Every finding on record at Courage Kenny Rehabilitation Institutes TRP

Based on observation, interview, and record review the facility failed to identify environmental risks for stairwell doors that had nonfunctioning alarms, disabled locks, and failed to adequately supervise 1 of 3 residents (R1) through the remote monitoring system. This resulted in immediate jeopardy for 1 of 3 residents (R1) who opened a stairwell access door, wheeled through the door, and fell down six stairs while secured by a lap belt in his wheelchair. R1 sustained a hematoma (localized collected of clotted or partially clotted blood outside causing swelling, pain, and skin discoloration) and was sent to the emergency department for evaluation. In addition, the facility failed to have a system in place for routine checks on the fire door alarm system to ensure the employee badges and the resident wander guard (an alarm placed on or near the resident's body to alarm when they attempt to leave the unit) were in working order. This had the potential to affect all residents who resided in the unit. The Immediate Jeopardy (IJ) began on 4/1/26 when R1 fell down the facilities stairwell. The Administrator and the director of nursing were notified of the immediate jeopardy on 4/7/26 at 5:15 p.m. The immediate jeopardy was removed on 4/9/23 at 5:43 p.m., but noncompliance remained at the lower scope and severity, level 2, F - widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: Video surveillance of the incident on 4/1/26 at 4:06 p.m. showed R1 was coming out of his room in his wheelchair headed toward the emergency exit door. He pushed open the door with his left arm, going through the door placed both hands on either the brakes on his wheelchair or the arm rests then the emergency door closed. Two staff were walking into the nursing station office at 4:08 p.m. At 4:12 p.m. the staff walked to the emergency door, opened the door, and appeared to be calling for help. The video surveillance had no auditory recording. Upon observation and interview on 4/7/26 at 12:17 p.m. R1 was seated in his wheelchair in his room with a 1:1 staff. R1 recalled the fall stating he fell down about seven steps, but that is all he could remember. He did not recall whether he was in his wheelchair or not. Upon observation and interview with the maintenance engineer on 4/7/26 at 1:45 p.m. the maintenance engineer used his employee key card to open the door to observe the stairwell where R1 fell. The door opened to six stairs going down and stairs going up. After viewing the stairwell, the surveyor pushed onto the door, the door opened with no alarm sounding or badge use. The maintenance engineer stated that it was a concern, and he would be bringing it up at the following intradisciplinary team meeting the following day. He stated he was not aware that R1 had gotten through the door and fallen down the stairs. He was going to speak with his supervisor, who was at another location and see if he should secure the door until the facility could fix the alarm. R1's consent to remote observation dated 3/11/26 indicated R1 would be monitored remotely via a remote observation video and audio device that is monitored 24 hours a day by a trained observation technologist within the facilities health system. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 6 indicating he was significantly cognitively impaired. R1 required moderate assistance with dressing, sitting to standing, chair to bed transfer, toilet transfer, walking 150 feet. R1 used a wheelchair. R1 was always continent of bowel and bladder. R1's pertinent diagnoses were cerebral infarction (stroke), weakness, acute respiratory failure, dysphagia (difficulty swallowing), dysarthria (motor speech disorder), paralytic gait (abnormal walking), and neurological neglect syndrome (brain damage usually following a stroke. R1's care plan dated 3/23/26 indicated R1 had a seat belt alarm, which was to be on when he was in wheelchair to aid in trunk support. R1's care plan did not include staff supervision until 4/1/26 following his fall. R1's care plan did not include R1 had a wander guard. R1's provider orders dated 4/1/26 indicated to discontinue the remote observation and start hourly rounding. R1's post-fall summary undated, indicated staff responded to a wander guard at the stairs, found R1 face down in the stairs with his wheelchair attached. R1 hit his head with a hematoma (a localized collection of clotted or pooled outside blood vessels caused by trauma, surgery or underlying vascular injury) forming. Emergency medical services were called and R1 was transferred to the hospital. R1's hospital after visit summary dated 4/1/26 indicated R1 was seen for a fall with a hematoma (localized collected of clotted or partially clotted blood outside causing swelling, pain, and skin discoloration) of the frontal scalp. R1's subsequent Transitional Rehabilitation Program note dated 4/2/26 indicated on 4/1/26 R1 was able to open a door to the stairway and fell down the first flight of stairs while still strapped to his wheelchair. He was sent for emergency evaluation. While in the Emergency Department he underwent a trauma workup and no significant injuries were found, besides a contusion on the front of his right forehead. He was set back to the facility that evening. At that time, he was placed on a 1:1 (a staff member would always be with R1). Prior to this he had remote observation. Upon interview on 4/7/26 at 2:00 p.m. the maintenance supervisor stated that the facility had not had the alarm in the stairwell in working order for months because the door did not need to be secure because the residents used the video surveillance system or the wander guard system (alarm placed on the resident that sounds an alarm when the resident is near a door). He was not aware of R1's fall. Upon interview on 4/7/26 at 2:31 p.m. R1's family member (FM)-A stated he was told that R1's remote observation alarm was delayed so R1 got out of his room without staff's awareness and by the time staff found him he had fallen down the stairs. When he visited staff would check on him, however not on a regular basis. (FM)-A used the unarmed door when he would visit R1 to enter and leave the facility, so he believed R1 thought that was his way out. Upon interview on 4/8/26 at 10:15 a.m. registered nurse (RN)-C stated R1's supervision was through the remote monitoring since the remote system watches residents 24 hours a day and redirects them for the staff on the unit. He would visualize R1 when he walks by his room, otherwise at shift change staff check in on all their residents. (RN)-C stated he was aware that the alarm on the door did not sound, and he did not have to use his badge to get through the door, he could not recall how long the door had been unarmed. (RN)-C did not notify anyone about the door, but management and other staff were able to walk through the door, so he did not think it was a concern. Upon interview on 4/8/26 at 10:35 a.m. the health unit coordinator (HUC) stated she was aware the door was unarmed. She did not report it to maintenance because she saw management use the door without their badge, so she assumed there were no concerns. Upon interview on 4/8/26 at 11:11 a.m. nursing assistant NA-A stated the supervision for R1 was the remote observation system because R1 was unable to use his call light to call for help. There were no criteria for checking on him and it would be unrealistic to check on him hourly because within the hour he could have fallen. She was unaware that the door was unarmed. Upon interview on 4/8/26 at 11:25 a.m. the security supervisor stated he came to the facility to check on the door. He stated the alarm had been turned off in March and turned back on 4/1/26. He stated he was not certain how the facility checked for the doors to be working. He could see that multiple staff continued to use their badge since the alarm was shut off. Upon interview on 4/8/26 at 12:25 p.m. the offsite remote observation supervisor stated her team did an investigation, and they found their team member did not follow the work standard. The technician who was watching R1 walked away from his desk and within a few seconds R1 had left his room. When the technician saw R1 was not in his room he called the charge nurse at the facility. The protocol should have been to have sounded the remote alarm so the facility would have heard the alarm and searched for R1 more quickly. Upon interview on 4/8/26 at 1:36 p.m. RN-D stated R1's supervision was the remote observation, the chair and bed alarms. He was wondering why he no longer needed to use his badge for the door, but thought management had made a change. Upon interview on 4/8/26 at 1:48 p.m. RN-E stated a little after 4:10 on 4/1/26 he received a call from the remote observation technician and what he thought the technician said was that R1 had left his room with a facility staff member so RN-E was not concerned. A few seconds later he heard a wander guard alarm sound. He ran to the door and found R1 had fallen down the first set of stairs in the stair well. R1 was face down with his wheelchair on top of him. He had to cut R1's lap belt off him. R1 was conscious, emergency medical services were called and R1 was taken to the hospital. RN-E stated after R1 was transferred to the hospital he was informed by NA-B that R1 had increased agitation and had attempted to leave the building the prior day. Upon interview on 4/8/26 at 3:10 p.m. NA-B stated she worked the evening R1 fell. She also responded to the wander guard alarm and found R1 face down with his wheelchair attached to him. R1 was supervised with the remote observation and his alarms, but they failed him on 4/1/26. Upon interview on 4/9/26 at 11:05 a.m. R1's Nurse Practitioner (NP) stated the facility uses multiple devices for all the residents for their safety. He stated after the fall he ordered staff to also supervise R1. Upon interview on 4/9/26 at 1:04 p.m. RN-B stated R1's supervision was the remote observation unit, and he should have been on hourly rounding as well. The facility was thinking of stopping the remote observation as they felt it was agitating R1 more. The wander guard alarm was started prior to the fall on 4/1/26 due to increased agitation and R1 attempting to elope out the same door the previous day. RN-B was not aware the door alarm had been turned off. Upon interview on 4/9/26 at R1's medical provider stated he was aware that R1 had gotten through the door and fell with his wheelchair attached to him. He could not be certain how having R1 belted into his chair could have changed the fall. He was not aware the emergency alarm on the door was not working and if they could have prevented the fall either. He stated the door needed to be fixed and even with all the devices staff should also be supervising the residents. Upon interview on 4/13/26 at 10:26 a.m. the Administrator stated the staff supervise the residents even with the use of the remote observation and alarms. She believed R1 was being supervised every hour by staff. Secure Care Products (wander guard) user manual with a revision date of 11/16/07 indicated Secure Care's software, parts and products have been designed to augment a facility's reasonable procedures for protecting residents, patients, and infants. However, no system or combination of procedures and equipment can eliminate all risk or assure complete security. Secure Care's system is not intended as a substitute for the careful identification and monitoring of residents, patients, and infants by a facility's professional staff. The manual indicated that weekly testing of wandering patients should be tested to make sure the transmitter is working.-Monthly testing should be performed for the fire alarm release feature.-The annual service was recommended to be sure the battery was replaced.-Onguard user guide (the employee badge alarm locks) dated 1/2005 indicated how to set up the alarms and how to check the arms but did not indicate how often a facility should be checking the alarms. Allegion user guide dated 2021 indicated The Von Duprin Chexit device is designed for controlled egress applications. It meets both life safety and security needs, as well as the requirements of NFPA101 for Special Locking Arrangement and IBC Special Egress-Control Devices. All control inputs, auxiliary locking, local alarm and remote signaling outputs are self-contained in the Chexit assembly. Numerous field configurable options allow the device to be customized for the specific code or application requirements. The standard Chexit device sounds an alarm and keeps the door secured for 15 seconds following an exit attempt with immediate release upon fire. The manual indicated how to test the powerup, the delayed egress and an advanced function test, however, did not indicate how often a facility should be testing the devices. Policies regarding accidents and equipment inspections were requested, however none was received. The Immediate Jeopardy (IJ) began on 4/1/26 when R1 fell down the facilities stairwell. The Administrator and the director of nursing were notified of the immediate jeopardy on 4/7/26 at 5:15 p.m. The immediate jeopardy was removed on 4/9/23 at 5:43 p.m., when the facility trained all staff about reporting when they are aware a door is unarmed. The facility made plans to make the second emergency door into an armed door to mirror the door R1 went out of. The facility placed signs on the unarmed door and used remote observation 24 hours a day to alarm if a resident or staff attempted to use the door. Staff were educated to respond immediately when they heard the remote alarm sound. The facility audited staff to ensure staff responded. but noncompliance remained at the lower scope and severity, level 2, F - widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to provide respect and dignified treatment for 1 of 3 residents (R3) reviewed for dignity. R3 was given a bed alarm that R3 stated he did not consent to. The alarm limited his freedom of movement when he was in bed due to feeling startled by the loud sound of the alarm. In addition, he was anxious because he was concerned his alarm would bother residents near his room.Findings include: The facilities Consent Form for Restraints dated 2/2/26 indicated R3 signed giving consent for the medication trazodone and side rails on his bed. The bed alarm was not on the consent form. R3's admission minimum data set (MDS) dated [DATE] indicated R3's BIMS score was a 14 indicating he was cognitively intact. R3 required moderate assistance for dressing and personal hygiene. He was dependent for toileting hygiene and transfers. He could roll from side to side in bed with moderate assistance. R3's pertinent diagnoses were cerebral infarction, dysphagia, aphasia, abnormalities of gait and mobility, weakness, and other signs of cognitive functioning. R3 had mentioned his concerns to the staff. R3's care plan dated 2/4/26 indicated R3 had a bed alarm. The care plan did not indicate how often the alarm was to be used or the placement of the alarm under his body. Upon observation and interview on 4/9/26 at 10:25 a.m. R3 was lying on his bed fully dressed. He stated he was fine with the lap belt alarm on his wheelchair and the alarm on his wheelchair when he left the unit (wander guard), but he was bothered by the bed alarm. He stated he did not consent to having the alarm on his bed because it startled him and made him feel like he could not freely move his body when he was in bed. He struggled with sleep due to the alarm and feared that other residents in nearby rooms could hear his alarm when it sounded and disrupt their sleep as well. Upon interview on 4/9/26 at 11:05 a.m. the Nurse Practitioner stated he was aware that R3 had complained about his bed alarm and stated the staff reassured him the alarm was there for his safety and R3 was very cognitively impaired, so staff had to remind him often about his safety needs. Upon interview on 4/9/26 at 1:04 p.m. registered nurse, (RN)-B the nurse manager stated she was not aware that R3 had complaints with his bed alarm, she stated she would fix it immediately by having staff place the alarm up higher on his back, so he can move his legs easier while in bed and the alarm should not sound then unless he stood up. Upon interview on 4/9/26 at 2:06 p.m. the director of nursing, (DON) stated she had not heard of R3's allegations, however when the alarm stops when a resident stops moving their legs. Upon interview on 4/9/26 at 2:33 p.m. R3's Medical Provider stated he had not heard of R3's bed alarm complaint and was not certain how the staff should proceed as safety was the main concern. He thought the staff approach could be modified. Upon interview on 4/13/26 at 9:55 a.m. the Medical Director stated if R3 was having concerns with the bed alarm the facility should try an alternative and the facility should be addressing the concerns stating there is a need to keep him safe, catch him when we think he is getting out of bed, and respect his right to move. A facility policy titled Resident rights dated 9/30/25 indicated Planning and Implementing Care - The facility will:-Permit the resident/resident representative to participate in the development, revision, and implementation of a person-centered plan of care. This includes the right to identify individuals or roles to be included in the planning process, the right to participate in establishing the expected goals and outcomes of care, the right to sign the plan of care, and the right to be informed (in advance) of changes to the plan of care.Inform the resident/resident representative of the right to participate in their treatment and provide support to the resident/resident representative in doing so. This should include information concerning the care to be furnished and the type of caregiver/professional to render services.-Ensure that the physician/practitioner or other professional has informed the resident in advance of the risks/benefits of proposed care, treatment and treatment alternatives/options and the right to choose same.Recognize the resident's right to request/refuse/discontinue treatment, to participate/refuse participation in experimental research, and to formulate an advance directive.

