Every finding on record at Cura of Le Sueur

Based on interview and document review the facility failed to ensure medications were administered according to physician orders which resulted in a significant medication error for 1 of 3 residents (R1) reviewed for medication administration. This resulted in actual harm for R1 when an increased dose of a diuretic (water pill) had been ordered but was later discontinued without a physician order. R1 did not receive an increased dose, nor any doses of prescribed diuretic for two days and subsequently developed shortness of breath, had to be sent to the emergency department (ED) where he received intravenous diuretic and needed to be hospitalized . The facility implemented immediate corrective action and corrected the deficient practice by 6/18/26, so the citation was issued at past non-compliance. Findings include: R1's face sheet dated 6/24/26, identified diagnoses of chronic systolic congestive heart failure (heart failure that occurs at the bottom of the heart), chronic kidney disease (a long-term condition where the kidneys are damaged), and diabetes. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, had no behaviors, no rejection of care, needed partial/moderate assistance for transfers, and was not taking a diuretic medication. Although R1's MDS indicated R1 was not administered a diuretic during the review period, R1's record identified R1 was prescribed and administered a diuretic medication. R1'a physician order for Bumex (diuretic medication) had a start date of 4/16/26. The order directed staff to administer Bumex 1 milligram (mg) daily related to hypertensive heart disease with heart failure (stop date of 5/18/26). R1's care plan dated 4/15/26, identified R1 had a diagnosis of CHF define. Goal to have no negative health effects from medical condition through next review. Interventions as follows: -Administer medications as ordered. Observe effectiveness and adverse effects. R1's nurse practitioner (NP) note dated 5/22/26, identified R1 was seen as a follow up for blood pressures, R1's blood pressure reviewed and noted to have hypertension (high blood pressure) with chronic kidney disease and heart failure. NP gave new orders to restart Bumex (diuretic used to treat excessive fluid retention caused by congestive heart failure) at 2 mg daily (increased from 1 mg). R1's physician orders identified the new order for Bumex 2 mg daily with a start date of 5/22/26 was transcribed into the electronic health record. R1's nurse practitioner nursing home visit note dated 6/12/26, indicated R1 was seen for a routine nursing home certification visit. R1 had a diagnosis of CHF and gained weight with a current weight of 197 pounds (lb.). R1's weight on 6/10/26 was 185 lb. and on 6/11/26 was 193 lb. (12 lb. weight gain since 6/10/26). R1 was currently on Bumex 2 mg daily and did have increased edema in right lower leg but denied shortness of breath or difficulty breathing. New orders to discontinue Bumex 2mg and start Bumex 3mg daily for congestive heart failure. R1's printed physician order dated 6/12/26 included both the orders to stop the Bumex 2 mg and start the Bumex 3 mg daily; the order was noted by registered nurse (RN)-A on 6/12/26. However, the electronic physician orders identified Bumex 2 mg was discontinued on 6/12/26 at 1:12 p.m. and the order for Bumex 3 mg had been transcribed into the electronic physician order on 6/12/26 but the start date identified 6/13/26. However, R1's Administrative Order Summary dated 6/13/26 at 7:20 a.m., R1's Bumex 3 mg had been discontinued by RN-A even though there was no indication of a corresponding physician order to discontinue the Bumex 3 mg had been given or directed by the physician. Review of R1's June Medication Administration Record (MAR) identified the Bumex 2 mg had been discontinued on 6/12/26 and did not identify the Bumex order for 3 mg on 6/12/26. The MAR identified R1 had not received any doses of Bumex on 6/13/26 and on 6/14/26. R1's progress note dated 6/15/26 at 6:56 a.m., identified R1 was having shortness of breath and oxygen saturation was 82% on room air (according to Mayo Clinic normal oxygen saturation values for a healthy person would be 95-100%); 87 % on nasal cannula at 2 liters (L); and 94% on mask at 4L. and was sent to the emergency department (ED). R1's ED note dated 6/15/26, identified R1 presented to the ED due to shortness of breath. R1 reported an onset of difficult breathing that began in the morning. According to the nursing home paperwork, R1's Bumex was discontinued on 6/12/26, and had not received any doses since then. R1 had a history of chronic systolic heart failure and had undergone a double thoracentesis (a procedure where a needle is used to remove excess fluid or air) in mid-January or early February of 2026 for pleural effusions (build up of excessive fluid between the layers of the thin membranes lining the lungs and chest cavity). A computed tomography (CT) Angiogram (imaging test that is used to diagnose blockages and/or blood clots) was performed and revealed findings in R1's lungs consistent of pulmonary edema (a condition defined by the abnormal buildup of excessive fluid in the lungs air sacs) and bilateral (both sides) pleural effusions. Acute shortness of breath is most likely due to fluid retention from chronic heart failure, attributed to recent discontinuation of Bumex rather than the intended dose increase. R1 received 3 mg of IV Bumex and oxygen requirement decreased from 6 liters/minute (l/min) to 3 l/min. R1 was not on oxygen at baseline. R1 kept in ED for observation and on 6/16/26 at 7:35 a.m., R1 remained hypoxic (a state of inadequate oxygen reaching the body's tissues and cells to maintain normal function), was requiring oxygen, and was admitted to the hospital. R1's hospital ED nursing note dated 6/15/26 at 9:08 a.m., identified that a call was placed to the nursing home where it was verified that an error was made and that R1's Bumex order had been discontinued with the last dose given on 6/12/26 and had not received any dose of Bumex since then. R1's Medication Error (Omission) Report dated 6/15/26, identified R1 was on Bumetanide (Bumex) 2mg and was seen on 6/12/26 by the NP who increased dose to 3 mg by mouth one time a day related to hypertensive heart disease. Noted that medication had been discontinued which was noted on a medication review in the emergency room. R1 in the emergency room due to shortness of breath. Root cause identified on 6/16/26 that medication omission occurred due to failure in the medication administration and order transcription process, compounded by gaps in clinical understanding of CHF and inadequate system safeguards to ensure timely medication delivery and follow up. R1's progress note dated 6/16/26 at 2:44 p.m., identified R1 returned from hospital at 1:10 p.m. Diet change to low potassium, low sodium heart healthy and diabetic. Fluid restriction of 2000 milliliters. During an interview on 6/23/26 at 1:58 p.m., ED registered nurse (RN)-F stated she had called the facility on 6/15/26 after not identifying any Bumex on R1's medication administration record (MAR) from the nursing home. RN-F explained she had talked to the assistant director or nursing who had identified that R1's Bumex that had been increased to 3 mg on 6/12/26, had been discontinued on 6/13/26 and R1 had not received any doses of Bumex since 6/12/26. During an interview on 6/24/26 at 1:47 p.m., licensed practical nurse (LPN)-A stated on 6/12/26 she had transcribed R1's new Bumex order to discontinue Bumex 2 mg and increase the dose to Bumex 3 mg daily. LPN-A then explained she had given RN-A the order to have a second nurse verify the order was placed correctly in the record per facility protocol but was unable to verify if RN-A verified it in the record that it was accurate. LPN-A explained RN-A then signed the order and gave it back to her and told her she could file it in R1's medical record. LPN-A explained nurses should ensure they verified the order prior to discontinuing any medication or before they sign the order to indicate the order was transcribed accurately. During an interview on 6/24/26 at 10:17 a.m., RN-A stated he was working on 6/12/26 and had been responsible for completing the second check on a new order for R1's Bumex. On 6/13/26 while he passed medications for R1 he noticed the order for Bumex 3 mg however for some reason believed that was the order that the physician had been discontinued. RN-A explained he discontinued the Bumex 3 mg order but did not verify the discontinuation against or in the presence of a signed physician order to make sure he had discontinued the right dose. On 6/15/26, R1 became short of breath and had low oxygen saturation so RN-A sent R1 to the ED for evaluation. After the facility received a call from the ED confirming that the Bumex had been discontinued he realized he had inadvertently discontinued the current order for the increase in the Bumex and not the old order instead. RN-A stated he should have visualized the order instead of going off his memory with what the correct order was supposed to be. During an interview on 6/23/26 at 2:48 p.m., RN-B stated the policy of the facility was to have two nurses verify every order that was transcribed into the EHR. One nurse would enter the order, then the second nurse would check for accuracy and sign the order which identified the second check had been completed. RN-B reviewed R1's EHR and identified R1's Bumex had been discontinued on 6/13/26 at 7:20 a.m., by RN-A, however, R1's order that was obtained on 6/12/26 for the increase in the Bumex had also been signed by RN-A indicating he had made sure the order was correct. RN-B stated that after learning R1's Bumex had been discontinued without a physician's order, she asked RN-A about it. According to RN-B, RN-A responded that he must have made a mistake and believed the medication had been discontinued. During an interview on 6/24/26 at 1:08 p.m., consulting pharmacist (CPharm) stated the discontinuation of R1's Bumex without a corresponding order was considered a significant medication error. CPharm further explained her expectation would be for any discontinuation of medication would have to have of a corresponding physician order before it could be discontinued. During an interview on 6/24/26 at 2:10 p, m., nurse practitioner (NP) stated she had completed a routine nursing home visit on 6/12/26 and due to an increase in weight she increased R1's Bumex from 2 mg daily to 3 mg daily. Because R1 had a diagnosis of congestive heart failure, the weight gain was indicative of fluid overload, and the increased Bumex dose was prescribed to reduce the excess fluid. However, the increased Bumex dose was never initiated because it had been discontinued without a corresponding physician order. As a result, R1 experienced actual harm, requiring transfer to the emergency department for intravenous diuretic therapy, increased oxygen support, and subsequent hospitalization. During an interview on 6/24/26 at 11:43 a.m., director of nursing (DON) stated her expectation would be that all nurses make sure there was a corresponding physician order prior to discontinuing the medication. DON further explained that when RN-A discontinued R1's Bumex without verifying the order he caused a significant medication error for R1. The following corrective actions were verified as implemented prior to the survey: -The facility reviewed the Transcription and Processing Provider Orders policy and deemed it to be accurate, and no changes needed. -R1 was hospitalized and returned on 6/16/26 with an order for Bumex 3 mg daily and was verified it was placed in the MAR correctly. -All current resident orders and MAR were reviewed to see if any orders had been discontinued without a physician order and no similar incidents were found. -Facility wide education began on 6/18/26 on transcription of orders and medication administration policies, including adherence to physician orders, the rights of medication administration and proper documentation. -Facility began audits began on 6/18/26 on medication transcription/discontinuation of medication to ensure orders were correctly transcribed or discontinued with a only a corresponding physician order. Audit will continue for 4 weeks and quarterly after that. Results and findings will be reviewed during the monthly quality meetings to ensure compliance is met. Review of the facility's Transcription Processing Provider Orders-Long Term Care Policy dated 2/26, identified the following: Transcribing and processing provider order: -After each provider order the process must be followed as noted above. Two staff members will sign and date upon verification of order processing indicating that the steps to the order process have been completed. The second person double checking the order should: Look at the provider's order in the chart. -Confirm appropriate start/end date and time in the MAR/ treatment administration record (TAR) by running the Medication Administration Record to ensure the correct date/time -Verify that all steps of the order were processed as noted above. Review of the facility's Discontinued Medications Policy dated 11/21, identified that staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. Policy Interpretation and Implementation: -A practitioner orders to discontinue a resident's medication must be documented in the resident's clinical record and on the MAR. -The nurse receiving the order to discontinue a medication is responsible for recording the information and notifying the dispensing pharmacy of the discontinuation. -Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with the established policies.

Based on observation, interview, and document review, the facility failed to ensure a resident was comprehensively assessed and appropriately monitored for fluid volume status after a reported significant increase in daily weight for 1 of 3 residents (R2) reviewed for change in condition.Findings include: R2's face sheet dated 6/24/26, identified diagnoses of edema (swelling cause by excessive fluid trapped in the body's tissues), diabetes mellitus (condition that you body uses sugar as fuel), paraplegia (a condition where half of the body does not function), sick sinus syndrome (a group of heart rhythm disorders caused by a malfunctioning sinoatrial node (the hearts natural pacemaker). R2's Annual Minimum Data Set (MDS) dated [DATE], identified R2's cognition was intact, had no behaviors, no rejection of care, was dependent for bed mobility/transfers, and was administered a diuretic medication. R2's care plan dated 6/23/25, identified R2 had the potential for pacemaker malfunction/failure or altered cardiac output related to sinus sick syndrome. R2 had a pacemaker. R2's goal was to remain free of signs and symptoms. Interventions as follows:-Observe/report to medical doctor (MD) any signs and symptoms of altered cardiac output or pacemaker malfunction. -Perform pacemaker checks as ordered. If abnormal update MD as needed. R2's physician orders identified the following orders:-Lasix (diuretic) 40 milligrams (mg) twice daily for edema. (dated 6/6/25)-Daily weights: Update the provider if greater than 3 pounds weight gain in one day or 5 lbs. in one week. (dated 1/15/26) R2's nurse practitioner nursing home visit note dated 5/1/26, identified R2 was worried about the swelling in his legs and R2 wondered why no one will do anything about this. R2 had trace edema to bilateral lower extremities and explained the importance of elevating his legs. R2's weight was 225 lbs. with a range of 222 lbs. to 229 lbs. Review of R2's record which included May and June Treatment Administration Record (TAR) did not identify any completed edema monitoring. R2's weight warning progress note dated 6/23/26 at 11:47 a.m., identified R2's weight was 242 lbs. taken on 6/23/26 at 10:40 a.m., which was up 10.2 pounds (lbs.) in one day. Request sent to interdisciplinary team (IDT) for reweight as well as a request to inform the provider about weight gain if weight is correct. During an interview on 6/24/26 at 1:25 p.m., dietician (D)-F stated on 6/23/26 she had identified R2's weight had increased by 10.2 pounds from the previous day. D-F explained she had entered a progress note in R2's EHR at 11:47 a.m., however she had not contacted nursing to ask for a reweight but did send an email to the IDT around 3:20 p.m. but was unsure if the facility had seen the email. D-F explained her expectation would be that if a resident's weight was obtained and the weight revealed an increase from the day prior that the resident should be assessed for fluid overload and have a re-weigh completed immediately. During an interview on 6/23/26 at 2:48 p.m., registered nurse (RN)-B stated if resident's weight was off from one day to the next, they automatically have staff reweigh the resident to see if the weight was accurate. During an observation and interview on 6/23/26 at 4:26 p.m., licensed practical nurse (LPN)-B stated she was R2's nurse, however, had not been informed that R2's weight had increased by over 10 pounds. LPN-B reviewed R2's record and identified R2 did not have his weight rechecked. LPN-B then returned to passing medications on the medications cart but then entered R2's room and obtained blood pressure, temperature, and oxygen saturation. Although LPN-B took vital signs, she did not listen to lungs for fluid presence nor evaluate for presence of edema. LPN-B informed R2 that his weight needed to be rechecked because it was way over what it was the day prior and propelled R2 to the scale in his wheelchair. R2's weight was 232.8 lbs. (R2's weight the day prior 231.8 lbs.) LPN-B then took R2 back to his room then left the room. LPN-B explained R2's weight must have been obtained in error due to the wheelchair weight possibly being subtracted incorrectly. LPN-B did not and was not able to articulate nor demonstrate checking for presence of edema to evaluate presence/absence of fluid overload. LPN-B was then prompted to complete an edema evaluation. LPN-B entered R2's room and LPN-B raised R2's pantlegs revealing bilateral lower extremities. Without pressing on R2's skin, LPN-B stated R2's edema was only 1+ edema (mild swelling where a slight indentation barely appears), however, when she pressed on R2's lower extremity, the result was 2+ pitting (mild to moderate fluid buildup in the body's tissue). LPN-B stated R2's edema in his legs was ongoing and had not changed. LPN-B reviewed R2's chart and was unable to identify any documentation of what R2's edema had been previously in his lower extremities. During an observation and interview on 6/23/26 at 4:58 p.m., director of nursing (DON) went into R2's room and assessed R2's bilateral lower extremities and identified 2+ pitting edema not 1+ pitting edema. DON stated she would need to provide some education to the nursing department to ensure they are able to know the difference in pitting edema. DON explained R2 should have had his weight rechecked immediately after it was identified in the morning that his weight was increased and had a comprehensive assessment in which would be paying special attention to edema, lung sound, and shortness of breath to ensure he was not going into fluid overload. DON further explained she had added edema/fluid overload monitoring into the resident with congestive heart failure, however, must have missed adding an order for edema monitoring for R2 since he does not have a diagnosis of congestive heart failure. Requested policy for daily weights and edema monitoring and did not obtain from the facility.

