During observations on 5/1/24 at 7:18 a.m., licensed practical nurse (LPN)-A entered R19's room to perform a blood sugar test. After placing gloves on her hands LPN-A proceed to utilize a lancet to puncture a small hole into R19's finger to obtain a blood sample. After puncturing then skin LPN-A then proceeded to place her gloved hand into her pocket and could be heard moving items around in her pocket. LPN-A then took the contaminated gloved hand out of her pocket and proceeded to push on the opening in the finger without changing gloves or washing hands. During interview on 5/1/24 at 8:02 a.m., LPN-A stated that she should have removed her gloves and washed her hands after putting them in her pocket and before going back to obtain the blood sample from the resident's finger. During interview on 5/1/24 at 8:22 a.m., the infection preventionist (IP) stated when a procedure is performed to puncture skin staff needed to wash hands and then done gloves for procedure. If the gloves became contaminated, they would need to be changed and hands washed again. Staff should never reach into their pockets and then go back to the resident without washing hands and changing gloves. During interview on 5/1/24 at 8:33 a.m., the director of nursing (DON) stated staff should never reach into their pockets while their hands are gloved and in the middle of a procedure. Facility policy Glucometers-Safe Use, Cleaning and Disinfection last reviewed 2/23, indicated aseptic technique must be observed and hand hygiene had to be performed. Glove also needed to be worn while doing the procedure. Facility policy Hand Hygiene last reviewed 6/23, indicated hand hygiene needed to be performed each time direct contact with residents is made and after touching inanimate objects that were likely to be contaminated with pathogenic microorganisms.

Based on observation, interview and document review, the facility failed to ensure eye drops were dated as to when opened and when they were to expire. This had the potential to affect all residents who utilized medicated eye drops. Findings include: On 5/1/24 at 9:015 a.m., a review of the North hallway medication cart was performed. Observation was made of latanoprost 0.005% medicated eye drops in the medication draw with the protective seal removed. An opened date and 'expiration date sticker was on the bottle but was not filled out. During an interview on 5/1/24 at 9:22 a.m., registered nurse (RN)-B reviewed the medication and confirmed the medication was currently in use and there was no open date or expiration date. RN-B stated the open date and expiration date had to be on the bottles so the staff would know how long the medication was good, once opened. During an interview on 5/1/24 at 12:21 p.m., pharmacist stated bottles of medicated eye drops needed to have the open date and expiration date written on them. Eye drops such as latanoprost were only good for 28 days after opened since the preservative in them would only be stable for 28 days. After the 28 days they may not be safe to use. During an interview on 5/2/24 at 9:10 a.m., the director of nursing (DON) stated an expectation that medication would be dated with the open date and expiration date when staff removed the protective seal and started using them for patients. Facility Policy Administration of Medication in Long Term Care last reviewed 4/11/22, indicated date opened stickers needed to be filled out for eye drops because they are good for 45 days from the date opened.

Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment for 1 of 1 resident (R12) reviewed for wandering. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], identified R12 was cognitively intact, used a manual wheelchair with substantial/maximal assistance for mobility, and did not exhibit wandering behavior. Diagnoses included depression and diabetes mellitus and identified R12 was cognitively intact. R12's care plan last reviewed on 3/25/24, gave no indication R12 exhibited wandering behaviors. Review of R12's mood and behavior monitoring sheets from January 2024 to April 2024 gave no indication R12 exhibited wandering behaviors. Review of R12's assessments gave no indication R12 was assessed for wandering. During interview on 4/29/24 at 2:12 p.m., R15 stated R12 enters R15's room uninvited at least once per week and has done so for at least the last 6 months. When R12 enters R15's room, R15 will use her call light to alert staff and staff will escort R12 out of R15's room. During interview on 4/30/24 at 9:26 a.m, nursing assistant (NA)-A confirmed R12 wanders into other resident's rooms at least 5 times per week. NA-A was unsure why R12 enters other resident's room and confirmed R15 will use her call light to have R12 escorted out of her room. During observation on 4/30/24 12:54 p.m., NA-A was sitting at the nursing station next to the dining area, with her back towards the dining area. R12 was sitting in her wheelchair in the dining area. On 4/30/24 at 12:57 p.m., R12 was observed wandering into R18's room. On 4/30/24 at 1:02 p.m., R18's call light was turned on. NA-A entered R18's room and escorted R12 back to her room. During interview on 4/30/24 at 2:40 p.m., licensed practical nurse (LPN)-A confirmed R12's history of wandering into other resident's rooms and states R12 has exhibited wandering behaviors for about a year. LPN-A states R12 was not confused, and LPN-A was unsure why R12 wanders into other resident's rooms. During interview on 4/30/24 at 3:02 p.m., registered nurse (RN)-B identified being aware of and having witnessed R12 wander into other resident's rooms. RN-B confirmed R12 has not been assessed for and R12's provider has not been notified of R12's wandering behaviors. RN-B confirmed there are no interventions in place to prevent R12 from wandering into other resident's rooms. During interview on 5/01/24 at 7:25 a.m., director of nursing (DON) identified having the expectation of an assessment being completed immediately for any resident exhibiting wandering behaviors. DON states being unaware of R12's wandering behaviors and plans to have an assessment completed immediately so appropriate inventions are implemented. During interview on 5/01/24 at 11:41 a.m., registered nurse (RN)-A identified having the responsibility of completing MDS assessments and updating resident care plans. For wandering assessments, RN-A reviews mood and behavior charting and consults with floor staff to determine if assessment was required. RN-A states review of R12's mood and behavior charting did not identify wandering behavior and, prior to yesterday (4/30/24), staff have not reported R12 exhibiting wandering behaviors, therefore a wandering assessment was not completed. RN-A states in response to staff reporting R12's wandering behaviors, RN-A updated R12's care plan to include SS Mood or Behavior Documentation: if wanders in other residents' room - please redirect to her room using calm reassuring approach. RN-A plans to complete a wandering assessment and update R12's MDS.

