Every finding on record at Cornerstone Villa

Based on observation, interview, and document review the facility failed to dispose of expired food items. The facility also failed to label food items with the open date and expiration date. This had the ability to affect all 35 residents in the facility.Findings include: During the initial tour of the kitchen on 12/01/2025 at 1:30 p.m., a Yoplait yogurt container with an expiration date of 11/28/25, was observed in the walk-in refrigerator. There was also a clear plastic container with a green lid containing several hard-boiled eggs in the walk-in refrigerator. The container lacked a label with the items in the container, the date the hard- boiled eggs were prepared, and when the hard-boiled eggs needed to be disposed of. During an interview on 12/01/2025 at 1:44 p.m., culinary aide (CA)-A stated hard boil eggs are made on Saturdays and on Wednesdays. They would be prepared, peeled and then placed into a clear container with the lid. A label needed to be placed on the container with the item name, date prepared, and expiration date. All staff were responsible to make sure food used was not expired, and if so to dispose of it. CA-A looked at the yogurt and acknowledged an expiration date of 11/28/25. CA-A was unsure when the yogurt was last served. CA-A also acknowledged the hard-boiled eggs had no label on the container. During an interview on 12/2/25 at 1:36 p.m., the culinary manager (CM) stated all food in the fridge should have a label on the container with the item's name, opened/made date, and expiration date. If the food item is at or past the expiration date when found, the item should be disposed of to decrease the risk of food borne illness. During an interview on 12/04/2025 at 8:38 a.m., the infection preventionist (IP) stated if expired or has no label then it needs to be disposed of. The label lets staff know what is in the container and if the food is still safe to consume. This decreases the risk of food borne illness. Facility policy Food Labeling and Dating undated, indicated all food would be labeled and dated accurately at the time of receipt, opening, or prepared. The facility would ensure all expired, improperly labeled, or undated food were immediately discarded. Prepared or cooked foods would be labeled and dated immediately after preparation. Held cooked food must be used or discarded within 72 hours for high-risk items such as proteins and dairy-based dishes.)

Based on observation, interview, and document review the facility failed to ensure a resident did not self-administer medications (SAM) as assessed and according to the care plan for 1 of 6 residents (R22) reviewed for medication administration.Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had diagnoses which included unspecified open-angle glaucoma, severe stage. R22's care plan dated 11/17/25, identified R22 did not wish to self-administer medications. Interventions included nursing was to store, document, and administer all medications and treatments per the physician orders. R22's Order Summary Report identified the following orders:9/4/19, atorvastatin calcium 40 milligrams (mg) by mouth for hyperlipidemia 10/17/25, Eliquis 5 mg by mouth one tablet twice daily for atrial fibrillation 7/21/23, folic acid 1 mg by mouth one time daily10/31/25, furosemide 40 mg by mouth in the morning daily related to heart failure10/31/24, iron 325 mg by mouth one tablet daily in the morning for anemia10/2/25, lisinopril 30 mg by mouth one time a day for hypertension 11/13/24, pantoprazole 40 mg by mouth in the morning for gastroesophageal reflux diseaseDuring an observation on 12/2/25 at 9:56 a.m., registered nurse (RN)-A prepared R22's medications and brought them to his room. RN-A did not wait to ensure he took them and said he had a SAM.A review of R22's electronic medication administration record verified he received the medications listed in orders on 12/2/25. A review of R22's self-administration record dated 11/3/25, identified the assessment was not completed. The section able to self-administer medications was marked as no. The comments identified the following, Resident does not wish to self-administer medications. Nursing to store, administer, reorder and document all medications and treatments per orders.During an interview on 12/3/25 at 2:11 p.m., the director of nursing (DON) verified it would not be okay to leave a resident's medications at the bedside unless the resident had been assessed and care-planned for SAM. The DON stated it was important the resident understood why they were taking the medications and that they were reliable to take them. The Self-Administration of Medications policy dated 6/2017, identified staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident.

Based on interview and document review, the facility failed to ensure post-dialysis access site monitoring was completed and documented to provide continuity of care and reduce the risk of complication (i.e., bleeding, clotting) for 1 of 1 resident (R1) reviewed for dialysis care and services.Findings include:R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had a diagnosis of dependence on renal dialysis (a life-sustaining treatment for kidney failure that filters waste and excess fluid from the blood). R1's care plan dated 7/28/25, identified he went to dialysis Monday, Wednesday, and Friday. R1's dressing was to be changed daily with a site check, no blood draws or blood pressures on the right arm with the dialysis graft. In addition, staff were to monitor the site for signs and symptoms of infection and bleeding. (The care plan did not identify which site).R1's Order Summary Report dated 11/25/25, identified staff were to monitor the right arm bruit (a consistent whooshing sound heard over an arteriovenous [AV] fistula or graft, indicating that blood is flowing properly) shiftly and to call with concerns of hemorrhage, site infection, or hypotension. On 12/1/25 at 6:28 p.m., R1's door was closed with a sign up NO VISITORS. The door remained closed throughout the survey. A review of R1's nursing notes from 11/25/25, through 12/4/25, did not identify any descriptions of R1's dialysis access site. On 12/3/25 at 10:07 a.m., nursing assistant (NA)- A stated R1 would return between 3:00 p.m. and 4:00 p.m. from dialysis.During an interview on 12/4/25 at 9:22 a.m., registered nurse (RN)-B stated she does not know when R1 returns from dialysis. RN-B stated she did not check the site upon his return on 12/3/25, but checked the bruit before he left, RN-B stated this only needed to be done once per shift. RN-B verified there had not been any additional training by the facility for caring for residents receiving dialysis. During an interview on 12/4/25 at 10:07 a.m., the director of nursing (DON) verified the facility had not provided any additional training for staff regarding care of residents receiving dialysis and acknowledged it was a high-risk and low-volume population. The DON verified there was a concern for bleeding post dialysis and that was why site checks needed to be completed post dialysis. End-Stage Renal Disease, Care of Residents dated 01/2021, identified staff caring for resident receiving dialysis would be trained in the care and special needs of those residents. Education and training would include, how to recognize and intervene in medical emergencies such as hemorrhages and infections, and the care of grafts and fistulas.

Based on observation, interview and document review the facility failed to ensure medications including a narcotic were labeled and stored properly in 1 of 3 medication carts reviewed for medication storage. Findings include: During a medication cart inspection on 12/3/25 at 11:09 a.m., with the director of nursing (DON) a syringe with a pink fluid in it and a paper medication cup with one white pill were both in a plastic drink cup in the cubicle for R24. There were no labels on the syringe, paper cup, or plastic drinking cup. The DON verified this as well. During an interview on 12/3/25 at 11:17 a.m., the DON verified it was not appropriate to find any unlabeled medications in the medication cart. The DON stated she thought the pink liquid was morphine (a potent, opiate analgesic used to treat moderate to severe pain. It is a controlled substance). The DON stated morphine should not be prepared until the medication was ready to be given. In addition, the DON stated the morphine was no longer double locked. The DON verified the cubicle in the drawer was for R24. A review of R24's Order Summary Report dated 9/29/25, identified R24 had an order for morphine sulfate concentrate 100 milligrams (mg) per 5 milliliters (ml) with instructions to give 1 ml by mouth four times a day for pain. R24 also had an order for ondansetron 4 mg with instructions to give by mouth four times a day for nausea. During an interview on 12/3/25 at 11:26 a.m., registered nurse (RN)-B verified the medications were for R24 and the pink liquid was morphine and the white pill was ondansetron. RN-B stated both of the medications were scheduled and R24 had already left for the activity. RN-B stated it was her understanding they were not supposed to interrupt an activity to give a medication. RN-B verified she should have labeled both medications, and she should have locked the morphine back in the narcotic drawer. During an interview on 12/3/25 at 12:25 p.m., the consultant pharmacist (CP)-D verified he would expect a medication to be given after it was prepared. CP-D verified the medication (narcotic) should have been wasted if the resident was not available to receive it immediately. CP-D stated the concern was the narcotic was no longer double locked. The policy Administering Medications dated 12/2025, did not address labeling and storing medications that were not given as scheduled. The policy Controlled Substances dated 6/2017, identified controlled substances must be stored in the medication room or med cart in a locked container, separate from containers for any non-controlled medications.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when she eloped from the facility and was found in the facility parking lot by a passersby. The IJ began on [DATE] at 8:44 p.m., when R1 wandered out of the facility. The administrator and director of nursing (DON) were informed of the IJ on [DATE] at 3:22 p.m. The facility had implemented corrective action on [DATE], prior to the start of the survey, and was therefore past noncompliance. Findings include: R1's Face Sheet dated [DATE], indicated R1 had vascular dementia. R1's care plan dated [DATE], indicated R1 was at risk for elopement, utilized a WanderGuard system (used to trigger alarms to alert staff when the resident is near an exit door). Interventions included monitor WanderGuard placement on walker every shift, and monitor function. Monitor and document any elopement attempts and wandering. R1's Provider Orders dated [DATE], directed to check WanderGuard placement every shift, and check signal strength of the WanderGuard every night. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had memory problems and severe cognitive impairment skills for daily decision making. The MDS indicated R1 had no wandering or exit seeking behaviors. R1's treatment administration record (TAR) for December, 2024 indicated R1's WanderGuard was checked on [DATE] evening shift and night shift, and on [DATE] day shift. The facility Risk Management Report Elopement dated [DATE], indicated R1 exited the facility with her walker unattended, and was returned to the facility via a passerby. The report lacked any further information. On [DATE] at 9:00 p.m., the temperature in [NAME] MN was 12 degrees Fahrenheit (F) with a wind of 10.7 miles per hour per World Weather. The wind chill was 2 degrees F. R1's Elopement Risk assessment dated [DATE] indicated R1 had some intermittent confusion, but no noted wandering. R1 had a purposeful destination in mind when she left her room was not at risk for elopement, but did have a WanderGuard on her walker per her preference. Review of the facility video footage dated [DATE] indicated R1 left the building at 8:44 p.m. and returned to the building at 9:02 p.m. R1 was noted to have a red winter coat and shoes on. R1's WanderGuard alarm did not sound as the WanderGuard was never placed on her walker or on her person. On [DATE] at 10:04 a.m., registered nurse (RN)-A stated on [DATE], during the day shift, she did not officially look at R1's walker to ensure the WanderGuard was present. However, she did document in the electronic medical record (EMR) she had checked for placement. It was an oversight on her part. On [DATE] at 10:13 a.m., licensed practical nurse (LPN)-A stated on [DATE], during the night shift, she didn't check R1's WanderGuard for placement or function. She did not make it to R1's room to check her WanderGuard that night, but she documented she had done it in R1's EMR. She had never checked for function for any resident's WanderGuard until receiving education on [DATE] when she was taught to check WanderGuard function. On [DATE] at 11:00 a.m., R1's medical doctor (MD)-A stated R1 was not able to make her own decisions and was not safe to leave the facility alone. If R1's WanderGuard was on her, she would have been intercepted before going outside. R1 was incredibly disoriented and would not have known to get back into the facility. She could have gotten hypothermia or been hit by a car as the facility was next to a highway, and even possibly died . On [DATE] at 11:40 a.m., the director of nursing (DON) stated staff were expected to check the placement of the WanderGuards every shift, and check the function of the WanderGuards every night. This was not occurring as staff were documenting it completed in the EMR, but were not actually completing the task. On [DATE] at 12:02 p.m., LPN-B stated on [DATE] around 8:45 p.m., R1 told her she needed to go somewhere. She redirected R1 to her room. About 15 to 20 minutes later, a family member came and got her, and told her R1 was outside. She went outside, and R1 was in a vehicle with a stranger. They stated they were from town, and saw R1 walking close to the road. They stopped and helped her into the car to drove her back to the facility. LPN-B assisted R1 out of the car, and back into the building. R1's WanderGuard alarm didn't sound, and then noticed R1 did not have a WanderGuard on. On [DATE] during the evening shift, she didn't check placement of R1's WanderGuard because she thought it had alarmed when R1 entered the double doors after an activity. The WanderGuard manufacture's manual directed to test WanderGuard signaling devices daily and record the results in the resident's records. The past non-compliance immediate jeopardy began on [DATE]. The IJ was removed, and the deficient practice was corrected by [DATE], after the facility implemented a systemic plan that included the following actions: Reviewed their policies on use of WanderGuards, re-assessed all residents who were at risk for elopement to ensure they had a WanderGuard in place and in working order, and re-educated all nursing staff on the expectation of WanderGuard function and monitoring policies. The facility completed daily audits to ensure compliance, and will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee. Verification of corrective action was confirmed by observation, interview, and document review on [DATE].

