Every finding on record at Cura of Melrose

Based on interview and document review, the facility failed to provide adequate supervision to prevent the elopement for 1 of 1 residents (R1) reviewed who was identified as an elopement risk, required a WanderGuard (a wireless wander management system to prevent residents from wandering or eloping. It uses a wearable bracelet paired with door sensors to trigger instant alarms if a resident approaches an exit) device and had exit-seeking behaviors. This resulted in Immediate Jeopardy (IJ) when R1's WanderGuard device alarmed as she exited the building and staff responded by turning off the alarm without investigating who exited the door, she left the facility and independently ambulated approximately four blocks from the facility before being found, which placed R1 at likelihood for serious harm or death. The IJ began on 6/28/26 when R1 exited the building without staff awareness through the main front unit doors while having a WanderGuard device on and in place. A facility staff member observed R1 walking down the sidewalk approximately four blocks from the facility and alerted the facility of the elopement. R1 was found on a city main street used to travel through parts of the city and neighborhoods. The administrator, and director of nursing, and regional nurse consultant were notified of the immediate jeopardy on 7/8/26 at 4:18 p.m. The immediate jeopardy was removed on 6/29/26, when the facility provided staff education for all employees regarding the WanderGuard device use and turning off alarms, and the deficient practice corrected on 6/29/26, prior to the start of the survey and was therefore Past Noncompliance.Findings include: Video review revealed on 6/28/26, at approximately 2:04 p.m. R1 was observed exiting the building unsupervised with another resident who was able to go outside independently. R1's WanderGuard alarm was activated when she exited and staff responded within approximately one minute. Two staff responded to the alarm, however neither staff member conducted further investigation into why the alarm was activated and the alarm was shut off. R1 was admitted [DATE] with diagnoses which included dementia, and generalized anxiety disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment, independent with ambulation, and required placement of a wander/elopement alarm device to be on at all times. R1's elopement/wandering risk assessment dated [DATE], indicated R1 had a history of ambulating all over the town she resided in prior to admission. R1 frequently ambulated throughout the day since admission to facility. Due to memory impairment and lack of safety awareness, a WanderGuard device was placed on their left wrist. R1's care plan dated 4/17/26, indicated R1 had a risk for elopement related to impaired cognition and safety awareness that placed R1 at risk for injury outside of facility. R1 had a WanderGuard in place (left wrist). R1 loved to walk. Frequently walked the town for miles daily prior to admission. R1 frequently walked in the facility and wanted to walk outside despite undesirable weather conditions. R1 was difficult to redirect into the building at times. R1 would not leave the facility unattended. Interventions included to implement the WanderGuard device at all times. Risks and consequences of R1 leaving the facility included but are not limited to injury from minor to major, falls, up to and including death, without staff knowledge and/or without staff. The care plan was discussed with the R1 and R1 guardian. On 7/8/26, at 9:11 a.m. during an interview nursing assistant (NA)-B stated she had been working the day R1 eloped. She heard the front main door alarm go off and walked over to the door, but NA-A had already turned off the alarm. There were people standing outside so she did not think to find out why the alarm went off. She learned later the next day that R1 was found walking down the street and staff were re-educated on the WanderGuard device and door alarms. NA-B stated we all need to make sure residents are safe and in the building. Multiple attempts were made to interview NA-A but were unsuccessful. On 7/8/26, at 11:05 a.m. during an interview registered nurse (RN)-A stated on 6/28/26, at approximately 2:12 p.m. she was in her car coming back to the facility from her break when she saw R1 walking down the main street of the town. When she saw R1 walking alone approximately four blocks from the facility. RN-A stopped her vehicle, approached R1 and proceeded to escort R1 back to the facility. RN-A immediately called the facility and informed RN-B that she had found R1 walking down the street. RN-B called the facility administrator and was instructed to have staff check all door alarms and wander guards. Education also went out to all staff immediately related to wander guards and door alarms. R1's medical provider and guardian were also updated. All staff had training related to WanderGuards and making sure they respond to the alarm and further investigate. During interview on 7/8/26 at 1:01 p.m., administrator and director of nursing verified due to R1's cognitive impairment she was at risk of harm when she eloped on 6/28/26, due to lack of insight and judgement. Staff should not have turned off the alarm without first doing an investigation as to why the alarm was triggered. The staff that responded to the alarm did not do any type of investigation to find out why the alarm sounded, staff just turned off the alarm and walked away. Staff did not follow the facility policy, placing R1 at risk of injury. R1 could have sustained injury while crossing roads and lacked the ability to know how to return to the facility. Immediate action the facility took included, R1 was placed on 30-minute safety checks, all residents with WanderGuards were checked for functionality, including R1. All WanderGuards and door alarms were found to be in proper working order. Education was immediately sent out to all employees regarding WanderGuards use and turning off alarms. A facility policy titled WanderGuard Alert System dated 8/2025, indicated the purpose of the policy is to provide a safe/secure environment for our residents at risk for elopement through monitoring, by utilizing the WanderGuard Alert system. A facility policy titled Elopement - Long Term Care dated 5/2026, indicated the purpose of the policy is to provide guidance for staff in reviewing residents for risk for elopement and responding during potential elopement. Policy procedure included It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical, and Should an employee observe a resident leaving the premises, he/she should: attempt to prevent the departure if not otherwise approved; obtain assistance from other staff members in the immediate vicinity, if necessary; instruct another staff member to inform the charge nurse or Director of Nursing and/or the facility Administrator that a resident has left the premises; and be courteous in preventing the departure and in returning the resident to the facility. The past noncompliance immediate jeopardy began on 6/28/29. The immediate jeopardy was removed on 6/29/26 and the deficient practice corrected by 6/29/26, after the facility implemented a systemic plan that included the following actions: education for all employees regarding WanderGuard use and turning off alarms.

Based on interview and document review the facility failed to protect 2 of 2 residents (R2 and R1) from abuse. Staff used a personal cell phone to take a picture of R2's soiled brief, buttocks, and large bowel movement and the picture was sent to several other facility staff. This resulted in actual harm to R2 as she verbalized not trusting facility staff and was fearful to have a bowel movement. R1 was abused when staff used their personal cell phone to record R1's voice as she was repeatedly stating, help me, help me. The video was sent to several facility staff phones with the caption, I want to kill myself. The facility implemented corrective action, and the deficient practice was corrected on 5/08/26, prior to the survey, and was issued at past non-compliance. Findings include: R2 R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had hemiplegia (muscular weakness) or hemiparesis (involving severe or total paralysis), anxiety disorder and depression. R2's MDS further indicated C2 was cognitively intact and usually understood by others. The MDS indicated she was dependent on staff for toileting and was always incontinent with bowel and bladder. R2's care plan (CP) dated 7/10/25, indicated R2 had alteration in elimination related to impaired mobility and incontinence of bowel and bladder, was cognitively intact and independent in decision making. R2 was difficult to understand at times, may become upset and had trouble rationalizing out a situation. In addition, R2 was identified as having trauma related to her adoptive family, R2 did not want to talk about it. A Facility Reported Incident (FRI), dated 5/08/26, indicated nursing assistant (NA)-A notified the DON she received a snapchat from NA-F but had not yet opened it yet. NA-A opened the snapchat to the DON on her phone with the administrator present. The message indicated it was sent by NA-F. The message included a picture of a resident's brief open, uncovered buttocks partially in the picture, and a bowel movement in the brief. Resident was not identified at that time. Immediate VA action plan implemented. HIPPA violation and exploitation of resident image occurred per report was indicated that occurred on 5/08/26 at 1:45 p.m. The Investigative Report Summary dated 5/13/26, indicated the social services designee (SSD) informed R2 that an image had been taken of her brief with a bowel movement (BM). The report indicated R2 was unaware this occurred while cares were occurring on 5/07/26 and did not appear distressed and had no concerns. Family member (FM)-A was informed of the incident and had no further concerns. The report also indicated a written statement was received by NA-C that stated she received a picture of R2 who was naked lying in bed with a brief covered in bowel on snapchat. I left the group chat and spoke with another coworker, NA-A, who also seen the picture and we both agreed to report it. Written statement from NA-I stated she was aware that a picture was sent, and it made someone uncomfortable. She stated she doesn't remember when the picture was taken, but she was in the room cleaning with the resident and the alleged perpetrator (AP) when it was taken. Written statement from NA-F stated she was pulled into the room to look at a big BM and was in a group chat and a picture was sent to the chat but did not see it, I was clicking through the snap chats really quick. The conclusion of the investigation indicated the incident was verified NA-F admitted in taking the photo 5/07/26 of R2's BM during brief changing, unaware of buttocks showing and was visible, and sending the image in a snapchat group message. The report indicated all NA's involved were suspended and following the investigation re-education was provided on 5/08/26. During interview on 5/13/26 at 1:34 p.m., NA-A stated she reported the incident involving R2, NA-A stated she was called into the room and saw R2's buttock and a dirty brief laying on the bed with a large BM. [R2] was literally naked on the bed and while I was walking out the door [NA-F] told me she sent me a picture to look at. NA-A stated that was when she went to DON's office to show her the picture. NA-A stated she did not think R2 knew the picture was taken but it was wrong. The morals and values at work are just wrong. During interview on 5/14/26 at 10:20 a.m., facilities regional nurse consultant (RNC) stated NA-F admitted in taking the picture of R2 and she was terminated due to company policy and procedures. During interview on 5/14/26 at 12:42 p.m., R2 stated she did not know what snapchat was and did not realize the content of the picture that was taken of her. After it was explained, R2 stated Oh, not really good, makes me feel nasty. R2 added, Oh yeah it's going to bother me, it's going to be hard to have a bowel movement. In addition, R2 stated, they should get fired, I hope so. During interview, R2 was tearful, her voice got quieter and her mood seemed more down as the conversation turned from introductions with writer to more specific information regarding the incident. During interview on 5/14/26 at 12:51 p.m., Family member (FM)-A stated the staff at the facility broke her [R2's] trust. Back in the day, before [R2's] stroke this situation would have embarrassed her and if she stated it would be hard to have a bowel movement, I believe it bothers her. R1 R1's quarterly (MDS) dated [DATE], indicated R1 had anxiety disorder, depression, non-traumatic brain dysfunction and Schizophrenia. The MDS further indicated that R1 was severely cognitively impaired, had verbal behavioral symptoms and required assistance with activities of daily living. R1's CP dated 2/11/26, indicated R1 was a vulnerable adult and calls out at night rather than use of call light and staff were to educate resident or responsible party regarding rights, encourage and praise positive behavior, if behavior patterns are concerned. The CP also indicated R1 was dependent on staff for meeting physical and social needs due to cognitive deficits, limited mobility and vision impairment. Staff were directed to respect resident's right to be alone at times. R1's Kardex dated 5/11/26, indicated mood interventions for yelling out included: check with resident if any of these are the reasons she would be calling out- bathroom, pain, uncomfortable clothes, lonely, hungry or thirsty. A FRI dated 5/08/26, indicated staff brought to the attention of the Director of Nursing (DON) a video a staff member had taken and shared. The video showed a picture of a staff member. In the background, you could hear a resident [R1] stating help me, help me. The staff member identified in the video was nursing assistant (NA)-I. The Investigation Report Summary (IRS) dated 5/13/26, indicated NA-I was identified as taking the video, and NA-F sent the video to the DON on 5/08/26. NA-F added to the message, I just want to bring to your attention that I'm not the only one that has done this. [NA-I] has also sent stuff into snapchat. NA-F then emailed a video to the DON that was originally sent by NA-I to NA-F. This video was a recording of the camera pointed at NA-I's face that was partially visible, with a statement, I want to kill myself. In the background resident R1 could be identified as saying help repeatedly. No residents were shown in the video. DON made administrator aware of the report. Both NA-I and NA-F were already suspended pending another investigation. R1 was assessed for safety. The investigation indicated education was provided to all facility employees regarding Vulnerable adult's act, photos/recording and vulnerable adult reporting and all staff were expected to complete education prior to the start of their next shift on 5/08/26. During interview on 5/13/26 at 1:52 p.m., NA-C stated she received the video of R1 yelling and NA-I's caption on snap chat. NA-C stated she left the group as soon as she saw the video. NA-C stated the group chat started about two months ago and they were all friends outside of work. The group chat started out as funny videos at soft ball or selfies. The pictures never included residents or things like that until the video of R1. NA-C alerted the DON and Administrator when she received the video of R1. During interview on 5/14/26 at 10:12 p.m., regional nurse consultant (RNC) for the company stated she assisted with the investigations. NA-I admitted to taking the video of R1 and was terminated for her actions and for not following the facility's policies. The Vulnerable Adult Policy effective 11/2025 indicated the organization values the dignity of each resident. It is our desire to provide care with the regard to the mission and values of the organization. The Policy further indicated under abuse any emotional or psychological abuse that includes but is not limited to humiliation, harassment, threats of punishment or derivation and unauthorized photographs and/or recordings of a resident, a resident's personal belongings and/or their personal space. The noncompliance started on 5/7/26, when staff took a picture, using their personal phone of a resident's buttocks then shared the picture via a social media platform with other staff at the facility. The noncompliance was corrected on 5/8/26, when the facility implemented training which included: What should I do if you see someone take a picture or video of a resident's incidents. Best rule of thumb don't even keep your phone on with you!