Based on interview and document review, the facility failed to ensure care-planned interventions for safety checks were consistently implemented for 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had memory impairment. The MDS outlined R1 required extensive assistance with toilet use and supervision for bed mobility, transfers, and eating. R1's care plan reviewed 3/15/24, identified R1 was to be checked on every hour by staff. On 4/11/24 at 1:05 p.m. licensed practical nurse (LPN)- A stated on 4/7/24, between 6:45 a.m. and 6:50 a.m. she went into R1's room and found R1 in her recliner. R1's right side of her face was bruised, her right eye was swollen shut, and she had a hematoma (collection of blood outside of a blood vessel) on the right side of her forehead. LPN-A stated this was the first time she had seen R1 that day. On 4/11/24 at 3:30 p.m., nursing assistant (NA)-A stated R1 was on hourly safety checks, and the last time she saw R1 was at 4:00 a.m. on 4/7/24. She had not done an hourly safety check on R1 after that time. On 4/12/24 at 9:32 a.m., registered nurse (RN)-A stated the last time she saw R1 on 4/7/24 was around 2:00 a.m. when NA-A was assisting R1 to her bedroom. NA-A was responsible for completing R1's safety checks. For safety checks, the staff were expected to visualize the resident to ensure they were safe. On 4/12/24 at 10:00 a.m., the director of nursing (DON) stated it was expected staff visualize the resident when doing safety checks. If a staff member last checked on a resident who was care planned to have hour checks at 4:00 a.m. and then not again until 6:40 a.m. the care plan was not being followed. The facility policy Falls Program- Care Center revised 4/27/23, directed safety checks are placed for staff to check on the resident, visualize the resident, and ensure that they are in a safe position within the room.

Based on interview and document review, the facility failed to ensure an injury of unknown origin was reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had memory impairment. The MDS indicated R1 required extensive assistance with toilet use, and supervision for bed mobility, transfers, and eating. R1's progress note dated 4/7/24 at 3:01 p.m., indicated at 6:50 a.m. R1 was found in her room in her recliner with a large hematoma (collection of blood outside of a blood vessel) on her right forehead, and a swollen and bruised right eye. R1 was unable to tell staff what happened, and no evidence of a fall was found. R1's Nursing Home Incident Report (NHIR) to the SA dated 4/7/24, indicated the report was submitted on 4/7/24 at 11:25 a.m. On 4/11/24 at 1:05 p.m., licensed practical nurse (LPN)-A stated they were busy that morning, and shorthanded, and she completed the report as soon as she could. LPN-A stated she should have filed the report within two hours. On 4/12/24 at 10:00 a.m., the director of nursing (DON) stated the expectation for an injury of unknown origin would be to report it within two hours. The facility Vulnerable Adult Maltreatment Prevention Plan revised 8/23, directed any mandated reporter who has knowledge of an injury of unknown source/origin shall immediately report but no later than two hours.

Based on observation, interview, and document review, the facility failed to ensure controlled medications were monitored and reconciled to prevent diversion of controlled medications. Findings include: During a review of the south medication cart on 7/13/23 at 10:59 a.m., it was noted there were approximately six narcotic cards (cards with narcotic medications in the cards) in the locked medication drawer of the medication cart. The bound narcotic book had medications signed onto pages in the one hundreds, with many pages with a line draw across the page. The director of nursing (DON) who was present for review of the cart stated they did not use the index page to sign the narcotics into the book. The DON stated when a narcotic was no longer in use and not in the narcotic drawer they would draw a line through the page which would indicate the narcotic was no longer in the drawer. Several cards were compared to the page number on the card and both matched. When the DON was asked how they would know if a card was missing she stated she was not sure. During an interview on 7/13/23 at 11:13 a.m., the director of nursing (DON) stated she was not sure why the facility was not using the index page to sign in narcotics. The DON stated the change of shift count was done with two staff. One staff would take out a card call out the page number the second staff would find the page number and they would verify the numbers matched (card to the book). The DON verified this system would not detect a missing card. During an interview on 7/13/23 at 11:41 a.m., the administrator verified the facility did not sign narcotics into the bound narcotic book using the index page. The administrator stated one staff would take out a card call out the page number the second staff would find the page number and they would verify the numbers matched. The administrator verified a missing card would possibly not be noticed during the count but would eventually be found when the resident asked for the medication. The administrator verified this process had the potential for diversion. During an interview on 7/13/23 at 12:08 p.m., the pharmacist (P)-A stated the procedure for signing narcotics into the locked medication drawer in the medication cart was to place a sticker on the first blank page of the bound narcotic book, write the number of the page on the card and place the card into the locked narcotic drawer. A nursing staff and a staff member from pharmacy would do this together. P-A stated staff should be using the index page to sign narcotic medications into the bound book. P-A stated if the index page was not being used staff would need to look at each page in the book to ensure there were no cards missing during the shift to shift counts. The facility policy Controlled Substance Medication dated 10/2022, directed staff to do the following: b) Controlled medications for residents will be received and documented into a bound inventory book with both pharmacy staff and nursing staff documenting receipt. d) A running inventory will be maintained in the bound inventory book.