Based on observation and interview, the facility failed to maintain 1 of 1 ice machine to prevent potential contamination and to ensure food and drinks were served in a safe and sanitary manner. This had the potential to affect all 21 residents who resided in the facility.Findings Include:On 2/23/26 at 10:45 a.m., during the initial tour of the kitchen with the dietary director (DD-D), a Manitowoc brand ice machine located in a hallway adjacent to the kitchen was observed with white/grey chalky, powdery, hard, crusty, rock-like, lumpy deposits present on: the inside lid of the ice machine, the outside lid, the front exterior surface, and both side exterior surfaces. The buildup appeared consistent with lime scale and mineral deposits. The DD-D stated the ice machine had lime scale buildup and that maintenance staff were responsible for cleaning the ice machine. DD-D further stated that, as of approximately two weeks prior, the facility no longer had maintenance staff, and she was unsure who was responsible for ensuring the ice machine was cleaned. DD-D confirmed the ice machine was used for resident consumption.On 2/23/26 at 11:32 a.m., registered nurse (RN)-A, identified as the regional clinical director, confirmed the ice machine was not clean and stated she would not expect to see white residue build up on the inside or outside of the machine. RN-A stated she would determine when the ice machine was last cleaned.On 2/23/26 at 4:43 p.m., a sign was observed posted on the ice machine indicating, Out of order do not use.On 2/24/26 at 1:45 p.m., the administrator stated the facility had known chronic issues with the ice machine and that, rather than continuing to spend money on repairs, the decision was made in April 2025, to replace the machine. The administrator stated the former maintenance director had been instructed to replace the ice machine; however, this was not completed as expected. The administrator stated they observed the ice machine with lime and calcium buildup to be present and would not expect the machine to be used if lime and calcium buildup were present. The administrator confirmed the ice machine should not have been used until it was cleaned, repaired, or replaced. The administrator further stated there was no specific facility policy regarding ice machine maintenance but would expect manufacturer recommendations to be followed.

Based on interview and document review, the facility failed to establish and maintain a system to ensure concerns voiced during resident council meetings were addressed and follow up with residents. This had potential to effect 6 of 6 residents (R1, R4, R5, R9, R18, R20) identified to have attended the meetings.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment.R4's quarterly MDS dated [DATE], indicated no cognitive impairment.R5's admission MDS dated [DATE], indicated no cognitive impairment.R9's quarterly MDS dated [DATE], indicated no cognitive impairment.R18's quarterly MDS dated [DATE], indicated no cognitive impairment.R20's quarterly MDS dated [DATE], indicated no cognitive impairment.On 2/23/26 at 2:08 p.m., the activities director (AD)-F stated the resident council did not have a current president and further gave permission for the survey team to review previous minutes of resident council meetings. These minutes were provided and identified the following concerns:Resident council minutes:9/28/25, indicated R1, R4, R18, R20, AD-F, administrator in training (AIT), and dietary director (DD) attended the resident council meeting. The minutes identified long call lights in the morning, ignored by staff, staff wearing dirty gloves in the hallways. Social services: grievances not processed in a timely manner, maintenance: things not getting done around the building, laundry wrongs paints in room. Dietary concerns were identified and addressed in minutes. The minutes lacked any further action or follow-up to the council's other concerns.10/26/25, indicated R1, R4, R18, R20, activities director and dietary director attended the resident council meeting. The concerns indicated nursing: why don't nurses help get people up, pills are late, short staffed, too many call ins; maintenance: garbage can outside the facility always full, laundry: need to hire more laundry staff; housekeeping rooms need to be cleaned daily, shower rooms are dirty. The minutes lacked any further action or follow-up to the council's concerns to the previous month.11/26/25, indicated R1, R4, R9, R18, R20, activities director and dietary director attended the resident council meeting. The concerns indicated nursing: short staffed, nurses don't help the nursing assistants, pills don't get passed out on time, agency staff do not know where things are at, long call lights; dietary: small portions, soup tastes like fowl, fish sticks are bad; maintenance: fans are dirty in the activity room; housekeeping: rooms need to be cleaned daily. The minutes lacked any identified action or follow-up to the council's presented concerns to the previous month.12/30/25, indicated R1, R4, R9, R18, R20, and activities aide (AA)-A attended the resident council meeting. The minutes identified the concerns nursing: new residents don't get showers right away, pills don't get passed out on time, long call lights; dietary: food doesn't go out on time; housekeeping: rooms need to be cleaned daily, some residents missing clothes. The minutes lacked any identified action or follow-up to the councils presented concerns to the previous month.1/27/26, indicated R1, R4, R5, R9, R18, R20, AA-A, AD, DD, and social services, attended the meeting. The following concerns were identified nursing: long call lights, sometimes takes 45 minutes; dietary: dumplings not good, too much water in cereals, lasagna was bad; maintenance: ceiling fans in the community room need to be cleaned; laundry: take a while to get clothes back, missing clothing; housekeeping: rooms need to be cleaned. The minutes indicated action taken regarding the dietary concerns however lacked any identified action or follow-up to the councils other presented concerns to the previous month.On 2/24/26 at 2:08 p.m., a resident council meeting was held with council members R1, R4, R5, R13, R15, R18, and R20 in attendance. Residents explained the council group met monthly and specific departmental concerns were discussed and departments failed to address or respond to any concerns or questions the residents present. R20 stated concerns had been voiced monthly regarding nursing, housekeeping, and various other departments in the monthly resident council meetings, and the facility had not provided follow up to the concerns. R8 and R1 stated monthly the same concerns are brought up regarding staffing and late medication administration. R1 and R8 stated they were not aware if the facility had addressed the concerns or what follow up was done and stated they would expect the concerns addressed and follow-up to the concerns.On 2/24/26 at 2:31 p.m., AD-F stated that concerns brought forward by residents during resident council meetings were communicated to department leaders monthly during QAPI meetings, and if urgent immediately. AD-F stated that follow-up regarding those concerns was not brought back to residents at the subsequent resident council meeting. AD-F stated she expected department leaders to address the concerns; however, it was not the facility's practice to report back to residents regarding actions taken. AD-F further stated she had not been trained that resident concerns required follow-up communication at subsequent meetings. AD-F confirmed there was no established system to track concerns from one meeting to the next and no mechanism to ensure residents received feedback regarding the status or resolution of their concerns. AD-F stated that going forward, the process would change to ensure follow-up was provided to residents regarding issues discussed during resident council.On 2/24/26 at 2:37 p.m., the administrator-in-training (AIT) and interim director of nursing (DON) stated that resident council concerns were discussed during QAPI meetings; however, no documentation was maintained reflecting the concerns, actions taken, or follow-up provided. The AIT and DON stated they would expect residents to receive follow-up regarding their concerns and would expect those concerns to be addressed and communicated at the next Resident council meeting.The facility Resident Council policy dated 4/25, indicated: Purpose: To give residents an opportunity to take an active role concerning their care and stay at this facility. To get residents involved in the decision that affects their lives. To voice needs and concerns, state preferences, plan activities, projects and make decisions. To voice any food related concerns, suggestions, compliments during Food Council portion of meeting, or at a separate Food Committee meeting.Policy: The Supervisor of Activities or staff designee will be the facility representative/coordinator at the meeting if residents desire. Residents may also facilitate the council meeting on their own. Dietary manager or staff designee will be the Dietary representative for Food Council at the meeting or at a separate Food Committee meeting. All residents are welcome to attend meetings. Other staff or visitors must be asked in, and accepted, in order to attend. Meetings will be held monthly unless deemed less or more frequently by the Activity Director or residents. Selection of officers or choice not to have them will be determined by residents on an annual basis. The Activity Director will keep notes during the meeting unless a resident wishes to do so. The monthly meeting will be scheduled by the Activity Director. The Activity Director will prepare an agenda for the meeting with input from other departments as applicable. The Activity Director will begin the meeting by reading minutes of the last meeting. Old business to be resolved as needed. New Business items. Open the floor to questions or concerns from residents. Meeting will be adjourned when all concerns have been addressed. Assist residents out of the activity area. The Activity Director will write up the minutes and file them according to regulations. Copies will be sent to Quality Assurance, Dietary, Social Services, Director of Nursing, and Administrator. The Activity Director will refer items to be resolved to appropriate individuals/departments.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4, 2025), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include:The CMS payroll-based journal (PBJ) staffing data report for quarter four of 2025, which included dates from 7/1/25-7/30/25, triggered for four or more days within the quarter with <24 hours/day licensed nursing coverage. The following infraction dates were identified: 8/3/25, 8/23/25, 8/24/25, and 9/6/25.Review of nursing staff schedules for each infraction date indicated a licensed nurse had been scheduled each of the three shifts (days, evenings, and nights).On 2/24/26 at 10:25 a.m., the assistant director of nursing (ADON) stated they were responsible for scheduling nursing staff, stated there was always a licensed nurse working every day, on each shift - days, evenings, and nights. On 2/24/26 at 2:05 p.m., registered nurse (RN)-A, known as the regional clinical director, indicated in an email all timecards were reviewed for each infraction date. RN-A confirmed that all shifts during those dates were worked by a licensed nurse, either a facility-employed nurse or an agency nurse. RN-A indicated, however, the facility was unable to specifically identify which licensed nurse hours were not included in the submitted PBJ data. RN-A stated that at the time of the identified discrepancies, the business office manager was responsible for reviewing timekeeping/payroll records and agency invoices. RN-A further stated that the review of payroll and agency invoices is compiled and reported by the corporate office in the PBJ submission. RN-A that since the that time, the facility implemented a revised process requiring agency staff to utilize a pay clock system to allow for more systematic entry, tracking, and reporting of hours worked within the facility to improve accuracy of PBJ reporting.On 2/24/26 at 1:45 p.m., the administrator stated there was a switch in payroll companies in August 2025, stated the facility had the required nursing staff however the information may not have been submitted accurately from the facility business office to the corporate office and then to the PBJ submission reporting.Facility PBJ Policy dated 2/26 indicated :The facility will electronically submit to CMS complete and accurate direct staffing information including information for agency and contract staff when applicable, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents (R1, R4, R5, R13, R15, R18, R20) reviewed during resident council. This deficient practice had the potential to affect all 21 residents residing in the facility. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment.R4's quarterly MDS dated [DATE], indicated no cognitive impairment.R5's admission MDS dated [DATE], indicated no cognitive impairment.R13's annual MDS dated [DATE], indicated no cognitive impairment.R15's annual MDS dated [DATE], indicated severe cognitive impairment.R18's quarterly MDS dated [DATE], indicated no cognitive impairment.R20's quarterly MDS dated [DATE], indicated no cognitive impairment.On 2/24/26 at 2:08 p.m., during resident council R1, R4, R5, R13, R15, R18, R20 attended and stated they did not receive mail on Saturdays and received the mail on Monday through Friday.On 2/24/26 at 2:31 p.m., activity director (AD)-F confirmed resident mail was not delivered on Saturdays and further stated activity staff delivered the mail to residents Monday through Friday. AD-F stated the mail was delivered to the facility on Saturdays from the post office, however, it was not delivered to the residents until Monday. AD-F was not aware that mail was expected to be delivered to residents on Saturdays.On 2/24/26 at 2:31 p.m., the interim administrator stated residents were expected to receive mail on Saturday if the post office delivered the mail.The facility Resident Mail policy dated 2/26, indicated:Mail will be delivered to residents' room within 24 hours in an obvious and accessible location, unopened and unread, including magazines and newspapers, unless assistance is requested by the resident/resident representative.

Based on interview and record review the facility failed to complete a comprehensive skin assessment and monitoring of impaired skin integrity for 1 of 3 residents (R1) reviewed for skin care. Findings include: R1's hospital discharge summary dated 4/24/25, identified invasive ductal carcinoma (cancer that starts in the cells lining the milk duct in the breast and breaks through the duct wall invading nearby breast tissue) had been discovered during a previous hospital stay 2/2025 and treatment had not begun yet. Current hospital stay was complicated by right breast pain with oncology follow-up 5/1/25 scheduled. Skin check identified tender, indurated (thickened/hard) right breast including the areola (pigmented area surrounding the nipple), without warmth and consistent with known breast cancer, likely lymphatic obstruction (blockage of lymph vessels which can lead to swelling). R1's face sheet dated 5/1/25, identified diagnoses of malignant neoplasm of lower outer quadrant of right breast (cancer). R1's care plan dated 4/24/25, identified two areas of concern which included potential for skin integrity impairment related to decreased mobility from baseline. Interventions included licensed nurse to observe skin weekly and turn and reposition per tissue tolerances. Alteration in comfort related to right breast cancer. Interventions included medications as ordered, non-pharmacological interventions including repositioning, massage, distraction, reposition/ambulation as tolerated and physical and occupational therapy as directed. R1's Skin Evaluation dated 4/24/25, identified an initial skin evaluation with no skin impairments noted. R1's Comprehensive Skin Risk Audit dated 4/24/25, identified skin history of cancer and no changes warranted to the interventions to maintain resident's skin integrity. R1's progress note at 6:36 p.m. note identified R1 reported pain in right breast area. Progress note at 9:52 p.m., identified R1 requested pain medication for right breast pain. R1's record did not include a comprehensive assessment of R1's right breast to ascertain any changes to the location. R1's progress note dated 4/25/25, identified R1 had pain 10/10 to right breast. R1's record did not include an assessment of the right breast. R1's progress note dated 4/26/25 at 5:27 a.m., identified pain medication given for right breast pain. R1's record did not include an assessment of the right breast. R1's progress note dated 4/27/25, identified R1's pain management was not under control and R1 requested to go to the emergency department for pain management. R1's progress noted dated 4/27/25, identified as a late entry progress noted identified a hospitalist called and requested initial admission details, including pictures of R1's right breast at admission to compare how the breast appeared currently in comparison to what the breast appeared like at the facility. No admission photos were in R1's chart. The doctor advised the right breast was full of abscess and required a surgical procedure to drain as it was infected. R1's progress note dated 4/28/25 at 9:07 a.m., identified a late entry for 4/24/25 that stated R1 had a small area of skin redness to right breast and the area was tender to the touch with 10/10 pain. There was no drainage to the sight and no symptoms of infection. A second note written at 1:38 p.m., identified R1 would not be returning to the facility after hospitalization . During an interview on 5/1/25 at 1:01 p.m., nursing assistant (NA)-D stated R1's breast was a little red and tender and R1 prefer that NA-D not touch them when doing cares. During a phone interview on 5/1/25 at 12:49 p.m., licensed practical nurse (LPN)-A stated he had not looked at R1's breast and was unaware of the breast cancer. During a phone interview on 5/1/25 at 12:50 p.m., registered nurse (RN)-C stated there were no treatment orders in the record that identified to monitor the right breast and that would be how the floor nurses would be aware of conditions to monitor on residents. During a phone interview on 5/1/25 at 12:36 p.m., RN-A stated that the floor nurse works under the orders that are transcribed in the treatment and medication record. R1 did not have any orders for the breast cancer site and there were no progress notes or assessments in the chart about the breast cancer site either. During a phone interview on 5/1/25 at 9:40 a.m., family member (FM)-A stated R1's breast cancer was a newer diagnosis. The breast cancer site was visible and bright red. During a phone interview on 5/1/25 at 9:28 a.m., certified nurse practitioner (CNP)-A stated R1 had a large breast lump between six and nine o'clock on the outer right breast with redness surrounding the site. CNP-A was aware of breast cancer site and had observed it at a previous facility on 3/10/25 and did not notice anything out of the ordinary or concerning when she examined it on 4/25/25. During a phone interview on 5/1/25 at 11:31 a.m., emergency department registered nurse (EDRN)-A stated on 4/27/25, R1's breast looked like it had an obvious abscess. The breast was red, raised, warm, and had an area that was coming to a head. During an interview on 5/1/25 at 3:58 p.m., the Administrator and director of nursing (DON) were present. The DON stated there was nothing in the admission or skin assessment that documented the right breast cancer site or what it looked like. DON stated on admission he completed the admission and skin assessments and R1's breast looked like a breast that had cancer. The skin assessment did not reflect the right breast cancer. The facility Comprehensive Person-Centered Care Plan policy dated 2/2025, identified the care plan would incorporate identified problem areas and incorporate risk factors associated with identified problems and develop interventions that are targeted and meaningful to the resident. When possible the interventions will address the underlying source of the problem areas and not just address symptoms or triggers. The facility policy Surveillance for Infections dated 1/2025, identified the infection preventionist (IP) would gather information by review of resident records.

Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing preventive measures to prevent the spread of influenza A, failed to post appropriate signage for 11 of 11 residents (R2, R9, R10, R79, R12, R4, R16, R1, R18, R22, R3) who exhibited symptoms of influenza A or had tested positive for influenza A, and further failed to ensure correct personal protective equipment (PPE) use. In addition; the facility failed to ensure correct use of gloves during wound care for 1 of 1 resident, (R16). This had the potential to affect all residents who resided at the facility. Findings include: R2's facesheet printed 1/15/25, indicated diagnoses of heart failure, pain syndrome, and kidney disease. R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors, and dependent on staff for personal hygiene and transfers. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R2 had symptoms of influenza A that included malaise and fatigue which developed on 1/11/25. R9's facesheet printed 1/15/25, indicated diagnoses of peptic ulcer and septic shock. R9's admission MDS assessment dated [DATE], indicated intact cognition, no behaviors, setup assistance for eating, substantial assistance for dressing and personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R9 had symptoms of influenza A that included malaise and fatigue which developed on 1/11/25. R10's facesheet printed 1/15/25, indicated diagnoses of Parkinson's disease, and neurocognitive disorder with lewy bodies. R10's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, use of a wheelchair, substantial assistance for upper body dressing, dependence on staff for bathing and personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R10 had symptoms of influenza A that included malaise which developed on 1/11/25. R79's facesheet printed 1/15/25, indicated diagnoses of cardiac pacemaker presence, anemia, and dementia. R79's admission MDS assessment dated [DATE], indicated moderate cognitive impairment, behavioral symptoms not directed towards others, use of a walker and wheelchair, set up assistance for eating, and substantial assistance with personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R79 had symptoms of influenza A that included malaise and body aches which developed on 1/11/25. R12's facesheet printed 1/15/25, indicated diagnoses of type 2 diabetes mellitus, obesity, and vascular dementia. R12's annual MDS assessment dated [DATE], indicated use of a wheelchair, setup assistance for eating, dependent on staff for personal hygiene, bathing, and dressing. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R12 had symptoms of influenza A that included cough and fatigue which developed on 1/11/25. R4's facesheet printed 1/15/25, indicated diagnoses of heart failure, kidney disease, and chronic respiratory failure. R4's quarterly MDS assessment dated [DATE], indicated intact cognition, verbal behaviors directed towards others, use of a wheelchair, setup assistance for personal hygiene, and partial assistance for upper body dressing. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R4 developed symptoms of influenza A that included chills, malaise, and cough which developed on 1/10/25, and tested positive for influenza A on 1/10/25. R16's facesheet printed 1/15/25, indicated diagnosis of osteomyelitis (bone infection). R16's admission MDS assessment dated [DATE], indicated intact cognition, no behaviors, independent with eating, dependent on staff for toileting hygiene, and partial assistance with personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R16 had symptoms of influenza A that included cough and malaise which developed on 1/9/25, and tested positive for influenza A on 1/10/25. R1's facesheet printed 1/15/25, indicated diagnoses of alcohol-induced dementia, hypertension (high blood pressure), and weakness. R1's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, no behaviors, use of a wheelchair, substantial assistance with bathing and personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R1 had symptoms of influenza A that included cough which developed on 1/12/25. R18's facesheet printed 1/15/25, indicated diagnoses of pressure injury of left heel, chronic respiratory failure, and history of cerebral infarction (stroke). R18's quarterly MDS assessment dated [DATE], indicated severely impaired cognition, behavioral symptoms not directed towards others, use of a walker and wheelchair, setup assistance for eating, dependent on staff for bathing, and partial assistance with personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R18 had symptoms of influenza A that included malaise, cough, and shortness of breath which developed on 1/9/25, and tested positive for influenza A on 1/12/25. R22's facesheet printed on 1/15/25, indicated diagnoses of amyotrophic lateral sclerosis (ALS) and repeated falls. R22's significant change MDS assessment dated [DATE], indicated intact cognition, no behaviors, use of a walker and wheelchair, and dependent on staff for eating, dressing, bathing, and personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R22 had symptoms of influenza A that included diarrhea and cough which developed on 1/9/25. R3's facesheet printed 1/15/25, indicated diagnoses of anemia, type 2 diabetes mellitus, chronic pain, and muscle weakness. R3's admission MDS assessment dated [DATE], indicated intact cognition, no behaviors, use of a wheelchair, set up assistance for eating, and substantial assistance with personal hygiene. Facility outbreak tracking spreadsheet dated 1/14/25, indicated R3 had symptoms of influenza A that included cough, malaise, and diarrhea which developed on 1/9/25, and tested positive for influenza A on 1/10/25. During observation on 1/13/24 at 11:15 a.m., a sign was near the entrance of the facility stating the facility was currently experiencing an influenza outbreak and masks should be worn in the facility. During observation on 1/13/24 at 11:39 a.m., resident rooms of R2, R9, R10, R79, R12, R4, R16, R1, R18, R22, R3 did not have droplet precaution signage to indicate droplet precautions should have been used due to positive or suspected influenza A. Signs on resident room doors at the time of initial observation on 1/13/24 at 11:39 a.m., indicated enhanced barrier precautions (EBP) for the rooms of R9, R10, and R16, but did not indicate the need for further droplet precautions due to influenza A. PPE During observation on 1/13/24 at 11:30 a.m., a large, uncovered garbage bin was in the center of the Meadows hallway with soiled gowns present in the bin. During observation on 1/13/25 at 12:22 p.m., nursing assistant (NA)-A, who was wearing a mask throughout the facility, donned a gown and entered R16's room. During interview on 1/13/25 at 12:39 p.m., NA-A stated she was unsure which rooms to wear a gown in, was not aware which residents had influenza A, and was not told she could not wear the same mask resident room to resident room. On 1/13/25 at 3:19 p.m., NA-F stated resident rooms were not posted on who had influenza or residents who had signs or symptoms of influenza. NA-F stated the same mask was worn from room to room regardless if a resident had influenza. On 1/13/25 at 3:21 p.m., NA-B stated the facility did not post precautions signs on resident doors that indicated what PPE was needed worn into the resident rooms, or specific reason the resident was on precautions. NA-B confirmed the mask worn into resident rooms was not changed or removed going from room to room of residents. On 1/13/25 at 3:25 p.m., NA-E stated a mask was worn at all times at the facility due to the influenza outbreak. NA-E confirmed the mask was not removed or changed going from room to room. On 1/13/25 at 3:31 p.m., registered nurse (RN)-A, known as the assistant director of nursing and infection preventionist, stated facility was currently in an influenza outbreak as of 1/10/25. RN-A stated there are residents with confirmed positive influenza tests and residents presumed positive due to signs and symptoms. RN-A stated there were also staff with confirmed influenza and staff with signs and symptoms. RN-A stated an electronic message went to all staff on 1/10/25, educating staff the facility needed to follow droplet precautions for all residents. RN-A stated PPE was spread throughout the facility that included gowns, eye protection, masks and hand disinfectant. RN-A further stated stated community dining and activities were stopped and residents have been eating and participating in activities in their rooms. RN-A stated staff were not educated to change masks from room to room and confirmed staff were expected to change masks from room to room. RN-A stated the residents with confirmed influenza and presumed influenza based off signs and symptoms did not have precautions signs posted to make staff, residents, and visitors aware of the specific isolation and PPE needed to be worn entering the rooms. On 1/13/25 at 4:09 p.m., during a follow up interview RN-A stated he arrived this morning for work and then was told he needed to leave and come back to cover the nursing shift for evenings as the there was staffing shortage for evenings and overnights. RN-A stated had not had time to get signs posted, PPE carts readily available and garbage's placed inside and outside resident rooms. RN-A stated the director of nursing was not at the facility due to influenza. During interview on 1/13/25 at 4:29 p.m., RN-A stated he had not had time to work on infection control for this outbreak because he had been working the floor so much and was not allowed any infection control hours. RN-A stated he discussed the first positive cases with the medical director on 1/10/25 and was told to treat anyone with symptoms as if they were positive with influenza A, and to implement appropriate precautions. On 1/13/25 at 4:42 p.m., the administrator stated she became aware of the influenza outbreak on 1/10/25 at 9:20 a.m., via an email from RN-A. The medical director was made aware the same day at 9:51 a.m., and RN-A sent a electronic message to all staff masks were required throughout the facility. The administrator stated RN-A was also the infection prevention nurse, and was working as a floor nurse during the outbreak. The administrator stated RN-A was not designated time or hours while the outbreak was going on to ensure the correct PPE was available, signs were posted or staff received education. The administrator stated RN-A was expected to delegate tasks if needed, however RN-A was responsible to ensure staff were following correct procedures for the influenza outbreak and was responsible to ensure PPE was available to the staff. The administrator confirmed signs were not posted on the resident doors presumed positive ( signs or symptoms of influenza) or the residents with confirmed positive influenza. The administrator stated the signs were expected for residents, staff and visitors to be aware of the isolation precautions and the PPE that was expected worn into the rooms. The administrator stated signs was important to prevent the spread of the influenza, and the administrator was not aware the same mask could not be worn from room to room. During observation on 1/13/25 at 5:53 p.m., RN-D was observed putting droplet precaution signs on the doors of the rooms of R2, R9, R10, R79, R12, R4, R16, R1, R18, R22, R2. During observation and interview on 1/13/25 at 6:07 p.m., NA-F was observed exiting R9's room with a gown on, doffing the gown in the hallway, and disposing of the gown in the large garbage bin located in the meadows hallway. NA-F stated she sometimes wore her gown in the hallway if the garbage in the room was full. NA-F further stated she should remove her gown in the room, rather than in the hallway to prevent the spread of infection. 44630 During observation on 1/14/25 at 8:53 a.m., LPN-C was observed exiting R12's room with a soiled gown in her hands and disposing of it in the large hallway garbage bin across the hall. LPN-C and NA-E both exited the room without doffing their masks. NA-E then exited the meadows hallway with her same mask on. LPN-C also continued on with the same mask on. During interview on 1/14/25 at 9:03 a.m., NA-E stated she was not aware of any training on how to don/doff PPE other than online training and would have liked to have had in-person training or a demonstration. NA-E further stated she was told she could wear her mask room to room. On 1/14/25 at 9:18 a.m., medical doctor (MD)-G stated signs posted on resident doors with influenza were expected o ensure staff, visitors and residents followed transmission based precautions to prevent the spread of influenza. During interview on 1/14/25 at 12:42 p.m., RN-A stated he would expect that gowns be removed before exiting positive or suspected influenza A rooms and masks should be removed immediately upon exiting the room and not worn room to room to prevent the spread of infection. RN-A further stated that contaminated gowns should be disposed of in the room or should be bagged prior to being brought to the large garbage in the hallway. RN-A stated droplet precaution signs had been put on the door of residents with confirmed or suspected influenza A yesterday 1/13/25, but should have been put in place when the outbreak started on 1/9/25. During interview on 1/14/25 at 6:15 p.m., RN-D, regional nurse specialist, stated she would expect gowns be removed in the room or bagged and sealed if brought in the hallway. RN-D stated masks should not be worn room to room. RN-D further stated proper signage and PPE use should have been in place to prevent the spread of infection to other residents, staff, and visitors. The facility Policies and Practice- Infection Control policy effective 12/2024, stated the objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility b. Maintain a safe, sanitary, and comfortable environment c. Establish guidelines for implementing Isolation Precautions, including standard and transmission based d. Establish guidelines for the availability and accessibility of supplies and equipment e. Maintain records of incidents and corrective actions relate to infections f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment g. The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Glove use/hand hygiene with wound care R16's admission MDS dated [DATE], indicated R16 was admitted to the facility on [DATE], cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone); skin conditions indicated R16 was at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, had infection of the foot, other open lesion on the foot, surgical wounds; skin treatments included pressure reducing device for chair and bed, surgical wound care, application of ointments/medications other than to feet, application of dressings to feet. R16's care plan printed on 1/14/25, indicated R16 had self care deficit related to morbid obesity and decreased functional ability due to bilateral pressure injury to heels, needed assist with ADL's (activities of daily living), alteration in skin integrity r/t (related to) pressure ulcer to bilateral heels and interventions included administer treatments as ordered and observe for effectiveness, assist/encourage to float heels while in bed, measure wound weekly; update MD (medical doctor) PRN (as needed) with change, observe for s/sx (signs/symptoms) of infection, and wound vac in place. On 1/14/25 at 9:19 a.m., LPN-A and medical doctor (MD)-G entered R16's room with gloves, gown, and mask. LPN-A with gloved hands, removed the old dressing from R16's left heel, used same gloved hands and opened a betadine gauze package and used the betadine swab on the wound. LPN-A, with same gloves, applied a foam dressing on the left heel and while the dressing was placed the same gloves touched the inside foam of the clean dressing. LPN-C removed gloves and exited the room with a gown on. LPN-A after exiting R16's room removed the gown and placed in opened garbage across the hallway from R16's room. On 1/14/25 at 10:37 a.m., LPN-A confirmed gloves were not changed during R16's wound care and stated she was expected to change gloves and complete hand hygiene after removing the old dressing and place new clean gloves on prior to applying the new dressing. LPN-A confirmed the gown was not removed prior to exiting R16's room, and stated the gown was expected to removed prior to exiting R16's room and stated there were not a garbage available to dispose of the gown at the time. On 1/14/25 at 11:12 a.m., RN-D, known as the regional nurse specialist, stated staff were expected to change gloves after old dressing was removed, wash hands and place new gloves prior to the clean dressing applied. The facility Wound Care policy dated 12/2025, indicated; Don gloves. [NAME] other personal protective equipment as applicable. Remove and discard used dressing, remove and discard soiled gloves. Performa hang hygiene Don gloves Cleanse the wound Discard disposable items remove and discard soiled gloves Perform hand hygiene Don gloves Proceed with dressing the wound as ordered, remove and discard soiled gloves Perform hand hygiene.