Based on observation, interview and document review the facility failed to protect 1 of 4 residents (R1) from avoidable accidents when care plan interventions were not implemented. This resulted in actual harm to R1 who fell out of a recliner and sustained a large hematoma (a solid swelling of clotted blood) and laceration to the front of her head.Findings include: R1's admission Record indicated she admitted to the facility 8/26/24. R1's diagnosis included dementia, depression, overactive bladder and osteoporosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she required substantial to maximal assistance for transfers and toileting. R1's care plan revised 12/19/25, identified a potential for injury related to a history of falls. Interventions included: signage in room, appropriate footwear and grip strips in room. The care plan identified a potential for injury related to a history of electric recliner use. The care plan indicated R1 sustained a fall from a lift recliner when operating the remote control independently on 12/16/25. The cord for the recliner was removed from the room. The care plan indicated the following interventions: 11/19/24, electric lift recliner: stationary only. Per therapy recommendation keep recliner unplugged to promote resident safety. The care plan indicated R1 was non-ambulatory and required the use of a mechanical stand device for transfers. R1's Kardex (care guide) dated 12/1/25, indicated, per therapy staff, keep recliner unplugged to promote resident safety. R1's incident reports and correlating Post-Fall Investigations identified the following: R1 incident report dated 5/29/25, indicated she was found face down on her wheelchair leg, on the floor in front of her recliner. The recliner was in the highest position, and it appeared R1 was attempting to self-transfer. Post-Fall Investigation dated 5/29/25, indicated Prior to fall, R1 was last observed resting in her recliner. R1 appeared to have attempted to self-transfer as recliner was in the highest position. Immediate intervention was to unplug the recliner for the night. New intervention indicated recliner to remain unplugged, however, R1's care plan dated 11/19/24, indicated recliner was not to be plugged in. R1's incident report dated 12/16/25, indicated staff were alerted R1 was on the floor face first, with pooling blood on the ground. R1 had her hands on her head trying to cover her forehead which filled her hands with blood. R1 had been last observed in her recliner and recliner was in the highest position at the time of the fall. R1 had a large hematoma on her forehead along with a skin tear. R1 also complained of pain to her right elbow. R1 was transferred to the emergency department (ED). Post Fall Investigation dated 12/16/25, indicated R1 had been resting in her recliner after lunch. R1 fell and hit her face on the ground after attempting to self-transfer from the recliner. R1's care plan reflected recliner to remain unplugged, care plan had not been followed. R1's ED Provider Note indicated R1 presented to the ED after she tried to get out of her lift chair in the nursing home and mis-stepped and fell forward onto her head. It sounded like she was non-ambulatory at baseline, but someone had her lift chair plugged in and so she tried to lift this up and tried to walk which was when she fell. She had no dizziness or lightheadedness that preceded the event, so it was a mechanical fall. R1 reported some left hip pain as well as right elbow pain and some mild neck pain. She reported a headache as well, especially overlying the large hematoma on the frontal region. R1's Progress Notes indicated the following: 12/16/25, Staff immediately paged an ambulance. Writer entered the room to see three staff present and nurse assessing resident for injuries. Writer noted recliner in high position and asked if it had been moved when staff responded to the fall. They stated no. Verified sticky notes in place on both sides of the cord indicating not to be plugged in per therapy. 12/16/25, Resident returned from ED at 6:30 p.m. R1 was transferred into bed as she was sleepy due to administration of hydromorphone in the ED. Cares completed along with skin check. No changes to skin besides the hematoma to right elbow and right forehead. Swelling was reduced from when she left to the ED and bruising is noted. Skin tear was scabbed and no longer bleeding. 12/17/25, Bruising to right eye forming, swelling and hematoma. 12/17/25, Noted that care plan had not been followed in relation to recliner to remain unplugged. Labels remain in place to cord and battery that indicated for the chair to not be plugged in. During observation and interview on 1/9/26 at 9:37 a.m., R1 was seated in a wheelchair in her room. R1 had a fading bruise on her forehead. R1 said, I'm not good. I don't like being in this chair with the table in front of it. R1 said someone told her there was something wrong with her recliner so she could not sit in it. R1 stated she remembered falling from the recliner chair and said she was trying to go to bed. R1 said she usually asked for help but did not know if she had that day, then said she probably had not. R1 stated she got hurt and had a bruise on her head. A sign on R1's recliner said, resident do not sit. At 11:20 a.m., R1 remained seated in her wheelchair and appeared to be asleep. R1 had one foot on a foot pedal and the other foot was on the floor. R1 had regular socks on her feet, no anti slip footwear. During interview on 1/9/25 at 11:47 a.m., NA-A stated the staff carried iPads with the Kardex for each resident on it. The Kardex was viewed with NA-A and indicated stationary chair, wheelchair stored in bathroom. The Kardex did not identify appropriate footwear. During interview on 1/9/26 at 12:01 p.m., registered nurse (RN)-A confirmed R1 was wearing nylon stockings that were not anti-slip. RN-A said R1 had some cognitive impairment and said most of R1's falls had been related to doing things she would have been safer to have staff assistance with. RN-A said fall interventions included signs, toileting assistance and getting her up early. RN-A said the most recent fall occurred because someone had plugged R1's recliner in and said it may have been staff or family. RN-A said if family plugged in the chair that was not something staff would have looked for. RN-A said appropriate footwear would include grip socks or non-slip footwear. During interview on 1/13/25 at 4:23 p.m., family member (FM)-A stated when R1 fell the lift chair was operational and R1 raised herself up. FM-A said the chair was not supposed to be plugged in. FM-A said a family member may have plugged in the recliner when they visited but said none of R1's family members had visited FM-A the day she fell. FM-A said it was not the first or even the second time R1 had fallen from the recliner. FM-A said R1 had declined cognitively and physically and would not have been able to plug the chair in by herself. During interview on 1/13/25 at 4:47 p.m., NA-B said, the day R1 fell, she had been coming out of another room and had been alerted by a hospice nurse that R1 was on the floor. NA-B said when she last saw R1, she was in the recliner asleep but could not remember if her feet were up or not. NA-B said when she found R1 she was face down in front of the recliner and said there was a lot of blood. NA-B said she was aware the recliner was not supposed to be plugged in due to previous falls but said she never thought to check to see if it was plugged in because she assumed no one would have plugged it in. NA-B said she was sure both family and staff had plugged in R1's recliner chair. During interview on 1/14/26 at 10:26 a.m., RN-B stated R1 had had more than one fall from the recliner and said the care plan had been updated to include leaving the chair unplugged in November of 2024. RN-B said she was not sure how the chair was getting plugged in but said if staff saw R1 in the recliner with her feet up they should have checked to make sure it was not plugged in. During interview on 1/14/26 at 10:45 p.m., the interim director of nursing (DON) stated R1 had multiple falls from the recliner and said it was care planned that the chair was not supposed to be plugged in. The interim DON said staff should have been checking to ensure the chair was unplugged and said the recliner was only to be used as a stationary chair. Facility Policy Using the Care Plan dated 1/2026, indicated the care plan shall be used to develop the residents daily care routines and be available to staff who have responsibility for providing care. The Kardex will be comprised of interventions from the care plan. Health care personnel are responsible for following the residents care plan.

The facility failed to implement care planned interventions to reduce the risk for burns for 1 of 4 residents reviewed (R4) who spilled hot coffee on herself.R4's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included parkinsonism, depression, anxiety and dementia. R4's care plan dated 12/11/25 identified intact cognition and indicated she was able to eat independently. The care plan identified a risk for altered nutritional status and directed staff to provide covered mugs for hot liquids outside the dining room. R4's Hot Liquid Safety Evaluation dated 9/19/25, indicated temperature of liquid not to exceed 180 degrees. The evaluation indicated R4 had an isolated event on 9/16/2025, follow up completed on 9/17/2025. Standard temperature of hot liquid supplied by facility was less than 180 degrees. No additional interventions indicated at this time, see progress note on 9/17/25. R4's Progress Notes indicated the following: 9/17/25, Discussed with R4 the coffee spill from the previous day. R4 indicated she was watching television and when she set her cup down, she was not looking and it fell onto her lap. R4 said she would be more careful and said the coffee was luke warm at best. Isolated event. 12/10/25, A pink/red area on left inner thigh measured 10 centimeters CM) x 6 cm and pink/red area on right inner thigh 13 cm x 3 cm. Areas are warm to touch and R4 reported they were tender. Cause indicated R4 spilled coffee in her lap. Staff to put covers on hot liquids when she took them outside the dining room. 12/11/25, Interdisciplinary team review, upon investigation, R4 was attending an activity where a movie was being watched. Coffee was served per preference. R4 was in control of the mug at the time she accidently spilled into her lap. Skin was immediately assessed. Care plan was updated to reflect the use of covered mugs when resident is consuming hot beverages outside of the dining room. During observation on 1/14/26 at 9:02 a.m., R4 was seated in a wheelchair in her room working on a puzzle. R4 had a coffee cup in front of her with no lid. R4 sated she just got the coffee and said it was nice and hot. R4 said the only reason she had spilled her coffee in the past was because she hit it with her elbow. She said ever since she was supposed to have a lid but said staff had not given her one. During interview on 1/14/25 at 9:08 am., NA-C said R4 liked to have coffee in her room and said she believed R4 was supposed to have a cover on the mug. During interview on 1/14/26 at 10:26 a.m., RN-B stated R4 had an isolated incident when she spilled in her room because she was not paying attention. RN-B said when R4 was not in the dining room she was supposed to have covered cups. During interview on 1/14/26 at 10:45 a.m., the interim director of nursing stated R4 should have a cover on her cup as directed in the care plan. Facility Policy Using the Care Plan dated 1/2026, indicated the care plan shall be used to develop the residents daily care routines and be available to staff who have responsibility for providing care. The Kardex will be comprised of interventions from the care plan. Health care personnel are responsible for following the residents care plan.