Based on observation, interview and document review, the facility failed to provide assistance with grooming for 1 of 2 residents (R25) reviewed for activities of daily living (ADL)'s. Findings include: R25's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R25 had diagnoses of malignant neoplasm of prostate (cancer of prostate), spinal stenosis lumbar region (a narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs that may cause pain or numbness in legs), weakness, and dementia. In addition, R25's MDS indicated he required supervision with activities of daily living (personal hygiene/grooming, bathing, toilet use). R25's MDS indicated he was occasionally incontinent of bladder. R25's care plan initiated on 3/29/23, indicated R25 had a self-care deficit with a goal to maintain optimal bathing/hygiene ability. The care plan indicated R25 required an assist of one with cares. During an interview on 7/11/23 at 9:37 a.m., R25's family member (FM)-A stated R25 would like to be shaved daily and needed help with this. During an observation on 7/11/23 at 11:47 a.m., R25 was seated in the common area at the counter he was dressed in clean clothes and wearing shoes and socks. R25 was noted to have beard growth (white stubble) on his face (chin and cheeks). During on observation on 7/11/23 at 3:03 p.m., R25 walked out to the common area and asked a nursing assistant (NA)-A about where his razor was. NA-A told R25 she didn't think it was lost but did not go to his room to help him find it. During an observation on 7/11/23 at 3:09 p.m., R25 was in his room, activities aid (AA)-A was heard to say she would ask staff to look for his razor. R25 came out of his room and said, I sure wonder what happened to my razor. AA-B asked R25 if she could go into his room and look for his razor, he gave her permission. AA-B came out of R25's room and said she found his razor and told him she had placed it on the counter in the bathroom. During an observation on 7/12/23 at 1:38 p.m., R25 was in his room on his bed. His beard was about 1/4 inch in length. When he was asked if he was growing a beard, he said he couldn't shave because he couldn't find his razor. During an interview on 7/12/23 at 1:43 p.m., NA-A stated it could sometimes be hard to get R25 to complete cares. NA-A stated they needed to do cares when he was ready. NA-A verified R25 was looking for his razor to shave the day before and no one helped him get set up to shave on his own. NA-A verified it was a missed opportunity to help him with cares. During an interview on 7/12/23 at 2:01 p.m., licensed practical nurse (LPN)-A verified staff should have helped R25 with shaving when he was asking about his razor the day before. During an interview on 7/13/23 at 10:25 a.m., the director of nursing (DON) stated she would expect staff to help a resident with shaving especially if they were talking about/looking for their razor. The facility policy on activities of daily living was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure self-administration of medications was assessed for safety and care planned accordingly to reduce the risk of an adverse event for 1 of 5 residents (R20) observed during medication administration. Findings include: R20's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R20 had diagnoses of diabetes, depression, pancreatic cancer with surgically removed pancreas, breast cancer, and hyperthyroidism. In addition, R20's MDS indicated R20 was cognitively intact and received insulin, antidepressant, and diuretic medications on 7 of 7 days during the assessment period. R20's current physician order report dated 7/12/23, indicated R20 received the following medications: acetaminophen 1000 milligrams (mg) three times daily polyethylene glycol 17 grams (gm) daily as needed mirtazapine 7.5 mg at bedtime insulin glargine 10 units at bedtime insulin ASPART 9 units daily and sliding scale artificial tears one drop each eye three times daily spironolactone 25 milligrams (mg) daily docusate 200 mg every two days aspirin 81 mg daily paroxetine 40 mg daily acetaminophen 1000 mg twice daily magnesium chloride twice daily Creon two capsules four times daily During an observation on 7/12/23 at 7:59 a.m., licensed practical nurse (LPN)-A entered R20's room administered R20's insulin, and instilled artificial tears which were kept at R20's bedside. LPN-A then left R20's medication cup with her pills on her bedside tray, stating she typically leaves the medication for R20 to take and then she checks to see if they were all taken when she would return to pick up the meal tray. Medications in the cup were as follows: spironolactone (treats high blood pressure and fluid retention) 25 mg daily aspirin (can reduce the risk of heart attack) 81 mg daily paroxetine (treats depression) 40 mg daily acetaminophen (can treat minor aches and pains) 500 mg two tablets three times a day magnesium chloride (heart dietary supplement) twice a day Creon (used to aid food digestion for people without a pancreas) two capsules four times a day During an interview on 7/13/23 at 9:47 a.m. the director of nursing stated staff can not leave medications in a resident's room unless they had an order for self-administration of medications (SAM) and had been assessed to be safe to self-administer their medications. During an interview on 7/13/23 at 9:54 a.m. the administrator verified nursing staff needed to stay with the resident until they took their medications or do an assessment for self-administration and obtain a physicians order for SAM. During an interview on 7/13/23 at 12:04 p.m., the pharmacist (P)-A stated a resident would need an order for SAM and an assessment for ensure they are safe to self-administer medications. PA-A stated nursing would need to stay and physically ensure the resident took all of their medications. The policy Self-Administration of Medication dated 4/13/17, indicated staff and the practitioner would ask residents if they wanted to self-administer their medications. The policy indicated the SAM wood be conducted initially and then periodically for example at quarterly care conferences. In addition, the policy directed Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party.

Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately with open dates. In addition, the facility failed to remove expired medications for 3 of 14 residents (R9, R12, R15) whose medications were observed during medication storage. Findings include: During the medication storage tour on 7/13/23 at 10:59 a.m., with the director of nursing there were medications with open and expiration dates lacking and/or items past the expiration date. In addition, there were several expired stored medications observed: R9's Latanoprost eye drops (used to treat certain kinds of glaucoma) had a yellow sticker with an open date filled in for 6/18/23 and an expiration date (discard date) of 7/7/23. R9's lubricant eye drops had a yellow sticker with no open date and no expiration date. R9's Symbicort inhaler (used to treat COPD) had an open date of 4/6/23, and an expiration date of 7/6/23. R12's milk of magnesia had a manufacturer's expiration date of 5/2023. R15's M-PAP liquid (a generic form of acetaminophen) had a manufacturer's expiration date of 5/2023. House use nystatin powder (used to treat fungal or yeast infections of the skin) had a manufacturer's expiration date of 4/2023. During an interview on 7/13/23 at 11:13 a.m., the director of nursing (DON) stated staff should be filling in the open and expiration dates upon opening new medications and night staff should be checking for expired medications. The DON stated there should not be expired medications in the medication cart. During an interview on 7/13/23 at 12:06 p.m., the pharmacist (P)-A stated he would expect the nursing staff to be checking for expired medications on a scheduled basis. P-A stated the yellow stickers with the open and expiration date should be filled out when the medication is first opened. PA-A stated some medications lose there effectiveness after a specific number of days and there is also the possibility of contamination for some medications and that is why they are discarded after a specific number of days. The policy Administration of Medications in Long Term Care dated 4/11/22, directed staff to do the following: 18. Date opened stickers will be attached to all insulin vials and eye drops. Expiration date will be determined based on date opened: a. Insulin: 28 days from date opened b. eye drops: 45 days from date opened

Based on observation, interview, and document review, the facility failed to follow the manufacturer's recommendation on the proper placement of a toileting sling for the overhead mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1, when she fell from the mechanical lift, resulting in a laceration to her head that required sutures. The immediate jeopardy (IJ) began on 4/23/22, at 2:40 p.m. when the facility failed to correctly place a toileting sling to a resident by crossing the leg straps, resulting in R1 falling out of the lift. The director of nursing (DON) was informed of the IJ on 4/29/22, at 2:00 p.m. The IJ was removed on 5/2/22/22, at 3:18 p.m. but non-compliance remained at the lower scope and severity of E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnosis List printed on 4/29/22, indicated R1's diagnoses included dementia with behavioral disturbances, scoliosis, pain, wheelchair dependence, weakness and repeated falls. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had long term and short term memory loss, was able to make herself understood and usually understood others, and was totally dependent on one staff for transfers. R1's care plan last reviewed 4/8/22, indicated R1 transferred with a mechanical lift, and staff could use two staff for transfers if R1 had behaviors. The care plan also indicated R1 had behaviors of hitting at staff, trying at bite at staff, and refusing meds and oral cares. On 4/23/22, at a progress note indicated at 2:40 p.m. R1 was being transferred with the ceiling lift and a toileting sling, she let go of the sling and fell to the floor. R1 was noted to have a 5 centimeter (cm) by 5 cm hematoma (occurs when an injury causes blood to collect and pool under the skin) with laceration to her head. R1 was sent to the emergency department (ED) where she required three staples to the laceration. On 4/23/22, an emergency department (ED) note indicated R1 was being transferred with a mechanical lift sling at approximately four to five feet in height, and the portion of the sling that supported R1's upper half of her body slid down and R1 fell to the floor. R1 struck her head on the ground. The ED report further indicated R1 reported some vision abnormalities, but had significant memory problems and dementia. R1 followed commands, R1's eyes were open, and R1's speech was unintelligible to clear simple words. R1 had bleeding and a hematoma from the right occipitoparietal region (back side upper area) of the skull. R1 was in no apparent distress. R1's right occipitoparietal skull had a hematoma and a three cm long ovoid (egg shaped) laceration. Three staples were placed to close the laceration. On 4/27/22, at 2:23 p.m. an overhead mechanical lift transfer was observed with R2 by nursing assistant (NA)-B and NA-C. R2 was transferred using the toileting sling. The leg straps under R2's legs were not crossed as recommended by the manufacturer. On 4/28/22, at 9:09 a.m. NA-D was interviewed and stated when using the full body lift sling, the leg straps were to be crossed. When using the toileting sling, staff did not cross the leg straps were not crossed because if the leg straps were crossed staff could not lower the resident's pants. On 4/28/22, at 9:33 a.m. registered nurse (RN)-A stated she was the nurse that came in to assess R1 following the fall from the lift. RN-A stated R1's head and shoulders were on the floor, and R1's legs were still in the sling, which was attached to the lift. RN-A stated NA-A reported to her R1 came out of the top of the sling. RN-A stated R1 was sent to the ED. On 4/28/22, at 9:45 a.m. trained medication aide (TMA)-A was interviewed. TMA-A stated the day R1 fell from the lift, she heard someone call for help and went into R1's room. TMA-A stated R1's head and shoulders were on the floor, and her feet were still in the lift sling. TMA-A stated nursing assistant (NA)-A told her R1 fell out of the lift. TMA-A stated it looked like the lift sling possibly was hooked to the lift incorrectly. TMA-A stated if the upper strap and hood neck guard were hooked too low, the resident's center of gravity was off, and the resident could flip out of the sling. On 4/28/22, at 10:45 a.m. NA-A was interviewed and stated she went to transfer R1 from the wheelchair to the bed to check and/or change the incontinent brief. NA-A stated she connected the six straps and the belt of the toileting sling. NA-A stated she told R1 to hang on to the straps. R1 was sitting up, held onto the straps for a few seconds and then let go. NA-A stated R1 stiffened and arched her back and came out of the sling onto the floor. NA-A stated when R1 arched, stiffened, and let go, this possibly set the center of gravity off. NA-A stated she did not know if R1 went over the top of the sling or through the bottom of the sling. NA-A stated she did not identify anything wrong with the lift or the sling. On 4/28/22, at 10:55 a.m. the director of nursing (DON) was interviewed and stated following R1's fall from the lift, they reenacted what could have happened. The DON stated R1's fall was a fluke. The DON stated by the way it was described, R1 stiffened, let go of the sling and slid out. The DON stated they updated R1's care plan not to use a toileting sling, to only use a full body sling, and have two staff with ceiling lift transfers. The DON stated they had emailed all staff on R1's changes. The DON stated they did not identify anything that needed immediate education, and would review the incident with staff at the next staff meeting the third week of May. The DON stated the sling type and size used on residents was determined by restorative staff and physical therapy staff. The DON stated using either one staff