Based on interview and document review the facility failed to resolve technical issues timely to ensure staffing data was submitted, for 2 of 4 quarters reviewed (quarter 2 and 3), to the centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings Include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for quarter 2 2024 (January 1 - March 31) and quarter 3 2024 (April 1st through June 30th), identified no data had been submitted. As a result, the metric for Registered Nurse (RN) hours and licensed nursing coverage was suppressed for those quarters. On 10/30/24 at 11:00 a.m., the human resources director (HR) stated it was her responsibility to gather the staffing data each quarter. She sends the data to the administrator who submits to CMS. HR indicated the facility was made aware of the submission errors in March of 2024 following an internal audit. HR explained the root cause of the submission errors was related their time and labor software program being switched to the cloud. They have been assigned a software support specialist to assistance with technical issues. On 10/30/24 at 11:15 a.m., the administrator confirmed she submits the staffing data each quarter to CMS and has never received a notice of submission failure. States she was made aware of the submission errors following the internal audit. In response, the administrator looked back at her past 2 years of CMS submissions and stated they all said, submission failed. At that time, the administrator did not reach out to CMS because she thought their time and labor software support specialist would be able to resolve their technical issues. Administrator identified reaching out to their software support specialist on 4 occasions since being made aware of the submission issue. Most recent contact attempt was on 10/10/24. As of today 10/30/24, administrator reports the issue will be resolved within the next two weeks. The expectation was for staffing data to be submitted each quarter before the deadline. It was important to ensure staffing data was submitted before the deadline because it could interfere with the facility's overall star rating and impact the accuracy staffing information being presented to CMS.

Based on observation, interview and document review, the facility failed to develop and implement a comprehensive water management program to reduce the risk of Legionella (a bacterial infection which can be found within man-made reservoirs) and associated infectious outbreak. These findings had the potential to affect all 38 residents within the facility. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in a timely manner for 1 of 1 resident (R190) who had a peripherally inserted central line (PICC). Findings include: Water Management: During the recertification survey, from 10/28/24 to 10/31/24, the facility's water management program was requested, and a series of policies were provided which included the following: Water Management Plan dated 2/2021, identified the individuals responsible for the program were the environmental service director (EVS), maintenance assistant and the administrator. The plan identified EVS would be responsible for oversight of the water management program. The plan identified the ice machine as a potential area where Legionella could grow and spread. The plan identified the ice machine would be cleaned and disinfected routinely on a quarterly basis by the maintenance staff. The plan further identified unoccupied areas (resident rooms) would be cleaned and disinfected by housekeeping on a weekly basis. The faucet is exercised during housekeeping duties to ensure stagnant water is flushed from the water lines. However, there were no provided diagrams of the facility's water system. Water Management Program Reduce Growth and Spread of Legionella undated, identified the purpose of a water management program was to provide education and guidance to staff to identify and manage hazardous conditions that would inhibit the growth and spread of Legionella. Water Supply dated 11/2009, identified the facility would handle and maintain it's water supply in accordance with recommendations of the Centers for Disease Control (CDC) the Healthcare Infection Control Practices Advisory Committee and the Food and Drug Administration (FDA). A document titled Minnesota Valley Testing Laboratories for room [ROOM NUMBER] bath identified the following information for a water sample: date collected - 1/31/24 date received - 2/5/24 date analyzed - 2/12/24, Legionella pneumophilia 474 MNP/100 milliliters (ml) During an interview on 10/29/24 at 1:41 p.m., maintenance (M)-A reviewed the above test and stated he was not sure how to interpret the results and verified no further actions were taken after receiving the test results. M-A stated when a resident room was unoccupied they would run water for 15 minutes and flush toilets. M-A stated the facility had a diagram which identified hot and cold water but did not have a diagram of the facility's water system that would identify areas which would encourage the growth and spread of Legionella. M-A verified the water management plan was reviewed on 2/2021, and yesterday. M-A verified the facility did not have a system in place to track empty resident rooms, length of time empty, and cleaning/flushing toilets/running water. During an interview on 10/30/24 at 8:31 a.m., client services (CS)-F with Minnesota Valley Testing Laboratories identified MPN as most probable number and stated the number could be interchanged with colony forming units (CFU). CS-F verified when testing water the ideal result would be zero and would have expected some type of follow up with a result of 474 MPN/100 ml. During an interview on 10/30/24 at 8:48 a.m., the infection preventionist (IP)-G stated she had not been made aware of the Legionella test results from the water sample taken in January 2024. IP-G was not aware of the process for tracking empty rooms related to the water management plan. During an interview on 10/31/23 at 10:03 a.m., the administrator stated the water management plan could be a little more in-depth. The administrator verified she was aware a Legionella test had been completed but had not been made aware of the results. The expectation would be that she would be alerted if M-A did not know how to interpret the test results. 49877 R190: Admission [NAME] Data Set (MDS) dated [DATE], identified R190 was admitted to the facility on [DATE], cognitively intact, diagnosed with diabetes mellitus and depression, and receiving intravenous (IV) antibiotics. Order summary, physician signed on 10/18/24, contained orders for PICC line monitoring and dressing change. Orders lacked any information related to EBP. During observation on 10/29/24 at 8:52 a.m., R190s door lacked EBP signage and a personal protective equipment (PPE) cart was not located outside of room. During interview on 10/30/24 at 1:22 p.m., IP-G stated she reviews the medical record of newly admitted residents to determine if EBP were required. If EBP required, IP-G would post EBP signage on their door, place a PPE cart outside of their room, and add an EBP order to their medical record. IP-G stated having a PICC line would require EBP. Furthermore, IP-G acknowledged R190 has a PICC line and should already be on EBP but was not. IP-G explained it was on the list to implement EBP for R190. During interview on 10/31/24 at 10:03 a.m., DON stated she had the expection of timely implementation of EBP to prevent the spread of infection. A policy, Infection Prevention and Control Manual Transmission-Based Precautions undated, identified EBP are implemented for residents at risk of developing or becoming colonized with a Multi Drug Resistance Organisms (MDRO). A resident with a central line was at risk. Furthermore, EBP should be implemented when completing high-contact care activities.

Based on observation and interview, the facility failed to monitor the temperature for 3 of 3 unit kitchenette refrigerators. In addition, the facility failed to ensure the use of hair restraints during food service. This practice had the potential to affect 37 of the 38 residents at the facility who take in sustenance orally. Findings include: Unit Kitchenette Refrigerators On 10/28/24 at 1:12 p.m., dietary manager (DM) stated the facility has 3 unit kitchenette refrigerators. The refrigerator's store resident snacks, beverages, and personal food. Items commonly stored in the refrigerators include milk, cheese sticks, and yogurt. DM stated the unit kitchenette refrigerators are cleaned daily by kitchen staff, but the temperatures were not monitored or recorded by kitchen or any other staff. Furthermore, the temperatures of the unit kitchenette refrigerators have not been monitored or recorded since he was hired approximately one year ago. DM immediately recognized the lack of temperature monitoring was a food safety issue. During observation on 10/28/24 at 1:20 p.m., DM located an internal thermometer in each unit kitchenette refrigerator. The temperature of each refrigerator was within safe cold food storage range. None of the unit kitchenette refrigerators had a temperature tracking sheet posted. On 10/28/24 1:31 p.m. DM reported the lack of unit kitchenette refrigerator temperature monitoring to the administrator. Administrator stated the temperature of all facility refrigerators must be monitored and recorded daily. During interview on 10/29/24 12:05 p.m., registered dietitian (RD) stated she was unaware the temperatures of the unit kitchenette refrigerates were not being monitored or recorded. RD identified this was a food safety issue and plans to resume the practice of auditing temperature logs. A policy, Refrigerators and Freezers, revised December 2014, identified monthly tracking sheets for all refrigerators will be posted to record temperatures. Furthermore, employees will check and record refrigerator and freezer temperature daily. Hair Restraints During observation on 10/29/24 at 10:44 a.m., DM was in the kitchen and began to transfer baked fries from a baking sheet to a holding pan. DM was not wearing a beard net and was observed to have a goatee approximately 1/4 inch in length. During interview on 10/29/24 at 10:51 a.m., DM stated kitchen staff are required to wear beard nets if their facial hair was longer than 1/4 inch. DM states his goatee was 1/4 inch, and he was not required to wear a beard net. DM was going off of past experience and was unsure if the length requirement was based on facility policy. During interview on 10/29/24 at 12:05 p.m., RD stated staff are required to use hair restraints while in the kitchen. All head hair must be covered, and facial hair only needs to be covered if it was beyond a certain length. DM could not recall the exact length requirement and was going off of what was done at the hospital. RD indicated DM's goatee was neatly trimmed and did not require a beard net. During interview on 10/29/24 at 1:41 p.m., administrator expected staff to use hair restraints while in the kitchen but was uncertain about the requirement for beard nets. Stated we have always just gone with requiring a beard net for facial hair longer than 1/4 inch. Administrator proceeded to consult the facility culinary infection prevention policy and the Centers for Medicare & Medicaid Services (CMS) State Operations Manual Appendix PP. Upon review, administrator indicated facial hair, regardless of length, must be restrained when working with food. Administration planned to implement the use of beard nets with facial hair to reduce the risk of food becoming contaminated with hair. A policy, Culinary Infection Control - General Practice, undated, identified culinary staff wear a hair net to restrain all hair at all times. Wear beard restraints if necessary. CMS State Operations Manual Appendix PP, issued 8/8/24, identity according to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was completed for all sections for 1 of 1 residents (R15) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2019, identified the purpose of the RAI process was to help ensure holistic care was provided. Findings include: R15's admission MDS dated [DATE], identified sections C and D were marked as not assessed. A section of the RAI labeled, SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in many careplanning decisions. A section of the RAI labeled, SECTION D: MOOD Intent: The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. On 10/29/24 at 3:04 p.m., R15 was observed walking up and down the hall with her walker making a huffing sound, R15 appeared distressed. On 10/29/24 at 3:14 p.m., R15 was observed in the dining area walking without her walker and mumbled shit under her breath. A staff member asked her if she needed some help and assisted her to a table and provided R15 with a cup of coffee. On 10/31/24 at 10:32 a.m., the director of nursing (DON) reviewed R15's admission MDS and verified sections C and D were not assessed. The DON stated social service was responsible for those sections and she would expect the sections to be assessed and the information entered. The DON stated the MDS coordinator was responsible to ensure all sections were completed prior to uploading the document. The DON verified if the MDS coordinator was missing information and not getting a response they should have reached out to her or the administrator for assistance. The DON stated the information was important to have to ensure the resident was receiving needed care. On 10/31/24 at 11:20 a.m., social service designee (SSD)-A stated the process was for her to complete the assessments and scan the document to the MDS coordinator. SSD-A reviewed R15's admission MDS dated [DATE], and verified the information was missing in sections C and D. SSD-A stated the information was needed to make sure R15 was receiving needed care. Resident Assessment Instrument dated 9/2010, identified the assessment coordinator was responsible for ensuring the Interdisciplinary Assessment Team conducted timely resident assessments. The information derived from the assessments would help the staff to plan care that allowed the resident to reach their highest practicable level of functioning.