Based on observation interview and document review, the facility failed to implement a process to assess for, determine medical symptoms, obtain an order prior to use, assess for use of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 3 of 3 residents (R1, R2, R3) reviewed for use of physical restraints.Findings include: Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 Section P: Restraints and Alarms indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The important consideration is the effect of the device on the resident, and not the purpose for which the device was placed on the resident. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This can only be determined on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material, or equipment (whether or not it is listed specifically on the MDS) attached or adjacent to the resident's body, and the effect it has on the resident. Physical restraints limit mobility and increase the risk for a number of adverse outcomes, such as functional decline, agitation, diminished sense of dignity, depression, and pressure ulcers. Upon observation and interview on 4/7/26 at 12:17 p.m., R1 was observed to have bilateral quarter side rails at the head of his bed and three-quarter length side rails at the foot of his bed. R1 was seated in his wheelchair with an alarmed seat belt around his waist. On the back of his chair, he had a wander guard bracelet attached to his wheelchair. R1 was not certain what the side rails on his bed were for. He stated that the bed was the bed he slept in. He could not take the lap belt off by himself. He then started speaking incoherently about working in his car in his shop. R1's Physical Device assessment dated [DATE], indicated R1 had left and right quarter side rails. R1 was able to demonstrate ability to appropriately use the device. The device did not restrict voluntary freedom of moment or prevent access to any body part. He understood the risk and benefits of the device. R1's symptoms were weakness, impaired mobility, impulsive movements, cognitive deficits, sensory deficits, impaired judgement, hemiplegia, fatigue, rehab, to facilitate independence and unable or unwilling to acknowledge impairments. R1's diagnosis was cerebral vascular accident (CVA). No less restrictive devices were tried. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a brief inventory of mental status (BIMS) score of 6 indicating he was significantly cognitively impaired. R1 required moderate assistance with dressing, sitting to standing, chair to bed transfer, toilet transfer, walking 150 feet. R1 used a wheelchair. R1 was always continent of bowel and bladder. R1's pertinent diagnoses were cerebral infarction (stroke), weakness, acute respiratory failure, dysphagia (difficulty swallowing), dysarthria (motor speech disorder), paralytic gait (abnormal walking), and neurological neglect syndrome (brain damage usually following a stroke). R1's care plan dated 3/23/26, indicated R1 may use half side rails for positioning and safety when in bed. R1. The side rails were to be used when he was in bed to allow for safe positioning due to spasms. His care plan did not indicate there were side rails attached to the foot of his bed or any interventions for those. R1 had a seat belt alarm, which was to be on when he was in wheelchair to aid in trunk support. The care plan did not indicate when the staff was to release the belt to give R1 freedom of movement. R1 had a wander guard (an electronic security system that uses a bracelet on a resident that alarms when the resident tries to wander outside the facility) that was not identified on the care plan or any interventions for use. Upon observation on 4/8/26 at 8:55 a.m., R2 was in bed, she had bilateral quarter side rails at the head of her bed. She had a seat belt alarm in her wheelchair and a wander guard bracelet attached to the back of her wheelchair. When she was dressed and moved to her wheelchair, she was unable to move her right arm and was unable to remove the lap belt on her own. R2 could not speak, she would nod yes and no to questions. R2's Physical Device assessment dated [DATE], indicated R2 had quarter size left and right-side rails. She was able to demonstrate the ability to use the device appropriately and they did not restrict her voluntary freedom of movement or prevent access to a body part. Her decision maker understood the risk and benefits. R2's symptoms were weakness, impaired mobility, hemiplegia, rehab, to facilitate independence. Her diagnoses of CVA and no less restrictive devices were tried. R2's admission MDS dated [DATE] indicated R2 was unable to speak, she sometimes could make herself understood and sometimes had the ability to understand others. R2's BIMS score was 00 which indicated severe cognitive impairment. R2 required moderate assistance with upper body dressing, oral hygiene and eating. Maximum assistance with lower body dressing, rolling in bed, sitting to lying and lying to sitting on the edge of the bed. She was dependent on toileting and transfers. Her pertinent diagnoses were cerebral infarction (stroke), aphasia (impairment caused by brain damage that impairs a person's ability to process language, speak, read, write, and understand speech), dysphagia (difficulty swallowing), symptoms and signs of cognitive functioning and abnormalities of gait and mobility. R2's care plan dated 2/27/26 did not indicate R2 had bilateral quarter sized side rails, the seat belt alarm, or the wander guard. Upon observation and interview on 4/8/26 at 10:25 a.m. R3 was lying on his bed fully dressed. He stated he was fine with the alarm belt on his wheelchair and the alarm on his wheelchair when he left the unit, but he was bothered by the bed alarm. He stated he did not consent to put the alarm on his bed because it startled him and made him feel like he could not freely move his body when he was in bed. He struggled with sleep due to the alarm and feared that other residents in nearby rooms could hear his alarm when it sounded and disrupt their sleep as well. R3's Physical Device assessment dated [DATE] indicated R3 had right and left quarter sized rails on his bed. He was able to demonstrate the ability to use the device appropriately and it did not restrict any voluntary freedom of movement or prevent access to any body part. Client and decision maker did not say they understood the risk and benefits. R3's symptoms were impaired judgement and hemiplegia. R3's diagnosis was a CVA, and no less restrictive devices were tried. R3's summary indicated quarter side rails on bed to help with turning and reposition. R3's admission MDS dated [DATE], indicated R3's BIMS score was a 14 indicating he was cognitively intact. R3 required moderate assistance for dressing and personal hygiene. He was dependent for toileting hygiene and transfers. He could roll from side to side in bed with moderate assistance. R3's pertinent diagnoses were cerebral infarction, dysphagia, aphasia, abnormalities of gait and mobility, weakness, and other signs of cognitive functioning. R3's care plan dated 2/4/26 indicated R3 had a bed alarm, seat belt alarm to be on when in his wheelchair to aide in trunk support, grab bars/bedrails. Email correspondence following the survey on 4/15/26 from the Administrator revealed a facility in-house email chain indicated RN-F interviewed R1, R2 and R3 on 4/10/26 at 3:53 p.m. see below:R3- says he likes and uses the bedrail, able to take off his seatbelt, thinks the seat belt is a good idea, doesn't like the bed or seatbelt alarms because there are too many false alarms, he would be ok with them if they only alarmed when he actually needed them to, but they alarm when he just raises his leg.R1 - says he likes and uses the bedrails, was unable to take off his seatbelt for me, even with prompting, says he hates the seatbelt and the seatbelt alarm and bed alarm.R2 - nodded yes that she likes and uses the bed rails, was able to take off her seatbelt when I asked her to show me, nodded yes that she likes the seat belt, and the bed and the seatbelt alarms. Email correspondence dated 4/11/26 from the Administrator to PT-A indicated R1, R2 and R3 all used the bedrails for either repositioning or transferring. The facility was going to find R1 a different type of belt that R1 could remove. R1 was still on a 1:1 (one staff with a resident all the time) therefore an alarm was not necessary. Email correspondence dated 4/12/26 email from PT-A to the administrator indicated she attempted to see R1 twice on Saturday 4/11/26 the first attempt he was too agitated and second attempt R1 had visitors. She would follow up to make sure this happens on Monday (4/13/26). She recommended 1:1 staff needed to are aware the change will happen. She indicated she was concerned if R1 could easily be able to get his seat belt off, he would stand up even with someone in the room and likely fall. She indicated she understood this is part of the state recommendation however she wanted to make sure they had a plan to keep him and staff safe. Upon interview on 4/8/26 at 11:11 a.m., nursing assistant (NA)-A stated she had never been told to release any of the residents on the unit who wore lap belts. R1 could remove his belt, because he often did it and staff would have to response, but he did not understand what the belt was for. R2 had never attempted to stand up or remove her alarm when NA-A had worked with her. R3 had complained about his bed alarm and was told by staff it was for his safety. Upon interview on 4/8/26 at 11:59 a.m. physical therapist (PT)-A stated it was the facilities standard of practice for anyone with a brain injury to get a lap belt and side rails placed upon admission. The reason for the restraints was because the residents could try to self-transfer and fall. Some residents need the lap belt because they are unable to understand how to call the nurse for help, if they release the belt the alarm would sound, and staff would assist. R1 could remove his belt, but he cannot remember things from day to day, was the reason he required the lap belt. The facility did not have it care planned that staff were to remove the seat belt as R1 could only walk with therapy assistance. R1 could follow only one step commands, he would become tired and then agitated so he could fall. Residents have side rails for turning and repositions and our beds are narrow, so the residents needed the rails to keep them safe from falling out of bed. Upon interview on 4/8/29 at 1:48 p.m. registered nurse (RN)-E stated all residents have the lap belts and side rails upon admission until they are assessed by therapy services. Nursing had nothing to do with any equipment assessments, Occupational and Physical Therapy completed equipment assessments. Upon interview 4/8/26 at 2:29 p.m. PT-B stated upon admission the residents did receive the lap belt and the side rails. The brain injury diagnosis the restraints were used was usually for forgetfulness and impulsiveness and the spinal cord injury residents diagnoses for the restraints for trunk support. Therapy assessed the residents usually within the first day of admission and would then assess the appropriateness of the lap belt and side rails. R1 was recommended to have the 24-hour remote observation, the seat lap belt, the bed alarm, and the side rails. R1 did not have the cognition to make himself safe so therapy implemented the safety devices. If R1 were to stand-up he would fall. The alarms were treating R1's impulsiveness. The seat belt alarm, the side rails, and the bed alarms were the least restrictive devices. Laps belts were not considered a restraint if the resident can remove it by themselves or ask someone else to remove it for them. The facility had different levels of belts, some disengaged easier than others. All facilities departments meet for daily interdepartmental meetings and discuss the needs of the residents. (PT)-B believed R2 could remove her lap belt, she stated if she cannot even though she is unable to speak, she could use her call light and could call for a nurse to assist her. R3 required the seat belt, side rails, and bed alarm due to falls. We need to have as many noises as possible, so we can get to the residents as soon as possible. Upon interview on 4/8/26 at 3:10 p.m. NA-A stated R1 took off his bed multiple times a shift. He did not understand what the belt was for, he would fidget with the belt when he was agitated. The staff only removed the lap belts for R1, R2, and R3 when they needed to use the bathroom or went to bed. Upon interview on 4/9/26 at 11:05 a.m. the nurse practitioner (NP) stated the lap belts; the side rails and the bed alarms were safety for the residents. Without the devices residents would fall. He was not certain what assessments therapy performed for the residents. He was not certain if any less restrictive devices had been attempted or what ongoing monitoring looked like. He did not order any of the devices. He signed whatever therapy assessed. He stated the medical diagnoses for R1, R2 and R3 would be cognitive concerns and impulsiveness. The residents did not have good judgement, which was the reason they had the devices, so they did not fall. Upon interview on 4/9/26 at 1:04 p.m. RN-B stated the standard process for admitting residents with a brain injury was to get a bed alarm, lap belt, and side rails. Therapy completed all the device assessments, no nursing. She did not have an admission protocol document to offer. Upon interview on 4/9/26 at 2:06 p.m. the director of nursing stated the benefits outweighed the risk with the lap belt, the side rails, and the alarm. A request was made during the interview for the DON to provide the following documentation for R1, R2 and R3 regarding the restraint use:Medical diagnosis, conditions, symptoms, and/or behavioral symptoms.Size and weight.Sleep habits.Medication(s).Acute medical or surgical interventions.Underlying medical conditions.Existence of delirium.Ability to toilet safely.Cognition.CommunicationMobility (in and out of bed)Risk of falling.evaluation of the alternatives that were attempted prior useInspections of the devices.No documentation was received for the requested documentation. Upon interview on 4/13/26 at 9:55 a.m. the Medical Director stated the facility was very aware of the restraint regulations. She stated the lap belts were used for trunk control. The department teams meet daily to discuss removal of any alarms when the resident is ready. She was not aware that residents received the lap belt, bed alarm, and side rails on admission automatically. The facility was weighing the risks versus the benefits, and the facility tried to minimize the risk of falls. Alarms in residents with dementia can worsen the dementia, but the residents at the facility did not service a dementia population. The facility used the side rails as a tool for the residents to be more independent in their beds. R1 can remove his belt, not on command due to his delirium. Her expectation was the staff were following the guidelines of the facility assessments. The care plans were made for the staff to always ensure resident safety. She was not familiar with R2 or R3. She stated if R3 felt restricted with his bed alarm the facility should have tried an alternative to not restrain him. Upon interview on 4/13/26 at 10:26 a.m. the Administrator stated having the devices of the lap belt, the bed alarm, and the side rails were the standard of practice used by the facility and for safety of the residents. It is the best practice. The facility admission policy titled admission and Continued Stay Criteria dated 8/30/26 indicating. The Transitional Rehabilitation Program (TRP) provides holistic, comprehensive, inpatient neurological rehabilitation services to assist adults with disabilities and/or recovering from illness, injury, or surgery in gaining greater independence. The TRP is licensed as a skilled nursing facility and serves as a bridge or transitional setting between acute care and returning to a community living setting. During the program, people are required to actively participate in therapies/programming to accomplish their goals. Admissions staff complete a preadmission assessment to determine whether the potential client requires the specialized programming offered by the TRP and whether the TRP can meet the potential client's needs. Care Specialties:Cerebrovascular Disorders (e.g., stroke, aneurysm)Spinal Cord InjuryBrain InjuryNeurovascular Disorder (e.g., spinal stroke)Other Complex Neurological/Neuromuscular disorders (e.g., Guillain-Barre Syndrome)The policy did not indicate any information on restraints being used. A facility policy titled Restraints dated 1/23/24 indicated that Transitional Rehabilitation Program (TRP) supports the right of residents to be free from any physical or chemical restraint. Restraints have the potential to produce serious consequences, such as physical or psychological harm, and loss of dignity. Restraints will only be utilized as outlined in the State and Federal Nursing Home Resident's [NAME] of Rights (see addendum 1). POSITIONING AND SAFETY DEVICESSafety devices are used to enable the residents to attain or maintain their highest level of independent functioning and safety. The decision to use these aids and positioning devices is made through resident participation in individual assessment and care planning by the interdisciplinary team. They are used only with resident consent and under physician order and direction.The interdisciplinary team conducts an individual assessment/evaluation to determine the need for any positioning/potentially restraining/safety device. A care plan is developed to identify the residents' needs and parameters for use of the device, i.e., bed rails up at night so residents may use it to assist with turning. This care plan is reviewed at least quarterly and updated as needed.Prior to implementing the care plan, the nurse will review the risks and benefits of the use of the device with the resident. The resident, or if unable, the resident representative, signs the informed consent form and it is placed in the health record.Anytime a resident is using a positioning device, staff will assess the client's safety and comfort and will release the restraint as often as the resident requires for comfort, toileting, or other activities of daily living.Per the Nursing Home Residents' [NAME] of Rights, if a competent nursing home resident or their legal representative requests a restraint, staff will provide education regarding alternatives and the risks involved with restraint use.The facility will provide a physical restraint to a resident only upon receipt of informed consent and a written order from the attending physician that contains statements and determinations regarding medical symptoms and specifies the circumstances under which restraints are to be used.The restraint will be monitored and there will be documentation that procedures have been followed.Periodic reevaluation of the need for restraints will be conducted in consultation with the residents, family, and physicians. A physical restraint is any manual method, physical or mechanical device, equipment, or material that meets all the following criteria: Is attached or adjacent to the resident's body. Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to their body. Devices used in the facility may potentially be considered restraining include, but are not limited to, wheelchair and commode belts, lap trays, positioning devices, and bedside rails.