Based on observation, interview and document review the facility failed to ensure the care plan was followed during staff assisted transfer for 1 of 3 residents (R1), who fell while being transferred. This resulted in actual harm when R1 sustained a fracture. Due to actions taken by the facility, following the fall, this is being issued at past non-compliance.Findings include:R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included Alzheimer's disease, vascular dementia with psychotic disturbance, age related osteoporosis, and R1 had moderately impaired cognition.R1's care plan revised on 12/1/25, indicated R1 had a self care deficit related to impaired mobility, Alzheimer's disease, depression, and a change in condition related to unknown etiology. R1's care plan identified R1 was non-ambulatory and required assist of one staff utilizing an EZ (brand of mechanical lift) stand for transfers as of 8/29/25. R1's care plan was revised on 12/1/25, identified R1 now required an EZ lift (full body mechanical lift) with assist of two staff members for transfers as R1 was non-weight bearing to right lower extremity.R1's Fall-Staff Assisted Fall incident report dated 11/29/25 at 6:15 p.m., identified resident was assisted to the floor with staff present. Staff attempted to pivot transfer and resident's legs got weak and they helped lower her to the floor slowly. There were no injuries noted. Resident was care planned to be an assist of one utilizing an EZ stand. Statement from nursing assistant (NA)-A, stated NA-A attempted to pivot transfer resident and she was unable to complete the transfer and slowly fell to her knees. NA-A helped her into a sitting position and called for help.R1's progress notes revealed the following:-On 11/29/25, communication to the physician included resident had a staff assisted fall/lowered to the ground this evening. Resident was an EZ stand, and staff tried to pivot, not looking at Kardex before transferring. Resident had no injuries noted.-On 11/29/25, at 6:15 p.m. resident was assisted to the floor with staff present. Staff attempted to pivot transfer and resident's legs got weak and they helped lower her to the floor slowly. No injuries were noted. Resident was care planned to be assist of one with an EZ stand. Resident denied pain. Immediate intervention implemented included printed off sheet of each resident's transfer status for staff to review.-On 11/30/25, fall follow up included resident was having some right foot pain, unknown if associated with fall. Resident has had this foot pain in the past and it has resolved on its own after about a week. Resident does not want ice or heat on area. Resident was given scheduled Morphine.-On 11/30/25, fall follow up included resident had been baseline that shift with no complaints of pain at that time.-On 12/1/25, LPN (licensed practical nurse) alerted writer to concern with resident's right lower extremity stating her foot was swollen. LPN indicated resident was able to bear weight but had complained of pain during sock placement. Based upon LPN's report, writer reviewed resident's chart to verify next hospice visit which was noted to be scheduled on that date. Message sent to hospice related to concern for further injury and unsure how to proceed.-On 12/1/25, Resident was having increased pain to her right foot. Resident had swelling and faint bruising noted. Swelling was noted specifically around her ankle and along to the top right side of her foot. Resident initially denied pain while standing in the EZ stand but staff reported that when applying her shoes resident was yelling out in pain. Hospice was made aware at visit today and sent a message to provider to advise and possibly do an x-ray.-On 12/1/25, fall follow-up indicated there was a new fracture to resident's right foot. Resident reported pain with movement of right foot or placing socks on. Resident denied pain when resting in one place. Resident declined ice at that time. Resident was not transferred utilizing a Hoyer (full body mechanical lift) and non-weight bearing to right lower extremity.-On 12/1/25, Resident was diagnosed with a slightly displaced fracture distal fibula metaphysis seen on x-ray. Family did not want to pursue surgery but were receptive to an orthopedic consult to get recommendations on weight bearing and stabilization of the ankle, and pain management.R1's X-Ray Ankle results dated 12/1/25, indicated slightly displaced fracture of distal fibula metaphysis (break in the lower part of the fibula bone), osteopenic appearing bone (a condition where bone density is lower than normal) and soft tissue swelling surrounding the ankle, and small ankle effusion (extra fluid in the ankle joint often caused by injury).R1's Pain Level Summary identified R1 rated her pain a 0/10 on 11/29/25 and a 10/10 on 12/2/25.On 12/3/25 at 11:06 a.m., family member (FM)-A stated he was notified of R1's fall by the facility staff shortly after the fall occurred. FM-A stated staff reported staff was transferring R1 thinking R1 could stand independently, however R1's medical record identified she required the use of a mechanical lift. FM-A stated R1 had reported pain since the incident and R1 was now a full body mechanical lift for transfers.On 12/3/25 at 11:30 a.m., R1 was observed in her room laying in her bed. R1 had her call light within reach, and her right foot appeared to be wrapped. R1 stated she fell out of her chair two weeks ago which resulted in her injury and rated her pain a 10/10. There was a sling size medium on R1's recliner, however R1 was not sure how staff get her out of bed but stated they get it done.On 12/3/25 at 12:00 p.m., NA-A stated she has been casually working at the facility for the last year. She had worked at the facility approximately three times in the last year. NA-A stated she worked at the facility on 11/29/25, and had not worked at the facility prior to that since beginning of September 2025. NA-A stated on 11/29/25, at approximately 6:30 p.m., NA-A was assisting R1 back to her room following the evening meal and R1 was requesting assistance from her wheelchair to her recliner. NA-A stated R1 stood up independently from her wheelchair and was unable to turn and pivot to sit in her recliner and started to fall to her knees. NA-A stated she assisted R1 to the floor and then assisted R1 from her knees to sit on her bottom. NA-A stated she was not utilizing a gait belt to transfer R1, and NA-A stated staff were expected to utilize a gait belt with all transfers for residents who were not independent however NA-A stated, I thought I would be able to do it with out one. Further, NA-A stated if she was not familiar with a resident, she would refer to the resident's Kardex and care plan but since I worked there, I know all the residents. NA-A stated staff who didn't work full time were expected to review each resident's care plan at the start of the shift, however that is not reasonable. However, since the incident NA-A stated she was immediately educated by the floor nurse to ensure, I am referring to each resident's care plan prior to assisting them. NA-A was suspended pending investigation, and a message was sent through the all-staff notification center regarding following care plans for transfers.On 12/3/25 at 12:18 p.m., NA-B stated R1 appeared to be confused at times and was assist of one staff and EZ stand mechanical lift for transfers, however recently changed to a full body lift because of the recent fall. NA-B stated she was working the evening of R1's fall. NA-B had been walking past R1's room when NA-A called to her to get the nurse. NA-B stated NA-A had asked is she [R1] not a pivot? which NA-B then said, no she is an EZ stand. Further, NA-B stated she was a part-time employee, and staff were expected to review each resident's Kardex to see their care levels. NA-B stated since the incident staff had to review each resident's care plan and transfers status and sign it.On 12/3/25 at 12:56 p.m., NA-C and NA-E accompanied by NA-D who was training, knock and enter R1's room. NA-C and NA-E each are carrying an electronic tablet device with them. R1 was sitting in her wheelchair and wanted to be transferred to her bed. NA-C grabbed the full body mechanical. NA-C and NA-E hooked the sling to the lift, then transferred R1 into her bed. R1 did not express pain or appear to be in pain during the transfer.On 12/3/25 at 1:08 p.m., licensed practical nurse (LPN)-A stated R1 had a diagnosis of dementia and memory was impaired. LPN-A stated for the past couple months R1 had required assist of one staff and EZ stand for transfers. LPN-A stated R1 would be considered a fall risk if staff were to transfer her outside of her careplan. LPN-A stated she was working on 11/29/25 at approximately 6:15 p.m. when staff reported R1 had fallen and was on the floor. LPN-A stated there was already another nurse in R1's room so LPN-A had offered to update R1's provider, hospice, family, and notify the on call registered nurse (RN)-A. LPN-A was directed by RN-A to write each resident's transfer status on paper and all staff had to review and sign it. Further, LPN-A stated there was an alert sent through the staff notification system on 12/1/25, reminding all staff to review the Kardex prior to transferring a resident.On 12/3/25 at 1:28 p.m., RN-B stated R1 previously required assist with a pivot transfer. R1's transfer status declined which resulted in R1 being switched to an assist of one EZ stand transfer a few months prior. RN-B stated on the evening of 11/29/25, approximately 6:15 p.m., RN-B was notified R1 was on the floor. RN-B entered R1's room to see R1 sitting on her bottom on the floor with NA-A behind her for support. RN-B stated NA-A reported she attempted to pivot transfer R1 and R1 got weak. NA-A lowered R1 to her knees and from there helped her into a seated position. RN-B assessed R1 for injury and there was no injury noted at the time, however RN-B confirmed she did not check R1's range of motion. Following the incident, RN-B was directed by RN-A to write down every resident's transfer status and review with all staff currently working and oncoming shifts, as well as immediately educate NA-A.On 12/3/25 at 3:12 p.m., NA-F stated care plan revisions were communicated verbally through shift report however, staff were expected to review each resident's Kardex prior to assisting the resident due to frequent changes. NA-F stated staff were also expected to carry a tablet with them for accessibility to those Kardex's.On 12/3/25 at 3:21 p.m., NA-G stated R1 required assist of one and an EZ stand to transfer, however R1 had a recent fall due to a staff member not reviewing her careplan and R1 was now requiring the use of a full body lift to transfer. NA-G stated R1 had complained of pain to her ankle and utilized ice and heat packs to alleviate the pain. Further, NA-G stated since the incident staff had to review every resident's transfer status and sign that staff reviewed them all and all staff were reminded to review each resident's Kardex prior to transferring the resident to ensure no changes were made. NA-G stated staff were also expected to always carry the tablet with them to be able to access each resident's Kardex.On 12/4/25 at 10:24 a.m., RN-A stated she received a phone call from LPN-A on 11/29/25, at approximately 6:15 p.m. shortly after R1's fall had occurred. RN-A stated LPN-A had reported R1 had a staff assisted fall due to NA pivot transferring R1, no pain or injuries noted. RN-A directed staff to educate NA immediately on following the care plans and checking the Kardex as well as educating other staff currently working and oncoming shifts to carry a tablet and refer to the resident's Kardex before assisting the resident.On 12/4/25 at 10:36 a.m., RN-C stated in September R1 had a change in condition and transitioned to an EZ stand assist of one for all transfers due to weakness and cognition. RN-C stated she was made aware on the morning of 12/1/25, R1's ankle was swollen. R1 obtained x-rays and then RN-C was notified R1 had a fracture. Since the incident, RN-C stated there has been several things sent out by communication board and text messages to all staff about checking resident's Kardex prior to assisting a resident.On 12/4/25 at 11:31 a.m., NA-A stated each staff had access to a tablet to reference the resident's care plans, however NA-A was unsure what the facility policy or protocol was regarding the tablets. NA-A stated she did not have a tablet on 11/29/25, the day of R1's incident.On 12/4/25 at 12:05 p.m., interim director of nursing (DON) stated staff had reported R1's fall had occurred, and care plan had not been followed. Following the incident, DON stated the staff involved was immediately educated to review each resident's Kardex prior to assisting, all current staff working received reminder to review the Kardex as well as oncoming shifts. DON stated the NA involved was suspended and has not returned to the facility and management was working on plan for the NA moving forward. DON stated she had sent a notification to all staff regarding utilizing the Kardex prior to providing cares, transfers and safety concerns. DON also stated audits on transfers have started to ensure correct transfer according to care plan, ensuring staff were aware of where to locate information, and tablets were accessible to staff.Review of facility policy titled Transferring/Ambulating a Resident dated 11/23, identified the purpose of the policy was to provide guidance on safely transferring a resident from one surface to another. A transfer belt (gait belt) should be used when assisting a resident who required physical assistance with a transfer unless another piece of equipment such as a standing lift or full mechanical lift was used. The resident's level of assistance was captured with the resident's plan of care. Further, the policy directed staff to verify the resident's transfer status within their plan of care (i.e. Kardex) and place the transfer belt snuggly around the resident's waist.