Based on interview and document review the facility failed to perform nurse assessments, and resident monitoring to ensure timely recognition of clinical decline, provider notification and prompt transfer to a higher level of care occurred for 1 of 1 resident (R29) reviewed for hospitalization . Findings include: R29's significant change Minimum Data Assessment (MDS) dated [DATE], indicated R29 was cognitively intact with the diagnosis of orthostatic hypotension, diabetes, hypopituitarism, and epilepsy. Section N indicated R29 received insulin daily. The report Order Summary, Active Orders as of 9/12/24, listed the following orders: -Blood sugars (BS) 5 times daily update diabetic center with severe hypoglycemia BS less than 60. -Contact MD if BS less than 70 or greater than 400 per protocol in chart under physician orders tab every shift. -Please document any additional low bs noted that need correction with snack -Glucagon kit 1 mg inject 1 mg as needed for low BS per protocol. BS 50-69, 15 G carb (4 glucose tabs) BS less than 50, 30 G carb (8 glucose tabs) If pt not alert give Glucagon 1 mg IM, repeat 15 minutes if unresponsive. Recheck BS every 15 minutes till greater than 100. Eat recheck 1 hour. -Zofran ODT 4mg give every 6 hours as needed for nausea and vomiting. R29's careplan for 9/2024 provided by the facility included Diabetes Mellitus initiated on 3/15/2022, which included instruction for monitoring and reporting to the doctor as needed signs and symptoms of hypoglycemia and or hyperglycemia. Monitoring for dehydration was added to the care plan on 11/9/23. The 9/2024, Weights and Vitals Summary for blood pressure (BP), temperature, respirations, and pulse had the following documented 9/12 into 9/13/24: 9/12/24 1:14 p.m. 84/64 pulse: 63 7:49 p.m. 86/63 pulse: 76 9/13/24: there were no documented vital signs. The chart lacked evidence to show staff had obtained and monitored R29's vital signs for clinical decline. The 9/2024, Weights and Vitals Summary for BS showed the following: 9/12/24 -11:10 a.m. 73 mg/dL -11:25 a.m. 75 mg/dL -4:50 p.m. 194 mg/dL -9:02 p.m. 116 mg/dL -10:45 p.m. 45.0 mg/dL 9/13/2024 -2:20 a.m. 120.0 mg/dL Nursing Assistant (NA) documentation sheets provided by the facility included the following BS. 9/12/24 10:45 p.m. 42 9/13/24 1:02 a.m. 123 3:05 a.m. 120 EMR Progress notes 9/12 to 9/13/2024 were as follows: 9/12/24 at 11:48 a.m., registered nurse (RN) E-MAR [electronic medication administration record] entry: BS was low and needed a snack and was going to an appt. 9/12/24 at 12:47 p.m., RN entry. Prior to leaving for appointment R29's BS had been dropping so R29 was given snacks before R29 left with family member (F)-1. R29's F-1 notified the facility R29's BS was 312 and rising, and R29 was vomiting. It was decided they would return to the facility and R29's doctor appointment would be re-scheduled. Note indicated a nurse would assess R29 upon return. 9/12/24 at 7:08 p.m., E-MAR entry by licensed practical nurse (LPN)-B: resident did not eat, not feeling well. 9/13/24 at 5:16 a.m., by LPN-A. Resident BS 42 at 22:45 [10:45 p.m.]. R29 reported they did not eat dinner. LPN-A prepared sandwich, chips, yogurt, and drinks and encouraged intake. R29 had been extremely pale, BP very low on PM shift, 86/63 and 64/40, unable to take bp on nights due to constant heaving and emesis, able to get BS up to 143. Covid test negative. R29 had nausea and frequent episodes of emesis. At 0400 [4:00 a.m.] R29's BS dropped to 87. R29 continued to vomit. At 0430 [4:30 a.m.] spoke with R29 to be seen in ED, R29 agreed. Parents called. At 0445 [4:45 a.m.] EMT's arrived. Unable to find vein for IV. R29 was transported by ambulance to Hibbing hospital. MD was faxed. The EMR lacked evidence of documented vital signs, BS, assessment and monitoring. In addition, the EMR lacked evidence that the hypoglycemic orders were followed and that the RN and or provider had been consulted and or notified of R29's worsening medical condition. During an interview on 10/30/24 at 10:39 p.m., LPN-A stated at shift change [on 9/12/24] it was reported R29 had had low BP, low and high BS, and had vomited on days and afternoons. That night LPN-A was on the Tamarack unit but as the LPN they rounded on willow and birch, and passed medications on Birch at 2:00 a.m., and 4 a.m. The Nursing assistants rounded on all units and checked Dexcom meters [meter giving continuous BS values]. LPN-A stated they first checked on R29 around 10:45 p.m. R29 had been vomiting, didn't feel well, had pale skin, and had a very low BS. To get R29 BS up, LPN-A indicated they had prepared a bunch of food and drink options and had encouraged R29 to eat. R29 had a hard time with it because of the nausea and vomiting. LPN-A couldn't recall how frequently they had checked R29's blood sugar after it was low [documented 42 and 45], but they remembered they had checked it and the Nursing assistants also checked it and had called and given them updates when R29 vomited. LPN-A stated [on 9/13/24] at 4:00 a.m., R29's BS started to drop again, but they couldn't get it back up again. R29 was still vomiting. They then contacted R29's parents and talked to R29 who agreed to go to the ED. The EMS crew tried to get an iv [intravenous access] in but couldn't because R29 was so dehydrated. LPN-A confirmed they had not gotten any follow-up BPs or vital signs on R29 that shift, nor had they called the doctor for R29's low blood sugars or to notify the doctor of R29's declining medical condition. LPN-A explained they didn't usually call the doctor on nights, but if there was something pressing, they would call. They felt they had done what they could for R29 and when it was out of their LPN scope, they had gotten R29 to the ED as fast as they could. When asked in retrospect if the on-call RN or provider should have been notified about R29's condition at any point during the night shift, LPN-A stated no. During an interview on 10/31/24 10:52 p.m., LPN-B stated they had received report on 9/12/24, from day shift that R29 was not feeling well. They recalled R29 had thrown up on the afternoon shift and had lower than usual blood pressures. They had called R29's family (F1) and updated F1 on R29's status. F1 had suggested R29 may need their hydrocortisone dose doubled. LPN-B explained when R29's body was under stress, their hydrocortisone dose had to be increased. LPN-B stated they had done a communication to the assistant director of nursing about R29's hydrocortisone dosing. LPN-B did not recall a blood pressure as low as 64/40 on their shift but indicated they had reported to the oncoming night nurse R29 needed to be watched closely due to their low bp, vomiting, and blood sugars. During an interview on 10/31/24 at 10:05 a.m., registered nurse (RN)-A stated they remembered the situation but had not received a call regarding R29 [RN-A was on call RN]. RN-A reviewed R29's EMR and stated there were gaps in documentation. With a report of low blood pressure, R29's blood pressure should have been rechecked and monitored for trending. The on-call doctor should have been called for a blood sugar as low as 45, especially since R29 had been throwing up for hours. RN-A stated if had they been working, or been called that night, they would have wanted to send R29 to the emergency department with the first low sugar. During an interview on 10/31/24 12:46 p.m., NA-A stated they knew R29 had been sick a few days and had thrown up all afternoon. NA-A stated they had probably checked on R29 about every hour. NA-A stared on a check R29 had been sweaty and pale and their BS had been really low, so they notified the nurse. They tried to get R29 to drink something, but R29 had projectile vomited everywhere. That was when the nurse decided to transfer R29 to the ED. During an interview on 10/31/24 at 11:04 a.m., the director of nursing (DON) opened R29's EMR and stated R29's blood pressure (BP) trended low so nurses may not have been alarmed by R29's BP. The DON verified the following orders were current on 9/12-13/2024: -contact medical provider if bs less than 70 or greater than 400 and chart under physician. -If BS under 50 give 30 grams of carbs or 8 glucose tabs. -Recheck blood glucose every 15 minutes until greater than 100. - Zofran 4 mg [milligrams] give every 6 hours as needed for nausea and vomiting. The DON confirmed the record did not contain evidence of BP monitoring or BS rechecks per protocol, nor had Zofran been given for nausea and vomiting. The DON stated when a resident was ill critical thinking should be used, they expected documented assessments each shift, and vital sign completion to assess for illness. Orders should be followed. Per order, the provider should have been called with the first low blood sugar. In addition, the provider should have been called for an order to send R29 to the ED. The lack of nurse notes and vital signs make it difficult to review and determine if R29 should have been transferred to the ED sooner than they were. During an interview on 10/31/24 12:15 p.m., medical doctor (MD)-D stated the on-call should have been called regarding low BP and vomiting. At the least the on-call would have initiated sick day steroids R29 needed to fight illnesses. Steroid dosing should have started when R29 started to vomit. Had the on-call been called about the low blood pressures or the low blood sugar R29 would have been sent to the ED. R29 could have benefited from earlier transfer to the ED, however the delay likely did not make a significant difference in R29's outcome. R29's ED Provider Notes dated 9/13/24, listed the following diagnoses: hypoglycemic, hypotension due to hypovolemia, dehydration, adrenal crisis, nausea and vomiting, and fever in adult. The note indicated R29 required straight catheterization to treat urinary retention. R29's initial ED blood sugar was 43 and the repeated result was 50. While in the ED R29's treatment included IV administration of dextrose 10%, dextrose 50%, a two-liter fluid bolus, hydrocortisone, nausea medication, and antibiotics. The noted indicated R29 required admit to the hospital for further evaluation and treatment. R29's Range Hibbing Hospital Discharge Summary dated 9/21/24, indicated R29 had been admitted to the hospital on 9/12/24, and was discharged on [DATE], with the following diagnosis: dehydration, urinary retention, hypoglycemia, acute colitis, fever in adult, hypotension due to hypovolemia, nausea and vomiting, low serum cortisol, hypopituitarism, and uncontrolled type two diabetes without complication with long-term current use of insulin. Discharge orders included a 13-day course of the antibiotics Cipro and Flagyl for the associated diagnosis of sepsis unspecified organism. The undated, untitled document page 3 subtitle Diabetic Management instructed staff to notify the provider if two BS results were lower than 70 or greater than 400 in a 24-hour period and/or a change in condition. If no change notify provider on the next business day. Page four subtitle Hypoglycemia: if a patient was hypoglycemic and able to swallow, staff were instructed to: -administer six ounces of juice, milk, regular pop, or other high carbohydrate beverage or boost via mouth or feeding tube. -repeat BS after 10 minutes, if less than 70 repeat intervention -if after two attempts to treat BS and still under 70 notify provider -once R is stable recheck BS after 60 minutes. -communicate any hypoglycemic event to provider the following business day. The Nursing Care of the Resident with Diabetes Mellitus dated April 2009, under Management of Hypoglycemia for symptomatic responsive resident instructed staff to: -immediately give four ounces of juice or five to six ounces of soda -recheck BS in 15 minutes -repeat juice if indicated, recheck BS in 15 minutes -monitor vital signs -if no improvement notify the physician for further orders Instruction under Documentation included document: -skin -level of consciousness -pain -accurate input and output -urinary symptoms including retention and incontinence -blood pressure problems including orthostatic hypotension -blood sugar results Policies related to nurse assessment, provider notification, on-call RN, and transfer to ED/hospital were requested and not received.

Based on interview and document review the facility failed to provide non- pharmacological interventions prior to administration of an as needed (PRN) antipsychotic medication for 1 of 1 resident (R11) reviewed for PRN psychotropic medication use. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included dementia and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). In addition, R11 was severely cognitively impaired with no hallucinations, delusions, behaviors, or rejection of cares. R11's MDS identified she had unclear speech but could usually understand and be understood. R11's care plan dated 11/17/22, identified R11 had as needed lorazepam (a medication used to treat anxiety, a benzodiazepines which are medications that slow down the nervous system) for agitation/anxiety, dyspnea (shortness of breath), and uncontrolled pain. Interventions included to administer lorazepam as ordered and monitor for medication side effects. In addition, R11's care plan dated 2/16/22, identified R11 had cognitive loss related to a diagnosis of dementia. Interventions included to administer medications as ordered, anticipate needs, ask yes/no questions, offer reminders and cues, and to call family as needed. R11's current physician orders included the following: Lorazepam 0.5 milligrams (mg) by mouth every six hours as needed for pain until 12/1/24. Prior to administering, assess for unmet needs related to inconsolable crying. Offer verbal reassurance, snacks, fluids, music. Attempt all non pharmacological interventions prior to administration, document what was attempted. R11's October 2024, medication administration record identified R11 received PRN doses of lorazepam 0.5 mg orally on the following dates and times: 10/2/24 at 7:26 p.m. 10/11/24 at 3:07 p.m. 10/15/24 at 3:34 p.m. 10/16/24 at 4:15 p.m. 10/22/24 at 4:57 p.m. R11's October 2024, medication administration record identified R11 did not have non pharmacological interventions documented. A review of a document titled Mood and Behavior Log for October 2024, did not having any documentation of behaviors by the nursing assistants. A review of R11's October 2024 progress notes did not identify what non pharmacological attempts were made prior to administration of lorazepam. On 10/30/24 at 12:36 p.m., the director of nursing (DON) reviewed R11's electronic medical record (EMR) and verified no non pharmacological interventions were documented prior to administering lorazepam in October. The DON stated she would have expected staff to document the non pharmacological interventions that were tried prior to the lorazepam administration. The Comprehensive Home Care Resource Manual dated January 2014, identified staff needed to create and maintain a correct and accurate medication record for each client receiving medication assistance or administration .