Based on observation, interview and record review the facility failed to develop a person-centered care plan that included all the medical devices in use and develop interventions for the safe use of the devices for 3 of 3 residents (R1, R2, and R3) who were reviewed for care plan development.Findings include: Upon observation and interview on 4/7/26 at 12:17 p.m. R1 was observed to have bilateral quarter side rails at the head of his bed and three-quarter length side rails at the foot of his bed. R1 was seated in his wheelchair with an alarmed seat belt around his waist on the back of his chair he had a wander guard bracelet attached to his wheelchair. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 6 indicating he was significantly cognitively impaired. R1 required moderate assistance with dressing, sitting to standing, chair to bed transfer, toilet transfer, walking 150 feet. R1 used a wheelchair. R1 was always continent of bowel and bladder. R1's pertinent diagnoses were cerebral infarction (stroke), weakness, acute respiratory failure, dysphagia (difficulty swallowing), dysarthria (motor speech disorder), paralytic gait (abnormal walking), and neurological neglect syndrome (brain damage usually following a stroke). R1's care plan dated 3/23/26 indicated R1 may use half side rails for positioning and safety when in bed. R1. The side rails were to be sued when he was in bed to allow for safe positioning due to spasms. His care plan did not indicate the side rails attached to the foot of his bed or any interventions for them. R1 had a seat belt alarm, which was to be on when he was in wheelchair to aid in trunk support. The care plan did not indicate when the staff was to release the belt to give R1 freedom of movement. R1 had a wander guard (an electronic security system that uses a bracelet on a resident that alarms when the resident tries to wander outside the facility) that was not identified on the care plan or any intervention. Upon observation on 4/9/26 at 8:55 a.m. R2 was in bed, she had bilateral quarter side rails at the head of her bed, she had a seat belt alarm in her wheelchair and a wander guard bracelet attached to her wheelchair. R2's admission MDS dated [DATE] indicated R2 was unable to speak, she sometimes could make herself understood and sometimes had the ability to understand others. R2's BIMS score was 00 indicated severe cognitive impairment. R2 required moderate assistance with upper body dressing, oral hygiene and eating. Maximum assistance with lower body dressing, rolling in bed, sitting to lying and lying to sitting on the edge of the bed. She was dependent in toileting and transfers. Her pertinent diagnoses were cerebral infarction, aphasia, dysphagia, symptoms and signs of cognitive functioning and abnormalities of gait and mobility. R2's care plan dated 2/27/26 did not indicate R2 had bilateral quarter sized side rails, the seat belt alarm, or the wander guard. Upon observation and interview on 4/8/26 at 10:25 a.m. R3 was lying on his bed fully dressed. He stated he was fine with the alarm belt on his wheelchair and the alarm on his wheelchair when he left the unit, but he was bothered by the bed alarm. He stated he did not consent to put the alarm on his bed because it startled him and made him feel like he could not freely move his body when he was in bed. He struggled with sleep due to the alarm and feared that other residents in nearby rooms could hear his alarm when it sounded and disrupt their sleep as well. R3's admission MDS dated [DATE] indicated R3's BIMS score was a 14 indicating he was cognitively intact. R3 required moderate assistance for dressing and personal hygiene. He was dependent for toileting hygiene and transfers. He could roll from side to side in bed with moderate assistance. R3's pertinent diagnoses were cerebral infarction (stroke), dysphagia (difficulty swallowing) aphasia (impairment of a person's ability to process language, speak, read, write, and understand speech), abnormalities of gait and mobility, weakness, and other signs of cognitive functioning. R3's care plan dated 2/4/26 indicated R3 had a bed alarm, seat belt alarm to be on when in his wheelchair to aide in trunk support, grab bars/bedrails. Upon interview on 4/9/26 at 9:12 a.m. nursing assistant (NA)-A stated even though R2's devices were not on her care plan she knew what to do because most of the residents have the same equipment and she has been trained and used all of the equipment before. She stated the side rails are used for positioning, the belt is to always be on when residents are in their wheelchairs, and the wander guard was so residents could not leave the unit. Upon interview on 4/9/26 at 2:06 p.m. the director of nursing (DON) stated if all the devices are not on the care plan they should be. Upon interview on 4/13/26 at 3:22 p.m. the Administrator stated her expectation that all cares, services, and interventions were on each resident's care plan. A facility policy titled Person-Centered Care Planning dated 1/3/25 indicated:A comprehensive person-centered plan of care will be developed for each client within 7 days after completion of the comprehensive assessment and will include measurable objectives and times to meet a client's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The comprehensive plan of care will minimally include: The services that are to be furnished to attain or maintain the client's highest practicable physical, mental, and psychosocial well-being. Any services recommended by the interdisciplinary team but refused by the client. The client's goals for admission and desired outcomes. The client's preference and potential for future discharge. Discharge plans1. The comprehensive care plan will be prepared by an interdisciplinary team that includes, but is not limited to:a. The attending providerb. An RN with responsibility for the clientc. A resident assistant with responsibility for the clientd. A member of food and nutrition services staffe. If practical the client and the client's representative. If not practical, document an explanation why the client or client representative are not part of the development of the plan of care.f. Other appropriate staff or professionals in disciplines as determined by the client's needs or as requested by the client.2. Review and revise the comprehensive plan of care after each assessment and include both the comprehensive and quarterly review assessments.

Based on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 3 of 3 residents (R1, R2, and R3) reviewed for side rails. The facility did not provide any documentation of inspection or entrapment assessments.Findings include: Recommendations for Health Care Providers Using Adult portable Bed Rails dated 2/27/2023 retrieved on 4/13/26 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds indicated, when evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system is used for purposes, or used in a care https: Evaluating the dimensional limits of gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment. Bed safety programs may also include plans for the reassessment of hospital bed systems. Reassessment may be appropriate when (1) there is reason to believe that some components are worn (e.g., rails wobble, rails have been damaged, mattresses are softer) and could cause increased spaces within the bed system, (2) when accessories such as mattress overlays or positioning poles are added or removed, or (3) when components of the bed system are changed or replaced (e.g., new bed rails or mattresses). This guidance describes seven zones in the hospital bed system where there is potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. Descriptions of the seven entrapment zones appear on pages 15-21 in this guidance. Summary drawings of entrapment for all the zones appear in Appendix E. The seven areas in the bed system where there is a potential for entrapment are identified in the drawing below. Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split Bed Rails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End. Health Care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions, health care providers are to avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment, and restrict the use of physical restraints including restrictive use of bed rails, or chest, abdominal, wrist, or ankle restraints of any kind on individuals in bed. When installing and using bedrails select the appropriate bed rail, follow the health care providers procedures or manufacture recommendations, inspect, evaluate, and regularly check bedrails are appropriately matched to equipment and patient needs considering all relevant risk factors, to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress, which may be caused by patient weight, movement, bed position, or by using a specialty mattress. The manufacture user-service manual for [NAME] Hill-Rom [NAME] Medical-Surgical Hospital Bed, undated, indicated Warning-Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all side rails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. Do annual preventive maintenance procedures to make sure the [NAME] Smart+ Bed operates as originally designed. The procedures include examinations of these:Overall condition SiderailsControls and motorsBattery Backup Brakes and casters [NAME] systemHead angle displayCommunication systemTransport systemTransport system batteries MattressAccessoriesWARNING:To help prevent serious injury and/or death, obey these warnings:Warning-Evaluate patients for entrapment and fall risk according to facility protocol and monitor patients appropriately.Warning-Make sure that all side rails are fully latched when in the raised position.Warning-Stay clear of pinch points and moving parts during siderail operation.Siderails are intended to be a reminder to the patient of the bed's edges, not a patient-restraining device. When appropriate, Hill-Rom recommends that medical persons determine the correct methods necessary to make sure a patient stays safely in bed.Siderails in the raised position are intended to make the patient aware of the proximity of the edge of the mattress and to assist in patient entry and exit.R1's Physical Device assessment dated [DATE] indicated R1 had left and right quarter side rails. R1 was able to demonstrate ability appropriately using the device as applicable. The device did not restrict voluntary freedom of moment or prevent access to any part. His decision made him understand the risk and benefits of the device. R1's symptoms were weakness, impaired mobility, impulsive movements, cognitive deficits, sensory deficits, impaired judgement, hemiplegia, fatigue, rehab, to facilitate independence and unable or unwilling to acknowledge impairments. R1's diagnosis was cerebral vascular accident (CVA). No less restrictive devices were tried. Upon observation and interview on 4/7/26 at 12:17 p.m. R1 was seated in his room in wheelchair. He had bilateral quarter rails at the top of his bed that were in the upright position. He had bilateral three-quarter length side rails at the bottom of bed that were lowered. R1 stated, he did not know what the side rails were, but they were on the bed he slept in. He then started speaking nonsensical about having to leave for work and repair cars. R1's Physical Device assessment dated [DATE] indicated R1 had left and right quarter side rails. R1 was able to demonstrate ability appropriately use the device as applicable. The device did not restrict voluntary freedom of moment or prevent access to any part. His decision made him understand the risk and benefits of the device. R1's symptoms were weakness, impaired mobility, impulsive movements, cognitive deficits, sensory deficits, impaired judgement, hemiplegia, fatigue, rehab, to facilitate independence and unable or unwilling to acknowledge impairments. R1's diagnosis was cerebral vascular accident (CVA). No less restrictive devices were tried. R1's physical therapy assessments and notes dated 3/11/26 - 4/8/26 did not indicate side rails were in use for R1 or any entrapment assessment. R1's occupational therapy assessments and notes dated 3/11/26 - 4/6/26 did not indicate side rails were in use for R1 or any entrapment assessment. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 6 indicating he was significantly cognitively impaired. R1 required moderate assistance with dressing, sitting to standing, chair to bed transfer, toilet transfer, walking 150 feet. R1 used a wheelchair. R1 was always continent of bowel and bladder. R1's pertinent diagnoses were cerebral infarction (stroke), weakness, acute respiratory failure, dysphagia (difficulty swallowing), dysarthria (motor speech disorder), paralytic gait (abnormal walking), and neurological neglect syndrome (brain damage usually following a stroke). MDS did not include use of bedside rails. R1's care plan dated 3/23/26 indicated R1 may use half side rails for positioning and safety when in bed. No other documentation related to the use of side rails was indicated. Upon observation and interview on 4/9/26 at 8:55 a.m. R2 was in bed, two nursing assistants were changing her incontinent brief and getting her dressed for the day. R2 had bilateral quarter sized side rails at the head of her bed. She was unable to roll herself in bed, staff assisted her to roll on her right side, and she held on to the side rail with her left hand throughout the cares. R2 was unable to move the right side of her body. R2 was only able to interview by nodding yes or no to questions. R2 indicated through nodding that she could not use her right hand, that she could not turn herself in bed and that she used the side rails when staff assisted her. She could not remove the side rails by herself. R2's Physical Device assessment dated [DATE] indicated R2 had quarter size left and right-side rails. She was able to demonstrate the ability to use the device appropriately and they did not restrict her voluntary freedom of movement or prevent access to a body part. Her decision understood the risk and benefits. R1's symptoms were weakness, impaired mobility, hemiplegia, rehab, to facilitate independence. Her diagnoses of CVA and no less restrictive devices were tried. There was no documentation for any entrapment assessments. R2's physical therapy assessments and notes dated 2/27/26 - 4/8/26 did not indicate side rails were in use for R1 or any entrapment assessment. R2's occupational therapy assessments and notes dated 2/27/26 - 4/8/26 did not indicate side rails were in use for R1 or any entrapment assessment. R2's care plan dated 2/27/26 did not indicate the use of side rails. R2's admission MDS dated [DATE] indicated R2 was unable to speak, she sometimes could make herself understood and sometimes had the ability to understand others. R2's BIMS score was 00 indicated severe cognitive impairment. R2 required moderate assistance with upper body dressing, oral hygiene and eating. Maximum assistance with lower body dressing, rolling in bed, sitting to lying and lying to sitting on the edge of the bed. She was dependent in toileting and transfers. Her pertinent diagnoses were cerebral infarction, aphasia, dysphagia, symptoms and signs of cognitive functioning and abnormalities of gait and mobility. R2's MDS did not indicate the use of the side rails. Upon observation and interview on 4/9/26 at 10:25 a.m. R3 was resting on his bed fully dressed. He had bilateral half rails at the head of his bed. He stated he could reposition himself in bed and use the rails. R3's Physical Device assessment dated [DATE] indicated R2 had right and left quarter sized rails on his bed. He was able to demonstrate the ability to use the device appropriately and it did not restrict any voluntary freedom of movement or prevent access to any body part. Client and our decision maker did not say they understood the risk and benefits. R3's symptoms were impaired judgement and hemiplegia. No other alternatives were tried. R3's diagnosis was a CVA, and no less restrictive devices were tried. R3's summary indicated quarter side rails on bed to help with turning and reposition. There was no documentation for any entrapment assessments. R3's physical therapy assessments and notes dated 2/2/26 - 4/8/26 did not indicate side rails were in use for R1 or any entrapment assessment. R3's occupational therapy assessments and notes dated 2/2/26 - 4/8/26 did not indicate side rails were in use for R1 or any entrapment assessment. R3's care plan dated 2/9/26 did not indicate the use of side rails. R3's admission MDS dated [DATE] indicated R3's BIMS score was a 14 indicating he was cognitively intact. R3 required moderate assistance for dressing and personal hygiene. He was dependent for toileting hygiene and transfers. He could roll from side to side in bed with moderate assistance. R3's pertinent diagnoses were cerebral infarction, dysphagia, aphasia, abnormalities of gait and mobility, weakness, and other signs of cognitive functioning. R3's MDS did not indicate the use of side rails. On 4/9/26 at 10:45 a.m. a request was made to the maintenance engineer for any documentation of assessments or inspections of resident side rails. No documentation was received. On 4/9/26 at 11:22 a.m. a request was made to the administrator for any documentation of assessments or inspections of resident side rails. She stated she would send the information. No information was received. Upon interview on 4/7/26 at 12:41 p.m. registered nurse (RN)-A stated she was unaware of any safety precautions or inspections on the side rails. She stated therapy was in charge of all equipment. She was not certain if R1 used the lower side rails or if they just were not removed from his bed upon his admission. Upon interview on 4/7/26 at 1:48 p.m. the maintenance engineer stated he had not done anything with side rails expecting to fix them when nursing reports they are broken. Upon interview on 4/8/26 at 11:59 a.m. Physical Therapist (PT)-A stated residents who have a brain injury are all admitted with side rails and a lap belt and then when they saw therapy for the first time devices could be adjusted. She stated nursing would complete any assessments for safety such as the zoning in the bed. A facility policy titled Restraints dated 1/23/24 indicated safety devices are used to enable the residents to attain or maintain their highest level of independent functioning and safety. The decision to use these aids and positioning devices is made through resident participation in individual assessment and care planning by the interdisciplinary team. They are used only with resident consent and under physician order and direction.PROCEDURE:1) The interdisciplinary team conducts an individual assessment/evaluation to determine the need for any positioning/potentially restraining/safety device. A care plan is developed to identify the residents' needs and parameters for use of the device, i.e., bed rails up at night so residents may use it to assist with turning. This care plan is reviewed at least quarterly and updated as needed.2) Prior to implementing the care plan, the nurse will review the risks and benefits of the use of the device with the residents. The resident, or if unable, the resident representative, signs the informed consent.The policy did not indicate any inspection timing of the devices.