or two staff was determined by an RN and restorative staff using the manufacturer's algorithm, and the determination was put into the care plan. The DON stated ceiling lift transfers were typically done with the assistance of one staff, unless the resident had behaviors or had recent changes, then two staff would transfer the resident. The DON stated the slings were checked weekly, and the lifts were checked monthly. The DON stated toileting slings could be used on residents who were incontinent, as it was easier to check and change incontinent residents. On 4/28/22, at 2:25 p.m. the DON was interviewed again and stated if a resident let go of the lift sling, this would not mean the resident would fall out of the sling. The DON stated R1 had stiffened and arched her back, and obviously had some contributing factor to her fall. The DON stated letting go of the sling alone would not cause a resident to fall out of the toileting sling. On 4/28/22, at 4:05 p.m. the Tollo ceiling lift and sling manufacturer's clinical education director (CED)-A was interviewed. CED-A stated the toileting sling was used for showers, toileting, or to check and change a resident for incontinence. CED-A stated the leg straps of the toileting sling must be crossed to keep the legs secure, and if they were not crossed, that could be why R1's legs were found tangled in the sling. CED-A stated the resident's arms should be on the outside of the sling to keep the resident from sliding through, but residents do not need to hold onto the sling. CED-A stated the manufacturer recommends using two staff when using the overhead lift, but this depended on the facility's policy. CED-A further stated she had been a CED since 2009, and had not heard of a resident arching their back and falling out of a sling. CED-A stated staff could have had the sling straps connected to the lift incorrectly, or at the incorrect length. If the toileting sling leg straps were not crossed, the resident would not be held in the sling and could fall out of the sling. CED-A stated the sling chest strap needed to be snug, if not the resident could slip out. CED-A stated if a resident slipped out of a sling, either the sling was not appropriate for the resident, or the sling was not hooked up correctly to the ceiling lift. On 4/29/22, at 10:56 a.m. NA-B was interviewed and stated when using the toileting sling on a resident, the straps are not to be crossed. NA-B stated if staff crossed the straps, it would be too difficult to lower the clothing to toilet a resident. On 4/29/22, at 11:13 a.m. NA-C was interviewed and stated when using the toileting sling on a resident, the straps were not to be crossed to be able to put the resident on the toilet and lower the pants. NA-C further stated only residents who could hang on to the sling straps could use the toileting sling. On 4/29/22, at 11:20 a.m. NA-E was interviewed and stated she had worked at the facility on and off for [AGE] years. NA-E stated the toileting sling leg straps were not crossed when going on the toilet to be able to lower the resident's pants. The sling was to be under the resident's arm and the chest strap held the resident in the sling. On 4/29/22, at 11:26 a.m. NA-F, the restorative aide, stated when using a toileting sling, the straps were not crossed because that would make it difficult to pull a resident's pants up and down. On 4/29/22, at 11:40 a.m. the DON stated when using a toileting sling, the straps need to be crossed. The DON stated this was how it was directed on the manufacturer's competency checklist. On 4/29/22, at 11:45 a.m. the DON had NA-B demonstrate and explain how to apply a toileting sling. NA-B applied the sling to herself. NA-B stated and demonstrated the leg strap of the toileting sling went under the thigh and came up around the same thigh creating a seat. NA-B did not cross the straps as directed on the manufacturer's competency checklist. On 4/29/22, at 11:50 a.m. CED-A was interviewed again. CED-A stated per the manufacturer's competency checklist, the straps on the toileting sling needed to be crossed. CED-A stated if this was not done, the resident would have the potential to fall from the sling. On 4/29/22, at 12:15 p.m. NA-F demonstrated how to apply the toileting sling. NA-F demonstrated, but did not correctly cross the straps as directed on the competency checklist. NA-F stated when using the toileting sling, staff don't cross the straps because that would make it difficult to get residents' pants or incontinent brief up and down and provide pericare. The manufacturer's Competency Assessment undated, directed when using the toileting sling, place leg straps evenly under each thigh. Cross leg straps evenly under each thigh. Cross leg loops by threading one strap through the red loop of opposite strap. Attach green or blue loops of leg straps to spreader bar. Attach red or yellow shoulder loops to shoulder hooks, raise the patient 1-2 inches above the surface. Stop- perform a safety check - ensure the loops are securely attached and the sling is positioned properly. Lift patient to intended surface. The facility policy Mechanical Lifts with Algorithms Attached dated 4/13/21, directed staff operating the lifts were to ensure proper positioning of canvas/cloth slings. It was extremely important the slings were properly placed under the resident. Before lifting the resident with the lift, make sure the loops of the sling are securely placed into the bottom of the hook of the lift. One or two Person Transfers: The nurse would evaluate the resident upon admission and with changes in medical, physical, or mental state using the ceiling lift algorithm to determine whether one or two person transfers were required with the ceiling lifts. If a resident was combative and or aggressive, a two-person transfer was required. If an aide is unable to successfully position the resident, a two-person transfer was necessary. Anytime the aide felt uncomfortable to transfer a resident without assistance, use two people. The Algorithm for Use of Ceiling Lifts revised 7/14, directed if the resident could not bear weight, if the resident was cooperative, did not have behaviors, was able to follow commands, had upper body strength and was able to sit up and hold on to the sling, staff may use one person assistance with the ceiling lift if compliant with physical therapy (PT) orders and the caregiver felt safe doing so. The IJ was removed on 5/2/22, when the facility reviewed and assessed all residents for the appropriateness of the use of a lift sling and correct sling size. Care plans, sling lists, and toileting plans were reviewed and updated. Licensed nurses and nursing assistants were provided manufacturer education, training for proper sling placement and use and competency assessments. Audits for appropriate use as per competency training would be performed five times a week for six weeks and then ongoing on a regular basis by the MDS/RN educator. Sling education would be provided upon hire and annually with competency testing. The Mechanical Lift policy was updated to include a sling assessment that would be completed by the MDS/RN educator, DON or nurse manager upon admission, with any condition changes, requests for sling assessment and quarterly. To ensure the resident has the safest sling for their specific needs. The Safe Patient Handling policy was updated to include the sling assessment and restorative nursing sling monitoring to be completed on a weekly basis. To ensure the slings are safe and in good condition. A quality assurance and performance improvement (QAPI) had been created to ensure that staff were correctly and appropriately utilizing slings during transfers and toileting. The MDS/RN educator and or the DON would provide ongoing audits for appropriate use as per competency training will be performed five times week for six weeks, then three times per week for four weeks, then ongoing as determined by audit results. This was verified through observations, interviews and document review.