Based on interview and document review, the facility failed to submit a report with sufficient information to describe the alleged violation to the State Agency (SA) without omitting information or misleading information to make the incident appear less serious than it was for 1 of 1 residents (R1) reviewed. Findings include:R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included Alzheimer's disease, vascular dementia with psychotic disturbance, age related osteoporosis. R1 had moderately impaired cognition.R1's care plan revised on 12/1/25, indicated R1 had a selfcare deficit related to impaired mobility, Alzheimer's disease, depression, and a change in condition related to unknown etiology. R1's care plan identified R1 was non-ambulatory and required assist of one staff utilizing an EZ (brand of mechanical lift) stand for transfers as of 8/29/25. R1's care plan was revised on 12/1/25, identified R1 now required an EZ lift (full body mechanical lift) with assist of two staff members for transfers as R1 was non-weight bearing to right lower extremity.R1's Fall-Staff Assisted Fall incident report dated 11/29/25 at 6:15 p.m., identified resident was assisted to the floor with staff present. Staff attempted to pivot transfer and resident's legs got weak and they helped lower her to the floor slowly. There were no injuries noted. Resident was care planned to be an assist of one utilizing an EZ stand. Statement from nursing assistant (NA)-A, stated NA-A attempted to pivot transfer resident and she was unable to complete the transfer and slowly fell to her knees. NA-A helped her into a sitting position and called for help. Facility report number 362429 to the SA dated 12/1/25, indicated on 11/29/25 at 6:15 p.m., Resident was lowered to the floor during a transfer. Resident was assessed at the time of the fall and no immediate injuries were noted. Swelling to the right ankle and foot appeared on 12/1/25, staff requested an order for imaging. Imagining results showing the following, obtained 12/1/25, Slightly displaced fracture distal fibula metaphysis, oblique image not obtained limiting evaluation of the distal tibia lateral aspect, lateral talar dome also limited evaluation, osteopenic appearing bone, soft tissues swelling surrounding the ankle, and small ankle effusion. Incident details included staff member involved with the fall was immediately suspended. Resident status was changed to non-weight bearing and transfer status adjusted to use of the Hoyer lift at this time. However, the facility report to the SA lacked evidence R1 was pivot transferred assist of one rather than with an EZ mechanical stand as R1 had required per plan of care.Review of email chain with director of nursing (DON) and SA revealed the following:-On 12/2/25 at 7:41 a.m., SA sent message to DON to answer the following questions: 1. What was the root cause of the fall? 2. What was [R1] care planned prior to the fall?-On 12/2/25 at 8:58 a.m., DON sent message to the SA stating the root cause of the fall was weakness and R1 was care planned for use of EZ-stand with one assist. The staff member has been suspended at this time during the investigation.DON failed to provide additional information regarding the root cause of the fall being R1 was pivot transferred with assist of one staff member when R1 required the use of a mechanical EZ stand assist of one to transfer.On 12/3/25 at 1:08 p.m., licensed practical nurse (LPN)-A stated she reported to registered nurse (RN)-A R1's care plan was not followed which resulted in a fall on 11/29/25, at approximately 6:15 p.m.On 12/4/25 at 10:24 a.m., RN-A stated she received a call from LPN-A on 11/29/25, at approximately 6:15 p.m., and LPN-a reported staff had pivot transferred R1 rather than utilizing an EZ stand as R1 required which resulted in a staff assisted fall.On 12/4/25 at 12:05 p.m., DON stated R1's fall was discussed at the interdisciplinary team (IDT) meeting on 12/1/25. DON stated it was reported R1's fall occurred and R1's care plan had not been followed at the time of the fall. DON confirmed she submitted the report to the SA after identification of R1's fracture, but DON was unsure why the report did not contain information related to how R1 was transferred at the time of the fall or that R1's care plan was not followed. Further, DON stated the SA reached out to her by email and had asked what R1's transfer status was prior to the fall to which DON answered the question and did not provide any further detail again regarding how R1 was transferred at the time of the fall and R1's care plan was not followed.On 12/4/25 at 2:15 p.m., during the exit conference with DON and administrator, administrator stated they had not investigated the incident yet or interviewed the resident or staff involved before making the report to the SA, so the facility had not confirmed the care plan was not followed, even though the incident report contained the information and was verbally communicated by RN-A.

Based on interview and document review the facility failed to notify the Ombudsman of transfers and discharges for 1 of 3 residents (R6) reviewed for hospitalizations. Findings include: R6's quarterly minimum data set (MDS) dated [DATE], indicated R6 was cognitively intact and had the following diagnoses: heart failure, hypertension, end stage renal failure and diabetes mellitus. R6's progress notes printed 9/11/25, indicated R6 was hospitalized from [DATE] to 5/5/25, with sepsis related pneumonia. Facility Ombudsman notification lacked evidence of R6's hospitalization in neither the April or May 2025 Ombudsman notifications. During interview on 09/10/2025 at 11:09 a.m., Director of Nursing (DON) stated the social worker was responsible for notifications to the Ombudsman for all hospitalizations, transfers and discharges. DON stated she was unsure of the social workers process as to when notifications were sent. DON then confirmed the Ombudsman notification list provided by facility did not include R6's hospitalization from 4/29/25 through 5/5/25. DON stated it was her expectation that all hospitalizations, discharges and transfers be reported to the Ombudsman. A policy related to Ombudsman notification was requested by not provided.

Based on document review and interview the facility failed to ensure monthly pharmacy reviews were accurately completed and included review of hospital discharge orders for 1 of 3 residents (R6) reviewed for hospitalizations.Findings include:R6's quarterly minimum data set (MDS) dated [DATE], indicated R6 was cognitively intact and had the following diagnoses: heart failure, hypertension, end stage renal failure, diabetes mellitus, and irritable bowel syndrome with constipation.R6's progress note dated 4/29/25, indicated R6 was emergently transferred to the hospital and was subsequently admitted with sepsis. R6 returned to the facility on 5/5/25.R6's discharge transfer paperwork dated 5/5/25, indicated the following orders: Atorvastatin 40 mg-Wait to take this until May 6th morning; Linaclotide 145 mcg cap-wait to take this until May 6th morning.During interview on 09/09/2025 at 9:33 a.m., Consulting Pharmacist (CP) stated she was familiar with R6's hospitalization on 4/29/25 through 5/5/25. She stated she completed her monthly pharmacy review on May 21st which included discharge paperwork from 5/5/25. CP confirmed she did not see the orders for Atorvastatin and Linaclotide to begin on May 6th and hadn't written a recommendation related to those meds. She missed the order and should have written a recommendation for the medications to be restarted. Additionally, CP stated the potential was there for R6 to experience increased constipation or fecal impaction as a result.During interview on 9/10/25 at 11:09 a.m., Director of Nursing (DON) stated the pharmacy consultant reviewed all resident medications at least monthly for errors and irregularities. DON stated irregularities were addressed by the appropriate person, either the physician or nursing staff. DON confirmed the consultant pharmacist did not catch the transcription error for R6 and stated it looked like everyone missed it. DON stated the pharmacy review was an important component for resident safety.A policy titled Consultant Pharmacist Medication Regimen Review with a last review date of 3/2025 indicated the purpose was to the define the intent and process for drug regimen reviews of residents within long term care. The consultant pharmacist will review the medication regimen of each resident at least monthly and as needed. Irregularities will be reported to the Director of Nursing, the attending provider and a summary to the medical director for review and considerations of irregularities that may need to be further addressed with the attending provider. The facility will provide the consultant pharmacist with access to the resident's medical records, both electronic and paper records. Medication Regimen Review activities may include evaluating medication orders to determine the resident's orders represent optimal therapy; diagnosis or indication supports medication use; route of administration is appropriate; the prescribed dose is appropriate; the administration schedule is appropriate considering side effects and compatibility with other medications and diet.

Based on observation and interview, the facility failed to maintain safe storage of medications on 1 of 3 medication carts when medication cart was left unlocked. Findings include:On 9/9/25 at 7:55 a.m., medication cart in common area of 100's unit was observed unlocked and unsupervised. Medication cart was placed outside of dining room, across from the unattended nurse's station.At 8:01 a.m., a staff person walked by cart to place something in the unattended nurses station. A second staff person walked past the unlocked medication cart. Neither attempt to lock the cart.At 8:04 a.m., a staff person with a laundry cart walked past the unlocked medication cart.At 8:05 a.m., registered nurse (RN)-C pushed a resident in a wheelchair past the unlocked medication cart.At 8:06 a.m., director of nursing (DON) walked past unlocked medication cart, but did not observe unlocked cart. RN-C walked past unlocked medication cart with supplies.At 8:07 a.m., housekeeping staff person walked past unlocked cart. RN-C walked past unlocked medication cart, noticed it was unlocked, and stopped to lock it prior to answering a phone.During interview on 9/9/25 at 8:09 a.m., RN-C confirmed she left the medication cart unlocked. RN-C was unsure when she left the cart unlocked. RN-C confirmed it was never acceptable to leave a medication cart unlocked.During interview on 9/10/25 at 10:54 a.m., DON stated she expected medication carts were locked any time someone turned away or left the cart. This would be important to prevent both staff and visitors from having access to medications. Facility policy titled Medication Guidelines - Long Term Care dated July 2025, included all compartments that contain medications should have been locked when not in use and should not be left unattended.

Based on interview and record review the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards of practice for 1of 24 residents (R1) reviewed for advanced directives documentation. This deficient practice gave staff access to inaccurate information. Findings include:R1's quarterly minimum data set (MDS) dated [DATE] indicated R1 admitted to the facility 3/13/25 and had the following diagnoses: hypertension, hyperlipidemia, arthritis, respiratory failure and depression.Review of R1's electronic medical record (EMR) on 9/7/25 indicated the code status as DNR, and current orders indicated DNR. However, the Advance Directive link in R1's EMR revealed an outdated advanced directive which indicated FULL CODE.A progress note titled Communication with Physician dated 7/28/25, indicated during hospitalization R1's code status was changed to Do Not Resuscitate, and the change was verified with R1's spouse. The note indicated social services would follow up and assist with updating healthcare directives.During interview on 9/7/25 at 3:08 p.m., registered nurse (RN)-C stated she would look to the EMR for a resident's code status, or the paper chart for the signed order from the physician. RN-C stated the paper chart and EMR should match. RN-C went on to say the advanced directive link in the EMR would be the best choice because it was linked to the signed official order. During interview on 9/7/25 at 3:10 p.m., trained medication aide (TMA)-A stated a resident's advanced directives were on the Kardex and on the Point of Care (POC) banner. TMA-A opened the EMR and clicked on the link to the resident Kardex. However, TMA-A did not access the Advance Directives link.During interview on 9/7/25 at 3:11 p.m., RN-B stated she could find the advanced directives in the resident's hard/paper chart or in the EMR on the banner. RN-B stated staff always verified they matched and compared the paper to the electronic chart to ensure they matched. RN-B did not access the Advance Directives link.During interview on 9/7/25 at 3:17 p.m., licensed practical nurse (LPN)A stated she would look to the resident's hard/paper chart to find advanced directives. LPN-A did not use the Advanced Directive link. During interview on 9/10/25 at 11;05 a.m., Director of Nursing (DON) stated it was the responsibility of the admitting or readmitting nurse to establish initial code status and obtain orders. DON stated staff could find code status in the EMR, the paper chart, and POC. DON located R1's code status on the EMR banner and stated it was listed as DNR. DON then confirmed R1's Advance Directives link was active and stated an outdated advance directive listed R1's code status as full code. DON stated her expectation was all locations listing code status matched. R1's did not match. DON stated it was important to have the correct code status in all locations to ensure the resident received the correct physician ordered care.A policy titled Code Blue/Cardiopulmonary Resuscitation-Skilled Nursing indicated the procedure to obtain advance directives through discussion with the resident and family and indicated how the wishes would be carried out in the event of cardiac arrest. The policy lacked a procedure to ensure all available locations of a resident's advance directives were matching.

Based on observation, interview, and document review, the facility failed to properly disinfect shared equipment between use for 1 of 2 glucometers (medical device used to check blood sugar levels) reviewed for infection control. Findings include:R126's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and diagnoses of diabetes mellitus (a disease where the body either does not produce enough insulin or not use insulin effectively) and dementia (memory loss).During observation and interview on 9/9/25 at 7:07 a.m., registered nurse (RN)-C completed a blood sugar check using a shared glucometer on R126 in R126's room. RN-C brought the shared glucometer back to the medication cart and used a Sani-Cloth germicidal disposable wipe on the glucometer for approximately 10 to 15 seconds. RN-C replaced the glucometer into the medication cart. RN-C confirmed she wiped the glucometer down for approximately 5 to 10 seconds and was dry soon after. RN-C checked the label and stated the contact time for the Sani-Cloth brand wipes was one minute .During interview on 9/10/25 at 10:54 a.m., the director of nursing (DON) stated she expected the glucometer to be disinfected between uses and following the policy.According to the [NAME] owner's manual, the device must be cleaned and disinfected after each patient with a CAVIPES disinfecting towelette by manufacturer Metrex and isopropanol as an active ingredient. Instructions included to allow the surface to remain wet for 2 minutes and allow to air dry.Facility policy for blood glucose sampling dated September 2025 included to follow the manufacturer's instructions for cleaning and disinfecting after each use.