Based on interview and document review, the facility failed to ensure a facility closure policy and procedure had been developed. This had the potential to affect all residents residing in the building.Findings include:A policy and procedure covering facility closure was requested from the facility, but facility failed to provide such documentation.Email correspondence dated 4/7/26 at 8:16 p.m. the Administrator indicated the facility did not have a policy/procedure on facility closure, as the facility had no intent to close.

Based on interview and document review, the facility failed to comprehensively reassess pressure ulcer interventions and develop and implement new interventions to prevent pressure injuries for 1 of 1 resident (R1) who was identified as refusing repositioning on the overnight and acquired a new pressure sore. Findings Include:Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP):Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed.R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated diagnoses of traumatic spinal cord dysfunction, neurogenic bladder (condition where nerve damage from the brain, spinal cord, or peripheral nerves leads to a loss of bladder control) and quadriplegia (paralysis that affects all of a person's limbs and body from the neck down). The MDS indicated R1 was cognitively intact and required extensive assistance of two with all activities of daily living. The MDS indicated R1 was at risk for developing pressure ulcers, no pressure ulcers and had pressure reducing device for his chair and bed.R1's Care Plan dated 10/27/25, indicated impaired skin integrity or potential for impaired skin integrity related to immobility. R1's Care Plan goal was to demonstrate a knowledge of risk factors and interventions for preventing skin breakdown with a revision date of 11/03/25. Interventions included assess condition of skin and document weekly, assist in keeping skin clean and dry, cleanse perineal area well with each incontinence, educate and encourage in the importance of meeting nutrition and hydration needs, educate and encourage participant in increasing skin tolerance. If resident refuses repositioning, provide education and document refusal and education provided (initiated 10/27/25). Replace on regular repositioning schedule (initiated 10/15/25), refer to physical therapy (PT) for positioning/seating/mobility needs (initiated 10/15/25), turn and reposition every two hours (initiated 10/15/25). The Care Plan further indicated R1 had indwelling foley catheter and received a new leg bag every morning and new bed bag at night with staff to empty every four hours. R1's Treatment Administration Record (TAR) indicated on 10/26/25, to apply Mepilex (foam dressing) to sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis and bilateral gluteal cleft) remove before showers and allow regular skin care. Cleanse with wound cleanser. Cover with large Mepilex. Change daily and as needed for dislodgement every evening shift. The TAR further directed staff to turn and reposition every 2-3 hours with a start date of 10/15/25. Progress Note dated 11/06/25, completed by register nurse (RN)-A indicated a pressure injury staged at Deep Tissue Pressure Ulcer/Injury: Persistent non-blanchable deep red, maroon or purple discoloration. The note indicated Wound history/plan: per client nursing had noted a red area on his coccyx last week. Floor nurse reported this to wound team on Friday 10/24/25, but was unable to be assessed as client was already up and in therapy for the day. Wound was seen over the weekend by nursing and WOC (registered nurse specializing in Wound, Ostomy, and Continence care) first thing on Monday. The note indicted R1 reports he occasionally declined repositioning at night. However, last Wednesday 10/22/25, R1 reports he spend all day in bed due to being sick. Referred to therapy for pressure mapping in bed and chair. The note indicated Wound Status Initial Assessment was on 10/27/25, coccyx 5 centimeters (cm) x1 cm x 0.1 cm and the left buttock 1.5 cm x 0 cm x 0 cm. right gluteal fold developed during stay on 10/24/25. Etiology: wound developed during stay and is from trauma possibly related to sling. Comments indicated as the coccyx wound is a deep tissue injury (DTI) it is impossible to know the extent of the injury before it surfaces and evolves. The coccyx is likely to evolve to a full thickness wound even with strict offloading. Education was provided to R1 about DTPI and the projected evolution. A photo was taken for R1 on his personal cell phone for his own records and education. During interview on 11/05/25 at 1:07 p.m., R1 stated he never had any skin issues at the two previous places he was at for the past 60 days and then arrived at this facility and within 11 days developed a pressure ulcer. R1 stated he did refuse his first or second night to be repositioned due to the night shift staff being so loud with his roommate when providing cares and he was so tired and did not want to be bothered. R1 stated he also got upset with one of the night NAR's when she was attempting to take his shirt off and felt she hurt him and requested for her to never come back in his room. R1 stated now all of the aides are saying he is refusing cares and staff which he feels is not true. R1 stated he recalled on 10/22/25, he was not feeling well and went to bed around 3:00 p.m. and slept until 11:00 a.m. the following day and does not recall any staff attempting to reposition him or offering to. R1 stated he feels that was when the pressure ulcer developed. R1 stated a NAR while changing him informed him he had a sore on 10/24/25, and it was not looked at by the nurse until 10/27/25 and was informed it was a pressure ulcer. R1 stated his pressure ulcer was looked at again by the wound nurse on 10/31/25, and I was told the dressing would be changed every evening over the weekend and no one came to change it. R1 further stated NAR-B worked Monday morning noticed drainage and told me she would inform the nurse working. That was when I asked for it (dressing) to be changed in the morning. During interview on 11/06/25 at 8:45 a.m., nursing assistant (NA)-A stated she worked the night shift with R1, and prior to him getting his pressure ulcer he would refuse to be turned and repositioned all of the time and would only allow to be turned usually one time during the night. NA-A stated after R1 received the pressure ulcer, he would usually let us turn and reposition him every three hours during the night. During interview on 11/06/25 at 9:58 a.m. registered nurse (RN)-A stated she does the wound rounds and completed R1's admission wound assessment on 10/14/25. RN-A indicated she had no concerns with R1's skin. RN-A stated she provided R1 with a new bed which was a adapt, group three wound mattress with alternating air. On 10/24/25 at 9:30 a.m., RN-A stated she was informed there was wound concern and needs to know prior to her wound rounds at 8:00 a.m. which residents she is to see. RN-A stated she was told R1 was at therapy and instructed the nurse to let her know when he is in bed and she would look at his skin. RN-A stated the nurse never got back to her and at around 6:00 p.m. she was able to see R1 who was busy all day with therapy and at that time was up in his chair and had visitors. RN-A stated she set up arrangements to look at his skin right away on Monday morning 10/27/25, that was when she saw he had a deep tissue injury (DTI) on his coccyx. RN-A stated R1 had a history of refusing to be repositioned during the night and was never informed of this and unfortunately the staff did not document this or the risks vs. benefits although knowing he was aware. RN-A stated R1 was on a every three to four hour turning and repositioning program and was immediately changed to a strict every two-hour schedule and after R1 saw the picture of his wound he has been compliant to his schedule. In addition, RN-A stated the nurse that originally found R1's wound on 10/24/25, should have filled out the proper paperwork and at a minimum filled out a progress note describing the new skin area which she failed to do. During observation and interview on 11/06/25 at 11:45 a.m., RN-A removed R1's dressings and indicated his deep tissue injury on his coccyx now had slough and some dead tissue. RN-A stated this would be expected with a DTI. R1 questioned RN-A if his dressing changes were to be completed daily over the weekend after she changed the dressing on Friday 10/31/25. RN-A informed R1 they were to be changed daily. RNA-A stated the dressing had not been changed until Monday 11/03/25, by the dayshift nurse. During interview on 11/06/25 at 12:46 p.m., R1's nurse practitioner (NP) stated she was informed on R1's pressure ulcer on Monday 10/27/25, when RN-A observed the wound and R1 was pressure mapped for pressure areas. NP further stated she was made aware after the finding of the pressure ulcer R1 was not allowing staff to turn and reposition him during the night. During interview on 11/06/25 at 2:57 p.m., RN-B stated he worked the weekend of 11/01/25 to 11/02/25 and had several issues going on that weekend with other residents with blood pressures and helping the nursing assistants. RN-B stated he screwed up and didn't get the dressing change done and just didn't get the dressing changes completed. RN-B stated the acuity has increased and staffing can be a component on his shift. During interview on 11/06/25 at 3:14 p.m., RN-A stated the dressing change was to be completed every evening and she will follow up with RN-B. RN-A stated for pressure injuries that are not significant in depth the dressings can be left on for three to five days but with R1 she would like the dressing changed daily so the wound could be monitored and assessed. RN-A stated she did expect some necrosis (dead tissue) on the wound due to natural evolution of the DTI and about 75% of DTI become necrotic.The Facility New Wound or Worsening Skin Concern undated, indicated nursing is to observe and assess the area of concern. Note the location, measurements, depth, drainage and appearance. Determine the best treatment based on the Wound and Skin Care Guidelines and place a nursing order for that treatment. Identify the potential causes for the wound. Document your assessment and intervention's initiated on a skin/wound progress note. Fill out a wound tracker form and email to team to communicate the presence of a skin concern of existing wounds. Notify responsible party/POA, with client approval, if they do not have a guardian and put completed check list in the DON mailbox.

Based on interview and document review, the facility failed to comprehensively reassess pressure ulcer interventions and develop and implement new interventions to prevent pressure injuries for 1 of 2 residents (R1) who was identified as refusing repositioning on the overnight and acquired a new pressure sore. Findings include: Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP): Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Braden Pressure Ulcer Risk assessment dated [DATE] indicated a score of 16, low. (The Braden Scale is a tool used to assess a patient's risk for pressure ulcers, with lower scores indicating higher risk. Scores between 15 and 18 are considered at mild risk). R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had spinal cord dysfunction, anxiety disorder, no mood, or behavioral issues. The MDS indicated R1 had upper and lower extremity impairment, used a wheelchair, required moderate assist with bed mobility, had a catheter, was frequently incontinent of bowel and had no pressure ulcers. R1's Care Plan dated 5/06/25, indicated impaired skin integrity or potential for impaired skin integrity related to injury sensation impairment. The care plan directed staff to provide skin checks with am and p.m. routines, take extra care with transfers, treat wound/open areas per physician orders, turn and reposition at night every 3 hours, protective specialty mattress, use turn sheet to avoid friction/shearing, cushion/pressure relieving devices, referral to dietician, referral to physical therapy for positioning seating needs, educate on nutritional needs, educate and encourage participant increasing skin tolerance, give verbal cues to reposition assist as needed, instruct and assist participation in learning methods of prevention of pressure ulcers. R1's Care Plan further indicated R1 experiences a disruption in the amount or quality of sleep, which interferes with their desired lifestyle related to anxiety, care needs, emotional state, unfamiliar surroundings. The care plan directed staff to assess and document sleeping pattern, assist and participate in quiet nighttime environment, help participant identify possible causes of interrupted sleep and what aides sleep, provide comfort measures, refer for complementary care services. R1's admission Skin assessment dated [DATE], indicated R1 was at risk for pressure ulcer, skin was clear with no impairment. R1's Wound assessment dated [DATE], indicated R1 had hemiplegia (paralysis to one side of the body) an hemiparesis (one sided muscle weakness) following cerebral infraction (stroke where blood flow to the brain is blocked) affecting right dominant side. The assessment indicated R1 had a left buttock pressure wound occurred during stay at the facility and was deep tissue pressure injury. The assessment indicated the wound was found by staff during a skin assessment. Assessment indicated resident typically goes to bed at 4:30 p.m. and only gets turned once at night to lay on her left side. The note indicated this was likely the cause of the pressure injury. However, the wound has linear sides that could have been caused by laying or sitting on an object. Assessment went on to identify resident did not have input on how the pressure ulcer may have occurred, but does not have feeling in this area. The assessment indicated the wound measurements were 7.5 centimeters (cm) x 5 x 0.1. The description indicated deep purple, none blanchable, square shaped with irregular ends. Small areas of open dermis 1 cm x 1.5 x 01 on medial wound edge. R1's Point Click Care (PCC)(electronic medical charting system) record from 4/17/25 through 5/21/25 lacked evidence of repositioning refusals on the overnight shifts. documentation of repositioning R1 remained in the hospital as of 5/22/25 and was unable to be observed or interviewed during survey. During interview on 5/21/25 at 11:05 a.m., nursing assistant (NA)-A stated she normally worked day shift but picked up the evening shift on 5/01/25. She had provided R1 a shower and noticed a reddened area on her buttocks and informed registered nurse (RN)-B. NA-A stated prior to finding the area she was not aware of R1 being on a repositioning program and new she would not want to be bothered during the night shift due to preferring to sleep and not be woken up on the overnight. During interview on 5/21/25 at 11:35 a.m., nurse practitioner (NP) stated R1 was very particular about her cares, and felt the staff have spent a lot of time encouraging her to reposition and attempting to meet her needs even though she would refuse. The NP further stated he was informed by administration she did not want to be turned much at night. NP indicated he felt the facility was doing what they could and relied on the wound care nurse for direction. He did not believe the new pressure injury could be directly correlated to just the refusals. The NP stated when the pressure injury was found on 5/01/25, it was deep and when it surfaced it was going to look bad. The NP stated R1 was sent to the hospital on 5/13/25, due to fever and possible wound infection. During interview on 5/22/25 at 6:40 a.m., registered nurse (RN)-D stated she was a charge nurse who worked with R1 during the night shift, and it would depend on R1's mood if she would allow the staff to reposition her. RN-D added, NAs always attempted and encouraged her but sometimes she wanted to just keep sleeping. During interview on 5/22/25 at 6:56 a.m., NA-B stated when R1 first admitted she would tell us she did not want to be bothered, and she would put her call light on when she wanted to be repositioned, she was getting repositioned at night but not always every 3 hours. There was no way to document R1's refusals in PCC (if she was repositioned successful at any point that shift) but the nurses were aware she would refuse. NA-B stated after a wound was found on her bottom, we were then instructed to have her reposition every two to three hours even then she would still refuse, but we would encouraged her. During interview on 5/22/25 at 9:48 a.m., administrator stated R1 was adamant she did not want to be disturbed during the night and would prefer to call for help to reposition at night due to her anxiety and focused need to not have her sleep disrupted. The administrator further indicated R1's record lacked a risk versus benefit related to her refusals to reposition. Additionally, R1's records did not indicate the refusals on the overnight due to how PCC works (can not mark a refusal unless resident refuses all shift), all though it was well known she refused at times. Administrator indicated the care plan did direct staff to provide verbal cues for repositioning as needed but a risk versus benefit discussion and notification to her team/Physician would have been helpful to potential avoid acquiring the pressure sore. During interview 5/22/25 at 10:30 a.m., physical therapist (PT) stated she completed pressure mapping on R1 on 5/03/25 and felt the pressure ulcer likely occurred if she was consistently getting repositioned at night. R1 also spends a lot of time in her wheelchair during the day going to appointment with therapy and activities and can shift her weight independently. We provided her with a new cushion in her wheelchair and a high performance specialty mattress on her bed to better combat the possible refusals. During interview on 5/22/25 at 11:45 a.m., RN-A stated she is the facility's wound care nurse and was informed of R1's unstageable pressure ulcer on 5/01/25. R1 had informed her she was refusing repositioning on the overnight when she wanted to keep sleeping. RN-A's assessment of the pressure ulcer also left her with an impression R1 could have slept on her cell phone all night or had continuous pressure from an object on her left buttocks. RN-A stated after R1's pressure ulcer was acquired she did agree to be repositioned around 10:00 p.m., 1:00 a.m. and 5:00 a.m. but was not aware of how refusals were being tracked during each shift. RN-A confirmed there was no risk versus benefits completed with R1 when she was refusing, and indicated not being repositioned every three hours could have also contributed to acquiring the pressure ulcer. During interview on 5/22/25, at 12:30 p.m., family member (FM)-A stated she was not informed R1 was refusing to be repositioned during the night and if she had been informed, she would have talked to her about the importance of getting repositioned. In addition, FM-A stated after the pressure ulcer was found she had spoken and emailed the facility related to repositioning and her concerning of not be informed and believing the facility was responsible for R1 acquiring the pressure sore. Allina Health Department MDS and Comprehensive Assessment Process policy effective date 6/01/23, All Minimum Data Set and Care Area Assessments will be completed as required and within the timeframe's identified in the Resident Assessment Instrument Manual. The rehabilitation team uses the information from the MDS assessment and supplementary assessments to develop client-specific care plans. The client, family/support person, and interdisciplinary team are involved in creating the care plan initially and on an ongoing basis. The facility had no other policies related to pressure ulcers.

Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The facility failed to: remove expired food from food storage areas; label and date food; assure proper hand hygiene while preparing resident meal trays; and storing resident food in an employee break room refrigerator. These practices had the potential to affect all residents, staff and visitors consuming food at the facility. Findings include: During an observation and interview with the dietary manager (DM) on [DATE] at 3:01 p.m., a container of Mrs. Gerry's premade coleslaw was noted to have been dated as opened on [DATE], and a discard date of [DATE]. There was also noted to be pre-cooked chicken pieces in a plastic bag with no label or dates. The DM stated once a week refrigerators were checked for expired food. Expired food could cause illness. During an observation and interview on [DATE] at 10:49 a.m., dietary aid (DA)-A was wearing gloves while preparing resident trays. DA-A left the serving area with the gloves on and went through a door to the side of the serving area. DA-A returned through the same door, and touched a door handle, with gloves. DA-A returned to workstation to continue setting up resident trays. DA-A confirmed these were the same gloves she left the area with. DA-A stated she should have removed her gloves and performed hand hygiene and apply new gloves before she resumed assembling resident food trays. During an observation on [DATE] at 1:28 p.m , the ground-floor cafe cooler had a note taped to the front indicating it was out of service and resident breakfast plates would be kept in the employee break room refrigerator. The DM confirmed this information. A stand-alone freezer was also in this area with a note taped to the front indicating it was for client (resident) food use only, no ice packs. The freezer contained two Walgreen's brand ice packs labeled don't throw and dated ,d+[DATE]. During an interview on [DATE] at 1:30 p.m., the DM stated it was important not to store ice packs with food due to infection control practices as the ice packs may have directly touched residents. The DM stated it was the responsibility of the nursing staff to make sure the things were labeled, dated, and appropriate to be there. The DM confirmed it was dietary's responsibility to care for and maintain refrigerators used for resident food. During an interview on [DATE] at 10:23 a.m., the administrator stated her expectation was unlabeled or expired food would not be stored in resident food storage areas, nor would there be non-food items stored alongside food items for residents. It was important for infection control. A facility policy, Food Safety Requirements: Use and Storage of Food and Beverage Brought in for Clients, Food Procurement dated [DATE], identified the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. The policy further identified proper labeling and dating of each food item received, leftovers to be used or discarded within three days, for food to be stored in covered containers or secure wrapping. The staff will check cafe refrigerators for proper temperatures, food containment and quality, and disposal of items. A facility policy, Dietary Hand Washing and Glove Use dated [DATE], identified staff will follow proper hand washing and gloving procedures, including washing hands upon returning to the workstation. Gloves are used to create a barrier between the food handler's hands and the food. Hands should be washed prior to donning gloves, and gloves will be changed after coming in contact with any item that may cause contamination. The policy contained picture directions for donning gloves and washing hands with soap and water.

Based on observation, interview, and document review, the facility failed to ensure compression socks were applied to 1 of 1 resident (R238) reviewed for quality of care. Findings include: R238 Diagnosis report printed 12/14/23, indicated diagnosis included cerebral infarction (stroke). R238 Order dated 11/29/23, directed to apply TEDS (compression socks) in AM before getting out of bed. R238 baseline care plan dated 11/29/23, and caresheet undated, identified R238 wore compression socks During interview on 12/11/23 at 6:43 p.m., R238 stated she did not have compression socks since admission on 11/29/23 but wore them prior to admission. R238 asked two staff about compression socks and was told they needed to be reordered. R238 stated she was worried about her left foot swelling. During observation on 12/13/23 at 7:37 a.m., R238 was observed wearing white non compression socks on both legs. During observation on 12/14/23 at 10:01 a.m., R238 was wearing fuzzy socks and canvas tennis shoes. Compression socks were not noted on either leg. During interview on 12/13/23 at 9:14 a.m., nursing assistant (NA)-B stated R238 has not had compression socks since she admitted . NA-B acknowledged R238 had compression socks listed on the care sheet and NA-B reported to a registered nurse (RN) R238 did not have compression socks. During interview on 12/14/23 at 10:28 a.m., RN-A would not confirm or deny R238 had orders for compression socks. During interview on 12/14/23 at 10:57 a.m., director of nursing (DON) stated when a resident admitted with orders for compression socks, she expected the resident was measured the evening of admission or on the next morning. DON expected the resident had compression socks within two days of admission. DON stated not having compression socks placed R238 at risk for blood clots or deep vein thrombosis (deep blood clot). A request for a facility policy on compression socks was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure required nurse staffing information was updated daily. This had the potential to affect all 34 residents, staff and visitors who may wish to review this information. Findings include: During an observation on 12/12/23 at 11:16 a.m., posted staffing at the front entry to the rehab center was dated 12/11/23. During an observation on 12/13/23 at 8:09 a.m., posted staffing at the front entry was dated 12/11/23. Health unit coordinator (HUC)-E stated the charge nurse was the person responsible for updating the posted staffing. During an observation on 12/13/23 at 11:09 a.m., the posted staffing was still from 12/11/23. During an interview on 12/13/23 at 12:00 p.m., the director of nursing (DON) stated the expectation was for the posted staffing to be for the current date because it was a requirement. During an interview on 12/14/23 at 8:39 a.m., the administrator stated the expectation was that the posted staffing be for the current date. A facility policy, Courage [NAME] Rehabilitation Institute - TRP dated November 2023, identified the facility will post the nurse staffing data on a daily basis at the beginning of each shift.

Based on interview and document review the facility failed to review and/or revise the infection control programs policies and procedures at least annually. This had the potential to affect all 34 residents, all staff, and all visitors at the facility. Findings include; Review of the facility's infection control policies was conducted on 12/14/23. The facility policy titled Department Plan: Infection Prevention and Control Program plan had an effective and approval date of 10/25/22, with the next review date of 8/31/25. During interview on 12/14/23 at 9:00 a.m., the infection preventionist (IP) stated the last documented review of the Infection Prevention and Control Program Plan was 10/25/22. IP stated that the facility follows the same requirements as the hospital and verified the facility does not review annually.

Based on interview and document review, the facility failed to ensure an allegation of verbal was reported immediately, but no later than two hours, to the State Agency (SA) for 1 of 1 residents (R1) reviewed for verbal abuse by a staff member. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 had a stroke with hemiplegia, was cognitively intact, received antipsychotic medication and required extensive assist with activities of daily living (ADL)'s. R1's Care Plan dated 10/31/22, indicated R1 had alteration in thought process and a cognitive impairment due to a recent onset of cerebral vascular accident (CVA). The care plan further indicated R1 had impaired decision making. A facility reported incident indicated on 12/27/22, at 6:00 a.m. R1 reported nursing assistant (NA)-A called her a piece of shit. The report indicated NA-A denied swearing at R1 and stated she was perseverating about food, and over the course of the shift, she brought her some warmed up pasta, two chocolate puddings and two cranberry juices, and had also cleaned up several candy wrappers from the floor. The report identified NA-A stated at one point R1 asked her to find something sweet for her from her bag, but NA-A could not find anything sweet, just chips so R1 became very angry at NA-A and called her a piece of shit resulting in NA-A leaving the room. The report indicated the investigation is still underway, as they intend to interview with other residents of the unit whether staff have ever cursed at them. Additionally, the report indicated NA-A was removed from the schedule pending the investigation and buddy cares have been implemented for R1. The report submitted to the SA was (over 10 hours after the incident occurred). During interview on 1/11/23, at 1:40 p.m. administrator stated she received an e-mail regarding the incident on 12/27/22, and opened it approximately at 9:30 a.m. that day. The administrator stated she tells her staff they should be calling her immediately when any allegation of abuse occurs and not to just send an email. The administrator stated after the investigation was completed it was found the allegation of abuse was unfounded. The administrator further stated staff will need to be re-educated on reporting immediately and the abuse policy also needs to be updated to indicate all allegations of abuse need to be reported immediately. The facility Maltreatment Of Vulnerable Adults:Prevention, Intervention And Reporting Procedures approval date 3/31/2020, indicated verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. The policy further indicated further indicated the definition for immediately means as soon as possible, but not later than two hours after the allegation is made if there is serious bodily injury, or not later than 24 hours if the event does not result in serious bodily harm. The policy indicated The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of client property, are reported immediately, but later than two hours after the allegation is made if the events resulted in serious bodily injury or not later than 24 hours if the events did not result in serious bodily injury.

Based on interview and document review, the facility failed to develop written policy and procedure to report abuse in accordance with federal regulation immediately, but no later than 2 hours, to the state agency. Finding include: Review of the facility's Maltreatment Of Vulnerable Adults: Prevention, Intervention and Reporting Procedures policy with an approval date of 3/31/2020, indicated .the definition for immediately means as soon as possible, but not later than two hours after the allegation is made if there is serious bodily injury, or not later than 24 hours if the event does not result in serious bodily harm. The policy indicated, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of client property, are reported immediately, but later than two hours after the allegation is made if the events resulted in serious bodily injury or not later than 24 hours if the events did not result in serious bodily injury. During interview 1/11/23, at 1:30 p.m. administrator stated she would expect staff to report allegations of abuse immediately to her and, after reading the policy, stated the policy was incorrect and needed to be updated to indicate abuse reporting immediately regardless if there is a serious injury or not.

Based on observation, interview and document review the facility failed to ensure appropriate hand hygiene and gloves usage was performed for 1 of 1 staff observed preparing sandwiches. This had the potential to affect 5 residents who would have received these sandwiches. Findings include: During an observation on 3/16/22, at 7:13 a.m. dietary director (DD) donned clean gloves and with a knife, sliced open plastic bags containing 20 lbs. of raw beef and poured into a large kettle. DD removed soiled gloves, donned clean gloves, and moved the raw beef around in the kettle with gloved hand. DD removed soiled gloves and donned one clean glove. With gloved hand, DD placed the soiled knife into a sink. DD removed the soiled glove and donned clean gloves without first performing hand hygiene. With clean gloves, DD opened the walk-in cooler, touched the handle and retrieved several items (bread, lettuce, cheese, luncheon meat) from the cooler to make sandwiches. With the same soiled gloves, DD pulled out a length of plastic wrap, secured it to the edge of the prep counter and with her soiled gloves opened the bread bag and removed 2 slices of bread and placed on the plastic wrap. She then with the same soiled gloves took a slice of cheese and placed it on the bread. DD then removed her soiled gloves and donned one clean glove and pulled luncheon meat out of a container and placed it on the sandwich. She proceed in this same manner until four additional sandwiches were prepared. On 3/16/22, at 7:27 a.m. DD stated she did not perform hand hygiene after working with raw meat, and stated, I should have. I know better. The facility provided a copy of Information for Food Service Personnel in Hospitals and Related Care Facilities, revised 1/95, in lieu of a facility food service policy. Additionally, hands are washed frequently, using recommended techniques during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and when switching between working with raw foods and working with ready-to-eat foods.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R3, R139) were offered or received the pneumococcal vaccination. Further, the facility failed to ensure 2 of 5 residents (R139, R90) were offered or received the influenza vaccination during the 2021 flu season in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R3's face sheet, printed 3/16/22, noted diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact. R3's admission nursing assessment dated [DATE], R3 was not up to date with his pneumococcal vaccinations. R3's immunization Record dated 3/15/22, identified R3 received the initial pneumococcal vaccine, [MEDICATION(S)], on 11/18/15. However, the recored failed to identify R3 was offered or received any additional doses. R139's face sheet, printed 3/16/22, noted diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R139's admission nursing assessment dated [DATE], indicated R139 did not receive the influenza vaccine while at the facility. Further, his pneumococcal vaccination was not up to date. R139's Immunization Record dated 3/15/22, failed to identify R139 was offered or received pneumococcal and influenza vaccinations. Attempts to interview R139 regarding vaccination status were unsuccessful. R90's face sheet printed 3/16/22, noted diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R90's admission nursing assessment dated [DATE], indicated she did not receive the influenza vaccine while at the facility. R90's Immunization Record dated 3/15/22, failed to identify that R90 was offered or received the influenza vaccine. On 3/16/22 at 9:46 a.m. registered nurse (RN)-A stated the charge nurse completed the admission assessment which included information regarding immunizations. Facility had signed standing orders to administer it. When the resident consented to the pneumococcal vaccine, the provider was updated for an order to administer the vaccine. RN-A stated refusals were documented on the consent form. The resident was provided with education on the vaccinations and the provider was updated On 3/16/22 at 10:31 a.m. director of nursing (DON) stated she expected the influenza vaccine was offered to new residents admitted between September and May of the following year. She expected the pneumococcal vaccine was offered to all residents who had not received it or were not up to date according to CDC recommendations. The DON expected residents who consented to the influenza vaccine received it at admission. Further, residents who consented to the pneumococcal vaccine received it after an order was received from the resident's provider. The DON expected refusals were documented on the vaccine consent form and the form was given to the resident's provider for review. She expected the resident was provided with education for each vaccine that was refused. DON confirmed, R3's and R139's medical records lacked evidence of the pneumococcal vaccine being offered or administered. DON also confirmed R90's and R139's medical records lacked evidence of the influenza vaccine being offered or administered. DON confirmed R3, R90 and R139 did not meet criteria to be excluded from receiving vaccines. Facility policy, Vaccination, Pneumococcal and Influenza reviewed 8/31/20, gave direction for nursing to assess pneumococcal vaccine and influenza vaccine status upon admission during the influenza season-generally begins in September and continues through May. If client does not meet criteria for vaccinations, document exclusion criteria in the medical record. If client is eligible to receive the vaccine, administer the vaccine unless exclusions apply.