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed. These deficient practices had the potential to affect all residents who resided in the facility. Findings include: Refer to F676: Based on observation, interview and document review the facility failed to ensure residents received assistance with meals for 3 of 3 residents (R1, R2, and R10) reviewed for dining who required staff assistance and/or supervision with meals. Refer to F684: Based on interview and document review, the facility failed to monitor weights per physician order for 1 of 1 resident (R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (R20 and R23). Refer to F688: Based on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R20, R22) reviewed for restorative services. Refer to F686: Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements) were completed for 2 of 2 residents (R16 and R20) reviewed for pressure ulcers. Refer to F804: Based on observation and interview, the facility failed to ensure meals were served at a warm and palatable temperature to promote quality of life and nutritional intake for 2 of 2 residents (R22 and R16) reviewed for dining. R16's facesheet printed 1/15/25, indicated diagnosis of osteomyelitis (bone infection). R16's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no behaviors, independent with eating, dependent on staff for toileting hygiene, and partial assistance with personal hygiene. R22's facesheet printed on 1/15/25, indicated diagnoses of amyotrophic lateral sclerosis (ALS) and repeated falls. R22's significant change MDS assessment dated [DATE], indicated intact cognition, no behaviors, use of a walker and wheelchair, and dependent on staff for eating, dressing, bathing, and personal hygiene. R22's care plan revised on 9/18/24, indicated a self-care deficit and dependent on staff for his activities of daily living with intervention of one staff assist for bathing. R3's facesheet printed 1/15/25, indicated diagnoses of anemia, type 2 diabetes mellitus, chronic pain, and muscle weakness. R3's admission MDS assessment dated [DATE], indicated intact cognition, no behaviors, use of a wheelchair, set up assistance for eating, and substantial assistance with personal hygiene. R2's facesheet printed 1/15/25, indicated diagnoses of heart failure, pain syndrome, and kidney disease. R2's significant change MDS assessment dated [DATE], indicated intact cognition, no behaviors, and dependent on staff for personal hygiene and transfers. R2's care plan printed 1/15/25, indicated self-care deficit and dependent on staff for bathing assistance. R21's facesheet printed 1/15/25, indicated diagnoses of dementia, failure to thrive, and anxiety. R21's quarterly MDS assessment dated [DATE], indicated severely impaired cognition, physical and verbal behaviors, and dependent on staff for personal hygiene and bathing. R21's care plan revised 1/3/25, indicated self care deficit, resident will appear clean, neat, and well kept, and bathing assist of one staff on Monday AM. Call light observations/ staffing interviews During continuous observation on 1/13/25, from 11:40 a.m. to 1:35 p.m., extended call light times were observed for R16, R22, and R3. At 11:40 a.m., R16, R22, and R3 all had their call lights on indicating the need for assistance. R3's call light was answered at 12:54 p.m., R16's call light was answered at 1:12 p.m., and R22's call light was answered at 1:26 p.m. R3's call light was on for one hour and 14 minutes, R16's call light was on for one hour and 32 minutes, and R22's call light was on for one hour and 46 minutes. During interview on 1/13/25, at 12:49 p.m., R22 stated he had been waiting for over an hour to use the urinal. R22 further stated it took up to two hours for his call light to be answered some days and he would be uncomfortable and incontinent if it took too long. R22 stated his son was coming to help him use the urinal due to the long wait time. R22 stated the staff were good, there just were not enough of them to help everyone. R22's son was observed arriving at R22's room and assisting with urinal use. During interview on 1/13/25 at 3:45 p.m., R16 stated it always took a long time for staff to answer his call light, sometimes up to two hours. R16 stated it was a common situation and the facility needed more staff so they could help him sooner and not be so rushed when they did come to help him. During interview on 1/13/25 at 11:46 a.m., nursing assistant (NA)-A stated they did not have enough staff to take care of the residents and it had been happening a lot lately. NA-A stated they got busy after breakfast and were still trying to catch up. NA-A further stated they were not able to answer call lights because so many residents required assistance of two staff and kept them in a residents room for over and hour, and they only had two staff working for the whole building. During interview on 1/14/25 at 8:59 a.m., NA-B stated today had been a better day because state was here so they had started using agency staff so it looked like they had more staff. NA-B further stated they never had four NA's working, but today they were letting four NA's work and were letting people get overtime and stay longer to help, and were offering bonuses, but that never happened. During an interview on 1/14/25 at 9:30 a.m., NA-E stated she had worked at the facility for over a year and had never seen it this bad. Sometimes there were only two NA's on duty and sometimes she was the only NA on duty for a while for the entire facility. Agency NA's started today (1/14/25) and it was her understanding just for the outbreak. During interview on 1/14/25 at 11:11 a.m., NA-E stated she had only worked with herself and one other NA for multiple days and at one time worked by herself. NA-E further stated it was hard to get her work done, she could not get her baths done, and even with three NA's it was hard to take care of the residents because so many residents required two NA's to assist them. NA-E stated she did not get baths done again this morning, could not get walking or range of motion done, and at times residents who were not usually incontinent would be incontinent because she could not get to them in time. On 1/14/25 at 2:26 p.m., NA-E stated resident vitals, weights, baths, and range of motion was not done as expected due to shortage of staff and the length of time some the residents require to assist with their cares. A facility document titled Residents needing assist of two for transferring printed on 1/14/25, indicated 13 of 25 residents required two staff assist for transfers and toileting. Facility call light response logs were requested and not received. Baths During observation on 1/13/25 at 7:00 p.m., no baths were observed completed. Review of the facility bath schedule indicated R22, R2, and R21 were scheduled for baths on 1/13/25. The facility bath schedule printed 1/14/25, indicated R2 and R21 had weekly scheduled baths on Monday and R22 had a scheduled bath twice per week on Monday and Thursday. During interview on 1/14/25 at 9:47 a.m., R2 stated he had not had his bath yesterday because staff told him they were too busy. R2 further stated he would not get a bath until his next bath because staff didn't have time for extra baths. During interview on 1/14/25 at 2:29 p.m., R22 stated he did not get his scheduled bath and it was not offered to him. R22 further stated staff try, but they can't get it all done. R22 stated he didn't think he would get his bath until his next scheduled bath day, but wanted his bath. During interview on 1/14/25 at 2:16 p.m., nursing assistant (NA)-F stated they did not get any baths done yesterday (1/13/25) due to being too busy. NA-F stated she documented that R2 had a bath, but he did not have a bath, and she did that because they had not been able to get baths done and had gotten in trouble for not giving baths so staff document was done so not get in trouble. NA-F stated she was unsure if the baths were rescheduled. During interview on 1/15/25 at 8:20 a.m., NA-A stated if baths were missed was not sure how they were rescheduled, or if they just had to wait until the next scheduled bath. NA-A further stated she thought the next shift should do it, but they were busy too. During interview on 1/14/25 at 12:14 p.m., licensed practical nurse (LPN)-C stated she worked on 1/13/25, and was not aware baths were not done. LPN-C further stated NA's were supposed to tell the nurse if baths were not completed. During interview on 1/15/25 at 8:47 p.m., registered nurse (RN)-C, also known as regional clinical director, stated if residents missed their baths they should have a bath within the next 24 hours if they can. RN-D further stated she was not aware of a facility bath policy. During interview on 1/16/25 at 12:09 p.m., RN-H, also know as regional clinical director, stated she would expect a bath that was missed on 1/13/25 to have happened by now, and should have happened within a reasonable time. A review of facility electronic health record (EHR) task logs for bathing on 1/16/25, indicated R22, R2, and R21 had not had a bath since missing their schedule baths on 1/13/25. Meal assistance On 1/13/25 at 1:47 p.m., the administrator stated she was asked by the nursing assistants to assist feeding R22 his meal. The administrator stated residents were crying to go back to bed, and stated when we only have two NA's on the floor things don't function and we need three NA's to function. The administrator stated when the facility doesn't have three NA's during the day shift, its a bad day, stressful things might get put behind. The administrator stated the nurse managers help when they are present at the facility, however RN-A and RN-B had to go home so they can can work evening and overnight shift. The administrator stated due to the staffing shortage and situation she had opened shifts to agency staff starting tomorrow (1/14/25). On 1/14/25 12:48 p.m., activities aide (AA)-B stated all the food had been delivered to resident, expect for R19's food as he required staff assistance with eating. On 1/14/25 12:53 p.m., NA-C stated R19 required staff assistance with eating and there were not staff available to help him eat yet. On 1/14/25 at 12:56 p.m., the administrator stated R19 was expected to have not had to wait for until now for staff assistance with eating. Facility Assessment Review of facility assessment dated ,d+[DATE], indicated the facility reviewed acuity within their resident population and listed 15-25% of residents and clinically complex and 30-40% of residents with reduced physical function. The facility assessment listed 30-40% of residents dependent for transfers and 25-35% dependent for toileting, and 87% of residents in a chair most of the time. The facility uses a comprehensive admission assessment process to identify individualized resident care needs and determine if the facility can meet the resident's need. The facility staffing plan within the facility assessment indicated they used a resident based approach to staffing which was based on the resident population and adjusted as necessary based off of shift day, evening, and overnight. Staffing Schedules Review of facility's nursing schedules for 12/15/24 through 1/14/25 lacked the required nursing assistants and nurses for the following based on facility assessment: 12/15: NA 6 hours 12/16: NA 3 hours 12/17: NA 2 hours, Nurse/TMA 3.5 hours 12/19: NA 2 hours 12/23: NA 8 hours 12/25: NA 8 hours 12/26: NA 8 hours, Nurse/TMA 8 hours 12/27: Nurse/TMA 8 hours 12/28: NA 2 hours, Nurse/TMA 3.5 hours 12/29: NA 2 hours 12/30: NA 1.5 hours, Nurse/TMA 3.5 hours 01/02: NA 2 hours 01/03: NA 3 hours, Nurse/TMA 4.5 hours 01/04: Nurse/TMA 2.5 hours 01/06: NA 3.5 hours, Nurse/TMA 7 hours 01/07: NA 4.5 hours, Nurse/TMA 8 hours 01/08: NA 2 hours 01/09: NA 18 hours 01/11: NA 4 hours 01/12: NA 16.5 hours, Nurse/TMA 8 hours 01/13: NA 24 hours, Nurse/TMA 8 hours 01/14: NA 10 hours 44630 On 1/14/25 at 2:37 p.m., RN-A, known as the assistant director of nursing and infection prevention nurse, confirmed due to not enough staff NA's were not able to give scheduled baths, answer call lights timely, walk or complete ROM with residents. RN-A stated the information about not enough staff was shared with the administrator, and administrator educated nursing staff to have a positive attitude, and help the NA's. RN-A stated the administrator was helping on the floor with resident cares due to the shortage of staff, and the administrator had pulled the business office staff to help with resident cares. The Le Sueur Facility Assessment policy revised 3/2024, indicated the below staffing ratios from the staffing plan: (ratios are staff/:residents) Nurses/TMAs Days and evenings: 2 licensed nurses 1:22-1:35 ratio 1 TMA 1:22-1:35 ratio Nights: 1 licensed nurse 1:35 ratio Nursing assistants: Days and Evenings: 1:10 ratio Nights: 1:22 ratio 42073

Based on interview and document review, the facility failed to ensure an annual performance review was conducted for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) and therefore failed to ensure annual training reflected the NA's areas of weaknesses identified on performance reviews. Findings Include: The following NA's personnel and training records were reviewed for annual performance reviews and training and identified the following: NA-A was hired on 6/14/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. NA-F was hired on 11/7/23. NA-F's personnel record lacked evidence an annual performance review was ever completed. NA-B was hired on 7/16/18. NA-B's personnel record lacked evidence of a current annual performance review. NA-E was hired on 6/7/21. NA-E's personnel record lacked evidence an annual performance review was ever completed. Review of online training transcripts for NA-A, NA-F, NA-B, and NA-E included online trainings on abuse prevention, behavioral health, workplace injury, cultural competency, dementia, dining and food safety, Elder Justice Act, emergency preparedness, fall prevention, HIPAA, infection control, infectious disease, Medicare, OSHA, resident privacy, QAPI, resident rights, substance abuse, trauma informed care, and vulnerable adult. All training logs were the same with no individualized training based on performance reviews. During interview on 1/14/25 at 8:59 a.m., NA-B stated she was not aware of a recent performance review or individualized training. She further stated she did the annual computer training completed by all employees, but was not aware of any other training. During interview on 1/14/25 at 11:11 a.m., NA-E stated she had not had any specific training and had only done the computer training she had to do yearly. During interview on 1/15/25 at 8:20 a.m., NA-A stated she had not had a performance review and did not know she should have had training based on a performance review. NA-A stated she did complete the yearly required computer classes. During interview on 1/16/25 at 12:12 p.m., registered nurse (RN)-A stated he was not aware of any training based off of performance reviews since he had started and further stated he did not know of any individual education provided to NA's. During interview on 1/15/25 at 9:08 a.m., administrator stated she was not aware of any completed performance reviews and was too new to be sure on training processes. A policy on performance reviews and training was requested but not received.

Based on observation and interview, the facility failed to ensure 2 of 3 tub/shower rooms were maintained in good repair and sanitary conditions for 15 residents who utilized two tub/shower rooms on the Prairie unit. Finding include: Prairie Unit - East During an observation on 1/14/25 at 2:15 p.m., the tub/shower room on the east Prairie unit was observed to have a large tub and separate walk-in shower, toilet, and vanity with sink and cupboards. A furnace filter measuring approximately two feet by eight inches was observed laying on the floor half-way under the wall-mounted heater. The filter was heavily laden with gray fuzzy material. On top of the heater where air came out where small square grates that had an accumulation of dust and webs on them. Next to the heater was a corner wall where sheetrock was missing on the lower one - two feet. The material exposed resembled cement - white and porous, and was crumbling. These open areas were discolored rust and brown. A ceiling vent, approximately 12 inches x 12 inches was heavily laden with gray fuzzy debris with some of it hanging down like a web. The floor of the walk-in shower was worn looking and stained a tan/rusty color. In addition, the hand-held shower head was attached to the shower with black zip ties. Prairie Unit North The floor of the walk-in shower was worn looking and stained with a tan/rusty color. In addition, the floor seemed to have tiny black marks resembling sand until closer inspection revealed the black marks did not come off. During an interview and observation on 1/15/25 at 1:17 p.m., together with maintenance director (MD)-A, viewed both tub/shower rooms on the Prairie unit. In the tub/shower room on Prairie east, MD-A pulled out and examined the filter and stated it looked pretty bad. MD-A stated he had ordered filters a couple of months ago, but they had not come in yet. MD-A stated he was not aware of the other concerns: crumbling wall, ceiling vent, zip ties and floor of the shower. In the tub/shower room on Prairie north, MD-A tried to scratch off the black marks on the floor of the shower with his fingernail, but it didn't come off. MD-A was not aware of this either and acknowledged these findings did not provide a home-like, nor sanitary environment for residents. On 1/15/25 at 4:01 p.m., with the administrator, looked at areas of concern in each of the Prairie tub/shower rooms. She had been aware of the filters after MD-A reported it to her, but unaware of other issues. The administrator stated she would expect the tub/shower rooms to be clean and in good repair. A policy on physical maintenance of the building, upkeep, and cleanliness was requested. The facility Maintenance - Plumbing, HVAC and Related Systems policy dated 1/2025, was received. The policy indicated to clean or discard filters in individual air-conditioning units in resident rooms at least monthly during the summer. Clear air vents and air handling units at least annually.

Based on interview and document review, the facility failed to ensure annual performance reviews were completed for 4 of 4 nursing assistants (NA-A, NA-F, NA-B, NA-E) whose files were reviewed. This had potential to affect all residents who currently resided in the nursing home and who could receive care from these staff. Findings include: The following nursing assistants (NA)'s personnel records were reviewed for annual performance reviews and identified the following: NA-A was hired on 6/14/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. NA-F was hired on 11/7/23. NA-F's personnel record lacked evidence an annual performance review was ever completed. NA-B was hired on 7/16/18. NA-B's personnel record lacked evidence of a current annual performance review. NA-E was hired on 6/7/21. NA-E's personnel record lacked evidence an annual performance review was ever completed. During interview on 1/15/25 at 8:10 a.m., administrative support stated she did not have any performance reviews for staff in personnel files. She further stated there had been too much leadership turnover and the performance reviews had not been completed. During interview on 1/15/25 at 9:08 a.m., administrator stated she did not have any completed performance reviews that she was aware of. Administrator further stated they had not been done due to change in leadership but she planned to start doing them when she knew the staff better. A policy on performance reviews was requested but not received.

Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements) were completed for 2 of 2 residents (R16 and R20) reviewed for pressure ulcers. Findings include: R20's facesheet printed on 1/16/25, included diagnoses of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease. R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required moderate assistance with activities of daily living (ADL). R20 had no risk of pressure ulcers, no unhealed pressure ulcers and no current pressure ulcers. R20 walked with staff assistance. R20's physician orders dated 12/3/24, indicated skin check on every Tuesday in the afternoon. R20's care plan dated 12/5/24, indicated R20 had the potential for skin integrity impairment related to decreased baseline functional ability due to recent surgery and hospitalization . R20's skin would remain free of skin integrity issues through next review period. Interventions included staff to inspect skin PRN (as needed) with cares and a licensed nurse was to observe skin weekly. R20's care area assessment (CAA) for pressure ulcers dated 12/4/24, triggered for pressure ulcer related to functional limitations and medical diagnosis. MASD (moisture associated skin damage) present to peri area/buttocks, mepilex (foam dressing pad) and barrier cream applied. No pressure ulcers. No scars over bony prominence. No other ulcers, skin tears. Pressure reduction gel cushion in WC (wheelchair). Pressure reduction mattress. Braden score 22 (indicating low risk for development of a pressure ulcer). Review of R20's skin checks titled Skin Evaluation Initial/Weekly since admission on 11/27/24, indicated that over the course of eight weeks, weekly skin checks were done only five times: 11/27/24, 12/14/24, 12/23/24, 12/31/24, and the last skin check was done on 1/14/25. No indication of MASD to coccyx or wound to right heel. Provider visit notes dated 1/15/25, indicated an approximately 1 cm (centimeter) x 1 cm scabbed area to right heel, and an approximately 2 cm x 1 cm open area to coccyx. Wound bed was 100% slough, no drainage. Assessment and plan indicated pressure injury of right heel, unstageable. Cleanse heel with wound cleaner, apply Betadine (antiseptic) daily to right heel. Wound care referral. Heel protectors on while in bed. Pressure injury to sacral region, unstageable. Cleanse with wound cleaner, apply foam dressing and change every three days. Offload coccyx area. During an interview and observation on 1/13/25 at 2:42 p.m., R20 stated he had a sore on his right heel, acquired at the facility. R20 was lying in bed and moved his right leg out from under the blankets. Observed a small round, approximately 1 cm diameter wound to the back of his right heel. The wound was dry and the skin around it was pink. R20 stated no one looked at his heels. R20 stated he had a sore on his coccyx too, but it had healed. During review of the EMR did not see skin checks or wound assessments indicating a heel wound. No wound care orders. Nothing mentioned in progress notes. During an interview on 1/15/25 at 9:59 a.m., observed nurse practitioner (NP)-H in room with R20. NP-H stated she was not aware of a wound to R20's heel; she would have to look at her notes. During an interview on 1/15/25 at 10:00 a.m., licensed practical nurse (LPN)-B had not been informed R20 had a sore on his heel but would look when she gave him his medications. During an interview on 1/15/25 at 10:04 a.m., with both registered nurse (RN)-B and NP-H, RN-B stated she was not aware of a wound to R20's heel. NP-H looked in the EMR and stated there was no documentation of it. NP-H stated R20 told her he had it for about a week. NP-H described it as a 1 x 1 cm pressure wound, unstageable. NP-H stated R20 also had a pressure wound on his coccyx that had opened up again. RN-B stated the wound on his heel was likely from R20 wearing leather sandals without socks. During an interview and observation on 1/16/25 from 11:47 a.m. to 11:52 a.m., observed R20's wound to his coccyx. No dressing had been over it. No socks on his feet nor were his heels off-loaded. Observed a small, round, whitish scab, approximately 1 x 1 cm. No drainage. Skin around wound normal color. LPN-B stated she would return later to dress it. LPN-B stated typically this type of information was passed on to the next shift during nurse-to-nurse shift report but it had not been, nor was it noted on their hand written hand-off form. During an interview on 1/16/25 at 12:00 p.m., RN-A stated he was not aware R20 had pressure wounds. RN-A stated he should have been informed as this was urgent - a change in condition. RN-A stated typically RN-B would have told him after provider rounds, indicating this is what we found, this is what the NP wants us to do then I would get started on the nursing end of it by putting prompts in the TAR (treatment administration record) and in POC (Point of Care in the EMR). RN-B stated he would have looked at the wounds himself and made sure they had supplies such as dressings and heel boots. RN-B stated they probably did not have any heel boots on hand. RN-A looked in the EMR and noted RN-B had come back last evening (1/15/25) and entered the new wound care orders into the EMR. RN-A stated skin checks were supposed to be done weekly on shower days. RN-A stated the TAR in the EMR prompted the nurse, and NA's let the nurse know when they were ready for a skin check when giving a shower. RN-A stated nursing staff say they don't have time to do skin checks .a more appropriate answer would be there was no management to make sure it was prioritized .with one nurse, it was hard to do it all. During a telephone interview on 1/16/25 at 12:21 p.m., RN-B stated she came back last evening (1/15/25) to enter wound care orders given by NP-H earlier in the day. RN-B stated she talked to the evening shift nurse but did not specifically tell her to pass R20's new wound findings and orders on to the next shift. RN-B was aware there were no spare heel boots or heel protectors on hand which was why they had not been started right away. During an interview on 1/16/25 at 12:56 p.m., in the absence of the DON, regional clinical director and regional clinical support were informed of findings and both indicated they expected staff to adhere to physician orders, policies and procedures and the DON was responsible for ensuring this occurred. 44630 R16's admission MDS assessment dated [DATE], indicated R16 was admitted to the facility on [DATE], cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone); skin conditions indicated R16 was at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, had infection of the foot, other open lesion on the foot, surgical wounds; skin treatments included pressure reducing device for chair and bed, surgical wound care, application of ointments/medications other than to feet, application of dressings to feet. The MDS failed to indicate R16 had a unstageable heel pressure ulcer/injury. R16's care plan printed on 1/14/25, indicated R16 had self care deficit related to morbid obesity and decreased functional ability due to bilateral pressure injury to heels, needed assist with ADL's (activities of daily living), alteration in skin integrity r/t (related to) pressure ulcer to bilateral heels and interventions included administer treatments as ordered and observe for effectiveness, assist/encourage to float heels while in bed, measure wound weekly; update MD (medical doctor) PRN (as needed) with change, observe for s/sx (signs/symptoms) of infection, and wound vac in place on right heel wound to promote wound healing. R16's document titled Wound Observation Tool dated 12/11/24, registered nurse (RN)-A, known as the assistant director of nursing and infection prevention nurse, indicated first observation of the wound, admitted with a unstageable left heel pressure wound, 20% epithelial (outer layer) tissue present, 5% granulation tissue present, 75 % necrotic (dead cells) tissue present , 100% moist, scant serosanguinous (containing both blood and serum) drainage, measurements included length 3 cm (centimeters), width 4.5 cm, and depth 0.5 cm, treatment: clean with betadine ( topical antiseptic ), cover with gauze, wrap with ace wrap. R16's wound observation tool document dated 12/16/24, RN-B indicated length 3 cm, width 4 cm, dept 0 cm, and no drainage, unchanged overall impression, 20 % slough, 90% necrotic tissue. R16's skin evaluation document dated 12/19/24, RN-F indicated previous skin impairments of right iliac crest (redness), left iliac crest (redness), groin (redness), right heel (wound vac), left heel (wound) and posterior left skin fold (redness). The document failed to include measurements. R16's skin evaluation documented dated 1/2/25, licensed practical nurse (LPN)-B indicated previous skin impairments of right iliac crest, left iliac crest, right heel, left heel. The document failed to include type of impairment and measurements. On 1/13/25 at 12:03 p.m., the R16 was lying in bed with foam cushioned boots on bilateral feet, and wound vac present on right heel. R16 stated he was admitted to the facility with pressure ulcers of the right and left heel. On 1/14/25 at 9:19 a.m., medical doctor (MD)-G and LPN-A were present in R16's room. MD-G observed the left heel, LPN-A removed the dressing from the left heel. MD-G described the left heel and stated new tissue had started to form, and stated the heel was healing. MD-G further stated weekly comprehensive skin assessment with measurements were expected. LPN-A was observed to place a new dressing on the left heel and no measurements were observed. On 1/15/25 at 8:13 a.m., R16 was lying in bed and stated he does not recall the last time staff took measurements of the left heel. R16 stated staff had used his personal cell phone to take pictures of the wound, and R16 stated the pictures needed to be sent to the wound doctor. On 1/15/25 at 8:22 a.m., RN-B stated R16 came with pressure wounds of bilateral heels, and confirmed the last wound check with measurements was 12/16/24. RN-B stated a comprehensive wound assessment with measurements was expected weekly and documented. On 1/15/25 at 8:26 a.m., nurse practitioner (NP)-H stated she was familiar with R16 and confirmed pressure ulcers of bilateral heels. NP-H stated weekly wound assessment with measurements were expected and documented. NP-H stated pictures on R16's phone were not the only documentation expected completed of R16's wounds. On 1/15/25 at 8:32 a.m., RN-G stated skin checks of all residents were expected weekly and the nurse assigned to the hall was responsible for the resident's skin check on their bath day. RN-G stated for residents with wounds a comprehensive wound assessment was expected and documented weekly. RN-G stated due to not enough staff and the acuity of the residents at the facility residents comprehensive wound assessments were not completed weekly. On 1/15/25 at 8:34 a.m., RN-A, known as the ADON and infection prevention nurse, stated nursing was responsible for weekly comprehensive wound assessments and documented measurements. RN-A confirmed R16 did not have weekly comprehensive wound assessments. RN-A stated previously RN-G was responsible for weekly comprehensive wound assessments, however with the shortage of staff, the facility no longer had an assigned wound nurse. RN-A stated the director of nursing and the regional clinical support staff were made aware last week skin checks were not able to be completed due to the acuity of the residents and shortage of staff. On 1/15/25 a 2:31 p.m., RN-D, known as the regional nurse specialist, and RN-H, known as the regional clinical director, stated today when reviewing residents, they became aware missing skin assessments, and stated prior to today they had not been aware skin assessments were not done weekly. RN-H stated pressure ulcers were expected measured weekly with a comprehensive assessment documented, and further stated wounds were expected discussed during IDT (interdisciplinary team) meetings. The facility Pressure Management policy dated 1/2025, indicated federal regulations require long-term care facilities to actively prevent and effectively treat pressure injuries. Each facility was to ensure a resident who enters the facility without a pressure injury doesn't develop pressure injuries, unless the resident's clinical condition demonstrates that they were unavoidable, and that a resident who has pressure injuries receives the necessary treatment and services to promote healing, prevent infection, and prevent the development of new pressure injuries. The facility Wound Care policy dated 1/2025, indicated complete the necessary documentation within the resident's medical record which may include observations of the wound, Note any abnormal observations made or any change in the condition. Report other information in accordance with facility policy and professional standards of practice. The facility Bathing Assistance policy dated 1/2025, indicated to notify the RN if any new bruises, open sores, or skin irritations are discovered.

Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no rejection of care, required setup or clean up assistance with eating, substantial staff assistance with personal hygiene and diagnoses included non-traumatic brain dysfunction, dementia, Parkinson's disease(progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder, taking an antipsychotic. R10's care plan dated 11/20/24, indicated potential for drug interactions and adverse effects r/t (related to) polypharmacy interventions included administer medications as ordered, observe for effectiveness and adverse effects, update MD (medical doctor) PRN (as needed) monthly medication regime review by pharmacy consultant, forward recommendations to MD for review. R10's medication administration record dated 1/1/25-1/31/25, indicated start date 8/6/24, quetiapine fumarate (antipsychotic medication) oral tablet give 50 mg (milligrams) by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition, Parkinson's disease. R10's Pharmacist Recommendations to Nursing documented dated 10/11/24, consulting pharmacist (CP)-L indicated please add an order for monthly blood pressures or document why this not able to be completed. On the document registered nurse (RN)-B dated 10/13/24, indicated order placed. R10's treatment administration record (TAR) dated 10/1/24-10/31/24, indicated start date 10/14/24, and end date 11/5/24, orthostatic blood pressure one time a day every one month(s) starting on the 14th for 28 day(s) related to anxiety disorder, after resident has been lying down for at least five minutes, measure resident's blood pressure and pulse. R10's record review indicated the last documented orthostatic blood pressure was dated 11/5/24, and R10's record review did not include an order for current monthly orthostatic blood pressures. On 1/16/25 at 12:22 p.m., RN-D, known as the regional nurse specialist, stated R10's order for monthly orthostatic blood pressures was entered incorrectly and the order fell off. RN-D confirmed there was not a correct order for R10 to have monthly orthostatic blood pressures. On 1/16/25 at 12:45 p.m., CP-L stated would expect monthly orthostatic blood pressures on resident on Seroquel, to monitor for side effects. The facility Consultant Pharmacist Medication Regimen Review policy dated 1/2025, indicated evaluating response to drug therapy to assure that each resident receives optimal medication therapy. The residents response to drug treatment is evaluated through the use of lab, physical assessment, medication administration record and other data to determine if the therapeutic goals are achieved. Side effects, adverse reactions and interactions lab test and drug disease. Medical condition and response to drug therapy are used to evaluate medication regime for unnecessary medications.

Based on observation, interview and document review, the facility failed to conduct a comprehensive reassessment after falls to identify root cause and ensure new interventions were implemented to prevent further falls for 1 of 2 residents (R79) reviewed for falls. Finding include: R79's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, dependent on staff for putting on/taking off footwear, sit to stand, chair/bed to chair transfer, toilet transfer, required substantial/maximal assistance with dressing, shower/bathe, personal hygiene, sit to lying, utilized a wheelchair, diagnoses included left femur fracture, non-Alzheimer's dementia, anxiety, depression, age related physical debility, fall in the last month, and a fracture related to a fall in the last six months, fall since admission or the prior assessment, two or more falls with no injury since admission. R79's care plan printed 1/14/25, indicated potential for injury r/t (related to) impaired mobility due to left hip fracture, impaired cognition dementia, antidepressant, narcotic, diuretic medication, impaired hearing, history of falls, has limited ROM (range of motion) LLE (left lower extremity); interventions included: bed at appropriate height, encourage resident to wear appropriate footwear, keep bed in lowest position, place fall mats on floor next to bed, when resident is in bed, keep call light within reach in bedroom and encourage resident to utilize it, urinal at bedside for falls prevention. R79's fall incident report dated 1/4/25, indicated R79 was on the floor in his room, lying on the floor in front of his recliner with the legs of the chair still extended, resident's positioning appeared R79 had crawled out of the recliner to the floor. R79 indicated he was getting out of that to go do the chores, and unable to tell actual events leading to him being on the floor due to confusion suspected related to his dementia. Immediate action taken included R79 was assessed and denied any pain, no evidence during assessment indicating any injuries occurred; absence of bruising, skin tears, redness,or pain with palpation, vitals taken, assisted to wheelchair appeared pleasantly confused throughout the shift as evidenced by his conversation with staff; several conversations pertained to him having to go get the chores done and/or the acreage he is currently farming, potentially hallucinating. The incident report failed to indicate new interventions related to the fall. R79's fall incident report dated 1/8/25, indicated staff via walkie talkie that assistance was needed in R79's room. Upon arrival, R79 was seated on the floor of his room facing the door and resting his back against recliner. R79 was unable to explain to staff what had happened or what he was trying to do. Resident Immediate Action Taken vital signs, pain, and range of motion were assessed while R79 was on the floor and found to be within normal limits, lifted from the floor using two assist via the hoyer lift, neurological assessments were initiated d/t (due to) suspicion of a head strike by the kitchen staff who witnessed the fall. The incident report failed to include predisposing factors and new interventions to prevent further falls. Progress note dated 1/10/25 at 11:02 a.m., the administrator indicated in regards to the influenza outbreak, family expressed concerns about R79 being a fall risk, would rather have R79 be out at the nurses station or in activities than be in his room. On 1/13/25 at 12:58 p.m., R79's family member (FM)-K stated R79 had fell three times since he was admitted to the facility. FM-K stated she discussed the falls with the administrator and asked when R79 was awake staff have R79 in his wheelchair at the dining area located near the nursing station for increased supervision. FM-K stated when visiting R79 he was frequently found awake in his room in bed and not located at the nursing station as discussed with the administrator. FM-K stated one fall was from the electric recliner and FM-K was unaware if R79 was assessed to use the recliner, and another fall was related to R79 brought back to his room and seated in the wheelchair or recliner and self-transferred. FM-K stated R79 was frequently confused and required redirection. On 1/14/25 at 11:02 a.m., the administrator stated when a resident had a fall a comprehensive assessment was expected in the electronic medical record (EMR),. The administrator stated the nurse present at the facility at the time of the fall was expected to implement immediate intervention, and the IDT (interdisciplinary team) met daily to discuss falls. The administrator confirmed the facility had a large gap related to falls and implementation of interventions and completion of a comprehensive assessment post falls. The administrator stated after a fall a comprehensive assessment into the cause of the fall and implementation of interventions were expected and expected the care plan updated to include the interventions. The administrator confirmed the director of nursing (DON) was overall responsible to ensure a comprehensive reassessment was conducted after a fall incident to identify root cause and ensure new interventions were implemented to prevent further falls. The administrator stated after R79's fall on 1/4/25, the interventions included observation of R79 while awake and have R79 at the dining area located by the nursing station. The administrator stated she educated the ADON (assistant director of nursing) regarding the interventions and entered a note in the EMR. The administrator confirmed the care plan was not updated as expected with the new interventions. The administrator stated R79 had a fall on 1/8/25, and confirmed no new interventions were put in place to prevent further falls. The administrator stated the IDT met and discussed R79's fall that occurred on 1/8/25, and the DON was not able to come to a conclusion regarding the fall to implement fall interventions. On 1/14/25 at 11:12 a.m., registered nurse (RN)-D, known as regional nurse specialist, stated after a resident fall the nurse was expected to enter the fall into risk management in the EMR. The facility was expected to complete a comprehensive fall investigation which included a root cause analysis, and implement a new intervention, and the care plan updated with the new intervention. RN-D stated IDT met and discussed falls. RN-D stated the DON was responsible to ensure a comprehensive fall investigation was completed, and further stated she was not sure who was responsible for ensuing the care plan was updated. RN-D confirmed a comprehensive assessment and new interventions were not implemented after R79's fall on 1/8/25, and the interventions discussed after R79's fall on 1/4/25 were not included on the care plan. On 1/14/25 at 11:30 a.m., RN-A, known as the assistant director of nursing, stated he was only aware of R79 having one fall since admission. RN-A stated IDT met daily and discussed falls, and were expected to discuss cause and new interventions related to the fall. RN-A stated he was not able to attend IDT daily due to having to work the floor as nurse, pass medications, and complete resident treatments. RN-A confirmed the new interventions were not consistently placed on the care plan, and were important to ensure staff were aware of the interventions to prevent falls. RN-A stated he was not given education regarding R79 expected at the nursing station when awake. On 1/14/25 at 2:17 p.m., R79's door was closed, upon entering R79's room he was awake and seated at the edge of his bed in a gown. On 1/14/25 2:26 p.m., nursing assistant (NA)-E stated R79 was not a fall risk, not aware of any interventions to prevent falls, and fall interventions were expected reported in shift report and on the care plan. NA-E stated R79 had been awake in his room throughout the day. On 1/14/25 at 2:49 p.m., R79's door remained closed, and entering the room R79 was still awake and seated at the edge of the bed. On 1/14/25 at 2:52 p.m., trained medication aide (TMA)-A confirmed R79 was a fall risk and stated when R79 was in his room the door was expected open. On 1/14/25 at 3:43 p.m., R79 was seated in the dining area located near the nursing station. R79 stated he gets bored lying in bed all day and was glad to be out of his room. On 1/14/25 at 3:54 p.m., NA-F confirmed R79 had fell while at the facility, and stated R79's door was expected open and while awake he was expected near the nursing station for staff to keep an eye on him. On 1/14/25 at 2:28 p.m., NA-G stated today was her first day at the facility as agency staff. NA-G stated she was not educated R79 was a fall risk, and did not have access to the EMR to access resident care plans to know interventions R79 may have related to falls. On 1/15/25 at 2:31 p.m., RN-H, known as the regional clinical director, stated the facility was expected to review all falls and the director of musing (DON) was expected to ensure an intervention was implemented to prevent further falls. On 1/16/25 at 11:40 a.m., RN-D stated an electric lift chair assessment was expected prior to R79 having access to the lift chair, and confirmed R79 had not been assessed to safely use the lift chair in his room, and the lift chair was now unplugged and a sign on the chair not to use. The facility Fall Management policy dated 9/2023, indicated: -a fall risk evaluation include a review of the resident's past history of falls, medical and physical history, medication use in attempts to identify factors which may place the resident at higher risk of falls. - an analysis of the fall will be completed - additional interventions may be imitated and/or updated as applicable. - the circumstances of the fall will reviewed with the IDT