Based on observation, interview, and document review, the facility failed to provide care consistent with professional standard of practice to prevent worsening of pressure ulcer identified on 6/20/25 for 1 of 3 residents (R1) reviewed when the facility failed to provide appropriate assessment and treatment. This resulted in actual harm to R1 when she was identified with stage 3 pressure ulcer at coccyx area during admission at the hospital on 7/15/25. Findings include: According to the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, revision 229, issued 4/25/25 a pressure ulcer and stage 3 pressure ulcer is defined as Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. On 7/29/25 at 10:09 a.m., during R1's wound dressing observation, RN-G stated R1's pressure ulcer measurements indicated the following: length: 5.5 cm; width: 3.5 cm; and depth: 1 cm. RN-G stated he noted an excoriation around the wound, blanchable, little slough, borderline stage 3 pressure ulcer. R1's admission Record dated 3/27/24 indicated R1's diagnoses included intervertebral disc degeneration, chronic respiratory failure with hypoxia, history of diseases of the skin and subcutaneous tissue, sepsis due to Escherichia coli, and post-traumatic stress disorder. R1's care plan dated 3/27/24, indicated R1 had intact cognition and was at risk for skin breakdown related to pressure due to incontinence, inactivity, immobility, and problem with friction and shearing with staff interventions to inspect skin with care, to evaluate and notify the provider and the family immediately of any new area of skin breakdown. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers. The MDS also indicated R1 required extensive assistance with activities of daily living (ADL) R1's skin evaluation document dated 6/20/25 at 8:24 p.m. indicated R1 had new skin impairment with an open skin area at her coccyx. The document also indicated Mepilex border (a wound dressing) applied, monitoring task initiated. R1's care plan review lacked evidence of the focus, goal and interventions reviewed after the new skin impairment finding on 6/20/25. Review of R1's medical record including skin assessments and progress notes, indicated the facility failed to document an assessment of the pressure ulcer, measurements, or description from 6/20/25 through 7/14/25, during the time the facility nursing staff was responsible for R1's skin integrity. R1's treatment administration record (TAR) dated 6/20/25, through 7/14/25, indicated R1 refused wound care on 7/1, 7/6, 7/7, 7/8, 7/9, and 7/10. Record review lacked indication of a notification to R1's physician or the nurse manager about R1's refusal of wound care. R1's skin assessment dated [DATE] at 7:35 p.m. indicated R1 had an open skin area at her coccyx with Mepilex dressing intact. The note indicated R1 refused to reposition often from the recliner. R1's skin assessment and progress notes 7/7/25 and 7/14/25, lacked documentation of R1's pressure ulcer of the coccyx area. On 7/15/25 at 6:33 p.m., a progress note indicated R1 was very drowsy/lethargic all shift with blood pressure of 62/42 and nursing staff sent R1 to the hospital for further evaluation per provider order. On 7/15/25, an emergency department (ED) provider note indicated emergency medical services (EMS) brought R1 to the hospital for evaluation of low blood pressures, increased fatigue, increased weakness, and some disorientation. The note also indicated a discrepancy in the history from the nursing home staff and there was very minimal documentation in the chart. R1's MDS dated [DATE] indicated no unhealed pressure ulcer/pressure injury identified. On 7/24/25 at 1:15 p.m., a licensed practical nurse (LPN)-A stated if you noted a new skin impairment, nursing staff should provide assessment, description, measurement, document in the progress note, and notified the nurse manager, the provider, and the family, and initiated a task to monitor its progress. LPN-A stated with a pressure ulcer or injury she would keep the pressure off, notified the treatment team, the dietitian, and the provider. On 7/24/25 at 3:32 p.m., LPN-B stated it was the standard of practice to check the status of an existing skin impairment compared to the initial assessment during the skin assessment and documented whether it was getting better or worse. LPN-B stated with a resolved skin impairment, nursing staff had to document it in the progress note and notified the nursing manager. On 7/28/25 at 8:54 a.m., LPN-C stated she reviewed the assessment of the week before her shift and looked at the areas of concerns, documented any findings in the progress note, and notified the care manager and the provider. On 7/28/25 at 11:54 a.m., a registered nurse (RN)-A stated ED provider note on 7/16/25 indicated R1 had sacral pressure ulcer present at the admission. RN-A stated a hospital wound nurse who was consulted to see R1 evaluated R1's sacral pressure ulcer to be at least stage III with 9 cm length and 7 cm width and was unable to determine the depth. On 7/28/25 at 1:16 p.m., LPN-D stated she would update the provider, the nurse manager, and the family about a new skin impairment. LPN-D stated she was just monitoring R1's open skin area progress but she did not document its status during her skin assessment on 6/30/25 since it was not a new skin impairment. LPN-D stated usually the RNs will do an evaluation for stuff like that. She just made sure the Mepilex dressing was in place. On 7/28/25 at 1:21 p.m., RN-B stated she did not document a description and measurement about R1's new skin impairment on 6/20/25, and did not notify the nurse manager or the provider. RN-B stated she initiated the task to monitor the open skin area at R1's coccyx and could not find any documentation about when it was resolved. On 7/28/25 at 3:12 p.m., a care coordinator, registered nurse (RN)-C stated she expected licensed nurses to describe and measure any new skin impairment, documented in the progress note, initiated a task for monitoring process, and notified the care coordinator and the provider. RN-C stated nursing staff did not notify the provider about R1's new skin impairment. RN-C stated she could not find any documentation about R1's resolved skin impairment prior to her hospitalization. RN-C stated R1 was back from hospital today and she sustained pressure ulcer at her coccyx area with 9.0 cm length, 8.2 cm width, and 0.7 cm depth with tunneling. On 7/29/25 at 10:09 a.m., during R1's wound dressing observation, RN-G stated R1's pressure ulcer measurements indicated the following: length: 5.5 cm; width: 3.5 cm; and depth: 1 cm. RN-G stated he noted an excoriation around the wound, blanchable, little slough, borderline stage III pressure ulcer. On 7/29/25 at 10:42 a.m., R1 stated the sore at her bottom was there for a little bit before she went to the hospital. R1 stated it hurt sometimes but she did not have pain at this time. R1 stated she could not remember what happened before she left for hospital. R1 stated she did not sleep in bed before her hospitalization, she preferred to sleep in her recliner. On 7/29/25 at 11:38 a.m., RN-D from R1's medical team office stated she could not find any new skin impairment notification in their system about R1 from 6/20/25 through 7/14/25. RN-D stated she received the only notification about R1's wound status today on 7/29/25 and they ordered a wound care consult. On 7/29/25 at 12:07 p.m., RN-E stated she assessed R1 when she came to the intensive care unit (ICU) for septic shock. RN-E stated the only reason she made the report to the State Agency (SA) was the skin impairment. RN-E stated R1 had a massive open skin area which looked like a pressure ulcer at her sacral area. On 7/29/25 at 12:09 p.m., a nursing assistant (NA)-A stated during the week when R1 went to the hospital, she reported a purple bluish bruising around R1's coccyx area to RN-F who looked at it but when she came back the next day, she could not find any documentations about the bruising. On 7/29/25 at 12:34 p.m., the medical director (MD)-A stated he expected nursing staff to follow change in condition and wound care policies. MD-A stated nursing staff had to notify the provider about a new skin impairment depending on the resident diagnosis. On 7/29/25 at 1:32 p.m., RN-F stated nurses had to report any new skin impairments to the case manager, the provider, and the family. RN-F stated nurses had to document the size, characteristics, status of an existing skin impairment or reopened, and initiated a risk management if the case manager wanted to do more investigation. RN-F did not recall getting a report from nursing staff about R1's coccyx area condition. On 7/29/25 at 3:34 p.m., the director of nursing (DON) stated she expected nursing staff to follow a change in condition and wound care policies about a new skin impairment finding. The DON stated with new skin impairment, nurses had to update the care team, record the measurement and the description of the wound, open a task to monitor its healing process, updated the dietary department, the care plan, the provider, and the family. The DON stated she could not find any care plan updated about R1's new skin impairment finding on 6/20/25. The DON stated she could not find any documentations about when R1's open skin area at her coccyx was resolved. Nursing staff did not update the nurse manager about R1's new skin impairment and staff failed to implement a pressure reduction cushion in the recliner for R1. The DON stated the professional standard of practice would be to describe and measure the wound, documented in the progress note, update the care team and the provider, initiated offload pressure reduction measures, and follow the provider recommendation. The facility policy for Change in Condition dated 7/2025 directed nurses to make detailed observations and gather relevant and pertinent information for the provider of a change in the resident's condition. The policy also directed nurses to record in the resident's medical record information relative to changes in the resident's status and update to the resident's plan of care. The facility Wound Care policy dated 1/2025 directed nurses to follow the professional standards of practice, to observe the wound and surrounding skin taking note of the appearance of the wound bed, surrounding skin, edema, redness, drainage, indications of wound status. The policy also indicated to notify the supervisor if the resident refuses the wound care.

Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: R1's admission Record dated 3/27/24 indicated R1's diagnoses included intervertebral disc degeneration, chronic respiratory failure with hypoxia, history of diseases of the skin and subcutaneous tissue, sepsis due to Escherichia coli, and post-traumatic stress disorder. R1's care plan dated 3/27/24, indicated R1 had intact cognition and was at risk for skin breakdown related to pressure due to incontinence, inactivity, immobility, and problem with friction and shearing with staff interventions to inspect skin with care, to evaluate and notify the provider and the family immediately of any new area of skin breakdown. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers. The MDS also indicated R1 required extensive assistance with activities of daily living (ADL) R1's skin evaluation document dated 6/20/25 at 8:24 p.m. indicated R1 had new skin impairment with an open skin area at her coccyx. The document also indicated Mepilex border (a wound dressing) applied, monitoring task initiated. The document lacked evidence of the provider notification. R1's skin assessment dated [DATE] at 7:35 p.m. indicated R1 had an open skin area at her coccyx with Mepilex dressing intact. The note indicated R1 refused to reposition often from the recliner. R1's treatment administration record (TAR) dated 6/20/25 through 7/14/25, indicated R1 refused wound care on 7/1, 7/6, 7/7, 7/8, 7/9, and 7/10. Record review lacked indication of a notification to R1's physician or the nurse manager about R1's refusal of wound care. Review of R1's medical record including skin assessments and progress notes, indicated the facility failed to document an assessment of the pressure ulcer, measurements, or description from 6/20/25 through 7/14/25, during the time period the facility nursing staff was responsible for R1's skin integrity. On 7/24/25 at 1:15 p.m., a licensed practical nurse (LPN)-A stated if you noted a new skin impairment, nursing staff should provide assessment, description, measurement, document in the progress note, and notified the nurse manager, the provider, and the family, and initiated a task to monitor its progress. LPN-A stated with a pressure ulcer or injury she would keep the pressure off, notified the treatment team, the dietitian, and the provider. On 7/28/25 at 1:16 p.m., LPN-D stated she would update the provider, the nurse manager, and the family about a new skin impairment. LPN-D stated she was just monitoring R1's open skin area progress but she did not document its status during her skin assessment on 6/30/25 since it was not a new skin impairment. LPN-D stated usually the RNs will do an evaluation for stuff like that. She just made sure the Mepilex dressing was in place. 7/28/25 at 1:21 p.m., RN-B stated she did not document a description and measurement about the new skin impairment on 6/20/25, and did not notify the nurse manager or the provider. RN-B stated she initiated the task to monitor the open skin area at R1's coccyx and could not find any documentation about when it was resolved. On 7/28/25 at 3:12 p.m., a care coordinator, registered nurse (RN)-C stated she expected licensed nurses to describe and measure any new skin impairment, documented in the progress note, initiate a task for monitoring process, and notified the care coordinator and the provider. RN-C stated nursing staff did not notify the provider about R1's new skin impairment and could not find any documentation about when R1's resolved skin impairment prior to her hospitalization. RN-C stated R1 was back from hospital today and she sustained pressure ulcer at her coccyx area with 9.0 cm length, 8.2 cm width, and 0.7 cm depth with tunneling. On 7/29/25 at 11:38 a.m., RN-D from R1's medical team office stated she could not find any new skin impairment notification in their system about R1 from 6/20/25 through 7/14/25. RN-D stated she received the only notification about R1's wound status today on 7/29/25 and they ordered a wound care consult. On 7/29/25 at 12:34 p.m., the medical director (MD)-A stated he expected nursing staff to follow change in condition and wound care policies. MD-A stated nursing staff had to notify the provider about a new skin impairment depending on the resident diagnosis. On 7/29/25 at 3:34 p.m., the director of nursing (DON) stated she expected nursing staff to follow a change in condition policy about a new skin impairment finding. the DON stated she expected staff to report any resident wound concerns to the provider immediately. The DON stated with new skin impairment, nurses had to update the care team, record the measurement and the description of the wound, open a task to monitor its healing process, updated the dietary department, the care plan, the provider, and the family. The DON stated nursing staff did not update the nurse manager about R1's new skin impairment. The facility policy for Change in Condition dated 7/2025 directed nurses to make detailed observations and gather relevant and pertinent information for the provider of a change in the resident's condition. The policy also directed nurses to record in the resident's medical record information relative to changes in the resident's status and update to the resident's plan of care.