Based on observation, interview and document review, the facility failed to ensure controlled medications were stored in a manner to prevent and minimize the risk of diversion for 1 of 1 medication storage rooms. Findings include: On 1/28/21, at 10:48 a.m. the medication storage room was observed with licensed practical nurse (LPN)-A. LPN-A opened the medication refrigerator, inside a drawer there were 14 syringes of [MEDICATION NAME] (United States Drug Enforcement Administration Schedule IV drug categorized as an antianxiety medication). The drawer was not locked. LPN-A stated the medication refrigerator was kept in a room accessible only via electronic key card system. Access was given only to registered nurses (RNs), licensed practical nurses (LPNs), trained medication aides (TMAs), and pharmacists. LPN-A verified the drawer was not locked, but should be. LPN-A attempted to lock the drawer, she did not have the key. LPN-A stated that she did not know where the key was kept. On 1/28/2, at 11:03 a.m. Pharmacist-B was interviewed and stated the drawer in the refrigerator should be locked. The key is to be kept in the medication cart. On 1/28/21, at 3:25 p.m. the director of nursing (DON) was interviewed and stated that the [MEDICATION NAME] should have been locked in the medication refrigerator. A policy on medication storage was requested, but not provided.

Based on observation, interview, and document review, the facility failed to implement identified pressure relieving intervention of repositioning for 1 of 3 residents (R20) at reviewed for pressure ulcers. R20's Face Sheet printed 1/28/21, indicated R20's [DIAGNOSES REDACTED]. R20's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R20's cognitive skills were severely impaired. The MDS identified R20 required assistance with toileting, personal hygiene, bed mobility, and transfers. The MDS further indicated R20 was at risk for pressure ulcers, had a an area of Intact skin with non-blanchable redness of a localized area over the coccyx, had pressure relieving devices in chair and mattress, and was on a turning/repositioning program. R20's Care Area Assessment (CAA) dated 10/21/20, indicated the following, (R20) has fragile skin on her coccyx (tailbone) and has had pressure ulcers in the past. Currently her coccyx has no breakdown but she does have skin breakdown/ulcers on her toes. She is repositioned every one hour side to side. (R20) has a pressure relieving overlay mattress and high profile ROHO (pressure relieving) cushion while in her wheelchair. R20's care plan dated 1/26/21, indicated R20 was to be repositioned every one hour and side to side only. On 1/27/21, from 8:10 a.m. to 9:44 a.m. R20 was continually observed. At 8:10 a.m. R20 was transferred from her bed to her wheelchair, and brought to the dining room. Following breakfast, R20 was placed in front of a television set. At 9:44 a.m. nurse assistant (NA)-C brought R20 to her room. NA-C transferred R20 to bed. The pressure ulcer on R20's coccyx was observed to be a reddened area approximately 5 centimeters (cm) in diameter. R 20 was not repositioned for one hour and 34 minutes. On 1/27/21, 10:05 a.m. NA-C was interviewed and stated R20 likes to watch the TV in the lounge so we let her. NA-C also stated, (R20)'s sores are healing, we change her position every hour, she looks a lot better. On 1/27/20, at 10:30 a.m. licensed practical nurse (LPN)-A stated R20 should be turned or repositioned every hour. On 1/28/21, at 12:30 p.m. the director of nursing (DON) was interviewed. The DON stated needed to be sitting upright for 30 minutes after she ate her meals. The DON stated that may have contributed to the extra 34 minutes that she went without a position change. The facility policy Skin Breakdown Prevention Policy dated 11/28/16, directed A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable.

Based on observation, interview, and document review, the facility failed to ensure restorative range of motion (ROM) programs were implemented as directed by the care plan for 1 of 1 residents, (R3) reviewed for ROM. Findings include: R3's Physician order [REDACTED]. R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R3 had a short and long term memory deficit with a moderate cognitive impairment for daily decision-making, displayed no refusal of care behaviors, and required extensive assistance with activities of daily living and mobility. R3's MDS further indicated R3 had a ROM impairment of both upper extremities and lower extremity on one side, and had not received restorative nursing care programs for ROM or splinting. R3's care plan initiated 9/30/14, indicated R3 had a decreased ability to perform self-care activities related to muscle weakness and decreased ROM. R3's care plan directed a restorative ROM program be completed three to six times weekly to include bilateral upper extremity and lower extremity active ROM, bilateral hand and wrist assisted active ROM. R3's Restorative ROM Documentation in the electronic medical record (EMR) dated between 11/18/20, and 1/26/21, indicated R3 had received ROM on 11/18/20, and 11/24/20, in November 2020; 12/29/20, in December 2020; and 1/5/21, 1/16/21, 1/19/21, and 1/26/21, in January 2021. R3's Nursing Rehabilitation summary for July in progress notes dated 8/19/20, 8/31/20, and 9/30/20, indicated R3 received a ROM restorative program three to six times a week and was meeting her goals to grasp long handled cups, touch her hand to her ear, and had flexion in both knees to put both feet on her wheelchair foot pedals. R3's quarterly Activity Note in progress notes dated 11/6/20, indicated R3 had a decline in her ability to fully participate in activities. R3's activity note indicated R3's arm and hand movement had become increasingly limited, so activities such as using a paint brush, even with a large handle, had become difficult. R3's Restorative nursing note for November, 2020, dated 12/9/20, indicated R3 was offered restorative programs three times in November due to staff shortages. R3 had refused once, and engaged twice during November. R3's Restorative nursing note for December, 2020, dated 1/26/21, indicated restorative nursing had not been getting done due to limited staff, as the restorative aide was covering nursing assistant shifts. On 1/27/21, at 8:32 a.m. staff set R3's breakfast in front of her. R3 attempted to pick up the banana with her left thumb and first finger, but was unable. R3 did not open other fingers, which were in a fist with fingers curled under. Staff returned to remove the banana from the peel