Based on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R20, R22) reviewed for restorative services. Findings include: R20's facesheet printed on 1/16/25, included diagnoses of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease. R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required moderate assistance with activities of daily living (ADL). R20 had no behaviors except rejection of care 1-3 days during MDS assessment period. R20 walked with staff assistance. R20's physician orders dated 11/27/24, indicated PT/OT (physical therapy/occupational therapy) for strengthening. R20's care plan dated 11/27/24, indicated R20 had a self-care deficient related to increased weakness from baseline due to recent hospitalization and surgery. R20's care plan goal was to maintain and increase strength by ambulating in the corridor 80-100 feet with gait belt and FWW (front wheeled walker). R20's rehabilitation (rehab) paper communication/instruction sheet for restorative nursing dated 1/6/25, indicated R20 should walk with 4WW (4-wheeled walker) with CGA (contact guard assist -- where caregiver provides light touch to help with balance) to nurses station and back to room three times a day. Review of R20's EMR (electronic medical record) TASK tab, which was where nursing assistants (NA's) looked to determine cares they were to provide for each resident, did not identify R20 to be on a walking program. During an interview on 1/13/25 at 2:45 p.m., R20 stated he was supposed to be walked, but no one ever asked him to walk. R20 stated physical therapy told him nursing staff were supposed to walk, but they don't. R20, who had open heart surgery stated he planned to go home eventfully and needed to get stronger to do that. During an interview on 1/15/25 at 10:35 a.m., physical therapist (PT)-I stated she put R20 on a walking program but didn't know what kind of follow through was happening with restorative nursing -- if they were walking R20 or not. PT-I stated R20 never refused when she asked him to walk. PT-I stated staff tell her they walk R20, but likely not as much as she did or potentially as much as he would like. PT-I stated the walking program she put R20 on was for three times a day, walking to the nurses station and back. PT-I stated PT referral forms for restorative nursing were given to the director of nursing (DON) for continuation of care. During an interview on 1/16/25 at 8:23 a.m., nursing assistant (NA)-C did not know if R20 was on a walking program. If a resident refused walking, NA-C told the NA on the on-coming shift so she would do it; she did not tell a nurse. During an interview on 1/16/25 at 8:28 a.m., registered nurse (RN)-A stated when therapy placed a resident on a restorative program such as walking or ROM, therapy staff provided nursing with a paper communication/instruction sheet. RN-A stated he then entered the exercise instructions into the TASK tab of the EMR for NA's to carry out. RN-A stated he also added the instructions to the residents care plan and the paper NA task list. RN-A provided a copy of the NA paper task sheet, and a walking program was not indicated for R20. When informed walking was not listed in the TASK tab for NA's to perform, RN-A stated he didn't know why that was as he had only recently started adding to resident care plans and the TASK tab -- usually that would have been done by the DON. During an interview on 1/16/25 at 8:33 a.m., NA-D stated R20 used to be on a walking program, but he wasn't any longer. NA-D obtained her iPad to look at TASKS in the EMR and stated R20 did not have walking listed as a task for NA's to do. If a resident refused walking, NA-D stated she would tell a nurse and try again later. NA-D stated we don't always have time to do restorative nursing - depends on the day - we aren't always staffed like this with four NA's on the day shift. NA-D stated they were only staffed with four NA's because State was here. R22's facesheet printed on 1/16/25, included a diagnosis of amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrigsdisease (a progressive disease that weakens muscles and impacts physical function). R22's significant change MDS assessment dated [DATE], indicated R22 was cognitively intact, had clear speech, could understand and be understood. R22 required substantial assistance or was dependent upon staff for ADLs. R22 did not walk independently. R22's physician orders did not identify physical or occupational therapy evaluation/treatment. R22's care plan dated 9/26/24, indicated to complete ROM exercises per therapy orders. Care plan dated 10/4/24, indicated R22 received restorative nursing related to left shoulder disorder, weakness, ALS, and muscle atrophy (wasting away of part of the body). ROM exercises to upper extremities/shoulders in place to support current level of function and ROM. R22 would continue to be able to participate in ROM exercises daily through next assessment. Report and document resident refusals to participate in ROM exercises. Follow restorative nursing program as noted in TASKS. During an interview on 1/13/25 at 2:19 p.m., R22 stated he was supposed to have ROM to his arms every day. R22 stated he wanted ROM to his arms so they didn't lock up. Observed several sheets of ROM instructions with illustrations taped to R22's wall, between his recliner and bed. Instructions were more for his legs than his arm. Review of the EMR from 12/17/24, to 1/11/25, under the TASK tab which was where NA's looked for what cares to provide residents and to document these cares, indicated the following: 1. Passive ROM in all shoulder planes daily as tolerated. Out of 24 opportunities, 20 entries recorded 2 to 25 minutes of ROM to shoulders. Three refusals were documented. The last date of documentation of this task was on 1/11/25. 2. Assist with passive ROM to BUE (bilateral upper extremities) 2 x per day. See handout for help (e.g., instructions taped to R22's wall). Question 1 of the task directed NA's to document the number of MINUTES spent providing passive ROM. Out of 48 opportunities, 21 entries recorded 2 to 25 minutes. Three refusals were documented. The last date of documentation of this task was on 1/11/25. 3. Assist with passive ROM to BUE 2 x per day. See handout for help. Question 2 of the task directed NA's to document the number of REPETITIONS of this exercise. Out of 48 opportunities, 19 entries recorded 3-40 repetitions. Three refusals were documented. The last date of documentation was on 1/11/25. During an interview on 1/14/25 at 9:30 a.m., NA-E stated R22 liked when she did ROM to his arms. NA-E stated R22 wanted her to do ROM yesterday, but she did not because she didn't have time, adding they frequently don't have time due to short staffing. During an interview on 1/15/25 at 10:44 a.m., PT-I stated R22 was discharged from occupational therapy (OT) and was handed off to NA's for restorative nursing. PT-I provided a copy of OT's recommendations to nursing for continued therapy, dated 10/8/24. Recommendations included: --ROM LE (left arm) AROM (assisted ROM) with 3-pound weights as tolerated --PROM (passive ROM) 2 x daily (no further specificity) These instructions were different than what was identified in the TASK tab in the EMR and different than the instructions posted in R22's room. PT-I was not aware of that and could not explain why, adding the occupational therapist who wrote the instructions no longer worked at the facility. During an interview on 1/15/25 at 1:47 p.m., RN-B stated R22 refused things, but later complained it wasn't done. RN-B looked at R22's care plan in the EMR and verified R22 was to have ROM exercises to upper extremities and shoulders, and to document if he refused. RN-B confirmed there were no progress notes indicating refusals. During an interview on 1/16/25 at 8:23 a.m., NA-C was asked how she knew if a resident needed ROM exercises. NA-C removed a paper task list from her pocket and there was nothing listed for R22 for ROM -- she was not aware if R22 was to receive ROM. NA-C stated she assumed if exercises were posted on a residents wall, they were for a resident to do on his/her own. During an interview on 1/16/25 at 8:28 a.m., RN-A stated NA's performed restorative services for residents including ROM exercises. RN-A was informed not all NA's knew R22 should have assistance with ROM exercises despite it being on his care plan and in the TASK tab for NA's. RN-A stated he was not aware and generally that would be something the DON would monitor. During an interview on 1/16/25 at 8:33 a.m., NA-D stated R22 received ROM to his arms, but NA's did not always have time to do it -- it depended on the day. NA-D did not recall R22 refusing. NA-D further stated if R22 refused, she would usually ask again later and report it to a nurse. During an interview on 1/16/25 at 12:56 p.m., in the absence of the DON, regional clinical director and regional clinical support were informed of findings and both indicated they expected staff to adhere to physician orders, policies and procedures and the DON was responsible for ensuring this occurred. The facility Restorative Nursing Services policy dated 1/2025 indicated residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitation care. The resident or representative would be included in determining goals and the plan of care.

Based on interview and document review, the facility failed to monitor weights as ordered for 1 of 1 resident (R10) reviewed for edema and 2 of 2 residents reviewed for nutrition (R20 and R23) Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no rejection of care, substantial staff assistance with personal hygiene and diagnoses included coronary artery disease, hypertension, diabetes, non-traumatic brain dysfunction, dementia, Parkinson's disease (progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder. R10's care plan dated 11/20/24, indicated nutritional problem or potential nutritional problem r/t (related to) diabetic diet restrictions and current dx (diagnosis) of Parkinson's Disease, requires set up assist, high BMI (body mass index) and interventions included monitor weights. R10's provider order dated 1/10/25, nurse practitioner (NP)-H indicated daily weights update provider if greater then three pound gain in one day or five pound gain in a week. R10's treatment administration record (TAR) dated 1/1/25-1/31/25, indicated start date of 1/11/25, daily weights, update provider if greater then three pound gain in one day or five pound gain in a week with start date. The TAR had no documented weights from 1/11/25-1/13/25. On 1/14/25 a weight of 212 pounds was documented. R10's document weight summary reviewed on 1/14/25, indicated on 12/19/24, documented weight was 209.6 pounds and on 1/14/25, a weight of 212 pounds. R10's record review had no documented refusals On 1/14/25 at 8:41 a.m., R10 was seated in a wheelchair in his room and medical doctor (MD)-G and licensed practical nurse (LPN)-A were present. MD-A stated R10 had plus one edema (retention of fluid) in bilateral lower legs and stated staff were expected to follow provider orders for weights. On 1/16/24 at 12:36 p.m., registered nurse (RN)-C, known as the regional nurse specialist, stated staff were expected to follow physician orders and expected R10's weights documented. 42073 R20's facesheet printed on 1/16/25, included diagnoses of coronary artery bypass surgery, heart failure, diabetes, and chronic kidney disease. R20's admission MDS assessment dated [DATE], indicated R20 was cognitively intact, had clear speech, could understand and be understood. R20 required moderate assistance with activities of daily living (ADL) and was independent with eating. R20 had no behaviors except rejection of care 1-3 days during MDS assessment period. R20 walked with staff assistance. R20's physician orders dated 11/27/24, indicated: weights daily in morning; call provider if weight increases by 2 pounds/24 hours and 5 pound/7 days from admission, every day shift for CHF (congestive heart failure). R20's care plan dated 12/10/24, indicated R20 had a behavior problem and frequently refused daily weights necessary to monitor his cardiac status. A goal with revised date of 12/30/24, indicated R20 would have fewer episodes of daily weight refusals by the next review date. An intervention dated 12/10/24, indicated to report daily weight refusals to nurse. Recorded weights (physician order indicated R20 was to be weighed daily): 1/7/25 175.0 Lbs (pounds) 1/3/25 175.0 Lbs 1/2/25 175.0 Lbs 12/27/24 173.1 Lbs 12/24/24 173.0 Lbs 12/23/24 174.4 Lbs 12/22/24 175.0 Lbs 12/21/24 176.0 Lbs 12/20/24 174.6 Lbs 12/19/24 176.2 Lbs 12/12/24 172.0 Lbs 12/10/24 176.4 Lbs 12/6/24 171.5 Lbs **Out of 40 opportunities from 12/6/24 to 1/15/25, to obtain a daily weight, only 13 weights were recorded. During an interview on 1/13/25 at 2:51 p.m., R20 voiced concern about food choices, adding he didn't always eat the food because he didn't like it. He did not know if he had lost weight because of this. Upon review of his EMR (electronic medical record), R20 had a physician order for daily weights. Upon review of R20's recorded weights, daily weights were not consistently recorded. The last recorded weight was on 1/7/25. During an interview on 1/15/25 at 10:35 a.m., physical therapist (PT)-I stated she knew R20 needed daily weights, so when she walked him, which was about three times a week, she weighed him. PT-I stated she reported the weight to a NA who wrote it down. PT-I stated the facility had two scales and recently they had not been working. During an interview on 1/15/25 at 2:02 p.m., RN-B looked in R20's EMR and read part of the care plan: report daily weight refusals to nurse. RN-B verified R20 had an order for daily weights and that his last recorded weight was on 1/7/25. RN-B did not recall being informed that R20 had refused to be weighed. During an interview on 1/16/25 at 8:23 a.m., nursing assistant (NA)-C stated residents were weighed on shower days. NA-C stated if a resident was supposed to have a daily weight, she did not know that -- someone would need to tell her. NA-C stated if a resident refused a weight, she would tell the NA on the on-coming shift so they could obtain it; she would not tell a nurse. During an interview on 1/16/25 at 8:33 a.m., NA-D stated if a resident needed a daily weight, it would be indicated in POC (Point of Care - an electronic documentation platform used by nursing assistants). NA-D looked and stated R20 got a daily weight in the morning. NA-D stated she would document if he refused and tell a nurse, but that R20 didn't refuse much unless he didn't feel good. During an interview on 1/16/25 at 9:12 a.m., R20 stated the only person who weighed him was PT-I when they walked to the scale. R20 stated if PT-I didn't weigh him, it didn't get done. R20 stated he had not refused a weight if asked. R23's facesheet printed on 1/16/25, included diagnosis of stoke. R23's admission MDS dated [DATE], indicated severe cognitive impairment. R23 had clear speech, was usually understood and could usually understand. R23 required supervision or moderate assistance with most ADLs and was ambulatory with supervision. R23's physician orders dated 11/4/24, indicated weights 2x per week to monitor weight, in the evening every Thursday and Sunday. R23's care plan dated 11/11/24, indicated a potential nutritional problem related to need for mechanically altered diet and to monitor weights. R23's recorded weights (R23 was to have measured weights 2x per week): 1/2/25 198.4 Lbs (pounds) 12/26/24 196.7 Lbs 12/19/24 195.6 Lbs 12/11/24 195.0 Lbs 12/5/24 199.6 Lbs 12/1/24 200.0 Lbs **Out of 13 opportunities from 12/1/24 to 1/12/25, to obtain a measured weight, only six were recorded. Review of R23's progress notes indicated a number of refusals for eating and getting up/out of bed. No documentation of refusals to be weighed. During an interview on 1/15/25 at 10:02 a.m., NA-A stated if a resident had an order for measured weights, it would be in POC. NA-A did not know which residents on Prairie unit had orders for a measured weight. During an interview on 1/15/25 at 2:02 p.m., RN-B stated weights were terrible around here, adding she kept reminding the NA's, but guessed they are too busy. RN-B stated some NA's carried a paper task list, but information on the list was minimal. RN-B looked in R23's EMR and verified he was to be weighed twice a week - Thursday and Sunday, and his last recorded weight was on 1/2/25. RN-B stated the scales hadn't been working and thought maintenance had been made aware. During an interview on 1/16/25 at 8:33 a.m., NA-D stated if a resident needed to be weighed, it would be indicated in POC. NA-D looked and stated R23 was to be weighed on Thursday and Sundays. NA-D stated she would document if he refused and tell a nurse. NA-D did not recall R23 refusing to be weighed but she had not worked with him for a while. During an interview on 1/16/25 at 9:25 a.m., RN-A stated the process for communicating to NA's that a resident needed to be weighed started with a provider order which was entered into POC and put on the NA paper task list. RN-A stated it was expected that if a resident refused to be weighed, the NA would tell the nurse, who would evaluate why the resident refused and perhaps get the order modified. RN-A provided a NA task list for Prairie unit which indicated R20 was to have a daily weight. There was no indication for obtaining a weight for R23. RN-A stated not all NA's used the task list. RN-A was aware R20 sometimes refused care, but had not been informed he refused to be weighed. RN-A was not aware of R23 refusing to be weighed. During an interview on 1/16/25 at 11:17 a.m., maintenance director (MD)-A stated staff called him on 1/10/25, about one scale not working and he told them how to replace the battery, adding he guessed it wasn't working right. During an interview on 1/16/25 at 12:56 p.m., in the absence of the DON, regional clinical director and regional clinical support were informed of findings and both indicated they expected staff to adhere to physician orders, policies and procedures and the DON was responsible for ensuring this occurred. The facility Resident Weight & Height policy dated 1/2025, indicated the purpose was to have an ongoing record of the resident's weight as an indicator of nutritional status and medical condition. Ongoing weights should be obtained monthly unless otherwise ordered by the provider. Resident weight results should be documented. The facility Requesting, Refusing and/or Discontinuing Care or Treatment policy dated 1/2025, indicated residents had a right to refuse treatment prescribed by his/her healthcare practitioner. If a resident refused care, the unit manager, charge nurse or director of nursing would meet with the resident to determine why the resident was refusing care, address concerns and discuss potential outcomes of the residents decision. Detailed information relating to the refusal of care or treatment would be documented in the resident's medical record. The healthcare practitioner must be notified of refusal of treatment.