Based on interview and document review the facility failed to ensure there was a certified and credentialed dietary manager, or a full time registered dietician, to oversee food services. This had potential to affect all 39 residents, staff, and visitors who consumed food from the kitchen. Findings include: During interview on 11/15/23 at 10:53 a.m., cook (CK)-A stated there was no certified dietary manager (CDM) at that time and the facility had not had one for a couple of years. The registered dietician (RD) was the acting CDM but she was only in the facility two days a week. During interview on 11/16/23 at 12:26 p.m., the RD stated she did not work for the facility but was contracted to work two days a week as the RD and also completed the duties of the CDM on the two days she was at the facility. The RD confirmed there was no full time CDM in the facility for at least the last two years. During interview on 11/16/23 at 2:32 p.m., administrator confirmed the facility did not have a CDM or a full time RD to oversee food services. There was a RD that was contracted with the facility two days a week. The administrator stated she oversaw the food services when the RD was not present. She acknowledged she did not have her CDM to be able to oversee the food services. The qualifications of CDM were requested, but not received.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all residents who resided at the facility. Findings Include: The PBJ Staffing Data Report, [NAME] Report 1705D, Quarter 2 2023, (January 1 - March 30) triggered for no RN [registered nurse] hours, which meant the facility did not have an RN on site for a minimum of 8 hours for one or more days during the reporting period. The report showed no RN hours for 1/14/23, 1/15/23, 2/25/23, and 3/11/23. On 11/17/23 at 10:34 a.m., the administrator reviewed payroll hours worked for the following dates and confirmed there was not an RN in the building on 1/14/23, 1/15/23, 2/25/23, and 3/11/23. During that time period staffing levels were low and licensed staff and unlicensed staff worked many extra hours to ensure residents were cared for. On the days there was not an RN in the building, there was one on call. Staffing levels have improved, however despite recruitment efforts, the rural location of the facility has made it a challenge to find and hire qualified applicants.

Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 4 of 4 residents (R87, R27, R33, R35) reviewed for hospitalization . Findings include: R87: R87's significant change Minimum Data Set (MDS) dated [DATE], identified R87's diagnoses included anemia, hypertension, hypothyroidism, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). In addition, R87's MDS identified R87 was cognitively intact. R87's progress note dated 10/22/22 at 6:45 p.m., indicated R87 was transferred to the emergency room . The facility was unable to provide a Bed Hold Policy Notification for R87. R27: R27's quarterly MDS dated [DATE], identified R27's diagnoses included hypertension, hyperlipidemia, dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and anxiety. In addition, R27's MDS identified R27 was moderately cognitively intact. R27's progress note dated 11/17/23 at 1:38 p.m., indicated R27 had been sent to the emergency room . During an interview 11/16/23 at 11:33 a.m., registered nurse (RN)-C said she called the ambulance, called R27's daughter but did not fill out a bed hold. During an interview on 11/16/23 at 11:41 a.m., the assistant director of nursing (ADON) said the resident or the resident's representative should be asked if they wanted their bed held. The ADON said it would be best practice to fill out a bed hold at the time they ask the resident or the resident's representative. R33: R33's admission MDS dated [DATE], identified R33's diagnoses included hypertension, diabetes mellitus, and bipolar disorder. In addition, R33's MDS identified R33 as moderately cognitively intact. R33's progress note dated 10/24/23 at 10:11 a.m., identified R33 was sent to the emergency room . During an interview on 11/14/23 at 12:56 p.m., R33 stated he was not sure if he was offered a bed hold when he had to go the emergency roiagnom on [DATE]. The facility was unable to provide a Bed Hold Policy Notification for R33. During an interview on 11/17/23 at 8:51 a.m., the director of nursing (DON) stated there was not a check list for staff when they would send residents to the emergency room or to the hospital. The DON stated they talk about the bed hold the next day. It was important to ask residents or their representatives if they wanted their bed held so they would have a place to return to and so they would not end up with a financial burden. 45842 R35: R35's discharge Minimum Data Set (MDS) dated [DATE], identified diagnoses of urinary tract infection and diabetes mellitus. Progress note dated 9/1/23, indicated R35 was transferred and admitted to the hospital for illness. R35's medical record lacked evidence a bed hold was provided at the time of transfer for hospitalization . During an interview on 11/16/23 at 1:57 p.m., licensed practical nurse (LPN)-E stated a bed hold was offered to any resident transferred to the hospital. If the resident was unable to sign the bed hold, then the discuss about the bed hold would be had with the family member responsible. Afterwards the conversation would be documented in the residents medical record. During an interview on 11/17/23 at 1:08 p.m., the DON stated whenever a resident was transferred out of the facility a bed hold should be completed. Staff would either have the resident or resident representative sign it or get verbal consent and document in the chart it was provided. The bed hold would then be scanned into the resident's medical record. The DON reviewed R35's medical record and acknowledged there was no signed bed hold as part of the medical record. The policy Cornerstone Villa Bed Hold Policy Notification dated 12/2013, identified In keeping with the federal Resident [NAME] of Rights, we are informing you of this policy: The bed hold policy had areas to indicate if they did or did not want to hold their bed and areas for signatures of the resident or the legal representative.

Based on observation, interview and document review the facility failed to ensure staff staff followed proper hand hygiene with glove use during dining service. This had the potential to affect all residents who dined in the Tamarack and Birch units. In addition, the facility failed to ensure staff followed standards of practice during insulin administration for 2 of 2 (R25, R33) residents observed during medication administration. Furthermore, the facility failed to ensure laundry was handled properly while transporting dirty linen. This had the potential to affect all residents who resided in the facility. Findings include: Medication Administration R25: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 was cognitively intact. Diagnoses included diabetes and a previous stroke. The facility provided Sanfori manufacturer insert Glargine (Lantus) Single Use Insulin Pen dated 2020, instructed users to cleanse the hub of the pen prior to attaching a needle to the pen. The facility provided Novo Nordisk manufacturer instructions Insulin Aspart (Novolog) Flex Pen dated 2019, directed users to cleanse the hub prior to attaching a needle to the pen. During a medication observation on 11/15/23 8:54 a.m., licensed practical nurse LPN-C removed the cap from R25's Novolog pen, did not sanitize the hub, and secured the needle to the pen. LPN-C, then removed the cap from R25's Lantus insulin pen and attached the needle without sanitizing the pen hub. LPN-C confirmed she had not sanitized the hub on the insulin pens and stated she wasn't sure if that needed to be done. R33: R33's admission MDS dated [DATE], indicated R33 was moderately cognitively impaired and had a diagnosis of diabetes. During a medication administration observation on 11/16/23 at 8:01 a.m., LPN-D sanitized hands, did not put gloves on, and proceeded to administer R33'3 glargine insulin dose by injection without wearing gloves. During an interview on 11/16/23 at 8:07 a.m., LPN-D stated they did not always wear gloves when they administered insulin, but indicated since a resident could bleed during an injection, they should wear gloves for infection control. During an interview on 11/17/23 at 9:38 a.m., the director of nursing (DON) stated for infection prevention control, they expected nurses to wear gloves for all medications administered by injection. The DON confirmed sanitizing the pen hub prior to attaching the needle was also a required infection prevention measure. The facility policy Subcutaneous Injections dated 3/11, included step by step instructions that directed staff to sanitize hands and apply gloves prior to administering medication by injection. Food Service During a continuous observation of meal service on 11/15/23, the following was observed: -At 11:25 a.m., cook-A was dishing up food on the unit. Cook-A's beard restraint was bunched up around his neck instead of over his beard. Dietary aide (DA)-A washed their hands and put on gloves. -At 11:28 a.m., DA-A put placemats and silverware on the tables and without sanitizing hands then delivered salads out to residents seated at the dining tables. -At 11:30 a.m., DA-A removed gloves, did not sanitize hands, applied new gloves, and removed a bowl of soup from the microwave. -At 11:32 a.m., DA-A removed gloves, did not sanitize hands, and took a plate from cook-A. -At 11:34 a.m., DA-A did not sanitize hands, put new gloves on and removed soup from the microwave. -At 11:34 a.m., R6 handed DA-B their personal mug, DA-B poured coffee into R6's mug and delivered it to R6. DA-B did not sanitize hands after handling R6's personal mug and before pouring and delivering milk and water to other residents. -At 11:36 a.m., cook-A's continued to dish up food with their beard restraint around their neck. -At 11:40 a.m., DA-A finished handing out condiments. DA-A did not wash hands, put on new gloves, and moved a burger and potatoes with a gloved hand to a new plate. DA-A placed the plate in the microwave. With the same gloves on, DA-A moved the plate from the microwave to the counter and put the cold food from the first plate onto the new plate. DA-A selected another plate from the counter, moved the burger and potatoes to a new plate with their gloved hand and then paced the plate in the microwave. DA-A removed gloves and washed hands. When the microwave was done, DA-A removed the plate from the microwave and delivered it. During an interview on 11/15/23 at 11:43 a.m., cook-A acknowledged they had not been wearing their beard restraint during food service and stated normally they wore it to prevent hair from getting into the food. During an interview on 11/17/23 at 9:52 a.m., the DON stated they would expect staff to sanitize their hands after handling resident's personal items. The DA should have sanitized their hands after they touched the personal mug and before they resumed beverage service. Staff are required to wear hair covering when food is being plated and served out of the unit kitchenettes. In addition to a hair net, staff with beards are required to wear a beard covering during food service to prevent food from being contaminated with hair. All staff including food service staff should sanitize their hands after they remove gloves and before putting on new gloves. The facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated 10/08, indicated food service employees would follow appropriate hygiene and sanitary procedures to prevent the spread of food borne illness, which included wearing hair nets or caps and/or beard restraints. The undated, facility policy Glove Use included the following direction under the section for glove use in the dining room: -The cook is required to wear gloves when serving and touching food. If gloves are contaminated, the cook should: remove gloves, sanitize hands, and apply new gloves. -If cabinets, bread wrappers etc. are opened, cooks should perform proper hand sanitization and glove change before dishing up food. -Servers in the dining room need to do hand sanitization before and between serving each resident. -Food items may not be touched by hands. -Hands need to be sanitized before and after glove use. 42587 Food Service During continuous observation on 11/15/23, the following was observed: -at 11:45 a.m., cook (C)-A removed covers from the steam table and then put on gloves. -at 11:48 a.m., C-A wearing the same gloves removed utensils from drawers in the kitchenette and placed the utensils in the food in the steam table. Wearing the same gloves C-A took buns, butter, and cheese and placed them on the counter to the right of the steam table. C-A opened a drawer wearing the same gloves and took out a knife. C-A wearing the same gloves removed a bun from the bag placed the bun on a plate, used tongs and placed a hamburger on the bun then placed a slice of cheese on the hamburger using gloved hands and placed a cover over the plate. C-A wearing the same gloves removed bowls from the cupboard, scooped some stew into the bowl then rested his gloved hands on the counter. C-A wearing the same gloves picked up a pen and made a notation on a paper on the counter, then wearing the same gloves removed another bun from the bag and placed the bun on a plate, placed a hamburger on the bun using tongs, then used gloved hands and placed a slice of cheese on the hamburger. -at 11:56 a.m., C-A continued to handle buns and cheese with gloved hands with no glove changes. -at 12:09 p.m., C-A wearing gloves walked to the Birch unit and picked up plates, wearing the same gloves continued to handle buns and cheese. During an interview on 11/15/23 at 12:19 p.m., C-A stated during training on glove use and hand hygiene was he was told to change gloves every so often. C-A verified he did not change gloves during the food service. During an interview on 11/17/23 at 1:51 p.m., the director of nursing (DON) stated staff should change gloves and perform hand hygiene after touching drawer handles and prior to putting on new gloves. The policy Preventing Food borne Illness-Employee Hygiene and Sanitation Practices dated 10/2008, directed staff to perform hand hygiene with the following: -Whenever entering or re-entering the kitchen. -Before coming in contact with any food surface. -During food preparation, as often as necessary to remove soil and contaminants to prevent cross-contamination when changing tasks. -Gloves are considered single-use items and must be discarded after completing the task for which they were used. -The use of gloves did not substitute for proper hand washing. Linen During an observation on 11/16/23 at 7:20 a.m., nursing assistant (NA)-D carried dirty linen from R33's room tucked under her left arm against her uniform. NA-D placed the dirty linen in a linen cart in the hallway. NA-D was not wearing gloves while carrying the dirty linen and picked up a pen without performing hand hygiene and made a notation on a paper. During an interview on 11/16/23 at 7:21 a.m., NA-D verified she carried dirty linen under arm against her uniform and said she should have used a bag to carry dirty linen from a resident room to the dirty linen cart. NA-D verified she should have performed hand hygiene after she disposed of the dirty linen. During an interview on 11/16/23 at 1:22 p.m., registered nurse (RN)-B verified staff should not carry dirty linen next to their uniform and should bring a laundry cart to the room. RN-B stated this was important to prevent the spread of bacteria/infections to other residents. During an interview on 11/17/23 at 1:51 p.m., the director of nursing (DON) stated staff should change gloves and perform hand hygiene after touching any equipment or items that might be contaminated to prevent the spread of infections. A policy on transporting used linen was requested, but not provided.

Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with established standards of care for 1 of 3 residents (R25) observed to receive medication during the survey. A total of two errors from 28 opportunities were identified resulting in a medication error rate of 7.14% (percent). Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 was cognitively intact, and diagnoses included diabetes and stroke. The facility provided Sanfori manufacturer insert Glargine (Lantus) Single use Insulin pen dated 2020, instructed users to cleanse the hub, apply needle, and prime the pen with 2 units of insulin. Administration instructions included slowly counting to 10 before withdrawing the needle from injection site. The facility provided Novo Nordisk manufacturer instructions Insulin Aspart (Novolog) Flex Pen dated 2019, directed users to cleanse the hub, apply needle, and prime the pen with 2 units of insulin. Administration instructions included keeping the needle in the skin with the button fully pressed for at least 6 seconds before removing the needle. During a medication observation on 11/15/23 at 8:54 a.m., licensed practical nurse LPN-C determined R25 should get 7 units of scheduled Novolog insulin and 4 additional units for sliding scale coverage. LPN-C applied the needle to the pen, and primed the pen with 1 unit of insulin. LPN-C determined R25 should also get 12 units of Lantus. LPN-C placed a needle on the pen, and primed the pen with one unit of insulin. LPN-C administered Lantus insulin in R25's right arm and left the needle in R25's arm for an approximated 4 to 5 count before they withdrew the needle. LPN-C then administered Novolog insulin in R25's right arm and left the needle in R25's arm for an approximated 3 to 4 count before they withdrew the needle. During an interview on 11/15/23 at 9:13 a.m., LPN-C stated she left each needle in R25's arm for about 1-2 seconds before pulling it out. This was done to prevent insulin from leaking out of the injection site. During a follow-up interview on 11/17/23 at 9:10 a.m., LPN-C stated they always primed insulin pens with one unit of insulin and verified that is how they had primed R25's observed doses on 11/15/23. During an interview on 11/17/23 at 9:38 a.m., the director of nursing (DON) stated they would need to look at R25's pen administration instructions before they stated how long the insulin pen should remain in the injection site. The purpose of leaving the needle in the injection site was to ensure the full administered dose was received. The DON confirmed leaving the needle in the injection site for 1-2 seconds post administration was not an adequate amount of time for proper insulin administration. To ensure an insulin pen is properly primed, two units should be dialed up and then wasted prior to dialing the number of units to be administered. The DON confirmed one unit of insulin was not adequate to prime an insulin pen. The undated, facility policy titled Subcutaneous Injections did not address medication administration with an insulin pen.

Based on observation, interview, and document review, the facility failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days for 2 of 5 residents (R12, R28) reviewed for unnecessary medications. Findings include: R12: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12's diagnoses included dementia, anxiety, and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). In addition, R12 was severely cognitively impaired. R12's care plan dated 11/17/22, identified R12 was taking Ativan (lorazepam) as needed for agitation, discomfort, dyspnea (shortness of breath), and end of life care. Interventions included to administer as needed medications, monitor for medication side effects, and pharmacist to review medications. R12's Order Summary Report dated 2/16/23, identified lorazepam oral tablet 0.5 milligrams (mg) by mouth every six hours as needed for pain. The order lacked a duration and/or a stop date. During an interview on 11/17/23 at 11:08 a.m., consultant pharmacist (CP)-E stated the lorazepam should have had a periodic review. CP-E stated the medication should have been re-assessed every six months because it was part of a group of medications that had great risks associated with their use. 45842 R28: R28's significant change MDS dated [DATE], identified R28's diagnoses included hip fracture and protein malnutrition. In addition, R12 was cognitively intact R28's care plan dated 1/21/22, identified R28 was taking Ativan (lorazepam) as needed for pain. Interventions included to administer as needed medications, monitor for medication side effects, and pharmacist to review medications. 28's Order Summary Report dated 2/24/22, identified lorazepam oral tablet 0.5 milligrams (mg) by mouth every four hours as needed for anxiety. The order lacked a duration and/or a stop date. During an interview on 11/17/23 at 11:08 a.m., consultant pharmacist (CP)-E stated the lorazepam should have had a periodic review. CP-E stated the medication should have been re-assessed every six months because it was part of a group of medications that had great risks associated with their use. During an interview on 11/17/23 at 1:38 p.m., the director of nursing stated as needed lorazepam orders were only good for 14 days unless the provider wrote the order for longer. There should be a stop date and documentation of the necessity of the drug before it could be ordered again. Facility Medication Regimen Review policy undated, identified the consultant pharmacist would review the medication regimen of each resident monthly in order to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. In addition, the policy identified all as needed psychotropic medications would be limited to 14 days.

Based on interview and record review, the facility failed to consistently monitor dialysis access site for 1 of 1 resident (R32) reviewed for dialysis care. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of dependence on renal dialysis and end stage renal disease. R32 received dialysis while at the facility. The significant change MDS did not include a documented cognitive assessment, however R32's admission MDS completed on 9/15/23, identified R32 had moderate cognitive impairment. R32's care plan dated 9/15/23, identified the following hemodialysis interventions. No blood draw left arm, monitor/document/report to MD [doctor] any s/sx [signs or symptoms] of infection to access site such as redness, swelling, warmth or drainage. Monitor/document/report to MD for s/sx of bleeding, hemorrhage, bacteremia, and/or septic shock. R32's current order list dated 9/15/23, identified the following orders. Check dialysis fistula left arm for bruit (swishing sound to indicate patent) one time a day, monitor left upper arm fistula each shift and contact dialysis unit or on-call after hours provider with any concerns including: hemorrhage, site infection, and/or hypotension. The undated treatment record (TAR) provided by the facility identified R32's dialysis fistula (access site) was not assessed for bruit (excluding refusal) 25 times between the dates of 10/1/23, and 11/16/23. Non-assessed days included 12 dialysis treatment days where R32's access site was not assessed for bruit upon return to the facility. The undated medication administration record provided by the facility identified R32's access site was assessed three shifts a day for bleeding, hemorrhage, bacteremia, and septic shock for all but six shifts in the given time period (excluding refusal and when documented R32 was out of the building) of 10/1/23, and 11/16/23. On 11/15/23 at 8:30 a.m., R32's left arm access site was covered with a dressing and tape. R32 stated some nurses at the facility checked his site when he got back from dialysis and indicated his fistula was so loud that it wasn't a problem to hear it. During an interview on 11/16/23 at 1:24 p.m., licensed practical nurse (LPN)-E stated R32's access site got assessed for bruit, bleeding, and infection on the day shift but often not on dialysis days because R32 left the facility during the night shift at 5:30 a.m., and often did not return until later in the evening shift. On 11/16/23 at 2:30 p.m., the director of nursing (DON) printed the facility provided TAR and made notes on the TAR to indicate days R32 was out of the facility for part of the day. DON stated on dialysis days R32 left the facility before the day shift started and typically returned around 9:00 p.m. It was also not uncommon for R32 to leave the facility for extended periods of time on non-dialysis days. If R32's access site did not get assessed for bruit on the day shift, it should be passed on to the next shift the daily bruit assessment still needed to be done. The DON stated it was important for R32's access cite to be assessed post dialysis and indicated on dialysis days they expected nurses to assess the site when R32 returned to the facility. In addition to assessment for infiltration, bleeding, and signs of infection, the site should be assessed for bruit to make sure the access site was still functioning correctly. The order is scheduled as due on the day shift, but will need to be modified because when the bruit assessment is still due for the day, it is not getting carried over to the afternoon or night shift for completion. All facility polices and protocols related to dialysis resident treatment and assessment was requested. The undated, Comprehensive Home Care Resource Manual did not include assessment parameters for the access site other than stating staff will be trained in the care and monitoring of the dialysis access site and emergency procedures pertaining to the access site.

Based on interview and document review, the facility failed to ensure a baseline care plan was provided in writing for 1 of 1 resident (R33) reviewed for care plans. Findings include: R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had diagnoses which included bipolar disorder, diabetes, hyperlipidemia, and hypertension. In addition, R33's MDS identified R33 was moderately cognitively intact. R33's Initial Care Plan dated 10/9/23, had signature areas for the resident/resident representative and staff signatures. All the signatures and the date at the bottom of the care plan were blank. During an interview on 11/14/23 at 12:55 p.m., R33 stated he had not had a care conference meeting since admission. During an interview on 11/17/23 at 8:48 a.m., the director of nursing (DON) stated residents should have and be provided with a written copy of their 48 hour care plan within five days of admission. The DON stated the assistant director of nursing (ADON) had a meeting with R33 but the ADON, the resident, nor any staff had signed or dated the paper. The DON stated it was important for residents to be involved with planning their care so they would receive person centered care. A policy on baseline care planning was requested but not provided.

Based on interview and document review, the facility failed to complete a significant change in status assessment (SCSA) when two or more areas of change in resident status were noted on the Minimum Data Set (MDS) for 1 of 1 resident (R23) reviewed for activities of daily living (ADLs). Findings include: R23's quarterly MDS dated [DATE], identified severe cognitive impairment and diagnoses which included dementia, hypertension, anxiety and Chronic obstructive pulmonary disease. The MDS also indicated R23 was not on oxygen, was not using opiods, was set up only for baths, and independent with all other ADLs. R23's provider orders dated 10/5/23, identified oxygen 2 liters per minute as needed to keep sats greater than 90% was started. R23's provider orders dated 11/3/23, identified liquid morphine 20 milligrams (mg) per milliliter , give 5 mg by mouth every 4 hours as needed for shortness of breath (SOB) was started. R23's medical records identified the following: -10/24/23, pharmacist met with interdisciplinary team to discuss R23's frequent use of morphine for breathing and SOB. -10/31/23, family requested a hospice evaluation due to R23 having a decline in respiratory status and needing increased assistance with all ADLs. -11/3/23, R23 was seen by provider for increased SOB. Morphine orders changed to increase frequency of use for SOB. -11/16/23, family of R23 requested change to total bed bath as showering was too taxing on her respiratory status. During interview on 11/16/23 at 8:25 a.m., licensed practical nurse (LPN)-E stated R23 had several declines since the beginning of October, 2023. R23 was requiring oxygen all of the time because of SOB, required frequent usage of morphine because of SOB and had required assistance of at least one staff member for all ADL cares. Hospice had evaluated R23 but not sure if they had admitted her. During interview on 11/17/23 at 10:18 a.m., the MDS coordinator (MC) stated she had noticed the documentation related to significant changes in R23's medical health conditions and ADL's. MC was aware the changes had been ongoing declines and not related to an acute illness since October, 2023. It was expected that hospice was going to be started and MC did not want to do two different SCSA's for R23. MC was not aware that hospice had not admitted R23, but acknowledged that an SCSA should have been done with the changes that were documented. During interview on 11/17/23 at 11:30 a.m., the director of nursing (DON) confirmed a SCSA should have been completed for R23. The facility policy for SCSA and MDS changes was requested but not provided. The CMS's (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual pages 2-21 through 2-28 identified 03. Significant Change in Status Assessment (SCSA). Assessment Management Requirements and Tips for Significant Change in Status Assessments: A SCSA is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident current status to the most recent comprehensive assessment and any subsequent quarterly assessments; and The resident's condition is not expected to return to baseline within two weeks. Guidelines for Determining a Significant Change in Resident Status: The final decision what constitutes a significant change in status must be based upon the judgment of the IDT (interdisciplinary team). MDS assessments are not required for minor or temporary variations in resident status - in these cases, the resident's condition is expected to return to baseline within two weeks. However, staff must note these transient changes in the resident status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. Some Guidelines to Assist in Deciding If a Change is Significant or Not: Decline in two or more of the following: Any decline in an ADL physical functioning area where a resident is newly coded as extensive assistance, total dependence, or activity did not occur; Resident incontinence pattern changes or there was placement of an indwelling catheter.