Based on observation, interview, and document review the facility failed to implement adequate use of personal protective equipment (PPE) and hand hygiene during direct care services for 1 of 1 resident (R3) who required enhanced barrier precautions (EBP) with an indwelling device and open wound with a dressing change. Findings include: R3's annual Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. He required substantial/maximum assistance with toilet hygiene, shower/bathe, personal hygiene, sit to stand, toilet and chair/bed to chair transfers, dependent for lower body dressing, and used a manual wheelchair for mobility. He had a suprapubic (a device inserted a couple inches below the naval/belly button, directly into the bladder) urinary catheter and always continent of bowel. Diagnoses included benign prostatic hyperplasia (BPH) (enlargement of the prostate), neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problems, osteoporosis (bone loss), dementia, Parkinson's (a nervous system disorder that worsens over time), and a stage three pressure ulcer (involve full thickness skin loss potentially extending into the subcutaneous tissue layer. R3's care plan dated 4/17/25, indicated care for a suprapubic catheter due to neurogenic bladder and chronic urinary retention and directed staff to monitor for any trouble with catheter leaking and signs and symptoms of a urinary tract infection (UTI) such as change in color or cloudy urine, burning, fever, chills and observe skin integrity at catheter site. He required assistance with activities of daily living (ADLs) and staff were directed to transfer him with a gait belt, walker, and assistance of two. Care plan did not include EBP. During a continuous observation on 4/24/25 from 1:42 p.m. to 2:03 p.m., -1:42 p.m. located outside of R3's room was EBP signage and a large container with pockets that hung on the outside of his door which contained PPE supplies. Signage identified everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident Care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use with central line, urinary catheter, feeding tube, and tracheotomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Nursing assistant (NA)-A and NA-B entered R3's room without application of PPE (gown and gloves) and assisted R3 into his wheelchair. NA-A positioned herself in front of him, reached down and attempted to pull R3's pant leg down with her bare hands and stated, his catheter bag was leaking. NA-A and NA-B placed gloves on. NA-B pulled up his left pant leg and identified the clamp to the urinary catheter tubing may have been broken and urine had leaked onto his pants leg, socks and left shoe. NA-A sat down on the floor in front of him and removed his left shoe and knee-high sock, carried it over to the sink while it dangled from her hand and rinsed it in the under running water. NA-B kneeled on the floor in front of him, placed papers towels on the floor underneath the catheter bag, disconnected the straps from his lower leg and tubing/catheter collection bag from R3, wiped off end of tubing with an alcohol swab, and connected the new tubing end to the resident's catheter tubing, then placed the old catheter collection bag and tubing into the garbage can. NA-A kneeled on the floor with left knee and positioned herself in front of him. Both NA-A and NA-B sat on the floor, threaded the leg straps through his leg bag and around his lower left leg. NA-B removed her gloves, washed her hands, and exited the room. NA-B re-entered the room, carried a pair of scissors without a gown on, placed gloves on, and sat on the floor in front of him, and cut the leg straps shorter. NA-A and NA-B removed their gloves, failed to sanitize or wash their hands, and applied clean gloves. NA-A and NA-B assisted him up to stand, pulled down his pants and brief, completed peri cares. NA-A stated the Mepilex dressing fell off his open wound on his buttock, needed to be changed, used walkie to radio licensed practical nurse (LPN)-A. - At 1:57 p.m. LPN-A entered the room without a gown donned and was already wearing gloves. LPN-A failed to remove gloves, sanitize or wash hands and apply clean gloves before caring for R3. LPN-A placed a Mepilex dressing over a quarter sized open area located on the left inner buttock. LPN-A placed a new dressing around the suprapubic urinary catheter site located on his abdomen, removed gloves, washed her hands and exited the room. NA-A and NA-B removed his soiled pants, placed a clean pair on, and assisted him into his wheelchair, removed their gloves, and washed hands with soap and water. Observation ended at 2:03 p.m. During an interview on 4/24/25 at 2:04 p.m., NA-A stated R3 was currently on EBP due to suprapubic catheter, wound on his buttocks, and current UTI. She should have gowned up when she entered his room and forgot to. NA-A added, it would be important to have applied a gown to prevent the spread of infection and verified the staff in R3's room during care all did not have gowns on. During an interview on 4/24/25 at 2:15 p.m., NA-B stated R3 was in EBP due to his suprapubic urinary catheter. Staff were expected to wear PPE included a gown when they worked with his urinary catheter, during cares, wound, and changing his brief, for infection control protection. She should have placed a gown on before she entered the room but it slipped her mind. She had not expected to find his urinary catheter leaking on his pants, socks, and shoe. NA-B verified he had a current UTI and was being treated for it. During an interview on 4/24/25 at 4:30 p.m., LPN-A stated R3 had an open pressure wound located on the upper left part of the right inside gluteal fold the size of a quarter. Due to how often he moved around the Mepilex dressing fell off. He was placed in EBP for his suprapubic catheter and had a current UTI. Staff would be expected to wear a gown and gloves (and goggles if expected to be splashed) to help the prevent spread of germs and infection. She forgot to wear a gown and should have protected her clothing while she changed his dressing over the suprapubic site and on his gluteal fold. During an interview on 4/28/25 at 4:56 p.m., director of nursing (DON) stated staff would be expected to follow the EBP sign the moment they realized they would be completing cares and/or toileting a resident to help prevent the spread of infection. It was not recommended for staff to have sat on the resident's floor due to infection control concerns. Facility Enhanced Barrier Precautions signage identified everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident Care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use with central line, urinary catheter, feeding tube, and tracheotomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Facility policy Enhanced Barrier Precautions dated 3/2025, identified the use of EBP within the facility was recommended by the Center of Disease Control (CDC) to reduce the transmission of multidrug-resistance organisms (MDROs) through the use of gown and glove use during high contact resident care activities that provide opportunities of transfer of MDROs to staff hands and clothing and maybe transferred from resident-to-resident during these high-contact care activities. Definition of a MDRO was organisms that have become resistant to multiple types of drugs that are normally used to treat those organisms. Examples of high-contact resident care activities required gown and glove use for EBP included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: urinary catheter, wound care, stage 2 pressure ulcers, diabetic ulcers, venous stasis ulcers, arterial ulcers, open social wounds. Clear signage wound be expected to be posted on the door or wall outside the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g. gown and gloves).

Based on record review and interview the facility failed to provide a reasonable call light response time for 4 of 4 (R27, R13, R36, R10) residents reviewed for dignity. Findings include: R27's quarterly MDS dated [DATE], indicated R27 was cognitively intact, and had the following diagnoses: anemia, HLD, depression, and post traumatic stress disorder (PTSD). R13's significant change MDS dated [DATE], indicated R13 was cognitively intact and had the following diagnoses: anemia (low blood count), atrial fibrillation (AFIB) (top two chambers of the heart beat irregularly), HTN, congestive heart failure (CHF) (heart does not pump blood efficiently), renal insufficiency (kidneys filter the blood ineffectively), HLD, and hyponatremia (low sodium levels in the body), and arthritis. R36's annual MDS dated [DATE], indicated R36 was cognitively intact and had the following diagnoses: cerebral vascular accident (CVA) (stroke), anemia, coronary artery disease (CAD) (hardening of the cardiac arteries), benign prostatic hyperplasia (BPH) (enlarged prostate), renal insufficiency, HLD, dementia, and depression. R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact, and had the following diagnoses: hypertension (HTN) (high blood pressure), hyperlipidemia (HLD) (elevated levels of fat in the blood), anxiety and depression. The Device activity report dated 6/29/24, listed call light times for a 24-hour period and had 36 response times greater than 30 minutes, 7 greater than 60 minutes, and the longest response time was 2 hours and 21 minutes. The Device activity report dated 8/21/24, listed call light times for a 10-hour period and had 14 response times greater than 30 minutes, 3 greater than 60 minutes, and the longest response time was 1 hour and 27 minutes. The Device activity reported dated 8/23/24 through 8/24/24, listed call light times for a 14-hour period and had 23 response times greater than 30 minutes, 8 greater than 60 minutes, and the longest response time was 1 hour 45 minutes. On 8/29/24 at 10:31 a.m., nursing assistant (NA)-E stated they felt that cares were not getting done, they felt rushed and unable to spend time with the residents they would like to. NA-E stated the call lights will be relayed by nursing staff or whoever was near the monitors which list out who called first. NA-E stated 5-6 minutes was an acceptable response time for call lights. The Device activity report dated 8/23/24 through 8/24/24, listed a call light time of 60 minutes for R27. On 8/29/24 at 11:06 a.m., R27 confirmed they had experienced long call light response times. R27 stated they were unable to make it to the restroom because of the long response time and urinated in their chair while waiting for help to come. R27 stated they felt angry when it took so long to get help. The Device activity reported dated 8/23/24 through 8/24/24, listed a call light time of 1 hour and 16 minutes for R13. On 8/29/24 at 11:16 a.m., R13 confirmed they had experienced long call light response times. R13 stated they are very independent and only need help with a few things from staff, so when they must wait so long it made them feel upset and angry when they, only put on the light a few times and still no one comes. The Device activity report dated 6/29/24, listed a call light time of 1 hour 57 minutes for R36. On 8/29/24 at 11:24 a.m., R36 confirmed they had experienced long call light response times. R36 stated they had been unable to get to the rest room in time and had soiled their bed. R36 stated they were frustrated and mad when they had to wait so long and were unable to make it to the bathroom. The Device activity report dated 6/29/24, listed a call light time of 1 hour and 10 minutes for R10. On 8/29/24 at 11:30 a.m., R10 confirmed they had experienced long call light response times. R10 stated they were unable to make it to the rest room while waiting for assistance and R10 was very upset and it made them feel bad to have to wait so long for help. On 8/29/24 at 10:50 a.m., licensed practical nurse (LPN)-A stated they feel rushed and were not able to spend as much time as they would like with the residents to complete their workload. LPN-A stated lights were called out over the walkie talkies, informing staff which lights were on and which had been on the longest. LPN-A stated residents had reported to them in the past they had been waiting a long time and were frustrated. LPN-A stated 15 minutes was an acceptable response time. On 8/29/24 at 11:36 a.m., the director of nursing (DON) (O)-B confirmed the facility's call light logs had reflected excessively long wait times and they were aware of the problem. The DON expected call lights to be responded to within 15 minutes. DON stated they were currently working to implement a new call light program which would be linked to the staff's Ipads and allow them to see which lights had been on the longest and assist them in expediting call light response times. DON stated they were working to improve communication with staff, residents and the overall culture of the facility in order to help prevent falls, meet resident needs and ensure a home-like environment for the residents.