Based on observation, interview and document review, the facility failed to thoroughly investigate, and reassess residents for elopement risk following a resident elopement for 1 of 1 residents (R1) reviewed for elopement. The survey resulted in an immediate jeopardy (IJ) to resident health and safety on 1/18/21, when staff opened the door and R1 exited the facility, was found approximately 1.5 miles from the facility on a busy road, was not dressed appropriately for the cold weather and was away from the facility for approximately 1 hour, when R1 was returned to the facility by a family member (F)-A. The immediate Jeopardy began on 1/18/21 when staff opened the door and R1 exited the facility, was found approximately 1.5 miles from the facility on a busy road, was not dressed appropriately for the cold. The administrator and director of nursing (DON) were notified of the IJ on 1/22/21 at 3:42 p.m. The immediate jeopardy was removed on 1/26/21, at 10:59 a.m. and the non-compliance remained at the lower scope and severity of a D, no actual harm with a potential for more than minimal harm. Findings include: R1's preadmission assessment dated [DATE], indicated R1 was diffusely weak and had full range of motion. R1 required partial assistance with walking and supervision for wheeling. R1 was prescribed [MEDICATION(S)] 5 milligrams (mg), 25 mg of trazadone and [MEDICATION(S)] 50 mg at night for [CONDITION(S)]. R1 was also taking Maintained 100 mg twice a day (bid) and [MEDICATION(S)] 1000 mg bid for [CONDITION(S)] prophylaxis. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 did not have any behaviors/wandering. R1's diagnosis included [CONDITION(S)] (TBI), unsteadiness on feet, cognitive communication deficit and dysphasia. R1 required extensive assistance of 1-2 staff for activities of daily living including walking on the unit and used a wheelchair. R1 was receiving physical therapy, occupational therapy and speech therapy due to TBI. R1's Social Services Assessment date 12/24/2020, indicated R1 had physical/cognitive deficits that increased the risk of potential abuse. An Interdisciplinary Rehabilitation Consult dated 12/24/2020, by physical therapist (PT)-1, indicated R1 had some emerging balance reactions, overall poor safety awareness in regards to R1's wheel chair. Physical therapy barriers are decreased safety awareness and insight, impaired memory. Discharge goals were for R1 to improve memory, improve executive function. R1 had severe cognitive deficits across all domains with poor safety awareness. R1's admission nursing assessment dated [DATE], by registered nurse (RN)-A indicated R1 arrived by wheelchair was alert and orientated to self, place, time and situation. In the behavior section of the admission assessment, RN-A indicated R-1 did not have any behaviors and did not display wandering behaviors. The wandering/elopement section of the admission assessment RN-A indicated the following: · Question 4a indicated R1 and was not ambulatory or self-mobile in a wheelchair. This question indicated if the answer to 4(a) is no-skip to question 5. · Question 4b wandering/elopement risk assessment-check all that apply: New admission to the facility that made statements the question to be here Client is cognitively impaired, with poor decision making skills and/or pertinent diagnosis (e.g.; dementia, [CONDITION(S)],delusions, hallucinations, depression, manic depression, schizophrenia) or Client is alert but non-compliant with facility protocols regarding leaving the unit None of the above RN A- selected None of the above-skip to question 5 · Question 4c indicated R1 did not have any wandering/elopement risk behaviors- check all that apply: RN-A selected 9 None of the above-skip to question 5 · Question 4d in response to wandering/elopement questions start the following interventions: I RN-A selected care plan for high risk elopement clients · Question 5 does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside of the facility)? RN-A selected no · Question 6 has the client taken medication to manage behaviors in the last 7 days? The following medications were options to select: antipsychotic, antianxiety and hypnotic. No was selected. During an interview on 1/21/2021, at 12:10 p.m. family member (F)-A stated R1 had poor decision making abilities, was impulsive and had short term memory loss from the TBI. Further, F-A stated R1's ability to walk independently had improved since R1 was admitted to the facility and was recently, probably the first week in January, cleared to independently transfer to and from the bed/toilet and needed supervision when walking in the halls for path-finding. Additionally, F-A stated F-B called her on 1/18/2021, at about 5:20 p.m. and stated R1 was missing. The facility searched for R1 and were unable to locate R1. F-A then drove towards the facility and found R1 walking towards the facility. Golden Valley Police Department was at the scene where R1 was found. F-A stated R1 was about 1.5 miles away from the facility when she saw R1. F-A stated R1 had on a coat, no gloves or hat and had slippers on. F-A stated the Golden Valley Police Officers informed her the temperature at the time was 10 degrees Fahrenheit with the wind chill. The sun set at 5:02 p.m. F-A then drove R1 back to the facility at approximately 6:05 p.m. Further, F-A stated R1 had fallen and injured her knee during the incident. A progress note dated 1/18/2021, at 9:56 p.m. indicated R1 was placed on a wanderguard due to an elopement on 1/18/2021. The note further indicated facility staff were unable to locate R1 at 5:11 p.m. when R1 was not in R1's room for dinner. Facility staff searched the building and other residents' rooms and were unable to locate R1. Staff contacted security and family at 5:17 p.m. and a Code Gray was initiated and 911 called at 5:36 p.m R1's orders on 1/18/2021, indicated post fall charting, a nursing order for hourly rounding and an order for a wanderguard due to elopement on 1/19/2021. R1's care plan was updated on 1/19/2021, to include a risk for wandering and elopement and a wander guard was initiated on 1/18/2021. During an interview on 1/22/2021, at 11:32 a.m. RN-B indicated a wandering/elopement assessment is completed on admission. If a resident was making statements about leaving or demonstrated exiting behaviors, the care coordinator would be contacted immediately. RN-B stated this happened pretty fast. Further, RN-B stated as a result of the elopement the facility needed to get consent from the resident or the resident's power of attorney to place a wander guard. Additionally, RN-B stated the staff will notify security guard to set the door alarms and a photo of the resident on a wanderguard is placed in the security office and at the nurses station. It is also noted on the dry erase board for safety behind the nurses station so the staff know what the resident looks like. RN-B stated there is not a routine re-assessment for wandering/elopement, it is generally if the resident's behavior changed. During an interview on 1/22/2021, at 11:40 a.m. the administrator and DON stated R1 was independent in her wc, and in theory a staff member needs to activate a push pad to allow a resident to leave the facility. Further, the administrator stated R1 was not assessed as a risk for elopement/wandering, as R1 was passive, a poor initiator and R1 had been allowed to go outside, which is a standard practice unless the resident was a risk for wandering/elopement or was not safe to be outside without staff monitoring. Additionally, the administrator stated a screener (S)-A was the individual who activated the push pad to allow R1 to exit the building. The administrator stated the facility had completed the following interventions after R1 eloped from the facility. Staff have been updated at change of shift huddles, a wanderguard was placed on R1, the corporate entity was completing a critical incident review and will provide feedback/systemic changes, so this doesn't happen in the future. Further, the administrator stated, the facility now has a heightened awareness, however the remaining residents in the facility had not been formally assessed for the risk of elopement. Additionally, the administrator stated S-1 who opened the exit door to allow R1 out of the facility had not been interviewed as to why she let R1 out of the facility. The administrator stated they had not interviewed this staff as S-A was not scheduled to work again until 1/25/2021. Further, the administrator stated there are residents at the facility that could potentially be a wandering/elopement risk and the facility had not assessed any other resident in the facility as a high risk for wandering/elopement. Additionally, the administrator stated she could not demonstrate in writing if other residents had been formally assessed for the risk of wandering/elopement. The administrator also stated R1 had the physical ability to elope the facility. During interview on 1/22/2021, at 12:15 p.m. RN-E stated R1 was a fall risk due to R1's impulsivity and R1 would not use the call light. Once R1 was cleared to be independent to transfer to bed/toilet and ambulate out of R1's room with supervision R1 was at less risk to fall. Further, RN-E stated she is educating staff during shift/safety huddles on R1's risk of elopement. Additionally, RN-E stated she did not formally look at other residents' risk for elopement. During interview on 1/22/2021, at 2:52 p.m. when asked regarding the process of completing the wandering/elopement section of the admission assessment, RN-C stated that if you select pertinent positive for questions 4b and 4c- see above- there will not be a trigger in the electronic health record to care plan the resident as a risk for elopement. Further, RN-C stated if you selected anything to question 4d, there is not a trigger for the nurse to select care plan interventions, it would need to be manually added to the resident's care plan. During interview on 1/25/2021, at 10:10 a.m. S-A stated the facility had trained her on how to screen individuals who enter the facility including taking their temperature, and asked screening questions regarding COVID-19. Further, S-A stated she really was not trained on people leaving the facility and stated when people were leaving the facility S-A was to activate the push pad to allow them to exit the facility. Additionally, S-A stated on 1/18/2021, at approximately 4:50 p.m. S-A activated the push pad and allowed R1 to exit the facility. S-A stated R1 looked like an employee, R1 then walked outside. Further, once facility staff were looking for R1, S-A went outside and could not see R1. Security was called as well as the Golden Valley Police Department. S-A stated she was re-educated on 1/25/2021, and that she does not work as a screener after 1/25/2021. During interview on 1/25/2021, at 4:05 p.m. the administrator stated the interdisciplinary team (IDT) agenda had been modified to include education for IDT when therapy documents a change in mobility status, therapy needs to trigger IDT to discuss whether it changes the resident's elopement risk, and the agenda format has been updated to prompt it. Additionally, the administrator stated this modification was added to the revised policy on comprehensive assessment and person centered care planning. During an interview with R1 on 1/25/21, at 3:30 p.m. R1 was sitting on her bed and appeared to be calm. R1 stated she remembered leaving the facility on 1/18/21 to go get coffee, which R1 stated she does at her home. Further, R1 stated she told her roommate she was going to get coffee and the person at the door told R1 it's a long walk and I should be careful. Further, R1 stated she believes the person at the desk knew she lived at the facility. R1 stated F-A found her an brought her back to the facility. Additionally, R1 stated she feels safe at the facility and was informed why R1 had a bracelet on R1's ankle and stated as long as they are honest with me it's pretty cool. During observation photos of R1 and R2 were posted behind the nurses station. Following interview and verification with multiple nursing and non-nursing staff, observation and record review, the IJ was removed on 1/26/21, at 10:59 a.m. All residents were reassessed for the risk of elopement. Nursing staff were educated to manually add a care plan intervention to the resident's care plan if they did not receive a trigger to add the interventions to the care plan. Security guards and screeners were educated on a change in process. If a resident is unable to activate the panel to exit the facility they are to notify nursing staff. Photos of residents assessed to be at a high risk for wandering were posted in the security office and behind the nurses station. The Person Centered Care Plan and Comprehensive Assessment policy were revised and routed to nursing and IDT staff. The agenda for the IDT meeting was revised to include a discussion if a resident had a significant change in status and the IDT team was educated on this change. Review of a policy titled Comprehensive assessment dated [DATE], with a revision date of 1/25/2021, indicates in the section for procedures with headings was modified to include: Timeline: As needed Role: All disciplines Task: Reassess and update Review of a policy titled Person Centered Care Planning dated 12/13/2018 with a revision on 1/25/2021 indicates to promote continuity of care, communication among staff and representative (if appropriate) are informed of the initial plan of care and services, Transitional Rehabilitation Program (TRP) clients will have a person-centered care plan. The care plan will address client-specific health and safety concerns to prevent decline or injury and will identify needs for supervision, behavioral interventions, and assistance with activities of daily living as necessary. 1. A baseline care plan will be developed within 48 hours of client admission and will be minimally include: a. Initial goals based on admission orders b. Provider orders c. Dietary orders d. Therapy services e. Social services 2. TRP will provide the client and their representative with a summary of the baseline care plan that includes, but is not limited to: a. The initial goals of the client. b. A summary of the client's medications and dietary instructions. c. Services and treatments that will be provided to the client. d. Updated information based on the details of the comprehensive care plan as necessary. e. The summary will be provided to the client and/or representative in a manner that is easy to understand. f. If significant changes are made to the plan the client and/or representative will be given an updated summary. g. Staff will document that the summary was provided to the client and/or representative. 3. The client will be provide input to the plan of care, and the plan of care will support the client's personal choices. 4. The baseline care plan will be revised if there are significant changes in the condition or needs.