Based on interview and document review, the facility failed to develop a consistent system to ensure cardio-pulmonary resuscitation (CPR) status was accurately reflected throughout the medical record to ensure 2 of 2 residents (R34, R35) who wanted CPR initiated in the event breathing and pulse ceased, would receive the appropriate care and services; and failed to ensure do not resuscitate (DNR) orders were signed by each resident's physician, and a system to identify residents' DNR status was accurate for 3 of 3 residents (R4, R26, R14) who did not want CPR performed. This resulted in an immediate jeopardy (IJ) situation for residents at risk for death in the event of cardiac/respiratory arrest, and/or serious bodily injury for residents who might be resuscitated when they had elected a DNR status. The immediate jeopardy began on [DATE], when it was determined the facility failed to ensure resident code status documentation reflected each resident's current resuscitation preferences and physician's orders [REDACTED]. The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ at 11:35 a.m. on [DATE]. The IJ was removed on [DATE], but non-compliance remained at a lower scope and severity of an E, a pattern, which indicated no actual harm with potential for more than minimal harm which is not immediate jeopardy. Findings include: R34's Admission Record printed [DATE], indicated R34's [DIAGNOSES REDACTED]. R34's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R34 had severely impaired cognition. R34's admission orders [REDACTED] R34's POLST (Physician order [REDACTED]. The POLST document was signed by the resident and physician on [DATE]. R34's Consolidated Order Report dated [DATE], indicated R34 had orders to receive CPR should it be needed. The report listed the order start date as [DATE]. R34's care plan dated [DATE], indicated R34 requested to be a full-code status, and staff was to perform CPR. A progress note dated [DATE], at 4:22 p.m. indicated R34 was admitted to the facility and was a full-code status. On [DATE], at 7:55 p.m. R34's room nameplate was observed to have a black border. On [DATE], at 7:57 p.m. nursing assistant (NA)-H was interviewed. NA-H stated if a resident's room nameplate had a gold border it indicated a resident should receive CPR, but if a resident's room nameplate had a black border it indicated the resident was DNR. NA-H confirmed R34's room nameplate had a black border, and stated CPR would not be performed. On [DATE], at 8:12 p.m. R34 was interviewed. R34 stated she wished to receive CPR in the event her heart were to stop beating, or if she would stop breathing. R34 stated resuscitation was when they pump on you to try to bring you back. R34 did not recall ever changing her code status. On [DATE], at 8:28 p.m. licensed practical nurse (LPN)-C was interviewed. LPN-C stated a resident code status was determined by looking at the nameplate located outside of the resident's room. LPN-C verbalized a gold border indicated a resident wanted CPR, and a black border meant a resident was DNR. LPN-C confirmed the nameplate outside of R34's room had a black border, and stated the resident would not receive CPR. R34's POLST document was then reviewed with LPN-C, and she confirmed the document indicated R34 wanted to be a full-code, and would want CPR initiated if needed. Upon recognizing the inconsistency, LPN-C stated she believed R34 would receive CPR, and said she would check the POLST document first. LPN-C stated she would notify the facility of the discrepancy immediately. R35's Admission Record printed [DATE], indicated R35's [DIAGNOSES REDACTED]. R35's quarterly MDS dated [DATE], identified R35 had severely impaired cognition. R35's POLST dated [DATE], indicated the resident wanted to receive CPR in the event her heart stopped beating or she stopped breathing. The POLST document was signed by a physician on [DATE]. R35's care plan dated [DATE], indicated the resident/family requested R35 be a full-code status. Interventions included performing CPR. On [DATE], at 7:42 p.m. R35's room nameplate was observed to have a black border. R4's Admission Record requested [DATE], indicated R4's [DIAGNOSES REDACTED]. R4's quarterly MDS dated [DATE], identified R4 had severe cognitive impairment. R4's POLST dated [DATE], identified boxes were checked which indicated DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death) and LIMIT INTERVENTIONS AND TREAT REVERSIBLE CONDITIONS . The document was signed by a physician on [DATE]. R4's signed physician orders [REDACTED]. On [DATE], at 8:15 p.m. R4's room name plate was observed to have a gold border. On [DATE], at 8:31 p.m. the director of nursing (DON) verified R4 would get CPR, against her preferences, if the staff looked at her door name plate in the event her heart stopped beating or she stopped breathing. The DON verified R4's name plate had a gold border, which indicated R4 was to have CPR, in contrast to R4's POLST which indicated R4 should be DNR. R26's Admission Record requested [DATE], indicated R26's [DIAGNOSES REDACTED]. R26's quarterly MDS dated [DATE], identified R26 had severe cognitive impairment. R26's POLST dated [DATE], identified boxes were checked which indicated DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death) and LIMIT INTERVENTIONS AND TREAT REVERSIBLE CONDITIONS . The document was not signed by the resident's physician. R26's signed physician orders [REDACTED]. R26's Treatment Administration Record (TAR) for ,[DATE], indicated R26's Advance Directive was CPR, DNR. R26's Medication Administration Record [REDACTED]. On [DATE], at 8:16 p.m. an interview was conducted with R26. R26 confirmed she did not want to be resuscitated in the event her heart were to stop beating or she stopped breathing. R26's door name plate had a black border, indicating R26 preferred to be DNR. On [DATE], at 8:31 p.m. the DON verified R26 would receive CPR if the staff looked at R26's electronic medical record (eMR) header or her POLST because R26's POLST was not signed by a physician, and R26's eMR header lacked indication of R26's advanced directives. The DON stated if a POLST was not signed by a physician it was not valid, and the resident would get CPR, regardless of the resident's expressed wishes. On [DATE], at 11:00 a.m. a progress note identified R26's POLST document was signed by R26, and indicated R26 desired a DNR status. The progress note further indicated the POLST document was not signed by a physician, the resident was informed the POLST was not valid, and CPR would be performed until a physician signed the POLST document. R14's Admission Record printed [DATE], indicated R14's [DIAGNOSES REDACTED]. R14's MDS dated [DATE], identified R14 had moderately impaired cognition. R14's care plan dated [DATE], indicated R14 had requested a do not resuscitate (DNR) status. R14's POLST undated, identified boxes were checked which indicated DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death) and LIMIT INTERVENTIONS AND TREAT REVERSIBLE CONDITIONS - Provide interventions aimed at treatment of [REDACTED]. Duration of invasive or uncomfortable interventions should generally be limited. The document was not signed by a physician. R14's care plan dated [DATE], indicated R14 had requested a DNR status. The care plan further indicated no CPR was to be performed. On [DATE], at 7:42 p.m. R14's room name plate was observed to have a black border indicating no CPR. R14's medical record contained a POLST in the paper chart dated [DATE], signed by the physician indicating CPR. The POLST had VOID written in large letters and had a line drawn across the face of the paper. Another POLST was located in the front pocket of the paper chart listing DNR however, the document was unsigned by the physician. On [DATE], at 8:14 p.m. R14 was interviewed. R14 stated, If my heart stops, let me go. On [DATE], at 7:32 p.m. licensed practical nurse (LPN)-A stated she would look at the resident's door name plate in the event the resident's heart stopped beating or the resident was not breathing. LPN-A was not sure exactly what the name plates meant, though she said she thought a black border meant DNR, and a gold border meant the resident should receive CPR. LPN-A stated she would then look at the POLST in the red envelope in front of the chart or under the Advanced Directives tab in the chart, if she weren't sure. LPN-A stated if the POLST said DNR, but was not signed by the physician, it would be considered not valid and she would do CPR. On [DATE], at 7:34 p.m. the DON stated the staff would look at the door plate in the event a resident was not breathing or had no heart beat. The DON stated the black border on the door name plate meant DNR, and a gold border meant full code or CPR. The DON stated if the staff were out of the resident's room, they would look at the computer, the POLST in the medical record, or send someone to look at the door name plate. The DON verified R14 had a black name plate indicating no CPR. The DON verified if the POLST was not signed, the POLST would be invalid, and CPR would be initiated. On [DATE], at 8:33 p.m. additional interview was conducted with the DON. The DON verified a resident who had an unsigned POLST would receive CPR , and confirmed the black border on a resident's room nameplate indicated the resident would not receive CPR. The DON stated code status was reviewed on admission, after each hospitalization , and annually with the interdisciplinary team. The DON stated the admitting nurse addressed a POLST with the resident upon admission. The DON further stated the admitting nurse was suppose to address the POLST on admission to the facility, and stated the POLST would then get faxed to the physician for signature, unless the physician was expected to round in the next few days in which case, the POLST would be posted for the physician to address during rounds. On [DATE], at 2:47 p.m. the administrator was interviewed. The administrator stated the facility did not really have a policy in regards to advanced directives. The administrator stated the facility pulled policies from other sources. The facility's [DATE] revised policy, Do Not Resuscitate Order, directed: The Do Not Resuscitate orders must be signed by the attending physician, and on the physician's orders [REDACTED]. The policy further indicated there was to be an interdisciplinary care planning team review of advance directives with the resident during quarterly care planning meetings. The policy lacked directives regarding referring to the door name plates to indicate a resident's advanced directive code status. The facility ,[DATE] revised policy, Advance Directives, directed if there were no Advance Directive upon admission, the resident or resident representative would be asked during the admission process. Further, the policy directed to not do CPR if there was a physician order [REDACTED]. The policy and procedure lacked directives regarding referring to the door name plates to indicate a resident's advanced directive code status. The IJ which began on [DATE], was removed on [DATE], when the facility had developed and implemented a Resuscitation Order policy, and it could be verified through interview and record review staff had been educated on the policy. In addition, residents POLST status were reviewed throughout the facilty to verify completion including physician signature. All resident room name plates were modified to be consistent, and staff were educated to verify code status by review of the residents' charts. It was also verified by interview with the DON and administrator regular audits had been initiated to verify current signed physician orders [REDACTED]. Although the IJ was removed, noncompliance remained at the lower scope and severity level of [NAME] while the facility continued to educate staff, and conduct audits to verify their revised system was effective.