Based on observation, interview and document review the facility failed to ensure residents received assistance with meals for 3 of 3 residents (R1, R2, and R10) reviewed for dining who requred staff assistance and/or supervison with meals. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate impaired cognition, no rejection of care, required setup assistance with eating, utilized a wheelchair, diagnoses included arthritis, dementia, and non-traumatic brain dysfunction. R1's care plan dated 1/3/25, indicated self care deficit related to dementia and intervention included eating: independent after setup. R2's significant change in condition MDS dated [DATE], indicated cognitively intact, required supervision with eating and dependent on staff for ADL's, diagnoses included anxiety, depression, and dysphagia (condition that makes it difficult to swallow). R2's care plan dated 10/22/24, indicated self care deficit and interventions eating: supervision, staff to monitor for swallowing at all meals, may need assistance with cutting up food. R10's quarterly MDS dated [DATE], indicated severe cognitive impairment, no rejection of care, required setup or clean up assistance with eating, substantial staff assistance with personal hygiene and diagnoses included non traumatic brain dysfunction, dementia, Parkinson's disease(progressive brain disorder that affects movement, balance, and coordination), anxiety, depression, and psychotic disorder. R10's care plan dated 11/20/24, indicated self care deficit interventions included eating: set up help only. On 1/13/25 at 12:08 p.m., R1 was seated in a wheelchair in the doorway of his room and a meal tray was located in front of R1 on a three tiered cart. R1 had three drinking glasses with lids not removed. R1 had a covered cup of ice cream on the tray table and was observed to reach for the ice cream and attempted to remove the lid from the ice cream container. R1 was observed to continue to use his hands and attempted to remove the lid and was unsuccessful. At 12:19 p.m., R1 placed the ice cream back on the cart. R1 stated he could not open the ice cream without help. On 1/13/25 at 12:20 p.m., housekeeping (HK)-A stated she delivered R1's tray and stated housekeeping was assisting with meal tray delivery today. HK-A stated R1's lids were not removed as she was unsure of the assistance R1 needed with meal set up. On 1/13/25 at 12:21 p.m., dietary manager (DM)-F was observed to remove the the lids from R1's ice cream and beverages after surveyor prompted DM-F, that R1 had been observed and attempted to remove lids and was unsuccessful. DM-F stated staff delivering the meal trays were expected to remove lids and provide assistance for R1 with meal set up. On 1/13/25 at 12:24 p.m., R2 was observed lying in bed and nursing assistant (NA)-A placed meal tray on bedside table that was placed over and in front of R2's upper body (add location of were tray was placed). Drinking glasses with lids were not removed and out of R2's reach. R2 stated he was not able to take the lids off without help and stated the drinking glasses were difficult to reach. R2 was observed to eat in bed with no staff assistance. On 1/13/25 at 3:31 p.m., registered nurse (RN)-A, known as the assistant director of nursing and infection preventionist stated residents currently ate in their rooms due to the influenza outbreak. On 1/14/25 at 8:31 a.m., R10 was seated in wheelchair in his room with tray table and meal in front of him. R10's beverages had straws placed in the drinking glasses and the straw wrapper was not removed from the straws. R10 had a banana with peel and not opened, and Styrofoam container with the lid not removed. R10 was observed and attempt to remove the wrapper from the straw and the straw fell on the floor. On 1/14/25 at 8:41 a.m., licensed practical nurse (LPN)-A entered R10's room and stated R10 was not able to remove straw wrappers and expected the staff who delivered the tray to remove the wrapper from the straw, open the banana and remove the lids from the food items. On 1/14/25 at 9:02 a.m., NA-B stated she delivered R10's meal tray today and confirmed the straw wrappers were not removed from R10's beverages as expected. NA-B confirmed R10 required assistance with meal set up when the tray was delivered and stated meal set up included straw wrappers removed, banana opened and lids removed from containers. On 1/16/25 at 12:22 p.m., RN-D, known as the regional nurse specialist, stated staff delivering meal trays were expected to provide meal set up and meal assistance for residents and ensure lids were removed, straw wrappers removed if resident was not able, and ensure food was within reach of the resident. The facility Resident Cares policy dated 4/2024, indicated prior to entering the resident's room ensure you are following the plane of care, assist or prompt with resident cares, ask the resident if there is anything else they need before you leave the room.

Based on observation, interview and document review the facility failed to develop a comprehensive person centered care plan to address falls and ensure the care plan was revised with the new fall interventions to prevent further falls for 1 of 2 residents (R79) reviewed for falls. Findings include: R79's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, dependent on staff for putting on/taking off footwear, sit to stand, chair/bed to chair transfer, toilet transfer, required substantial/maximal assistance with dressing, shower/bathe, personal hygiene, sit to lying, utilized a wheelchair, diagnoses included left femur fracture, non-Alzheimer's dementia, anxiety, depression, age related physical debility, and fall; fall in the last month, and a fracture related to a fall in the last six months, fall since admission or the prior assessment, two or more falls with no injury since admission. R79's care plan printed 1/14/25, indicated potential for injury r/t (related to) impaired mobility due to left hip fracture, impaired cognition dementia, antidepressant, narcotic, diuretic medication, impaired hearing, history of falls, has limited ROM (range of motion) LLE (left lower extremity); interventions included: bed at appropriate height, encourage resident to wear appropriate footwear, keep bed in lowest position, place fall mats on floor next to bed, when resident is in bed, keep call light within reach in bedroom and encourage resident to utilize it, urinal at bedside for falls prevention. R79's fall incident report dated 1/4/25, indicated R79 was on the floor in his room, lying on the floor in front of his recliner with the legs of the chair still extended, resident's positioning appeared R79 had crawled out of the recliner to the floor. R79 indicated he was getting out of that to go do the chores, and unable to tell actual events leading to him being on the floor due to confusion suspected related to his dementia. Immediate action taken included R79 was assessed and denied any pain, no evidence during assessment indicating any injuries occurred; absence of bruising, skin tears, redness,or pain with palpation, vitals taken, assisted to wheelchair appeared pleasantly confused throughout the shift as evidenced by his conversation with staff; several conversations pertained to him having to go get the chores done and/or the acreage he is currently farming, potentially hallucinating. The care plan failed to indicate new interventions related to the fall. R79's fall incident report dated 1/8/25, indicated staff via walkie talkie that assistance was needed in R79's room. Upon arrival, R79 was seated on the floor of his room facing the door and resting his back against recliner. R79 was unable to explain to staff what had happened or what he was trying to do. Resident Immediate Action Taken vital signs, pain, and range of motion were assessed while R79 was on the floor and found to be within normal limits, then lifted from the floor using two assist via the hoyer lift, neurological assessments were initiated d/t (due to)suspicion of a head strike by the kitchen staff who witnessed the fall. The care plan failed to include new interventions to prevent further falls. Progress note dated 1/10/25 at 11:02 a.m., the administrator indicated in regard to the influenza outbreak, family expressed concerns about R79 being a fall risk, would rather have R79 be out at the nurses station or in activities than be in his room. On 1/14/25 at 11:02 a.m., the administrator stated interventions were expected after each resident fall and expected the care plan updated to include the interventions. The administrator confirmed the director of nursing (DON) was overall responsible to ensure a comprehensive reassessment was conducted after a fall incident to identify root cause and ensure new interventions were implemented to prevent further falls. The administrator stated after R79's fall on 1/4/25, the interventions included observation of R79 while awake and have R79 at the dining area located by the nursing station. The administrator stated she educated the ADON (assistant director of nursing) regarding the interventions and entered a note in the EMR. The administrator confirmed the care plan was not updated as expected with the new interventions. On 1/14/25 at 11:12 a m., registered nurse (RN)-D, known as regional nurse specialist, stated after a resident fall the nurse as expected to enter the fall into risk management in the EMR. The facility was expected to complete a comprehensive fall investigation which included a root cause analysis, and implement a new intervention, and the care plan updated with the new intervention. RN-D stated IDT met and discussed falls. RN-D stated the DON was responsible to ensure a comprehensive fall investigation was completed, and further stated she was not sure who was responsible for ensuing the care plan was updated. RN-D confirmed a comprehensive assessment and new interventions were not implemented after R79's fall on 1/8/25, and the interventions discussed after R79's fall on 1/4/25 were not included on the care plan. On 1/14/25 at 11:30 a.m., RN-A, known as the assistant director of nursing, stated he was only aware of R79 having one fall since admission. RN-A stated IDT met daily and discussed falls, and were expected to discuss cause and new interventions related to the fall. RN-A stated he was not able to attend IDT daily due to having to work the floor as nurse, pass medications, and complete resident treatments. RN-A confirmed the new interventions were not consistently placed on the care plan, and were important to ensure staff were aware of the interventions to prevent falls. RN-A stated he was not given education regarding R79 expected at the nursing station when awake. On 1/14/25 at 2:17 p.m., R79's door was closed, upon entering R79's room he was awake and seated at the edge of his bed in a gown. On 1/14/25 2:26 p.m., nursing assistant (NA)-E stated R79 was not a fall risk, not aware of any interventions to prevent falls, and fall interventions were expected reported in shift report and on the care plan. NA-E stated R79 had been awake in his room throughout the day. On 1/14/25 at 2:28 p.m., NA-G stated today was her first day at the facility as agency staff. NA-G stated she was not educated R79 was a fall risk, and did not have access to the EMR to access resident care plans to know interventions R79 may have related to falls. On 1/15/25 at 2:31 p.m., RN-H, known as the regional clinical director, stated the facility was expected to review all falls and the director of musing (DON) was expected to ensure an intervention was implemented and added to the care plan to prevent further falls. The facility Fall Management policy dated 9/2023, indicated: -a fall risk evaluation include a review of the resident's past history of falls, medical and physical history, medication use in attempts to identify factors which may place the resident at higher risk of falls. - an analysis of the fall will be completed - additional interventions may be imitated and/or updated as applicable.

Based on interview, observation and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for pressure ulcers for 1 of 2 residents (R16) reviewed for pressure ulcers. Findings include: R16's admission MDS assessment dated [DATE], indicated R16 was admitted to the facility on [DATE], cognitively intact, no rejection of care, required partial/moderate assistance with personal hygiene, dependent on staff for toileting, shower/bathe, lower body dressing, and transfers; diagnoses included unstageable pressure ulcer of the right heel, and osteomyelitis (infection of the bone); skin conditions indicated R16 was at risk of developing pressure ulcers/injuries, no unhealed pressure ulcers/injuries, had infection of the foot, other open lesion on the foot, surgical wounds; skin treatments included pressure reducing device for chair and bed, surgical wound care, application of ointments/medications other than to feet, application of dressings to feet. The MDS failed to indicate R16 had a unstageable heel pressure ulcer/injury. R16's care plan printed on 1/14/25, indicated R16 had self care deficit related to morbid obesity and decreased functional ability due to bilateral pressure injury to heels, needed assist with ADL's (activities of daily living), alteration in skin integrity r/t (related to) pressure ulcer to bilateral heels and interventions included administer treatments as ordered and observe for effectiveness, assist/encourage to float heels while in bed, measure wound weekly; update MD (medical doctor) PRN (as needed) with change, observe for s/sx (signs/symptoms) of infection, and wound vac in place on right heel wound to promote wound healing. On 1/14/25 at 9:19 a.m., medical doctor (MD)-A and licensed practical nurse were present in R16's room and observed R16's left heel. MD-A stated R16 was admitted to the facility with pressure ulcer of the left heel. On 1/15/25 at 7:56 a.m., registered nurse (RN)-C, also known as the MDS coordinator, confirmed R16's admission MDS was incorrect, and R16 does have a heel pressure ulcer. On 1/15/25 at 9:27 a.m., RN-E confirmed she completed R16's admission MDS and confirmed R16's MDS was inaccurate as the MDS did not include R16's pressure ulcers of the heels. On 1/16/24 12:22 p.m., RN-D, known as the regional nurse specialist, stated R16's MDS should have been completed accurately to reflect the heel pressure ulcers. The facility Minimum Data Set, Management of, Long Term Care policy dated 1/2025, indicated all MDS assessments and records will be completed and electronically encoded into the facility's electronic medical record and transmitted to the state database in accordance with current regulations.