and handed it to her. R3 then ate her banana independently. R3 had difficulty lifting food to her mouth, but was able. Staff finished setting up R3's meal and cut her toast for her. Staff returned at 8:56 a.m. to assist R3 with feeding. On 1/28/21, at 10:46 a.m. the director of nursing (DON) stated they had not had as much restorative staff due to a shortage of staffing during COVID-19, but were starting restorative programs again this week. On 1/28/21, at 11:06 a.m. occupational therapist (OT)-A evaluated R3's ROM. OT-A stated R3's mobility had been declining overall, and her ROM had also declined. OT-A stated they had tried adaptive equipment for eating, and were trying to maintain some degree of independence. OT-A stated R3 grimaced with shoulder movements, which limited a full assessment of her shoulder movements. OT-A had to lift R3's left foot to place on the wheelchair foot pedal at the end of the assessment, before propelling R3's wheelchair. OT-A documented a decreased ROM of left wrist flexion, left hand closer, left elbow flexion, left shoulder adduction, right elbow flexion, right wrist flexion, right fist closure, and right shoulder flexion. On 1/28/21, at 11:27 a.m. OT-A stated R3 has had a slight functional decline which could have been somewhat prevented with implementation of her restorative ROM program, but R3 also had a significant [MEDICAL CONDITION] arthritis that was progressing, so some decline was expected. OT-A stated a restorative ROM program would be beneficial for R3. On 1/28/21, at 9:45 a.m. nursing assistant (NA)-B stated she had worked as a nursing assistant, staffing was up and down, but was able to get her cares done. The facility policy Restorative Nursing Program for LTC Residents reviewed 6/18, directed the purpose of restorative programs was to maintain or improve functional abilities or strengths or prevent deterioration, and included ROM programs. The facility procedure directed restorative nursing staff or nursing staff to carry out procedures developed by the Rehabilitation staff, as directed.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R1) observed for smoking was dressed properly for smoking outside with winter temperatures below zero degrees Fahrenheit (F). Findings include: R1's Physician order [REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], indicated R1's speech could be unclear but usually understood, and he had moderately intact cognition. The MDS further indicated R1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further identified R1 had a Wanderguard (a monitoring device used to ensure safety, the alarm is activated when a resident attempts to leave a safe area) in use. R1's Care Area Assessment (CAA) for Cognitive Loss/Dementia dated 1/24/21, indicated R1 had a hard time communicating at times due to a previous stroke, and was at risk for injury due to cognition impairment. Staff were directed to allow time to answer, to anticipate his needs, and ensure safety. R1's care plan indicated R1 chose to smoke, his smoking assessment identified the need for supervision with smoking, and his safety may be impaired by cognition [MEDICAL CONDITION]. R1's outcome was to remain free from injury. R1's smoking assessment dated [DATE], indicated R1 smoked cigarettes, had been offered resources to quit smoking, and had been observed smoking. R1 was able to safely utilize lighter/matches, could safely handle lit smoking material, was able to demonstrate safe smoking behavior, and would wear appropriate safety devices. R1 was identified as requiring supervised smoking. On 1/27/21, at 8:12 a.m. R1 was observed as he finished his breakfast, and self-propelled his wheelchair to the smoking door. R1 sat at the door waiting until staff were able to take him out to smoke at 9:12 a.m -at 9:10 a.m. nursing assistant (NA)-A told R1 they were going to get him a warm blanket. NA-A told R1 it was -33 degrees F outside. According to the National Weather Service the temperatures in Cook, MN on 1/27/21, the high was six degrees F above zero and negative 22 degrees F below zero. -9:12 a.m. R1 was observed seated outside in the smoking area, wearing a baseball cap, shirt, pants, and a bath blanket draped around his shoulders. No jacket, gloves, or boots. -at 9:14 a.m. NA-A who was watching R1 smoke from a window, went outside and placed a smoking apron on him. NA-A returned inside and continued to watch R1 smoke from inside. -at 9:17 a.m. R1 was brought back inside, approximately 4 inches of bare skin was observed between right sock and the bottom of his pant leg. He was placed in the living room area near the electric fireplace. -at 9:58 a.m. NA-A was interviewed. NA stated R1 could smoke one cigarette after each meal. NA-A stated she offered him a jacket, but he refused, so she used a warm blanket. NA-A stated she thought R1 would get agitated if she made him wear a jacket. Writer only heard NA-A tell R1 he had to wear a bath blanket to go outside to smoke. -at 10:05 a.m. R1 was interviewed. When R1 was asked if he had a jacket, he pointed toward his closet. R1 was not able to say if he was cold when he was outside. -at 10:09 a.m. licensed practical nurse (LPN)-A was interviewed. LPN-A stated a lot of times R1 would wear a ball cap and jacket when going outside to smoke. -at 1:02 p.m. R1 was observed seated outside smoking, he was wearing a smoking apron, baseball cap, no jacket, gloves, boots, or blanket. -at 1:03 p.m. activities assistant (AA)-A was interviewed. AA-A stated it was about -26 degrees F in the morning. AA-A stated she thought it might be about 5 degrees F currently. AA-A verified she should have had R1 put in a jacket before going outside to smoke. -at 12:38 p.m. the director of nursing (DON) was interviewed. The DON stated she would expect staff to bring R1 a jacket to wear before going outside to smoke with the current winter temperatures. On 1/28/21, at 8:45 a.m. R1 was observed waiting by the door to go outside to smoke. R1 was wearing a jacket and winter cap. The facility policy Smoking Policy and Procedures, for Patients and Residents in Long Term Care dated 4/12/17, indicated the facility was a smoke-free facility. The facility had an exception to the adoption of the no smoking policy for residents who were recognized smokers prior to the adoption of the smoke-free policy. The policy indicated there was a designated smoking area for those designated residents. The policy directed staff to use a smoking apron for those residents who required supervised smoking. The policy did not address appropriate attire for winter weather.