Based on observation, interview, and document review, the facility failed to ensure care and services were provided to reduce or prevent the development of, or worsening of pressure ulcers for 2 of 3 residents (R54, R1) reviewed for pressure ulcers. This resulted in actual harm for R54. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. R54's [DIAGNOSES REDACTED]. R54's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R54 had moderate cognitive impairment, and was independent with bed mobility, transfers, ambulation, dressing, toileting and personal hygiene. The MDS further indicated R54 was not at risk for, and did not have any pressure ulcers. On 10/24/16, a progress note indicated R54 returned to the facility from the hospital due to a left [MEDICAL CONDITION]. On 10/24/16, a Skin Ulcer Risk Assessment and Care Plan Tool indicated R54 had no history of pressure ulcers, and no skin problems were identified. The Braden Scale (for predicting pressure ulcer risk) dated 10/24/16, indicated R54 was low risk for pressure ulcers. On 10/25/16, a progress note indicated R54 had no special treatments, and had routine skin care. On 10/26/16, a Bed Tissue Tolerance Test (a test to determine the ability of the skin and its supporting structures to endure the effects of pressure without adverse effects) determined R54 needed to be repositioned every two hours or when needed. On 10/31/16, a 5 day MDS indicated R54 required extensive assistance from staff with bed mobility, transfers, dressing and toileting. The MDS identified R54 had not ambulated. The MDS further indicated R54 did not have a pressure ulcer, but he was at risk for pressure ulcers, and had a pressure reducing device in the chair. The MDS indicated R54 did not have a pressure reducing device on his bed and he was not on a turning and repositioning program. On 11/2/16, a progress note identified R54 had a suspected deep tissue injury (SDTI) on the left heel that measured approximately 3 centimeters (cm) by 5.6 cm. The progress note also identified R54's left buttock had a red area that measured 6 cm by 2.4 cm, with an open area within that measured 2.4 cm by 2.2 cm. A progress note also indicated the physician was updated on the pressure ulcers, an Allevyn (a padded adhesive dressing) was was ordered, and an air mattress was provided for R54's bed. On 11/3/16, a progress note identified the pressure ulcer measurement consisted of: left heel SDTI 3.5 cm by 6 cm. Left buttock SDTI measured 6 cm by 4.5 cm, with a superficial open area with a red center that measured 4 cm by 2 cm. On 11/6/16, a progress note indicated the pressure ulcer measurement on the buttock was worse, and measured 6.2 cm by 4.8 cm. The pressure ulcer had a foul smell and black areas. The MD gave an order for [REDACTED]. On 11/7/16, the 14 day MDS indicated R54 continued to require extensive staff assistance with bed mobility, transfers, dressing, and toileting. The MDS indicated R54 ambulated with extensive staff assistance. The MDS further indicated R54 was at risk for pressure ulcers, and had two Unstageable pressure ulcers that were not present on the prior assessment. The MDS identified R54 had pressure reducing devices on the bed and in the wheelchair, but was not on a turning and repositioning program, and did not have any nutrition or hydration interventions to manage skin problems. On 11/10/16, a Nursing Home/Clinic Transfer Form indicated R54 had been seen at the wound clinic. Orders included to reposition every him two hours when sleeping and every one hour when awake, offload as much as possible, wear heel protectors in bed, and encourage R54 to use his hands to move the wheelchair and not his feet. The left buttock was a Stage 2 pressure ulcer and the left heel was an Unstageable pressure ulcer. On 11/16/16, a progress note indicated R54 left for a wound clinic appointment. On 11/17/16, a progress note indicated the facility called the wound clinic for an update on R54. R54's pressure ulcer on his left hip had been debrided, and R54 had been admitted to the intensive care unit (ICU) for intravenous (IV) antibiotics due to an infection in the pressure ulcer. On 11/20/16, R54 returned to the facility. A Braden Scale determined R54 was low risk for pressure ulcers. An Admission Skin Assessment was completed and identified R54's left heel SDTI, and the Stage 3 pressure ulcer on the left buttock. On 11/21/16, a Bed Tissue Tolerance Test was performed and determined R54 needed to be repositioned every two hours at night and every one hour when awake. On 11/27/16, a 5 day MDS indicated R54 had one Stage 3 pressure ulcer and one Unstageable pressure ulcer. R54 had pressure reducing devices on the bed and in the wheelchair, and was on a turning and repositioning program. The MDS indicated R54 did not have any nutrition or hydration interventions to manage skin problems. On 11/28/16, a progress note indicated R54's left buttock pressure ulcer had worsened to a Stage 4 pressure ulcer. The pressure ulcer measured 3.7 cm by 2.5 cm, and was three inches deep. R54 had a wound clinic appointment the next day. On 11/29/16, the Wound Clinic Transfer Form dated 11/29/16, indicated the ROHO cushion in the wheelchair needed to be evaluated and inflated as it was bottoming out. On 12/4/16, R54's 14 day MDS dated [DATE], indicated R54 had one SDTI and one Stage 4 pressure ulcer. R54 had pressure reducing devices on the bed and in the wheelchair, and was on a turning and repositioning program. The MDS identified R54 did not have any nutrition or hydration interventions to manage skin problems. On 12/6/16, the Wound Clinic Transfer Form indicated the ROHO cushion was not relieving the pressure and needed to be replaced. A 12/12/16, a late entry progress note (did not provide the correct date for the note) indicated the left buttock pressure ulcer was a Stage 4 and measured 3.5 cm by 2 cm and was 3 inches deep. The pressure ulcer had undermining (deep tissue damage around the wound margin) through the whole wound that measured 0.5 cm to 2.4 cm. The left heel SDTI measured 4 cm by 5.6 cm. On 12/16/16, a Wound Clinic Transfer Form directed to increase the dressing changes to three times a day. The wound clinic spoke with therapy about inflating the ROHO cushion. On 12/19/16, a progress note indicated the left heel SDTI measured 3.2 cm by 3.8 cm and was decreasing in size. The left buttock pressure ulcer measured 3 cm by 1.5 cm by 3.2 cm and had tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation) measured 4.5 cm. On 12/20/16, R54's 30 day MDS indicated R54 had one SDTI and one Stage 4 pressure ulcer. R54 had pressure reducing devices on the bed and in the wheelchair, and was on a turning and repositioning program. R54 did not have any nutrition or hydration interventions to manage skin problems. A 12/26/16, a late entry (did not provide the correct date for the note) indicated the left buttock pressure ulcer was a Stage 4 and measured 2.5 cm by 1.8 cm by 3.7 cm. The tunneling measured 4.8 cm. The note further indicated Occupational therapy had replaced R54's wheelchair base seat the previous week. The care plan dated 12/29/16, indicated R54 had a Stage 4 pressure ulcer on the left gluteal (buttocks) and SDTI on the left heel. R54 was at risk for further pressure ulcers related to impaired mobility. The care plan directed staff to administer treatments as ordered and monitor for effectiveness, alternating pressure mattress on the bed, ROHO (air) cushion on the wheelchair, assist R54 to turn and reposition at least every two hours and more often as needed or requested when in bed, and every one hour when in the wheelchair, monitor nutritional status, serve diet as ordered, monitor and record intake, monitor, document and report to the physician any changes in skin status, and wears a left heel boot. The nursing assistant (NA) care sheet (not dated) indicated R54 was to have a heel lift boot on the left foot when in bed, the wheelchair and during transfers. The care sheet did not direct how often to reposition R54. On 12/31/16, R54's annual MDS indicated R54 had one SDTI and one Stage 4 pressure ulcer. R54 had pressure reducing devices on the bed and in the wheelchair, and was on a turning and repositioning program. R54 did not have any nutrition or hydration interventions to manage skin problems. On 1/1/17, the Pressure Ulcer Care Area Assessment (CAA) R54 required extensive staff assistance with bed mobility, and had a current Stage 4 pressure ulcer on the left buttock, and a SDTI on the left heel. The wounds were being managed by the wound clinic. Nursing was to change the dressings as ordered, and monitor the wounds for signs and symptoms of infection or worsening condition. R54's goal was that he would be free from further pressure related skin injury through the next review. The CAA failed to comprehensively assess R54's risk for pressure ulcers, and his current pressure ulcers. On 1/11/17, the Nutrition CAA indicated R54 required extensive assistance with bed mobility and had a Stage 4 pressure ulcer on the left buttock, and a SDTI on the left heel. R54's protein was adequate to assist in healing. The CAA further indicated the dietary director would speak with the consultant this month for other possible interventions. On 1/12/17, the progress notes indicated the facility received a new order for nutritional supplement per dietary recommendations due to a 12 pound weight loss in the past month, and to aid in wound healing. In addition the physician ordered a multivitamin with minerals and vitamin C. On 1/13/17, the progress notes indicated the facility spoke with the wound clinic about miscommunication for the wound treatment as the pressure ulcer on the buttocks appeared to be closing from the outside. Treatment orders were changed to wet to dry dressings due to that was the treatment the facility was doing while they were out of the Mesalt (a sodium chloride impregnated gauze). R54's next appointment was changed from 1/25/17 to 1/16/17. On 1/25/17, the progress notes indicated the pressure ulcer on the buttocks had an exposed tendon present, and the remainder of the pressure ulcer was 100% red beefy tissue. The pressure ulcer measured 1.2 cm in length, 0.8 cm in width and was 2 cm deep. Tunneling was 4 cm deep. Undermining was present and was approximately 1.2 cm. The inside of the ulcer was healing slowly and the outer ulcer opening edges were rolling and contracting. The left heel pressure ulcer measured 2.8 cm long by 3.5 cm wide. The ulcer was slowly decreasing in size. Zinc was ordered for two weeks and dietary would add protein. On 1/31/17, the director of nursing (DON) entered a progress note that indicated R54's repositioning in the bed and the wheelchair was changed to every two hours per the 11/20/16, hospital discharge orders. This was an increase in the repositioning time while up in the wheelchair, despite the deterioration in the pressure ulcers, and was not based on an assessment. On 1/31/17, R54 had continuous observation from 5:30 p.m. until 6:10 p.m. At 5:30 p.m. R54 was observed up in the wheelchair in the unit dining room for supper. A heel lift boot was on the left foot. At 5:50 p.m. R54 removed himself from the dining area and returned to his room. An alternating pressure mattress was observed on the bed. At 6:10 p.m. R54 was assisted to the toilet by staff and then returned to the wheelchair. On 2/1/17, R54 had continuous observation from 7:00 a.m. until 8:40 a.m. At 7:00 a.m. R54 was observed up in the wheelchair in the unit dining room for breakfast. At 7:45 a.m. R54 exited the dining room, was weighed, brought to his room by staff and remained up in the wheelchair. At 8:23 a.m. nursing assistant (NA)-A assisted R54 on to the toilet. A properly inflated ROHO cushion was observed on the seat of the wheelchair. NA-A then assisted R54 onto the bed and positioned R54 onto the right side. The heel lift boot remained on the left foot. At 8:40 a.m. R54 requested to get up in the wheelchair. NA-A assisted R54 into the wheelchair. On 2/1/17, at 2:41 p.m. R54's pressure ulcers were observed. The pressure ulcer on the buttock measured 0.9 cm long, 0.9 cm wide with 4 cm tunneling and 2.1 cm undermining. The pressure ulcer appeared to be a hole on the left buttock with rolled edges. The left heel pressure ulcer had a round black area with lifted edges that covered the entire heel. On 2/1/17, at 12:39 p.m. NA-B stated R54 had a pressure ulcer on his buttocks. NA-B stated R54 was to be repositioned every two hours and R54 liked a pillow under the left hip when in the wheelchair to get some of the pressure off and his foot was to be on the foot rest. NA-B further stated R54 did not complain of pain very often. If he has pain he requests to get off of his buttocks. On 2/1/17, at 1:05 p.m. NA-A stated he takes care of R54 the most. NA-A stated R54 had a pressure ulcer on his buttocks. R54 was to be turned and repositioned every two hours unless he requested to be repositioned more often. R54 did not complain of pain. R54 will request to get off of his buttocks because he is tired of sitting. NA-A further stated sometimes R54 will stay laying down for five minutes and sometimes he will lay down for an hour. R54 always lays on his right side and does not complain of heel pain. On 2/01/17, at 12:41 p.m. licensed practical nurse (LPN)-B stated R54 had a pressure on the left side of his buttocks and was seen at the wound clinic. LPN-B stated R54 had a circulating air mattress on the bed and special cushion in the wheelchair. R54 was to be repositioned every two hours when in bed and in the wheelchair. LPN-B stated R54 did not complain of pain during the pressure ulcer treatment. On 2/1/17, at 1:18 p.m. the DON stated skin risk assessments and the Braden Scale were done on admission, re-admissions, weekly for four weeks and quarterly. The assessments were completed by the floor nurse, either a licensed practical nurse (LPN) or a registered nurse (RN). If a resident was at risk for pressure ulcers an additional air mattress would be added to the bed, a cushion would be added to the wheelchair, and the resident would be repositioned as assessed by the Tissue Tolerance Test. The DON further stated if a resident had a pressure ulcer, the facility would fill out an incident report, notify the physician and ask for a referral to the wound clinic. The DON was informed R54 returned from the hospital on [DATE]. The DON verified the MDS dated [DATE], indicated R54 did not have any pressure ulcers and was at risk for pressure ulcers, lacked a pressure reducing device on the bed, and was not on a turning and repositioning program. The DON stated she would expect the device on the bed and the repositioning program. The DON verified R54's skin broke down on 11/2/16, and an air mattress was placed on the bed that day. The DON verified the 14 day MDS dated [DATE], indicated R54 had two Unstageable pressure ulcers, he was not on a turning and repositioning program, and did not have any nutritional interventions. The DON stated turning and repositioning should have been implemented at that time. The DON further verified R54 was hospitalized and received intravenous (IV) antibiotics for the wound on 11/17/16. The DON verified the five day MDS dated [DATE], identified a turning and repositioning program, but lacked nutrition or hydration interventions to manage skin problems. The DON stated dietary was informed of the pressure ulcer and should have assessed R54. The DON verified the 14 day MDS dated [DATE], the 30 day MDS dated [DATE], and the annual MDS dated [DATE], lacked nutrition and hydration interventions. The DON verified a nutritional supplement, a multivitamin with minerals and vitamin C was added on 1/12/17, for wound healing. When asked if it was common practice to notify the dietitian two and a half months following the development of a pressure ulcer, the DON did not respond. The DON stated she changed R54's repositioning to every two hours when awake on 1/31/17, following review of his chart, and verified it was not based on an assessment. The DON stated R54 was laying down on days and afternoons as it made it easier for R54 to attend activities. On 2/1/17, at 1:44 p.m. the occupational therapist (OT) stated R54's wheelchair seat was evaluated, and a hard pan seat was placed on the wheelchair. The OT stated the ROHO cushion contracted when R54 was going to the wound clinic due to the cold outside temperatures. The OT further stated the ROHO cushions were checked daily, and staff tried to get R54 out of the chair and walk, but R54 liked to spend a lot of time in the wheelchair. On 2/1/17, at 2:06 p.m. the dietary manager (DM)-D stated if a resident had a pressure ulcer she would make sure the resident was getting enough protein and calories to help it heal. The DM-D stated she would also add zinc to the diet, and would discuss it with the dietitian. The DM-D further stated R54's protein was increased, and when R54 lost weight a nutritional supplement was added. The DM-D stated she finds out about pressure ulcers from morning report, or the wound nurse will tell her. The DM-D stated she reviewed the history and physical when a resident returned from the hospital, or when there was a new admission. The DM-D stated she was unsure when she was made aware of R54's pressure ulcer. On 2/1/17, at 3:15 p.m. the DM-D stated she became aware of R54's pressure ulcers when reviewing the progress notes for the annual MDS. On 2/2/17, at 11:38 a.m. the DM-D stated the facility had a monthly high risk meeting where weight loss and skin issues were discussed. The DM-D further stated R54 was discussed at the 1/31/17, meeting, but not prior. R54 was brought up at the meeting due to the pressure ulcers, an acute illness, recent [MEDICAL CONDITION], and a weight loss of 12 pounds in December, 2016. The facility's Prevention of Pressure Ulcers policy dated 3/05, indicated the purpose of the policy was to provide identification of pressure ulcer risk factors and intervention for specific risk factors. The policy further directed to when in bed, change the resident's position every two hours or more frequently if needed, and determine if the resident needs a special mattress. For a resident in a chair, change the position at least every hour and use a gel or air cushion to relieve pressure. The dietitian would assess the resident's nutrition and hydration and make recommendations based on the individual assessment. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had a severe cognitive impairment, required extensive assist of one staff for bed mobility, transfers, and toilet use. R1 was frequently incontinent of bladder and occasionally incontinent of bowel. R1's MDS further indicated R1 was at risk for pressure ulcers. R1's Admission Record printed 2/2/17, indicated R1's [DIAGNOSES REDACTED]. R1's care plan dated 8/25/14, indicated R1 was at risk for potential pressure ulcers related to immobility and history of pressure ulcers, and had an actual Stage 3 pressure ulcer on the sacral area. R1's care plan with interventions dated 8/25/14, directed staff to monitor nutritional status and intake, and record, and to monitor skin with daily cares and on bath days, and turn and reposition R1 every 2 hours. The nurse and physician were to be notified of changes in skin. R1's care plan with interventions dated 12/29/16, directed staff to ensure a pressure reducing wheelchair cushion and circulating air mattress were in place. The care plan further directed nursing to provide treatment as ordered and notify the physician if signs and symptoms of infection and worsening of the pressure ulcer, or if it were not healing. R1's progress notes dated 12/1/16, indicated R1 had a new pressure ulcer on the upper buttocks, measuring 0.5 centimeters (cm) in diameter. R1's progress notes documentation lacked monitoring of the new pressure ulcer until 12/15/16. R1's progress notes dated 12/15/16, indicated R1 had a Stage 3 pressure ulcer, measuring 0.4 cm x 0.8 cm with a depth of 0.1 to 0.2 cm. The pressure ulcer floor was 40% slough (yellow, dead tissue that adheres to the ulcer floor). The progress notes further indicated an Allevyn dressing (a dressing used for chronic wounds to help protect the ulcer and provide the proper environment to promote healing) was applied. R1's electronic medical record (eMAR) dated 12/28/16, indicated R1's pressure ulcer was decreasing in size and measured 0.4 cm x 0.4 cm and had a depth of 0.1 cm, and the slough was absent. The note further indicated the pressure ulcer floor was 100% red granulation tissue (new tissue that forms on the surface of the wound during healing). The documentation indicated a new Allevyn dressing was applied and [MEDICATION NAME] (a topical antibiotic ointment) was added to help with moisture and redness. R1's progress notes dated 1/2/17, indicated the pressure ulcer was closed. An Allevyn dressing was applied to the fragile tissue. R1's progress notes dated 1/20/17, indicated R1's sacral pressure ulcer continued to be healed. R1's electronic treatment administration record (eTAR) for 12/16, indicated barrier cream with incontinence cares was initiated on 12/1/16, and was put on hold on 12/15/16. The eTAR indicated an Allevyn dressing to sacral area was initiated on 12/15/16, and the eTAR for 1/17, indicated the Allevyn dressing was last applied on 1/9/17. R1's Skin Ulcer Risk Assessment and Care Plan Tool dated 5/7/16, lacked a summary of skin problems and risk factors to determine whether R1 was at risk for pressure ulcers. On 2/2/17, at 11:21 a.m. the dietary manager (DM)-D, stated she did not recall if she had heard that R1 had a pressure ulcer, and verified there was not a formal notification of skin breakdown to the dietary department. DM-D stated she hears in morning report, and then she reviews the intake to make sure it is appropriate. DM-D verified the facility does not have interdisciplinary team meetings to discuss residents with skin breakdown, but stated they have a high risk nutrition meeting to address those nutritionally at risk. DM-D verified she makes notes from meetings in a notebook, and does not enter notes in the electronic medical record. DM-D stated she did not think they had discussed R1 during these meetings. On 2/2/17, at 11:41 a.m. DM-D verified R1 had not been discussed during their high risk meetings. On 2/2/17, at 2:17 p.m. the director of nursing (DON) stated residents with skin breakdown would normally be looked at to make sure they are getting enough nutrition and protein and would be added to the high risk meetings. The DON verified R1 had a history of [REDACTED]. The DON stated the registered nurse (RN) reviewed the cushions after the pressure ulcer developed to make sure there were no pressure areas on the cushions, but verified therapies had not evaluated R1 for positioning or for cushions. The DON stated the interventions were still appropriate because R1's pressure ulcer healed quickly, though she verified the pressure ulcer had worsened between identification on 12/1/16, and documentation on 12/15/16, when the Alevyn dressings were initiated. The DON verified there should have been monitoring, documentation, and treatment of [REDACTED]. The facility's Prevention of Pressure Ulcers policy dated 3/05, lacked direction on frequency of pressure ulcer assessments.