Based on interview and document review, the facility failed to ensure 12 of 25 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12) reviewed for drug diversion were free from misappropriation of their property when their medications were taken by a staff member. This resulted in diversion of 121 oxycodone tablets, one tramadol tablet and two doses of liquid lorazepam. The immediate jeopardy (IJ) began on 9/27/24, when registered nurse (RN)-A notified the director of nursing (DON) with her concerns that trained medication aide (TMA-A) had been signing controlled medications out of the narcotic logbook. However, TMA-A was not documenting medication in the medication administration record (MAR) as given. R1 and R2 notified RN-A and their provider they had not received as needed (PRN) medications. The facility initiated an internal investigation, which included additional narcotic record review and audits against electronic medical records. Discrepancies were found in the following records: R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12. Records indicated narcotics were signed out in the narcotic logbook to indicate removal from the medication cart but were not signed in the MAR to indicate medication was administered. Facility suspended TMA-A while they conducted their investigation. TMA-A was subsequently terminated and the facility notified law enforcement. The administrator was notified of the IJ on 10/3/24 at 5:01 p.m. The facility had implemented immediate corrective action on 9/27/24 to prevent recurrence, therefore the IJ was issued at past non-compliance. Findings include: Review of the facility narcotic record indicated the following medications were signed out as removed from the medication cart, however, were not documented in the MAR as administered: R1 - 23 oxycodone tablets R2 - six oxycodone tablets R3 - 18 oxycodone tablets R4 - 12 oxycodone tablets R5 - 15 oxycodone tablets R6 - three oxycodone tablets R7 - four oxycodone tablets R8 - 11 oxycodone tablets R9 - four oxycodone tablets and one tramadol tablet R10 - 20 oxycodone tablets R11 - four oxycodone tablets R12 - two doses of liquid lorazepam R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and diagnoses of acquired absence of right and left leg above knee, phantom limb syndrome with pain, muscles spasms, and unspecified pain. R1's Physician's Order Sheet printed on 10/1/24, indicated a physician order for oxycodone (an opioid medication used to treat moderate to severe pain) five milligrams (mg) by mouth every four hours as needed for moderate to severe pain with a pain rating of 7-10. R1's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A, was not documented as administered in R1's electronic health record. R1's record indicated no negative outcomes occurred from not receiving the narcotic medications. R2's Minimum Data Set (MDS) entry tracking record indicated admitted [DATE], indicated moderate cognitive impairment, no disorganized thinking, no behavioral symptoms, upper extremity impairment on both sides, use of a wheelchair, and dependent on staff for eating, toilet use, dressing, and personal hygiene. R2's Physician's orders printed 10/1/24, indicated diagnoses of multiple fractures of ribs, anxiety, and amyotrophic lateral sclerosis (ALS). R2's pain assessment dated [DATE], indicated use of scheduled and as needed pain medications, frequent pain presence, and pain occasionally affecting sleep. R2's Medication Administration Record (MAR) printed 9/26/24, indicated physician's orders for scheduled acetaminophen and as needed oxycodone HCL five milligrams take one to two tablets by mouth every three hours (pain medication) as needed. R2's individual narcotic record indicated six doses of oxycodone were signed out of the log from 9/17/24 through 9/23/24. Facility MAR dated 9/1/24 through 9/30/24, indicated three doses of oxycodone administered during R2's stay. Facility investigation pain interview dated 9/25/24, indicated R2 reported pain managed well with acetaminophen and adamant about only taking one dose of oxycodone while at the facility. R2's Physician visit progress note dated 9/24/24, indicated R2 was not aware of oxycodone use when mentioned by his provider and again insisted only one dose was needed during the beginning of R2's stay due to rib pain. R2 requested the medication be discontinued as the acetaminophen was managing pain well. During interview on 10/2/24, R2 stated he had no pain concerns, continued to take acetaminophen, and did not take more than one dose of oxycodone in the month of September. R3's quarterly MDS dated [DATE], identified R3 had intact cognition and diagnoses of pain in right hip, cellulitis, and open wounds. R3's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone five mg by mouth every four hours as needed for severe pain related to hip prosthesis. R3's MAR indicated while the controlled medication that was signed out of the narcotic log book by TMA-A, it was not documented as administered in R3's electronic health record. R3's record indicated no negative outcomes occurred from not receiving the narcotic medications. R4's admission MDS dated [DATE], identified R4 had intact cognition and diagnoses of fracture of left femur, gout, fibromyalgia, and vertebral disc degeneration. R4's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone ten mg by mouth every four hours as needed for pain related to femur fracture. R4's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R4's electronic health record. R4's record indicated no negative outcomes occurred from not receiving the narcotic medications. R5's admission MDS dated [DATE], identified R5 had intact cognition and diagnoses of colon cancer, back pain, spinal stenosis, and radiculopathy. R5's Physician's Order Sheet printed on 10/2/24, indicated a physician order for oxycodone five mg by mouth every six hours as needed for severe pain related to low back pain. R5's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R5's electronic health record. R5's record indicated no negative outcomes occurred from not receiving the narcotic medications. R6's discharge MDS dated [DATE], identified R6 had intact cognition and diagnoses of fracture of the right femur, pain in the right shoulder, unspecified pain, muscle spasms and senile degeneration of brain. R6's Physician's Order Sheet printed on 10/3/24, indicated a physician order for oxycodone five mg by mouth every six hours as needed for severe pain. R6's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R6's electronic health record. R6's record indicated no negative outcomes occurred from not receiving the narcotic medications. R7's quarterly MDS dated [DATE], identified R7 had intact cognition and diagnoses of chronic pain syndrome, major depressive disorder, low back pain, osteoarthritis, anxiety disorder and muscle spasms of the back. R7's Physician's Order Sheet printed on 10/3/24, indicated a physician order for oxycodone five mg - give two and a half mg by mouth as needed for moderate to severe pain. R7's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R7's electronic health record. R7's record indicated no negative outcomes occurred from not receiving the narcotic medications. R8's quarterly MDS dated [DATE], indicated intact cognition, scheduled and as needed pain medications, occasional pain that did not affect sleep, therapy, or daily activities. R8's Physician's orders printed 10/2/24, indicated diagnoses of chronic pain syndrome, left hip pain, and disc degeneration causing back pain. Medication order for pain management was oxycodone five milligram tablet take one tablet every six hours as needed for pain. Review of MAR and individual narcotic record dated from 5/1/24 through 8/31/24, indicated 11 doses of oxycodone five milligram tablets were signed out on the individual narcotic record but were not documented on the MAR as administered to R8. R8 no longer resided in the facility and did not respond to phone call for interview. R9's significant change MDS dated [DATE], indicated intact cognition, diagnoses of fracture of first and second cervical vertebra with routine healing, wedge compression fracture of fourth thoracic vertebra with routine healing, acute pain due to trauma, and chronic migraine headaches. R9's Physician's orders dated 8/28/24, included tramadol HCL oral tablet 50 milligrams give 50 milligrams by mouth two times per day as needed for pain related to chronic pain syndrome and oxycodone five milligram tablet give one half to one tablet every four hours as needed for pain. Review of R9's individual narcotic record and MAR dated from 8/1/24 through 9/30/2024, indicated four doses of oxycodone and one dose of tramadol documented on the individual narcotic record as removed but not documented on the MAR as administered. A facility document titled Pain Interview dated 9/25/24, indicated R9 reported headaches rated 10 out of 10 on a one through 10 pain scale and pain medication use four out of five days for headaches. During interview on 10/2/24 at 1:34 pm, R9 indicated no concerns with neck pain from fractures. R9 stated pain was from chronic migraines and not new. R9 further stated no concerns with getting tramadol or oxycodone pain medications when needed and reported a new medication order for celebrex oral capsule 100 milligram capsule every 12 hours as needed was working well and giving relief for headaches. R10's admission MDS dated [DATE], identified R10 had intact cognition and diagnoses of fracture of shaft of right tibia and fibula, fracture of right foot, mood disorder due to known physiological condition with depressive features, depression, anxiety disorder, and unspecified pain. R10's Physician's Order Sheet printed on 10/1/24, indicated a physician order for oxycodone five mg by mouth every four hours as needed for pain. R10's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R10's electronic health record. R10's record indicated no negative outcomes occurred from not receiving the narcotic medications. R11's discharge MDS dated [DATE], indicated intact cognition, diagnoses of sacral (lower back) fracture with routine healing, femur fracture with routine healing, chronic pain syndrome, and long term use of opiate analgesic (pain medication). MDS further indicated scheduled and as needed pain medication use, almost constant pain presence, pain frequently affecting sleep, therapy, and daily activities. R11's Physician's orders dated 8/28/24, included oxycodone HCL oral tablet 10 milligrams by mouth every six hours as needed for pain related to chronic pain syndrome. Review of R11's individual narcotic record and MAR dated 8/28/24 through 9/10/24 indicated four doses of oxycodone were signed out of the individual narcotic record but were not documented on the MAR as administered. R11 discharged from the facility on 9/10/24 and did not respond to phone call for interview. R12's significant change MDS dated [DATE], identified R12 had severe cognitive impairment and diagnoses of senile degeneration of the brain and anxiety. R12's Physician's Order Sheet printed on 10/2/24, indicated a physician order for lorazepam (antianxiety medication) 0.5 mg by mouth every four hours as needed for agitation related to senile degeneration of the brain. R12's MAR indicated the controlled medication that was signed out of the narcotic log book by TMA-A was not documented as administered in R12's electronic health record. R12's record indicated no negative outcomes occurred from not receiving the narcotic medications. When interviewed on 10/1/24, at 2:05 p.m. the director of nursing (DON) stated RN-B brought it to her attention. RN-B had been doing rounds with the provider. One of the residents insisted they were not taking that much Oxycodone. RN-B brought the narcotic book and noticed that the same staff member was signing the Oxycodone out of the narcotic book. The DON instructed RN-B to look for more incidents, after two more were brought to her a whole investigation was launched into all controlled medications. We completed pain assessments and found that no resident had uncontrolled pain due to not receiving their pain medication. During interview on 10/2/2024 at 1:43 p.m., R1 stated he was not receiving the amount of oxycodone that was documented. R1 stated he told the provider and RN-A that he took oxycodone approximately once a day if even and never three times a day. R1 stated he was told that oxycodone was signed out up to three times a day frequently and he knows that he did not receive those medications. R1 stated he thought it was strange when the TMA-B, that worked in the evenings, would come in and ask him how his pain was and when he asked why she was asking, TMA-B stated that she was following up on his pain following his pain medication to see if it was effective. R1 stated that he never received pain medication earlier with TMA-B stating it was signed off. R1 stated he bet that TMA-A signed it out and again stated that he never received those medications. R1 stated that occurred on several different occasions. During interview on 10/2/24 at 1:50 p.m., LPN-A stated when administering a PRN narcotic, she signed the narcotic out in the narcotic logbook and then would document the administration in the EMAR for that resident. During interview on 10/2/2024 at 2:17 p.m., R7 stated his pain was well-managed and would experience more pain when not positioned correctly in his wheelchair. R7 stated his pain medications are scheduled and that he had only needed to ask for an as needed dose one time since admission. During interview on 10/2/2024 at 3:19 p.m., RN-A stated she was rounding with the provider who asked RN-A how often R2 was taking his oxycodone. RN-A reviewed the narcotic logbook with the provider. RN-A stated the provider was asking R2 about constipation issues related to oxycodone use. R2 stated he had only taken one dose of oxycodone since his admission. RN-A informed R2 of the doses of oxycodone that were signed out with R2 responding if he was taking oxycodone, he was not aware of it. RN-A stated she updated the director of nursing (DON) thinking TMA-A may need re-education on administration of PRN medications. RN-A stated she then rounded with R1's provider who came in specifically for a medication visit and oxycodone renewal. Provider asked RN-A how many times R1 was taking oxycodone with RN-A reviewing the narcotic logbook which indicated R1 was taking the PRN oxycodone one to three times a day. R1 stated to provider and RN-A he took as needed oxycodone maybe once a day, sometimes two times but never three times. R1 asked if TMA-A was documenting the narcotic administration. R1 thought it was suspicious when TMA-B, who worked in the evenings, would come in and ask if the oxycodone was effective. R1 stated he told TMA-B that he never took an oxycodone. RN-A stated she notified DON who began investigation and found that there were 24 doses signed out of the narcotic logbook but was not documented on the EMAR. During interview on 10/2/24 at 4:26 p.m., TMA-A stated she documented the oxycodone in the narcotic logbook but would forget to document them in the EMAR. TMA-A stated the reason for forgetting to document them in the EMAR was that she got lazy with her job and become a disgruntled employee. During interview on 10/3/24 at 9:03 a.m., TMA-B stated that she would ask the resident what they wanted the narcotic for and get a specific reason and would always let her charge nurse know so they were aware of what occurred during her shift. TMA-B stated if a narcotic was administered during the day shift, she would follow up with the resident to see if the narcotic was effective or not. TMA-B stated she asked R1, several times towards the beginning of her shifts, if his oxycodone was effective with R1 stating that he did not receive the oxycodone. TMA-B stated she would tell him according to the record, TMA-A gave the oxycodone to R1. R1 was adamant he did not receive that dose of medication. TMA-B stated this started in September. TMA-B did not think anything of it due to TMA-A being pregnant and assumed not able to consume the narcotic. TMA-B stated looking back on it now, she realized she should have reported it sooner. TMA-B stated if she was suspicious of medication diversion, she would immediately go to the charge nurse and report it. When interviewed on 10/3/24, at 1:19 p.m. the DON stated, they had done re-education on the updated controlled substance policy, all staff that touch medications had been re-educated with exception of one nurse on vacation who will be re-educated upon return. Education included notifying the nurse or DON if a resident state they did not receive a medication despite documentation showing they did. They did not drug test the staff person, the evidence was so overwhelming the result would not have mattered, she started with a couple of pills here and there, in about August had significantly increased with the number of doses. In a subsequent interview on 10/3/24, 4:44 p.m. the DON stated the expectation was staff follow the policy, if residents requested an as needed (PRN) medication or it's identified they were having pain, the TMA would talk to the nurse who was responsible to assess the resident then direct the TMA on what medication to give. The nurse was expected to follow up with the resident to assess effectiveness of pain medication. The facility's Controlled Substances policy dated 9/24, directed controlled substances will be prepared following the guidelines within Medication Guidelines. Controlled substances will not be removed from their secure storage until ready to prepare for administration. Controlled substances will be documented at the time of removal from secure storage and will be administered immediately by the individual removing them from their secure storage. Controlled substance record will be thoroughly documented to include: a. Date and time of administration b. Dose being administered. c. Route of administration d. Signature of the authorized personnel e. Amount remaining Discrepancies of Controlled Substances - any controlled substances which are unaccounted for will be immediately reported to the director of nursing services and/or their designee. All authorized personnel that are present at the time of the discrepancy may be asked to remain in the facility until the discrepancy is resolved. The Director of Nursing Services and/or their designee will review the discrepancy and attempt to identify the cause of the discrepancy which may include bit is not limited to: recalculating the documented dose administered and amount remaining for that controlled substance, review and comparison of doses administered documented within the medication administration record for that resident and/or other residents with same/similar medications, review of controlled substance delivery records, communication with the providing pharmacy, etc. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a report of such findings. The facility's Medication Administration by Unlicensed Personnel policy dated 9/23, indicated the unlicensed personnel may administer PRN medications if approved by the licensed nurse. This Immediate Jeopardy (IJ) is being issued at Past noncompliance (PNC) after it was verified the facility put the following corrective action in place. -Staff education was initiated on 9/27/24 which included the following topics: Medication Administration by Unlicensed Personnel and Controlled Substances training including: Ensuring the meds are secure at all times, Every dose given must be documented in the narcotic record and the electronic medication administration record, At the time of follow up for a PRN medication, if a resident denies receiving the medication, immediately report it to the nursing supervisor for review. -AP was immediately suspended and then was terminated concluding investigation. -Management conducted audits on all residents with prescribed controlled medications to confirm medications were not diverted. 48013 50764

Based on interview and document review, the facility failed to ensure fall risk interventions were implemented in order to minimize the risk for falls and injury for 1 of 3 (R1) residents identified at risk for falls. This deficient practice caused actual harm to R1 who utilized a remote control to raising a lift chair to the standing position, and subsequently fell sustaining bilateral femur fractures. Although the resident suffered injury, the facility immediately implemented corrective action on 7/29/20 therefore, this deficient practice is being issued as past non-compliance harm. Findings include: R1's undated Face Sheet included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set assessment dated [DATE], included a brief interview of mental status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS also indicated R1 required extensive assistance with dressing and was totally dependent on staff for all other activities of daily living (ADLs). R1's care plan last reviewed/revised 7/8/20, indicated the resident was at a low risk for falls due to physical limitations from [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke). Transfers with A-2 (assist of 2) and EZ lift (a type of mechanical lift). Able to use the call light appropriately. Can be resistive with toileting/repositioning. No recent falls. Interventions included: Unplug lift chair when in use. The Prairie Resident Care Sheets updated 8/1/20, which nursing assistants (NAs) utilized to help provide resident care, included: UNPLUG RECLINER when in use for R1. An undated Prairie List #2 sheet utilized by the NAs to refer to and write notes on also included for R1: Unplug recliner when in use. A State Agency (SA) report submitted 7/29/20, at 4:21 a.m. indicated on 7/28/20, at 11:45 p.m. R1 was using her lift chair, elevated it up resulting in her falling forward onto the ground. The report further indicated R1 was sent to the emergency room (ER) and was diagnosed with [REDACTED]. An additional report submitted to SA on 7/29/20, at 13:07 (1:07 p.m.) indicated: Writer resubmitting into appropriate system. Per (RN-A): Resident was observed on the floor in her room at 11:45 p.m. Resident was face down partially laying on right side. Resident unable to state what had happened but it was noted that her recliner chair was plugged in when it is supposed to be unplugged when resident is sitting in her chair. Resident was able to move all extremities, but appeared very painful. Resident was helped back to bed with EZ lift and three assist. Tylenol was given and ice pack applied to left knee area due to noted swelling. Resident had some bruising starting to form around her left eye. Uncertain as to where any other injury as resident unable to communicate clearly. Resident's son was informed of incident. Resident was sent to Ridgeview Le Sueur Medical Center for further evaluation. It was determined around 2:19 a.m. that resident obtained a fractured femur and was transported to Methodist Hospital in St. Louis Park. Facility cameras were reviewed by DON (director of nursing) prior to resident's fall to determine last staff members to be in resident's room. The last seen staff members in resident's room prior to fall were NAR's (NA-A) and (NA-B). DON has reached out to both NAR's to further interview and investigate situation. Resident currently has a bed hold. Action taken to protect the resident: Resident's electric lift chair removed and manual recliner placed in resident room. Education will be provided to staff regarding following resident care guides. When interviewed on 8/3/20, at 10:10 a.m. NA-B confirmed having worked the evening shift on 7/28/20, and verified having assisted with transferring R1 into her recliner after the resident's bedtime cares. NA-B confirmed at the end of his shift on 7/28/20, R1 was still in the recliner. NA-B stated, (R1) is a full assist and would not be able to self transfer or ambulate on her own, though could respond yes or no to questions. NA-B confirmed when the resident was in the recliner it was supposed to be unplugged. NA-B was unable to verify whether R1's recliner was unplugged the evening of 7/28/20, but had assumed it was unplugged because she was sitting in it. NA-B was unable to state whether R1 could use the recliner's remote control independently. When interviewed on 8/3/20, at 10:37 a.m. NA-C confirmed having worked the shift when R1 fell on [DATE]. NA-C confirmed finding R1 on the floor in her room after the fall, stating she'd been walking down the hall to answer a call light, then heard a clang and some yelling. NA-C said when she'd gone to investigate, R1 was on the floor in her room with the recliner all the way up which meant it had been plugged in, when it wasn't supposed to be. NA-C further stated, It says it right on her care plan. NA-C confirmed it was the responsibility of the staff that put the resident into the recliner to make sure it was unplugged. When interviewed on 8/3/20, at 10:48 a.m. NA-A confirmed she and NA-B had transferred R1 into her recliner the evening of 7/28/20. NA-A confirmed R1 had an electric lift chair recliner but could not confirm or deny if they had unplugged the recliner when R1 was transferred into the recliner. NA-A stated there was another resident on that unit who also needed to have their recliner unplugged while in it. NA-A stated there was one time she'd left the other resident's recliner plugged in and a co-worker had informed her the recliner needed to be unplugged when the resident was in it. NA-A stated she wasn't totally sure if R1 had the same criteria. NA-A stated she was new and on 7/28/20 had been working with another NA who was new. NA-A confirmed having training related to resident care plans, and also verified having access to resident care plans to review interventions. NA-A reported having worked at the facility for 2 months. When interviewed on 8/3/20, at 11:35 a.m. NA-D stated there was a communication binder at the nurses' desk which included the resident care sheets for NAs to refer to. NA-D confirmed when R1 was in her recliner it was to be unplugged. When interviewed on 8/3/20, at 11:50 a.m. registered nurse (RN) case manager-B confirmed R1 was to have her recliner unplugged when seated in it. RN-B stated the NA's should all know this as it is documented on the Resident Care Sheets, as well as the Prairie List sheets that the NA's have access to. RN-B stated staff are encouraged to print out and carry with those sheets with them to refer to. When interviewed on 8/3/20, at 12:40 p.m. the DON confirmed NA-A and NA-B had assisted R1 into her recliner after getting the resident ready for bed the evening of 7/28/20. The DON stated it was care planned for R1's recliner to be unplugged when the resident was in it, and stated when NA-A was interviewed during the investigation, NA-A confirmed she had put R1's remote control for the recliner on the arm of the chair after transferring the resident into the recliner. The DON Stated NA-A had confirmed she had forgotten to unplug R1's recliner. The DON stated NA's received training during their general orientation on where to find resident information. The DON also stated she'd interviewed both NA-A and NA-B related to where to find resident information and they were each able to tell her the correct answer. The DON stated staff removed the electric recliner-lift chair from R1's room following the resident's fall with fractures with a plan to replace it with a manual recliner. The hospital physician progress notes [REDACTED].o. (year old) female WC (wheelchair)/bedbound elderly female with significant post stroke deficits (nonverbal, non ambulatory, gtube dependent for nutrition) admitted early am 7/29 this am, transferred from LaSouer (sik) hospital for LEFT distal femur fracture after a fall in her NH (nursing home). CT (computed tomography scan) of the fracture here shows an incidental RIGHT distal femur fracture as well. Found to have UTI (urinary tract infection)/frankly purulent urine when catheterized. Ortho consult appreciated. This fracture has a high risk of becoming an open fracture, repair therefore required. Higher risk surgical candidate given age and comorbidities, however they are optimally manage at this time. A facility policy titled, Vulnerable Adult Abuse and Neglect Prevention Plan reviewed 4/23/20, included: Safety Measures K. The nursing home resident's Plan of Care includes and identifies any areas where each individual resident is vulnerable to abuse. Functional disabilities and mental incapacities are identified as potential abuse factors. All areas of vulnerability, abuse, or neglect in the Care Plan are identified by asterisk. This procedure complies with state regulations. A facility policy titled, Fall Prevention Plan reviewed 11/2019, includes: II Care Plan A. Resident Care Plan will be developed to address implementation of fall precautions. On 7/29/20, corrective action was implemented for this deficient practice. Nursing assistants were re-educated to protocols to ensure use of the resident Care Plans, and care sheets to ensure they were aware of interventions developed for implementation to meet the individual needs of residents. The facility initiated an immediate investigation and followed up with staff determined to have been involved with R1's care prior to the fall. A revision to the resident's reclining chair was made, due to the resident's assessed risk for misuse of the electric lift recliner.