Based on interview, and document review, the facility failed to provide the correct food consistency for 1 of 1 resident (R26) reviewed for choking. R26 sustained actual harm and death when she choked on fruit provided at the meal. Findings included: R26 was admitted on [DATE], and had [DIAGNOSES REDACTED]. The medical record contained DNR/CODE STATUS document dated 2/16/13, that indicated, "Do not resuscitate/Do not intubate." The document was signed by R26, the guardian/conservator and a witness, all on 2/26/13. R26 was temporarily placed on the National Dysphagia Diet (NDD) level 1 (pureed diet) due to a change in health status and was provided a speech therapist (ST) dysphagia evaluation on 6/17/13. The ST evaluation indicated P26 was alert and oriented to self and thin liquids were tolerated without overt signs/symptoms of penetration or aspiration. A ground food diet with diced soft fruit was tolerated with mildly prolonged mastication but adequate transfer and clearing of [MEDICATION NAME]. Cyclic feeding may be needed to clear mild oral residuals. Feeding assistance and cues may be needed during mealtime to encourage pt participation. Diet orders dated 6/17/13, directed NDD level 2 (mechanically altered) with ground or minced meats with fork mashable fruits and vegetables. Foods to avoid included raw fruits like pineapple and dried fruit, and no seeds or skins. R26's diet order indicated bread was okay, thin liquids, encourage cyclic feeding, feeding assistance/supervision as needed. Medical record review included the quarterly minimum data set ((MDS) dated [DATE], that indicated R26 had severe cognitive impairment and required limited assistance with eating. The care plan dated 6/18/13, directed a National Dysphagia Diet Level 2 (NDD2), to eat in the dining room, staff to cut up food and set up the tray. The care plan did not address specific foods to avoid. Progress notes on 8/8/13, at 5:20 p.m. indicated R26 had choked on fruit at the dinner table and registered nurse (RN)-B who was in the dining room responded. R26 was noted to be choking and RN-B began the [MEDICATION NAME] maneuver while other staff called for assistance from the emergency room staff at the attached hospital. The [MEDICATION NAME] maneuver was repeated with 4-5 pieces of pineapple removed from R26's mouth. After approximately 10 minutes, R26 was taken to her room where the [MEDICATION NAME] maneuver was repeated from the front while sitting and standing as well as from the front while lying down. R26 had a few agonal breaths throughout the process. The hospital physician was called and pronounced R26 dead at 5:20 p.m. The investigative report dated 8/9/13 , indicated that further review identified the contraindication for pineapple with the NDD2 diet. Further review of the menu, as well as additional staff interviews confirmed the canned tropical fruit served to residents on 8/8/13 contained pineapple. At that point the facility staff determined the incident was potential neglect of healthcare and reported to the administrator and state agency at approximately 9:30 a.m.. All staff on duty were immediately provided update and education regarding provision of appropriate food for modified diets to all residents. Part of the action to prevent recurrence was the addition of special limitations for all modified diets on the daily menu for dietary staff. In addition, the practice of placing food on the tables prior to the meal service was discontinued to ensure food was not available without staff supervision. The physician's note dated 8/8/13, (not timed) indicated they were called to see R26 subsequent to choking spell. [MEDICATION NAME] maneuvers were done by nurses, but the patient had aspirated and was pronounced dead at 5:20 p.m. The director of nurses (DON) was interviewed on 8/14/13, at 9:31 a.m. and stated she was called at home after the incident and came to the facility right away. The DON reviewed with staff what happened, talked to residents to see how they felt, and reviewed the medical record the following morning. The NDD2 (National Dysphagia Diet Level 2) diet was noted to exclude pineapple. Staff were interviewed regarding the events prior to R26 ingestion of the pineapple. A few residents were in the dining room as well as the registered nurse (RN), an activity aid and some dietary staff. Another resident alerted the staff R26 was choking. No one else observed R26 ingest the fruit. No one knew if R26 entered the dining room independently or was assisted by staff or another resident. The RN directed the activity aid to call for hospital staff for assistance and the [MEDICATION NAME] maneuver was performed. When the first attempts were unsuccessful, R26 was taken to her room and the hospital physician was called to assist. The DON stated 4-6 pieces of pineapple and other fruit were expelled from R26 mouth. Dietary staff were in the dining room and had set out resident's fluids and desserts in preparation for the meal service. Food provided for each resident was noted on the dietary card for each resident. All staff were to serve the food as directed by the information on the dietary card. R26 was seated at a table where staff would normally be assisting another resident as well as supervising R26; however, the food had not been served, except for the fruit. The following morning it was noted the tropical fruit ingested by R26 contained pineapple and that the NDD2 diet excluded pineapple. Facility staff determined the event should have been reported to the administrator and state agency as potential neglect of healthcare. The administrator and state agency were notified on 8/9/13, at 9:45 a.m. Immediate interventions to prevent recurrence included no food to be served ahead of the meal time until staff were present to assist. Dietary staff were educated regarding food to be served with each diet. Special requirements for each diet were added to the daily menus. Observations on 8/12/13, at 5:30 p.m. and on 8/13/13, at 12:20 p.m. indicated the food was served to residents after staff were in the dining room to supervise and assist. Residents were provided food that corresponded to directions on the dietary cards. Review of incident/accident reports for the previous year indicated no previous incidents of residents choking. The assistant director of nursing (ADON) was interviewed on 8/15/13, at approximately 11:00 a.m. and stated that dietary, activity and nursing staff were in the dining room and R26 was served her fruit and drink ahead of time. No one was able to say if R26 was assisted into the dining room by staff or independently entered the area. A root cause analysis was completed with several factors identified. Staff may not have been clear as to what was allowed on the NDD2 diet. The standard for the NDD2 diet was for ground meat and no tropical fruit. Preventative measures included no food to be served ahead of mealtimes, better communication between staff/departments, and all hands on deck for meal service.