Based on interview and document review, the facility failed to ensure a safe environment when staff did not implement the individualized care plan developed to minimize the risk for falls for 1 of 3 residents (R1) reviewed for falls. The facility's failure resulted in actual harm (facial fractures leading to death) for R1. Findings include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. The nursing assessment dated [DATE] indicated R1 was orientated to person, but not place or time. The nursing assessment dated [DATE], indicated R1 needed supervision for transferring and repositioning. R1 was in the process of being assessed for elopement risk which takes 72 hours. R1 did not have a personal alarm. An admission physical therapy (PT) assessment was completed on [DATE] which indicated R1 required contact guard assist (CGA) by staff at all times. CGA was defined by PT as staff holding on to the resident at all times while ambulating with a walker. R1 was not to be ambulating alone. The initial care plan dated [DATE], identified R1's needs for assistance with ambulation, transfers, and repositioning as well as weakness causing mobility impairments. Review of the facility's Resident/Accident/Incident Report form dated [DATE], at 8:45 p.m. revealed nursing assistant (NA)-A observed R1's body lying on the cement outside of the front door of the building. Licensed Practical Nurse (LPN)-B also responded to the after hours door alarm and was the second to arrive. R1 was lying face down on the sidewalk, moaning with a lot of blood present. Registered Nurse (RN)-C arrived shortly after and started an assessment while LPN-B called an ambulance. In the report, LPN-B indicated R1 had been walking around the facility with her walker, by herself, attempting to get out any door she could open. The fall incident report dated [DATE], indicated R1 was ambulating just prior to the fall. A facility investigative report dated [DATE], indicated at 8:40 p.m. R1 was in the common area. At 8:43 p.m. R1 walked with her walker to tamarack nurses desk. At 8:46 p.m. R1 leaves and ambulated to the front entry area of the facility. The front door alarm went off and upon investigation by staff, R1 was found outside the front door on the sidewalk. The report stated R1 must have gotten the walker entangled in the door way. R1 was admitted to one hospital and transferred to a larger hospital the same night. Due to the extent of the injuries, R1 was placed on comfort cares and died at the hospital. Hospital record dated [DATE] was reviewed The hospital record indicated the resident fell from a standing position. The resident received multiple facial fracture, the hospital needed to intubate the resident to maintain a patent airway. R1 was transferred to a larger hospital for evaluation and due to the severity of the injuries, the family chose comfort care. R1 died at the hospital. R1's death certificate indicated cause of death was complications of cranial facial fractures secondary to a fall. During an interview on [DATE], at 1:10 p.m. the administrator stated she had watched the video surveillance from the night R1 fell . R1 went out the front door and she fell . During an interview on [DATE], at 3:30 p.m. director of nurses indicated after the investigation was completed, R1 should not have been walking by herself. During an interview on [DATE] at 3:40 p.m., RN-F indicated R1 should not have been walking around by herself because she had not been assessed yet. She said R1 was too unsteady to ambulate alone and R1 only knew who she was, not where she was and did not have a concept of time. During an interview on [DATE] at 10:30 a.m. social services (SS)-E indicated she did the admission for R1. She said PT evaluated R1 on [DATE], recommending CGA only. SS-E said R1 should not have been walking by herself. SS-E conducted the investigation following R1's fall and stated LPN-B and RN-C indicated R1 was walking by herself before the fall. R1 was walking from one unit to the next unit. SS-E said R1 was only orientated to who she was. During an interview on [DATE], at 12:05 p.m. nursing assistant (NA)-A stated a staff person told her R1 was ambulating independently. NA-A said there was not a wanderguard or alarm on the wheelchair because R1 was being assessed for the risk of elopement. NA-A said she heard the front door alarm and when she got there and she found R1 on the ground outside the facility. NA-A said the walker was off to the left side and it appeared like R1 had lost her balance. During an interview on [DATE], at 12:30 p.m. Physical therapist (PT)-D indicated she evaluated R1 who needed a CGA at all times. PT-D stated R1 should not have been ambulating independently. During an interview on [DATE] at 12:55 p.m. Licensed Practical Nurse (LPN)-B stated after the evening meal, she saw R1 walking around the unit independently using a walker. She also said R1 was walking on another unit as well. LPN-B said R1 looked like she was looking at other people, but appeared not to have a purpose while walking around. LPN-B indicated residents were assessed by PT and the nurses follow PT's direction. She said PT instructed staff to give R1 standby assist. LPN-B said she did not send anyone to ambulate with R1 because R1 was walking well by herself. LPN-B said she didn't think R1 was in any danger. On [DATE], at 2:55 p.m. the administrator and investigator review the facility video surveillance. The video showed R1 walked around the building independently without staff supervision or CGA. R1 walked through two units, it looked like she talked to another resident, turned around and went into the reception area of the building. R1 pushed opened right door of the double doors and walked out. R1 did not use the push button to automatically open the door, R1 pushed the door open herself. R1 went to the second set of double doors, pushed the right door open herself and fell while going through the door. The video does not show the details of how R1 fell , only of R1 falling. The walker was found by staff in front of the left side of the two doors. An undated facilities fall policy and procedure indicated a fall risk assessment would be completed at the time of admission to the facility. Each resident would receive adequate supervision and assistance to prevent resident falls. And, all residents new to the facility must have close monitoring.