Based on observation, interview and document review, the facility failed to implement interventions to prevent further development of decreased range of motion and ability for 2 of 2 residents (R29, R53) reviewed for positioning and mobility. Findings include: R29's annual Minimum Data Set (MDS) dated [DATE], included diagnosis of stroke, arthritis, and hemiplegia or hemiparesis (weakness or inability to move one side of your body). R29's annual MDS included he had limited range of motion on one side of his upper body. On 8/27/24 at 11:39 a.m., R29 was positioned by staff at a table in the dining room. Right arm was noted to be on his lap with right hand curled inward. R29's care plan dated 8/2/24, included a restorative nursing intervention of passive range of motion for right upper and lower extremities which included passive stretching and extensions of the right fingers and thumb. R29's occupational therapy discharge summary dated 7/14/24, included discharge recommendations for passive range of motion to R29's right upper extremity. R29's Follow Up Question report for 7/1/24 to 7/31/24, included a task for passive range of motion to fingers and wrist. Responses were as follows: Resident refused was documented 6 times Resident not available was documented 1 time Not applicable was documented 6 times Missing documentation or zero minutes was documented 11 times Task was documented as complete 10 times R29's Follow Up Question report for 8/1/24 to 8/29/24, included a task for passive range of motion to fingers and wrist. Responses were as follows: Resident not available was documented 2 time Not applicable was documented 13 times Missing documentation or zero minutes was documented 12 times Task was documented as complete 1 time During interview on 8/28/24 at 7:26 a.m., nursing assistant (NA)-A stated she did not have time to do range of motion. NA-A stated not applicable would be documented under the range of motion task if it was not offered and not completed. During interview on 8/29/24 at 8:27 a.m., director of therapy (DOT) stated it was very important for R29 to have his range of motion completed to prevent development of contractures and loss of range of motion in his joints. R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was severely cognitively impaired, and had the following diagnoses: anemia (low iron in the blood), hypertension (HTN) (high blood pressure), renal insufficiency (kidneys not working properly/failing), dementia, malnutrition, anxiety and depression. R53's medical record indicated a restorative nursing program for passive range of motion (ROM) for bilateral (both sides) lower extremities daily and as needed on nights and evenings. The follow up question report dated 6/1/24 through 6/30/24, indicated the number of minutes spent completing the program, refusals and not applicable documentation of the ROM program. Resident refused was documented 2 times Not applicable was documented 9 times Task was documented as complete 9 times From 7/1/24 through 7/28/24: Resident refused was documented 1 times Not applicable was documented 19 times Task was documented as complete 6 times The undated Follow up Question: Question 1, indicated the number of minutes spent completing the ROM program, refusals and not applicable. From 8/1/24 through 8/27/24: 1 out of 21 days the program was completed. 1 out of 21 days showed zero minutes completed. 19 out of 21 days not applicable. R53's medical record lacked any rational or reasoning why the ROM program would not have been completed on the above listed days. On 8/26/24 at 2:27 p.m., R53's family member (O)-C stated R53 had a ROM program for their legs but it was only done when the staff had time. O-C felt R53 could have benefited from the ROM program. On 8/29/24 at 10:31 a.m., the nursing assistant (NA)-E stated they would complete the ROM program sometimes, but only if they had time. NA-E stated they normally documented if the ROM was completed in the task tabs in point click care (PCC) and put how long they preformed the ROM program and would leave it blank if they did not have time to do it. On 8/29/24 at 10:50 a.m., the licensed practical nurse (LPN)-A stated R53 had a ROM program which began in January of this year. LPN-A stated the facility used to have a restorative aide, but not anymore, and they rarely had the time to complete the program. LPN-A stated the NA's and nurses can complete the program and it was documented in the task tab of PCC and they would put not applicable when it was not completed. LPN-A stated when ROM was not completed it should have been reported to the nurse on duty but they very rarely had time to check and see it was completed or document why not. During interview on 8/29/24 at 9:53 a.m., director of nursing (DON) stated a task should have been documented in the resident's chart if it was completed. The floor nurse should have been updated if a resident was refusing. The DON confirmed R29 had a task for passive ROM and the task was often documented as not applicable. The DON stated completing passive ROM was important to keep residents at their current health status. Facility policy Restorative Nursing Services dated January 2024, included resident would receive restorative nursing care as needed to help promote safety and independence. 49657

Based on interview and document review the facility failed to inform a responsible party in advance of the risks/benefits and receive informed consent of proposed care for 2 of 5 residents (R16, R19) reviewed for unnecessary medications. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and diagnoses of unspecified dementia, mood disturbance, and anxiety. R16's last signed physician orders dated 7/18/23 indicated Ativan (an antianxiety medication) 0.5mg by mouth two times a day related to Anxiety and Venlafaxine HCI (an antidepressant medication) 50mg by mouth two times a day related to Major Depressive Disorder initiated 10/27/2021. However, the record lacked evidence of an Informed Consent for required Medications indicating possible risks/side effects was provided to the responsible party for Ativan and Venlafaxine HCI. R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of dementia, hallucinations unspecified, major depressive disorder, and unspecified psychotic disturbance. R19's last signed physician orders dated 7/25/23, indicated Mirtazapine (an atypical antidepressant medication) 15mg by mouth one time a day for depression/anxiety related to major depressive disorder initiated on 1/12/23. However, the record lacked evidence an Informed Consent for Required Medications indicating possible risks/side effects was provided to the responsible party for Mirtazapine 15mg. On 8/10/23 at 1:48 p.m., the director of nursing (DON) confirmed an informed consent was not obtained from either R16's nor R19's responsible party, but should have been. The facility's Psychotropic Medication Use policy, undated, indicated informed consent including effects and potential side effects will be obtained from resident and/or responsible party for each psychotropic medication.

Based on observation, interview, and document review, the facility failed to follow the care plan for 1 of 3 residents (R39) observed for cares and at risk of falling. Findings include: R39's significant change Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R39 required 2 assistance with transfers and had 2 plus falls since the prior MDS. R39's activities of daily living (ADL) Care Area Assessment (CAA) dated 9/3/22, identified she staff were to transfer with two assists. R39's care plan dated 9/16/22, included a focus of ADLs due to self care deficit and directed staff to transfer and assist to toilet with two assist. R39's nursing assistant worksheet, Kardex, dated 9/22/22, directed staff to, Transfer: Assist of 2 pivot with gait belt. EZ stand [a mechanical standing lift] PRN [as needed]. Give cues for compliance with 50% WB [weight bearing] to LLE [left lower extremity]. During observation on 9/21/22, at 8:57 a.m. R39 was transferred from the bed to wheelchair and then to the toilet, by nursing assistant (NA)-B, utilizing a transfer belt and pivot transfer. NA-B did not tell R39 to not put full weight on left leg. It was observed R39 put full weight on both legs during the transfers. NA-B stated she had transferred R39 yesterday and today with just herself and it went, fine. When interviewed on 9/22/22, at 9:00 a.m. trained medication aide (TMA)-A stated, We transfer her with one or two staff depending on if she is feeling weak or if she says she has pain, then would use two. When interviewed on 9/22/22, at 9:10 a.m. NA-A stated, I transferred her with one this morning. When interviewed on 9/22/22, at 10:51 a.m. licensed practical nurse (LPN)-A reviewed a physical therapy (PT) evaluation dated 7/29/22, for R39 and identified R39 should be left leg weight bearing at 50% and transfer with 2 assist and a wheeled walker and pivot transfer to commode if resident unable to walk to the bathroom. When interviewed on 9/22/22, at 11:08 a.m. registered nurse (RN)-A stated, nursing can change the care plan based upon clinical judgement. RN-A stated, With fractures, I am more comfortable with physical therapy making that decision. R39 was at risk for falls and the Kardex directed the staff to transfer with two assist. RN-A stated if that was not happening, she would have to educate staff. When interviewed on 9/22/22, at 12:55 p.m. NA-A stated, We transfer [R39] with one or two staff, we go according to report in the morning or physical therapy will verbally tell us. A physical therapy assistant [PTA] told me to transfer [R39] with one or two staff, I am not sure her name. NA-A stated, R39 transferred herself twice yesterday, and they had to remind her to get assistance. NA-A checked the Kardex and acknowledged R39 was to be transferred with two assist. NA-A had been just using one because sometimes R39 transferred herself and the PTA told her to use one. When interviewed 9/22/22, at 1:24 p.m. PT-B stated, they had not seen R39 for a couple months. However, staff had asked them to assess R39 today after the surveyors were asking about the transfer status. The assessment determined R39 was able to transfer with one assist. The facility policy titled, Transfer Techniques, dated 10/2020, included, Policy- to provide guidance to staff on how to perform transfers for residents that require physical assitance of one or two staff, and directed staff to refer to resident's plan of care and verify resident's transfer status.

Based on interview and document review, the facility failed to ensure a preadmission screening and resident assessment and review (PASARR) level 2 had been completed for 1 of 1 residents (R19) reviewed for PASARR level 2. Findings include: R19's admission Minimum Data Set (MDS) indicated an admitted [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility document titled, Senior 'LinkAge Line, dated 12/2/20, indicated, yes for R19 having a major mental disorder diagnosable as listed in diagnostic and statistical manual of mental disorders. Yes for R19 having the major mental disorder having resulted in major life activities that would be appropriate for the persons development stage within the past 3 to 6 months. Yes to R19's treatment history indicated yes to one of the following; the psychiatric treatment is more intensive that outpatient care, or within the past two years and due to the mental disorder, the person has experienced an episode of significant disruption to the normal living situation for which supportive services were required. The document indicated R19's provided information meets criteria for Mental Illness (MI) and needs to be referred to lead agency for further evaluation (level 2 PASARR). R19's medical record failed to identify if R19 had been seen by a behavior health specialist until 2/2/22. Review of Psychiatry progress note from 2/2/22 review indicated R19 was not seen by behavioral Health specialist until 2/2/22 following admission of 1/12/22. Psychiatry progress note from encounter 2/2/22 identified R19 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's medical record from admission 1/12/22 through 9/21/22, did not indicate a level 2 PASARR had been completed since admission. When interviewed on 9/21/22, at 1:45 p.m. Social Services Director (SSD-S) stated they do not have a PASARR level 2 at this time for R19, and she had a call out to the county that day. The intent of the call was to understand what happened with R19's PASARR, and had not yet heard back from the county. When interviewed on 9/22/22, at 11:30 a.m. SSD-S described the process for how the facility reviews the need for a PASARR saying, It depends where the patient comes from, if the patient comes from the hospital the preadmission screening is completed by the hospital. If they come from home, the clinic social worker or we, at the facility complete it. If we complete it, then we would fax it out from our facility. The SSD-S stated, in the case of R19, she discharged to the community, so the hospital did not complete one, and that they had to contact Senior Linkage to get it faxed to them. The SSD-S closed with, Typically residents do not leave the hospital or get admitted unless the level 2 has already completed. Facility policy last approved 9/2022 for PASRR indicated purpose of proper screening to avoid unnecessary admissions, and to screen people for mental illness or developmental disabilities based on Omnibus Budget Reconciliation Act (OBRA). Under policy procedures section D: document directs social services will coordinate and ensure the competition of an annual resident review (PASRR Level 2) for each individual admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The level 2 update shall determine if continues placement at the facility is appropriate. The documentation will be maintained in the medical record. Resident #19