Based on interview and document review, the facility failed to ensure the correct medication and dosage were provided for 1 of 1 residents (R25) reviewed for medication errors. This resulted in actual harm when R25 experienced increased lethargy and required interventions including increased clinical monitoring, lab draws, withholding of food, fluids, and medications, and administration of intravenous (IV) fluids in response to the significant medication error. Findings include: R25's entry tracking record Minimum Data Set ((MDS) dated [DATE] identified R25 was cognitively intact with medical [DIAGNOSES REDACTED]. R25's Medication Administration Record [REDACTED] [MEDICATION NAME] tablet give 3 mg (milligram-a unit of measurement) by mouth at bedtime for [MEDICAL CONDITION]; [MEDICATION NAME] [MED] tablet give 25 mg by mouth at bedtime for [MEDICAL CONDITION]; Dasatinib tablet Give 70 mg by mouth one time a day for [MEDICAL CONDITION]; [MEDICATION NAME] tablet give 4 mg by mouth three times a day for [MEDICAL CONDITION] for 7 days; [MEDICATION NAME] tablet 400 mg give 1 tablet by mouth two times a day for [MEDICAL CONDITION]. On 2/18/20, at 2:15 p.m. family member (FM)-B stated R25 had received another resident's medication in error one evening in January 2020. FM-B stated R25 received sedatives, muscle relaxants, and antidepressants which had been ordered for another resident and the dosing was a much higher level than what was prescribed for R25. He also received other medications that were not prescribed for R25. FM-B stated the facility had notified FM-C for R25 and the provider immediately, and called FM-B later in the evening. FM-B stated an EKG (An electrocardiogram-EKG or ECG- a test which measured the electrical activity of the heartbeat) was completed, staff monitored R25's condition closely, and fluids were encouraged. FM-B stated R25's medications were held the following day and R25 was difficult to arouse. He was unable to stay awake. FM-B stated they did labs, and gave him intravenous fluids. The nurse whom gave R25 the wrong medications had set up medications for the other resident, became distracted, and administered the medications to R25 in error. FM-B expressed concerns regarding the error occurrence and the potential complications related to this error. R25's narrative notes of [DATE] identified at approximately 7:30 p.m. R25 was inadvertently given medications which were ordered for a different resident by registered nurse (RN)-E. R25 received the following medications: [REDACTED] *[MEDICATION NAME] [MED] 100 mg (stool softener) *[MEDICATION NAME] 4 mg short acting muscle relaxant. (Usual dose of 2 mg initially) *[MEDICATION NAME] [AGE] mg (an antidepressant-Usual geriatric dose -10 mg orally 3 times a day AND 20 mg orally once a day at bedtime) *[MEDICATION NAME] 40 mg (muscle relaxant and an [MEDICATION NAME] agent-recommended initiation for adult therapy: Initial dose: The following gradually increasing dosage regimen is suggested, but should be adjusted to suit individual patient requirements: 5 mg orally 3 times a day for 3 days, then 10 mg orally 3 times a day for 3 days, then 15 mg orally 3 times a day for 3 days, then 20 mg orally 3 times a day for 3 days) *[MED] 0.4 mg (used to promote urination-standard dose) *[MEDICATION NAME] 150 mg (Antidepressant- Initial dose: 150 mg orally per day in divided doses; this may be increased by 50 mg orally per day every 3 to 4 days). R25's did have a prescription for this medication, however, the dose administered at 150 mg was six times more than the dose of 25 mg prescribed for R25. The narrative note dated [DATE], indicated the error was identified at approximately 7:35 p.m. A call was placed to nurse practitioner (NP)-A at approximately 7:45 p.m. and orders were received to monitor R25's vital signs (VS-respirations, pulse, blood pressure, and temperature) every two hours for 24 hours. NP-A instructed staff to hold R25's [MEDICATION NAME], [MED], and senna plus. R25 was given the following: [MEDICATION NAME] 400 mg ([MEDICAL CONDITION] for [MEDICAL CONDITION]), Dasatinib 70 mg (a [MEDICAL CONDITION] medication [MEDICAL CONDITION]) [MEDICATION NAME] 4 mg (a steroid), and [MEDICATION NAME] 40 mg (blood thinner). The narrative notes of 1/28/20 indicated R25 was noted to be lethargic and intermittently alert and oriented this shift. The narrative note identified R25 took medications, however, required cues to swallow and drink water. A previous narrative note of 1/26/20 identified R25 took pills whole with water with no trouble, and did not indicate any need for prompts or cues. The note identified R25 displayed audible wheezing (and) occasional cough. NP-B was notified and additional orders were received to hold [MED] and [MEDICATION NAME] (an antidepressant medication), and hold any oral intake until R25 was fully alert. A subsequent narrative note on 1/28/20 indicated resident was extremely difficult to rouse at the beginning of the shift, however, at approximately 4:45 p.m. client woke up and was A&O x 3(alert and oriented to person, place, and time). A review of R25's physician's orders [REDACTED]. The orders also indicated R25 was to have blood work drawn on 1/29/20 for a complete blood count, and complete metabolic profile. Additional orders on 1/28/20, instructed staff to continue to monitor VS every two hours until 8:00 a.m. on 1/29/20. The orders also directed staff to hold R25's [MED] and [MEDICATION NAME] the evening of 1/28/20. A review of Medline Plus, on the United States (US) Department of Health and Human Services (DHS) National Institute of Health (NIH) identified the potential side effects as follows for the antidepressants and muscle relaxant/[MEDICATION NAME]: *[MEDICATION NAME]: Potential side effects identified: dizziness, drowsiness, weakness, nervousness, depression, vomiting, tingling sensation in the arms, legs, hands, and feet, dry mouth, constipation, diarrhea, stomach pain, heartburn, increased muscle spasms, back pain, rash, sweating. Serious side effects may include: nausea, extreme tiredness, unusual bleeding or bruising, lack of energy, loss of appetite, pain in the upper right part of the stomach, yellowing of the skin or eyes, unexplained flu-like symptoms, seeing things or hearing voices that do not exist, slow heartbeat, and changes in vision. *[MEDICATION NAME]: Potential side effects identified: slow or difficult speech, dizziness or faintness, weakness or numbness of an arm or a leg, crushing chest pain, rapid, pounding, or irregular heartbeat, severe skin rash or hives, swelling of the face and tongue, yellowing of the skin or eyes, jaw, neck, and back muscle spasms, uncontrollable shaking of a part of the body, [MEDICAL CONDITION] unusual bleeding or bruising, [MEDICAL CONDITION], hallucinating (seeing things or hearing voices that do not exist). Symptoms of medication overdose include; irregular heartbeat, [MEDICAL CONDITION], coma (loss of consciousness for a period of time), confusion, problems concentrating, hallucinating (seeing things or hearing voices that do not exist), agitation, drowsiness, rigid muscles, vomiting, fever, and cold body temperature. *[MEDICATION NAME]: Potential side effects identified may include: dizziness, weakness, confusion, headache, nausea, constipation, difficulty falling asleep or staying asleep, tiredness, and frequent urination. Serious side effects with use of [MEDICATION NAME] may include: seeing things or hearing voices that do not exist, and [MEDICAL CONDITION]. *[MED]: Potential side effects identified include: headache, nausea, vomiting, bad taste in mouth, diarrhea, constipation, changes in appetite or weight, weakness or tiredness, nervousness, dizziness or lightheadedness, feeling unsteady when walking, decreased ability to concentrate or remember things, confusion, nightmares, muscle pain, dry mouth, rash, sweating, uncontrollable shaking of a part of the body, numbness, burning, or tingling in the arms, legs, hands, or feet, decreased coordination, tired, red, or itchy eyes, and ringing of the ears. Serious side effects identified which required immediate medical treatment include: chest pain, fast, pounding, or irregular heartbeat, loss of consciousness (coma), [MEDICAL CONDITIONS], shortness of breath, unusual bruising or bleeding. Signs of overdose identified may include the following: difficulty breathing, stopped breathing, chest pain, irregular heartbeat, low blood pressure (sometimes leading to [MEDICAL CONDITION]), slow heart rate, coma (lack of responsiveness), dizziness, headache, [MEDICAL CONDITIONS], lack of coordination, and tremors. On 2/20/20, at 10:26 a.m. NP-A stated they were contacted as the on-call NP when R25 received the medications prescribed for another resident. NP-A stated the medications given were very different than the medications prescribed for R25. NP-A stated they were concerned the medications might put R25 down, and stated R25 was at risk of respiratory suppression (a decline in the ability of a person to inhale and exhale which can be a common side effect of drugs that suppress functions of the central nervous system). NP-A stated R25 was at risk for unresponsiveness. NP-A stated they had updated NP-B regarding the event and of the need for follow up the following morning. On 2/20/20, at 10:53 a.m. RN-A stated there had been staff education a couple of months ago regarding the medication administration process to make sure everything was completed accurately. RN-A stated there had been no recent training or education. On 2/20/20, at 10:54 a.m. RN-F stated staff were trained on medication administration with the annual skills agenda which was scheduled to be done in a couple of weeks. RN-F stated there had been no recent training for medication administration. On 2/20/20, at 11:41 a.m. NP-B stated R25 had an order in place for an EKG as a baseline reading prior to starting [MEDICAL CONDITION] medication. NP-B stated they reviewed R25's orders and orders were placed to hold medications the following morning as well. NP-B stated the primary concern for R25 was sedation. Additionally, NP-B stated there were concerns regarding potential need for lab work to watch liver function and cardiac function related to the side effects of the [MEDICATION NAME] and [MEDICATION NAME]. NP-B stated they ordered IV fluids to help flush medications through R25's system. NP-B ordered continued close monitoring (every two hours) until R25 became more responsive. NP-B stated this was a significant medication error. On 2/20/20, at 12:10 p.m. RN-G, clinical coordinator, stated any medication error follow up would be completed by the director of nursing (DON) and was unaware what had been completed. On 2/20/20, at 12:23 p.m. DON stated after the error was identified, RN-E immediately contacted the provider for follow up interventions. DON stated R25 was monitored closely throughout the night and the following day. DON stated R25 was placed on NPO (nothing by mouth) status related to increased lethargy (a state of sleepiness or deep unresponsiveness and inactivity). DON stated on the day following the error, R25 remained in bed, was given IV fluids, and did not participate in therapy. The DON further stated R25's airway was monitored, as well as monitoring of his vital signs. DON stated she received notification on [DATE] of the error and had spoken with RN-E in follow up on 1/28/20, The DON stated N-E stated he would set up more than one residents meds at a time and then administer them once set up. The DON went on to state that staff have been instructed to set up one resident's meds at a time and then administer them to the resident prior to setting up the next medications. On [DATE], RN-E stated he was interrupted during this process, and inadvertently had given the medications to R25. DON stated R25 was monitored very closely, with VS every two hours, that medications were held and R25 received IV fluids to help flush medications through his systems. The DON stated her concerns with R25 receiving the incorrect medications included the potential for lethargy, shortness of breath, and a drop in blood pressure. The DON also stated other ill effects was dependent on R25's liver and kidney function and other existing medical conditions. On 2/20/20, at 1:20 p.m. upon interview and review of the Medication Variance Report for the event of [DATE], the DON identified the counseling was completed with RN-E on 2/12/20 (16 days after the event) as well as follow up/education and medication administration observation. DON stated the corrective plan of action required approval through Human Resources (HR) before it was able to be implemented. The document indicated this was a Corrective Action/Performance Improvement Plan. The DON stated she had observed RN-E while setting up medications on 2/18/20 and identified he was setting up only one resident's medications, however, stated she had not completed formal documentation in follow up. The DON further stated following the incident there had been no additional information provided to the general nursing staff, either via memos or training regarding the appropriate process for med set up and administration. DON stated there had been training historically, but was unable to recall when specifically. Upon review of RN-E's file, it was noted RN-E had been previously counseled for med errors in 2017, however, the documentation lacked indication as to specific details. A facility policy titled Medication Administration, effective 12/13/18, to be reviewed 12/31/19, indicated medications are administered without necessary interruptions. Additionally, it identified client's were to be identified before medication administration with use of two methods of identification, which included having checked photograph with the medical record, having called the client by name or having asked them to verify their name, and verification by other personal.

Based on observation, interview and document review, the facility failed to ensure care was provided in a dignified manner when a urinary leg bag was uncovered and visible to others for 1 of 3 residents (R348) reviewed for care provided in a dignified manner. Findings include: R348's record indicated an admission date of [DATE] and [DIAGNOSES REDACTED]. During an observation on 2/18/20, at 4:42 p.m. R348 had entered his room. R348 was wearing shorts and had a clear plastic urinary bag attached to the calf of his left leg and his right leg was wrapped with an ace bandage from his toes to the right knee. During an interview on 2/18/20, at 4:42 p.m. R348 stated he was embarrassed by the urinary bag being exposed. R348 confirmed that the bag had been placed on his leg and exposed since admission on [DATE]. During an interview on [DATE], at 9:11 a.m. R348's family member (FM)-A stated he'd visited frequently since admission and today was the first time the urine bag was not attached to R348's leg and exposed. Further, FM-A stated that R348 only wore shorts. During an interview on 2/20/20, at 9:08 a.m. nursing assistant (NA)-B stated when a resident has a catheter bag attached to the leg it should be covered unless the resident refused and stated it didn't bother him. During an interview on 2/20/20, at 9:22 a.m. registered nurse (RN)-A stated urine bags should be attached to the lower leg and covered. During an interview on 2/20/20, at 9:43 a.m. director of nursing (DON) stated clients should be asked if they want their catheter bags covered. A facility policy for Care of Client with a Urinary Catheter lacked direction on covering a catheter for privacy or dignity of the client.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of staff to resident abuse, for 1 of 2 residents (R7) reviewed for allegations of abuse. Finding include: R7's admission Minimum Data Set ((MDS) dated [DATE] indicated R7 was cognitively intact and required extensive assistance with most activities of daily living (ADL's). An incident investigation submitted to the [STATE] department of health (MDH) on 1/31/2020, at 12:11 p.m. included the following information. At about 2:00 p.m. on 1/24/2020, R7 reported to nursing assistant (NA)-C that on 1/22/2020, during the evening shift, R7 stated alleged perpetrator(AP) called R7 a racist and yelled at her to stop crying. The administrator was notified immediately and an investigation was initiated. NA-E was removed from the schedule pending outcome of the investigation. A Grievance Investigation dated 1/24/2000, included interviews with NA-E, NA-C and health unit coordinator (HUC)-D on 1/24/2000, and lacked any interviews with other residents. Further, the grievance investigation indicated: · Review of the medical record (if indicated): Nothing relevant noted · Interviews with the client's roommate, family members, and visitors: Not indicated · Search of the client's room (with client permission): Not indicated · Interviews with any witnesses to the incident or concern: (Completed by administrator and PCS- no indication of the role-See attached A Corrective Action/Performance Improvement Plan dated 1/31/2020, included a summary of incident and or behavior indicated: On 1/24/2020, (R7) brought forward a concern regarding a statement you had made. After talking with (R7) and with you (AP), it was determined that on 1/22/2020, you were assisting (R7) to bed and (R7) was upset about not getting a shower that date. IN attempting to explain the situation to (R7) that (AP) stated we feel like you're being racist toward (AP) and (nursing assistant (NA)-D) because (R7) always refused showers from (AP) and (NA-D), but you take showers from( NA-C). Further, the document indicated (AP's) statement made (R7) feel uncomfortable. (R7) was offended by being called a racist. AP was counseled on expectations and performance improvement plan. Action taken toward AP was a written warning. Failure to meet and maintain the expectation detailed above may result in additional corrective action, up to an including termination. The document was signed by AP on 1/30/2020, and administrator on 1/30/2020. During interview on [DATE]20, at 3:00 p.m. R7 stated she feels safe and the staff treat R7 with dignity and respect. Further, R7 stated there was one episode where AP called R7 a racist because R7 allowed another Caucasian staff member, NA-C to give R7 a shower and would not let AP and NA-D give R7 a shower. Further R7 stated the situation was reported 2 days after the incident and the administrator investigated. Additionally R7 stated AP has not worked with R7 since the incident and has since terminated employment. During interview on 2/20/2020, at 11:44 a.m. the administrator stated NA-D did not hear AP call R7 a racist. Further, the administrator stated AP made a statement to R7 and referred to R7 as a racist. Additionally the administrator stated no other client's were interviewed as it seemed like an isolated incident and no other client's had concerns regarding being called a racist and it did not seem like a widespread concerns for the administrator. Additionally, the administrator stated whether or not the AP said anything similar to other client's, the AP was given appropriate discipline, and that the administrator did not think it was necessary to interview other client's as AP admitted the incident and it was substantiated. When the surveyor asked if interviewing other residents may establish a pattern, the administrator stated there was enough information to say the situation was fully investigated.