Based on interview and document review, the facility failed to ensure routine COVID-19 testing occurred for all exempted (not COVID-19 vaccinated) and not up-to-date (not vaccinated with all recommended COVID-19 vaccination(s)) staff according to the community transmission rates identified in CMS (Centers for Medicare and Medicaid) guidelines. In addition, the facility failed to ensure COVID-19 testing occurred for all impacted staff during an outbreak according to CMS guidelines for outbreak testing. This had the potential to affect all 69 residents who resided in the facility at the time of the survey. CMS Memorandum QSO-20-29-NH, revised 3/10/22, identified Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. The memo identified Routine Testing Intervals were to be twice a week for staff who were not up-to-date with recommended vaccinations when the county COVID-19 level was High (red). In addition, the memo identified any nursing home-onset COVID-19 infection in a resident triggered an outbreak investigation in which testing should begin immediately for all staff regardless of vaccination status. Facilities were provided two options for outbreak testing: contact tracing or broad-based (facility-wide) which also included an option for group-level testing. CDC (Center for Disease Control and Prevention) guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes, updated 2/2/22, identified if a health care worker was not -up-to-date with recommended vaccinations and worked infrequently at a facility, they should ideally be tested within the 3 days before their shift (including the day of the shift) when the county transmission rate was high. Review of the facility's community transmission rates from 5/23/22 to 6/20/22, indicated the facility was in the red (high) level which required COVID-19 testing two times a week for not up-to-date staff. A facility Positives in the Past Four Weeks list identified the following number of Pine Haven (secured memory care unit) residents who tested positive for COVID-19 on the associated dates: 6/13/22: two residents 6/15/22: eight residents 6/16/22: one resident 6/17/22: seven residents 6/18/22: one resident In addition, the facility list identified one [NAME] unit resident on 6/21/22 who tested positive for COVID-19. A provided Weekly Situation Update - Positive Resident email, dated 6/13/22, identified the facility experienced a HIGH COVID-19 transmission level and that day a resident on Pine Haven tested positive for COVID-19. The email directed Anyone who worked in Pine Haven starting Saturday June 11th needs to test: On Wednesday June 15th. Further direction on testing to come. In addition, the email directed not up-to-date and unvaccinated staff with a current exemption they needed to test twice weekly. A provided subsequent Weekly Situation Update - Positive Resident email, dated 6/21/22 at 7:57 a.m., identified the facility experienced a HIGH COVID-19 transmission level and there were 19 COVID-19 positive residents on Pine Haven. The email indicated the facility was in outbreak status in Pine Haven and again directed anyone who worked in Pine Haven starting 6/11/22 needed to test twice weekly, along with all staff who were not up-to-date and unvaccinated with exemption. Review of the facility's COVID-19 staff testing log spreadsheet revealed the following facility determined testing time-frames and adjustments: -6/3/22, 6/6/22, and 6/9/22 not up-to-date staff were to test two times a week. -6/14/22, 6/16/22, and 6/20/22 not up-to-date staff and Pine Haven staff were to test two times a week. -6/21/22 and 6/24/22 all staff were to test two times a week due to outbreak facility status. The spreadsheet, and facility provided working schedules, dated 6/3/22 through 6/24/22, indicated the following staff members who lacked identified evidence they performed twice a week and/or immediate COVID-19 testing per CMS guidelines in relation to their COVID-19 vaccination status and/or frequency of scheduled work and/or where they worked during the facility outbreak status when 20 of the residents tested positive for COVID-19 from 6/13/22 through 6/21/22. In addition, the staff data reflects information related to the day(s) worked and testing dates identified as completed. Exempted (non-vaccinated) staff (6/3/22 - 6/24/22): -Registered nurse (RN)-A worked five days with two of those on Pine Haven prior to testing on 6/16/22. -Nursing assistant (NA)-A worked five days on Lilac and [NAME]. No testing identified. -NA-B worked nine days with one of those days on Pine Haven. NA-B tested on [DATE] and 6/22/22. Not up-to-date (lacked recommended booster doses) staff (6/3/22 - 6/24/22): -Licensed practical nurse (LPN)-A worked on 6/7/22 and started twice weekly testing on 6/9/22. -Housekeeper (H)-A worked one day on 6/7/22 on Pine Haven. No testing identified. -H-B worked nine days before she tested on [DATE]. -Trained medication aide (TMA)-B worked six days before she tested on [DATE]. Five of those days were on Pine Haven. -TMA-D worked six days before she tested on [DATE]. -NA-C worked 12 days with four of those on Pine Haven. She tested on [DATE] and 6/24/22. -NA-E worked one day (6/7/22) before she tested on [DATE] and then worked two days after before she again tested on [DATE]. -NA-G worked seven days before she tested on [DATE]. -NA-L worked six days before she tested on [DATE]. -NA-N worked six days before she tested on [DATE]. -NA-O worked ten days before she tested on [DATE]. -Dietary aide (DA)-D worked 6/14/22, 6/15/22, 6/17/22, and 6/21/22. She tested on [DATE] and 6/18/22. The spreadsheet identified she worked every other weekend and lacked evidence she tested within three days of her shift. Pine Haven staff (Pine Haven outbreak) (6/13/22 - 6/24/22): -LPN-B worked three days beginning 6/13/22 before she tested on [DATE]. -TMA-C worked 6/17/22 before she tested on [DATE]. -NA-D worked two days (6/13/22, 6/15/22). No testing identified. -NA-F worked two days (6/14/22, 6/20/22). In addition, she worked on 6/24/22 on another unit. She tested on [DATE]. -NA-H worked five days beginning 6/18/22 before she tested on [DATE]. -NA-I worked four days beginning on 6/17/22. No testing identified. -NA-J worked five days beginning on 6/18/22. No testing identified. -NA-K worked 6/15/22 and tested on [DATE]. -NA-M worked nine days beginning on 6/14/22. No testing identified. -NA-S worked on 6/16/22. No testing identified. -NA-T worked five days beginning 6/13/22 before she tested on [DATE]. -NA-Q worked four days beginning 6/15/22. No testing identified. -H-C worked three days beginning 6/13/22 before she tested on [DATE]. -DA-E worked three days beginning 6/13/22. No testing identified. Facility staff (all facility outbreak) (6/21/22- 6/24/22): -DA-A worked two days (6/22/22 and 6/24/22). No testing identified. -DA-B worked two days (6/21/22 and 6/22/22). No testing identified. -DA-C worked two days (6/21/22 and 6/24/22). No testing identified. -DA-F worked three days beginning 6/22/22. No testing identified. -DA-G worked three days beginning 6/21/22. No testing identified. -TMA-A worked four days (6/21/22 through 6/24/22). No testing identified. -NA-P worked on 6/21/22. No testing identified. -NA-R worked three days beginning 6/21/22. No testing identified. -H-D worked two days (6/21/22 and 6/22/22) prior to testing on 6/24/22. During interview on 6/27/22, at 1:25 p.m. the administrator stated COVID-19 staff testing was based off of vaccination status and county transmission rates. She explained COVID-19 testing for staff not up-to-date was expected to be completed twice a week. For staff who worked every other weekend, they were expected to test two to three days before their shift. Staff obtained two to four Vault testing kits from the facility each week in which they were allowed to test whenever they want as long as they tested twice a week and at least two days apart from each other. Staff performed the tests either at the facility or at home. She stated Vault testing was initiated approximately three months earlier. Lab results took approximately two days to receive back from Vault and if the result was inconclusive, or the staff was symptomatic, they were required to follow up with employee health for a rapid swab test. She indicated the facility continued to use Vault for testing instead of conducting rapid testing once the outbreak was identified as staff are very good at wearing all of their PPE (personal protective equipment) and are being good at reporting symptoms. The administrator explained upon COVID-19 being identified on Pine Haven, contact tracing was attempted and inconclusive, thus, all staff who worked on Pine Haven were tested within two to three days. Further, she explained being the initial positive residents were contained within Pine Haven, Pine Haven group-level staff testing was conducted; however, once a positive resident was identified on 6/21/22, facility wide staff testing was initiated and continued. With review of staff testing and vaccination spreadsheet, the administrator confirmed there were staff who lacked the required twice a week testing. She explained she reviewed lab results one or two times a week depending on when the results were received back; however, she denied she performed a formal audit each week which ensured all staff tested as required. The administrator verbalized when staff failed to test as directed it placed the facility at risk for COVID-19: Unless we know they [staff] are negative [for COVID] they are potentially at risk for having COVID even if asymptomatic. When interviewed on 6/28/22, at 12:08 p.m. NA-Q stated she typically worked on Pine Haven and acknowledged she entered COVID-19 positive resident rooms. She acknowledged she was expected to test twice a week and tested , whenever I get around to it .usually on my days off. She stated she was about two weeks behind on testing .it has been so busy. She stated she was informed to stay out of other neighborhoods as much as possible and thus was unable to obtain tests. She did confirm she could have asked another staff to obtain them for her. She verbalized the importance of testing was due to increased number of COVID-19 positive residents within the facility; however, she did not think the residents were at risk due to her lack of expected testing. When interviewed on 6/28/22, at 12:24 p.m. dietary aide (DA)-E acknowledged she primarily worked on Pine Haven and interacted with residents. She stated she knew COVID-19 positive residents resided on that unit. She explained she was first directed to test twice a week on 6/27/22 as no one instructed her to test prior to that. She stated important facility updates were provided by her supervisor or through her email; however, she acknowledged she does not routinely check her email despite her being expected to check her email at least once every day due to lack of time either at home or at work. She reported, I obviously work in the area where there is COVID and we need to know if we are positive so we do not get residents or other employees sick with COVID. During interview on 6/28/22, at 12:51 p.m. DA-G stated she started testing maybe eight or ten days ago and she was expected to test twice a week; however, when questioned when she tested she indicated she just sent one in today and could not identify any other specific dates. She stated, I do not think I got the test results back. DA-G explained she did not like to test and stated, just seems like everybody is vaccinated anyways .most everybody. We keep our distance and we wear our masks. I honestly do not see an issue [risk of not testing as expected] as she interacted with residents very little and her only interaction basically was when she brought the residents their plates. When interviewed on 6/28/22, at 1:10 p.m. NA-A stated she tested twice a week as she was unvaccinated which was expected since her hire date three or four months ago. She indicated she tested twice a week; however, acknowledged she missed some testing and did not always test twice a week. She explained her busy life and work schedules were the reasons for the missed tests. She verbalized expected testing was important in order to make sure she remained healthy, that she did not cross contaminate between the two facilities she worked at. When interviewed on 6/28/22, at 1:16 p.m. H-D stated she was not scheduled to work on Pine Haven when residents were identified with COVID-19; however, she worked when other unit residents tested positive for COVID-19. She indicated she was informed of the expected twice weekly testing on 6/24/22. H-D explained if testing was not performed as expected the residents were at risk for COVID-19. When interviewed on 6/28/22, at 1:32 p.m. housekeeping director (HD) stated staff were expected to test twice a week right now. She indicated she sent out an email on 6/23/22 to housekeeping staff which directed twice a week testing. She denied knowledge some of the housekeeping staff lacked expected testing since the facility was determined to be in a facility wide outbreak status on 6/21/22. She acknowledged there was a definite infection control risk if staff lacked required testing as management needed to know if staff brought infection(s) into the building in order for the residents to be kept safe from those potential infections. When interviewed on 6/28/22, at 3:02 p.m. dietary manager (DM) stated everybody should be testing twice a week with two full days between each test .regardless of vaccination status. She denied knowledge any of her dietary staff were behind in such testing and she denied she was involved in any auditing to ensure her staff followed the testing requirements. DM explained expected testing was important to see if it [COVID-19] has been transmitted and you have to keep testing as the incubation period is different for each person. In addition, she explained staff could be asymptomatic and spread COVID-19 if they could touched their mask, which was so easy and then they touched the residents' silverware or plates. When interviewed on 6/28/22, at 3:21 p.m. nurse manager RN-B stated all staff were testing twice a week due to the facility being in outbreak status. She explained initially unvaccinated staff were expected to test twice a week; however, when COVID residents were identified on Pine Haven, then the staff exposed on Pine Haven started to also test twice a week. RN-B stated when a non-Pin Haven resident tested positive then all staff were expected to test twice a week. She explained after she received an email notification on 6/21/22 which identified all staff were to test twice a week she sent a text message to nursing staff which updated staff on the email delivered information. RN-B stated she spoke to the ICP after the initial positive residents were identified and the ICP encouraged staff to test at least once that week; however, two times was best and then continue with twice weekly testing after that. RN-B denied involvement in auditing the testing spreadsheet; however, she did acknowledge the administrator had emailed her staff information prior about staff not being up-to-date on testing. Once she received that information, she emailed the staff about the need for testing. She explained if there were no staff response received back, or administrator follow-up response, she assumed they completed the missed test. She expressed surprise at the facility currently having missed tests and explained there was a lot of transition on status testing needs. RN-B stated lack of required testing placed residents at risk for COVID as the residents could potentially be exposed from asymptomatic staff. During interview on 6/28/22, at 3:56 p.m. the infection control preventionist (RN)-C stated she initially was informed staff were not testing as expected when she was informed of the potential infection control deficiency related to an issue with staff testing. She denied she was allowed access to the testing spreadsheet and she acknowledged she was not involved in any audits to ensure staff tested as expected. RN-C explained unvaccinated staff no matter what tested twice a week due to the high county transmission rate. Further, she explained when COVID-19 was identified on Pine Haven, those staff were also expected to test twice a week as they were able to keep the doors locked and it was contained to just one area. Once COVID-19 was identified on another unit, all staff were then to be tested twice a week. She stated twice a week testing was important to help mitigate the spread of COVID-19 in the facility. During interview on 6/28/22, at 4:27 p.m. the director of nursing (DON) stated the administrator updated her on 6/24/22 staff were behind on the required twice a week testing. Prior to 6/24/22, she denied such knowledge. She stated she was allowed access to the testing spreadsheet; however, she had not reviewed it recently. The DON stated she expected staff to follow the testing requirements as staff could potentially be asymptomatic and spread COVID. A policy COVID-19 Staff and Resident Testing Plan, dated last reviewed 4/2022, indicated COVID-19 testing was a priority to help inform clinical care and infection prevention and control practices in their setting. The policy directed whole house surveillance testing or targeted surveillance testing of staff when the following situations occurred based on the guidance from Minnesota Department of Health: one or more residents are confirmed to have COVID-19, a cluster (two or more) residents and/or staff develop symptoms consistent with COVID-19.