Based on observation, interview, and document review, the facility failed to ensure that residents with pressure ulcers received the necessary care and treatment to promote healing and prevent further development of pressure ulcers for 3 of 4 residents (R55, R59, and R85) in the sample who were at risk for pressure ulcers. The facility's failure to implement interventions for R55 resulted in actual harm. Findings include: R55 was admitted to the facility without documented pressure ulcers and developed a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). R55 was given a new wheelchair and Flovair cushion on 10/4/12, without an assessment of the appropriateness of the chair and cushion. As a result R55 sustained actual harm from the development of the Stage III pressure ulcer. R55 was admitted on [DATE], and had [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE], indicated R55's cognitive skills were severely impaired. R55 required extensive assistance for bed mobility and personal hygiene. He was totally dependent for transfers and toilet use. The MDS assessment identified R55 was at risk for the development of pressure ulcers. The MDS also noted there was no history of pressure ulcers. The care area assessment (CAA) completed on 8/23/12, reported R55 was dependent in all areas of mobility. He was to be repositioned every two (2) hours at night. The CAA identified risk factors for pressure ulcer development were immobility, incontinence, altered mental state and the use of antidepressants. An admission body audit was completed and indicated the skin was intact. Weekly Braden Scale skin assessments were completed for four weeks after R55 was admitted and identified R55 at high risk for the development of pressure ulcers. The plan of care (POC) dated 8/23/12, did not address pressure ulcer prevention. It did however direct staff to observe for redness, open areas, scratches, cuts, and bruises and report those changes to the nurse. A Stage I pressure ulcer (An observable, pressure-related alteration of intact skin) was identified on 8/31/12, on the left ischial tuberosities (LIT) (left buttock area). As a result, the nursing staff requested that physical therapy (PT) do pressure mapping to the area and possibly provide a new cushion. No documentation was found if R55 had pressure mapping or received a different cushion. The Stage I pressure ulcer resolved by 9/14/12. On 10/12/12, the nursing staff noted the skin (LIT) had become reddened but was intact. It was not identified as a pressure ulcer, nor were any specific interventions implemented. The area was reassessed on 10/17/12, and the LIT area remained "pink/red" but not open. On 10/21/12, staff identified an open area on the LIT measuring 2.0 cm x 6.0 cm with 98% reddened and well defined edges. The area had scant clear drainage and was defined as a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). On 10/22/12, another staff person identified the LIT area "opened superficially" and measured 1.5 cm x 3.0 cm with 95% noted as "pink/red" and 5% noted as yellow. The staff identified the edges as poorly defined with light bloody drainage. On 10/24/12, a reassessment of the wound was completed and the area measured 3.0 cm x 6.3 cm and had 70% redness, 20% noted yellow and 10% noted brown. The edges were poorly defined with light drainage and was described as a Stage II pressure ulcer. According to the assessment R55 was given an air bed and PT was contacted and asked to do a pressure mapping. As a result of the pressure mapping R55 was given a new Roho cushion. A note by the nurse practitioner on 10/26/12, revealed "[AGE] year-old male presents today for evaluation of left IT wound. He has had area of blanchable [DIAGNOSES REDACTED] (Reddened area of the skin that temporarily turns white or pale when pressure is applied with a fingertip), in the last week it has opened up. A few weeks ago he received a new wheelchair with a new cushion. Previously on Roho cushion. Nursing has contacted physical therapy, pressure mapping to obtain an adequate pressure relief cushion." On 11/2/12, the wound assessment was completed and identified a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). The area was 1.0 cm wide by 2.5 cm long with 20% granulation, 70% slough, and 10% dark red. The edges were poorly defined with moderate serosangeanous drainage. The assessment noted the wound had worsened. The pressure ulcer was observed and measured on 11/6/12, at 9:15 a.m. by registered nurse (RN)-D. The entire reddened area measured 4.2 cm long and 2.1 cm wide and was irregular in shape, with no obvious odor or drainage. The open area (inside the reddened area) measured 2.5 cm long and 1.5 cm wide. RN-D stated the pressure ulcer had 60% slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy (at times), 5% reddened area, and 35% granulation (pink-red moist tissue that fills an open wound, when it starts to heal). RN-D did not identify the stage of the pressure ulcer which had been identified as a Stage III on 11/2/12. An interview was completed on 11/6/12, at 1:50 p.m. with nursing assistant (NA)-A, who stated that R55 required extensive assistance with all of his personal cares and did not have any pressure ulcers until recently. She indicated he now is repositioned in bed every two hours. NA-A reported she used the nursing assistant assignment sheet to determine the care given and provide the sheet that she used for the date of 11/6/12. The nursing assistant sheet directed staff to place the resident in bed when not in therapy. He was to be turned every two hours side to side, and to be off the left buttocks as much as possible. She reported the nursing assistant assignment sheets were revised by her, when there were any changes in the resident's condition. An interview was completed with clinical manager (CM)-B on 11/6/12, at 2:18 p.m. CM-B reported a tissue profusion assessment was completed by the night staff on 8/12/12. The results indicated R55 tolerated being in one position for over three hours. Initially this had been attempted however R55 became uncomfortable with this and the reposition plan was reduced to every two hours. CM-B reported that upon admission, R55 was easily fatigued and frequently made requests to lie in his bed. She also indicated that staff did attempt to reposition him every two hours. She reported on 10/4/12, the resident received a new tilt in space chair and flovair cushion. On 10/22/12, she was informed of the pressure ulcer and requested that PT complete pressure mapping. She indicated that as a result of the pressure mapping, PT provided R55 with a new Roho cushion. She further stated that once the pressure area was identified, they also added an air bed, referred to the nurse practitioner, and nursing staff were instructed to increase the frequency of lying him down. She also reported that his nutritional supplements were changed to a supplement that was higher in protein content. She did not indicate the frequency of the off-loading, but did state that he should be placed in his bed when not attending therapy or meals. The nurse manager reported she felt the pressure ulcer was a result of the new Flovair cushion which came with the tilt in space chair. An interview was completed with physical therapist (PT)-B on 11/7/12, at 11:05 a.m. PT-B reported R55 received a new wheelchair and a Flovair cushion (which came with the chair) on 10/4/12. PT-B indicated that pressure mapping was not done with the new cushion until requested by nursing staff on 10/24/12. She reported that on 10/4/12, the resident indicated the chair felt good. PT-B also reported pressure mapping is not part of the facility's process when a resident receives a new chair and cushion. PT-B reported that after completing the pressure mapping on 10/24/12, the LIT area showed significant pressure. Upon replacing the Flovair cushion with a Roho cushion, pressure mapping revealed good distribution of pressure. She acknowledged that doing pressure mapping would be beneficial after a resident receives any new chair or cushion. The facility's policy titled Skin Assessment and Care dated September 2008, identified a participant who enters (facility name) without pressure ulcer does not develop pressure ulcer unless the individual's clinical condition demonstrates that they were unavoidable. The policy directed staff to develop a care plan addressing the individual needs of each resident. The care plan interventions were to include redistribution of pressure, positive appropriate pressure redistributing surfaces and the provision of an individualized repositioning plan. The facility failed to follow the policy which led to the development of a Stage III pressure ulcer and resulted in harm to the resident. R82 was left to sleep in her own urine for approximately 10 hours and during that time the stage one pressure ulcer on the coccyx deteriorated to a stage two. During interview on 11/5/12, at 5:47 p.m., registered nurse (RN)-H verified R82 had a stage one pressure ulcer (an observable, pressure-related alteration of intact skin). A progress note dated 10/26/12, indicated "Was seen by nurse practitioner (NP) in room during skin rounds. NP looked at coccyx area and recommended area to be covered with [MEDICATION NAME] dressing as protecting layer to prevent shearing causing further damage to area, and frequent turning in evening and night." A wound summary completed on 10/26/12, by the NP, identified R82's pressure ulcer measured 1.5 centimeter (cm) by 1.0 cm and assessed it to be a stage one. The plan of care was noted to treat with a [MEDICATION NAME] dressing and change every three days or sooner if it became saturated or came off. The first nursing wound assessment dated [DATE], noted R82's pressure ulcer to measure 0.5 cm by 1.0 cm, with well-defined edges, no drainage, no pain, no odor and was a stage one. On the same assessment form an entry was made on 11/2/12, which stated the NP looked at wound again and identified it was stable and there were no order changes. During interview on 11/8/12, at 1:00 p.m., R82 described the lack of care received during the previous night and indicated lying in her own urine for the entire night. R82 stated on 11/7/12, at 10:00 p.m., the nursing assistant (NA) was assisting with transporting to bed when R82 identified needing to be catheterized and felt some incontinence of urine. The RN came in and provided straight catheterization, noted the bedding was wet and informed R82 that the NA would be in to clean up the wet bedding. R82 stated the NA came in and provided personal hygiene, but failed to change the bedding. At midnight the night RN came in and inserted an indwelling Foley catheter per R82's request and noted the bedding was wet, but did not remove them. R82 stated the night nurse did not say anything at the time about the bedding being wet, but had reported off to the day shift that it was. Then, on 11/8/12, at 8:15 a.m., NA-B came in a discovered that the sheets were soaking wet. R82 further indicated the dressing covering the pressure ulcer on the coccyx had come loose from the wetness and the wound was now open. During interview on 11/8/12, at 1:50 p.m., NA-B confirmed the night RN had reported off at 7:00 a.m. that morning that R82's bedding had been wet at midnight. NA-B stated he thought "it was weird" that when he went to assist R82 with getting up for the morning at 8:15 a.m., the bedding was wet because the Foley catheter was draining the urine so the bed should not have been wet. NA-B concluded the bed must have gotten wet prior to the insertion of the catheter at midnight and it was likely R82 laid in urine all night long. During interview on 11/8/12, at 2:05 p.m., RN-B indicated she had applied a [MEDICATION NAME] dressing to R82's pressure ulcer that morning as no dressing had been reapplied after R82's therapy in the pool the previous day. RN-B described an open area was now present within the wound which had not been there previously. During interview on 11/8/12, at 2:10 p.m., RN-I verified the night nurse had recorded her verbal shift report sometime between 6:30 and 7:00 a.m. which stated she had placed the Foley catheter at midnight and that R82's bedding was wet at that time. RN-I further verified the Foley was still in place, was patent and intact with no leaking. RN-I indicated she did not know whether R82's bedding had been changed during the night and had no explanation as to how it might have gotten wet after the placement of the Foley. RN-I indicated she had not yet followed up with the night nurse to find out more information. When interviewed on 11/8/12 at 2:30 p.m., the director of nursing (DON) revealed she was unaware R82 had slept in urine all night and expressed concern as her expectation was that the RN should have changed the bedding immediately. DON further confirmed R82's pressure ulcer had now deteriorated to a stage two (a partial-thickness skin loss involving epidermis and/or dermis) due to the open area within the wound. During follow up interview on 11/8/12 at 4:20 p.m., the DON called RN-B and clarified whether or not a dressing had been present when she had applied the [MEDICATION NAME] that morning. RN-B initially stated, "No" but then changed her mind and stated that yes, an Allyvan dressing was present but was all curled and wrinkled and was not the type of dressing that was prescribed. DON stated she had spoken with the RN who was on duty during the previous afternoon on 11/7/12, who indicated she had applied the Allyvan dressing after R82 returned from the pool because the dressing was handy at the time despite not being what was prescribed. The Skin Assessment and Care policy dated 09/08 indicated each participant would receive the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care related to skin care; a participant having pressure sores would receive necessary treatment and services to promote healing. The policy further indicated interventions to minimize exposure to moisture and keep skin clean. The facility failed to provide a wound vac for R59 who had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), who required a wound vac. R59 was admitted to the facility after being discharged from a hospital on [DATE], and had [DIAGNOSES REDACTED]. The hospital discharge summary indicated that R59 had a wound vac in place during the hospital stay and the wound was improving. It was noted that R59 should continue the wound vac until follow up in the wound clinic (no date). The hospital discharge summary further directed staff to note the wound vac was removed on discharge and a wet to dry dressing placed. It was noted the wound vac should be resumed when R59 arrived at the facility. R59 sought out a surveyor on 11/5/12, in the evening and indicated that he had not received his wound vac since he was admitted on [DATE]. R59 was interviewed on 11/6/12, at approximately 8:30 a.m. R59 indicated that he had asked the staff multiple times since his admission when he was going to get the wound vac and the staff always indicated that they were looking into to it. The resident's concern was that he was [AGE] years old and if his wound did not heal, he wound have to be confined to a nursing home and he was hoping that when the wound healed he would be able to be placed in a facility other than a nursing home. R59's coccyx wound measurements on 10/2/12, were: width 1.0 centimeters (cm), length was 2.3 cm, and depth was 1.7 cm. R59's tissue profusion dated, 10/2/12, indicated the resident had a pre-existing open area on his coccyx on admission to the facility and that R59 was to be turned from side to side every two hours. R59's progress note dated 10/3/12, indicated a coccyx wound, "Change Vac M-W-F (Monday, Wednesday, Friday). Cut Vac foam dressing a little smaller than the wound (to encourage contraction), and apply to wound bed. Be sure to apply vac drape (clear, sticky dressing), to intact skin under the foam to protect skin from injury. Cover with the vac drape and set negative pressure at 125 mm (millimeters) HG continuously." This did not occur because the wound vac had not arrived, the coccyx wound however, was cleansed and dressed. A physician's orders [REDACTED]. Nurse Practitioner to assess 10/5/12, for further orders and recommendations till wound vac arrived." A physician's orders [REDACTED]. An order directed staff for wound care to coccyx, "Clean with wound cleanser, pat dry, calcium alginate rope, pack lightly wound bed, cover with allevyn foam, change dressing daily and as needed." A nursing progress notes dated 10/8/12, indicated that R59 had not received the wound vac. There was no further documentation that anyone had called the medical equipment company to follow on the wound vac. R59 was seen on wound rounds on 10/12/12, for a stage 4 coccyx ulcer. The notes included the following, "The stage 4 wound was healing. R59 had returned from the hospital with wet to dry dressing order twice a day until wound vac received. Continue to wait for wound vac to be received. Currently the wound had been dressed with calcium alginate, secondary allevyn and being changed daily. The nurses were unable to report to physician if the wound dressings were saturated in between dressing changes. The plan of care was to cleanse wound and pat dry. The nursing staff were to continue with calcium alginate rope, pack lightly and cover with secondary allevyn dressing and the dressing was to be changed twice a day do to evidence of moisture. Wait for wound vac to be received." R59 was was seen in the clinic on 10/19/12, for a follow up of coccyx wound. The notes from the appointment included, "Stage 4 wound healing. Continue to wait for wound VAC, in the meantime dressing the wound with alginate and cover with secondary perform dressing, and change daily. R59 had no sensation in the area and was experiencing no pain, quadriplegic. R59 was repositioned every 2 hours hs, (hour of sleep) and had a pressure relief cushion. The plan of care was to continue with plan for wound vac once received." A nursing progress note on 10/22/12, indicated that R59 had been picked up for a doctor's appointment. Nursing had placed a call to KCL (name of manufacturer) to inquire about status of wound vac order. The process notes further indicated that an application for the wound vac had been faxed to KCL about 2 weeks ago and there no indication in the chart the wound vac request had been followed up on. The physician's progress notes dated, 10/26/12, included, "R59 had been seen for a follow up of coccyx wound stage 4, continue to wait for KCL wound vac. The nurse manager has contacted the equipment company several times this week, will contact them again today. R59 had no pain or sensation in this area. R59 received assistance with position changes every 2 hours during the night and pressure relief cushion with pressure mapping during the day. Plan of Care: Continue with alginate and change if dressing was saturated, at this time the wound was stagnant. Urgent need for wound vac. The wound measured 2 cm by 1 cm by 1 cm, undermining from 5:00 to 1:00 o'clock. The appearance of wound bed: 90% granulation tissue and 10% of exudate, large serous sanguineous drainage and the dressing was saturated." On 11/2/12, the coccyx wound measured 1.0 cm by 2.0 cm, by 1.0 cm and had undermining at 2:00 o'clock of 2 cm. R59 was observed during the dressing change to the coccyx on 11/7/12, at 8:30-8:50 a.m. The dressing change was done according to the physician's orders [REDACTED]. A nursing progress note on 11/7/12, indicated that a call had been placed to KCL in the afternoon after speaking with the administrator to order a wound vac for R59 and will have it charged to the facility. A voice mail was then left on the case managers phone at KCL. The message requested KCL deliver the wound vac ASAP (as soon as possible) and charge the facility. The nurse practitioner was updated that medical assistance was still reviewing the case causing the hold up for the R59. Registered nurse (RN)-B was interviewed on 11/7/12, at approximately 1:15 p.m. about the status of the wound vac for R59. RN-B indicated that the nurse manger would be the one to talk to. Nurse manager (NM)-A was interviewed on 11/7/12, at 2:15 p.m. and indicated that she had talked to the administrator on 11/7/12, in the morning and had received approval to get the wound vac for R59 and that the facility wound pay for it. NM-A indicated that her last day of work at the facility would be 11/8/12, and she wanted to tie up all the loose ends which included getting a wound vac for R59. NM-A indicated that medical assistance had not made a decision as to whether they would be paying for the wound vac to date and confirmed that the facility had not been able to get a wound vac. NM-A confirmed that R59 would be receiving treatment with the wound vac once it was received in the facility and physician orders [REDACTED]. NM-A was asked for a policy and procedure on what was the facility's policy on obtaining medical equipment for the residents. Nothing was provided at the time of the survey. R59 received his wound vac on 11/8/12 in the afternoon. A wound team memo dated 3/9/10, indicated that the clinical nurse manager would follow up on any care plan revisions and referrals that were needed, in-house and outside, i.e.., PT (physical therapy), physician, wound clinic, and other outside physicians. All team members would be involved with staff and client/family education to promoted wound healing.