Every finding on record at Cura of Sauk Centre

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with dignity and respect for 1 of 3 residents (R26) reviewed for dignity.Findings include:R26's annual Minimum Data Set (MDS) dated [DATE], identified R26 had severe cognitive impairment and required assistance with all activities of daily living (ADLs). R26's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by a physical injury), arthritis (inflammation of the joints causing pain and stiffness), Alzheimer's disease (a progressive brain disorder that causes memory loss and cognitive decline), and spinal stenosis (narrowing of the spinal canal that can cause pain or nerve pressure). During observation on 3/3/26 at 11:28 a.m., R26 was observed sitting in a wheelchair in the dining room. A mechanical lift sling remained under R26. The leg straps of the sling were positioned upright between R26's legs and were visibly protruding upward. The straps were visible to others in the dining room. During observation on 3/3/26 at 4:12 p.m., R26 was observed in the chapel seated in a wheelchair with the mechanical lift sling still in place. The sling leg straps were again observed sticking straight up between R26's legs and were visible to other residents and staff in the area. R26's comprehensive care plan, printed 3/5/26, indicated it was acceptable to leave the sling underneath R26 for safety and potential skin alteration; however, the care plan did not include instructions regarding positioning of the sling while R26 was seated in common areas. During an interview on 3/05/26 at 8:31 a.m., nursing assistant (NA)-B stated the Hoyer sling was typically left under R26 while seated in the wheelchair. NA-B stated the sling should have been tucked in as much as possible around the sides, so it was not visible. NA-B further stated the leg straps should have been removed from between R26's legs and tucked in as much as possible so they were not noticeable in order to maintain R26's dignity. During an interview on 3/05/26 at 8:34 a.m., registered nurse case manager (RN)-A stated the Hoyer sling was care planned to be left under R26, and staff should have ensured the sling was not folded or positioned off to the side. RN-A stated the sling should have been tucked in as much as possible. RN-A further stated the leg straps should have been removed from between R26's legs and tucked under the legs. RN-A confirmed the straps should not have been left between R26's legs or sticking up, as this would have been a dignity concern. During an interview on 3/05/26 at 11:25 a.m., the director of nursing (DON) stated if the Hoyer sling was left under R26 while seated in the wheelchair it would typically be care planned, as removing the sling could cause more harm to R26 due to rigidity. The DON stated staff were expected to tuck the sling in as much as possible, so it was not highly visible. The DON further stated the leg straps should have been removed from between R26's legs and tucked in, or a lap blanket could have been placed across R26's lap to cover the sling. The DON confirmed leaving the straps between R26's legs would have been a dignity concern. Review of the facility policy titled Quality of Life - Dignity, dated 10/25, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy further indicated that residents shall be treated with dignity and respect at all times.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's clinical status for 1 of 3 residents (R3) reviewed for MDS accuracy.Findings include:R3's significant change Minimum Data Set (MDS), dated [DATE], identified R3 had severe cognitive impairment and required assistance with all activities of daily living (ADLs). R3's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by physical injury), hypertension (high blood pressure), diabetes mellitus (high blood sugar due to insulin problems), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), overactive bladder (frequent and urgent need to urinate), sacrococcygeal disorder (condition affecting the sacrum or tailbone), chronic pain (long-lasting pain), obstructive sleep apnea (breathing repeatedly stops during sleep), pain in the thoracic spine (pain in the middle portion of the spine), hallucinations (seeing or hearing things that are not present), retention of urine (inability to fully empty the bladder), and insomnia (difficulty sleeping). The MDS indicated R3 experienced one fall with a major injury since admission. Review of R3's progress notes and incident documentation dated 8/28/25 through 11/30/25, indicated R3 experienced falls on 8/28/25, 9/2/25, 9/5/25, 9/7/25, 9/18/25, 9/23/25, 9/25/25, 10/5/25, 10/20/25, 10/22/25, 10/24/25, 10/28/25, and 11/3/25. Documentation did not identify R3 sustained a major injury, such as a fracture, dislocation, closed head injury with altered consciousness, or another injury requiring extensive medical intervention as a result of any one of these falls. During an interview on 3/4/26 at 3:41 p.m., the MDS Coordinator (MDS) confirmed the MDS indicated R3 experienced a fall with major injury and stated R3 did not sustain a major injury from the fall and that it must have been accidentally coded incorrectly. During an interview on 3/4/26 at 3:52 p.m., the Director of Nursing (DON) stated R3 had not experienced a fall with a major injury since admission on [DATE]. The DON stated MDS assessments should always be double-checked to ensure they included accurate and correct information before submission. Review of the facility policy titled Minimum Data Set, Management of, Long Term Care, dated 1/25, indicated the facility would ensure the MDS was accurately and comprehensively completed.

Based on observations, interviews and document review, the facility failed to comprehensively develop a resident care plan for 1 of 1 resident (R48) reviewed for pain management.Findings Include: R48's diagnoses report, print date 3/5/26, included the following: other displaced den's fractures (a break in the upward bony projection of the second cervical vertebra, causing severe neck pain and instability), cervicalgia (pain in the cervical spine (neck), sprain of right acromioclavicular joint (located at the top of the shoulder). R48's quarterly minimum data set (MDS) dated [DATE] indicated R48 was independent with activities of daily living, frequently experienced pain, with a BIMS (brief interview for mental status) of 13 - cognitively intact. A review of R48's Care Area Assessment (CAA), dated 11/04/25, documented the following:[R48] is an 80 [year old] male admitted to facility for continued rehab and pain control after a hospital stay in St. Cloud and subsequent swing bed stay in Sauk Centre hospital after a fall causing Type III fracture of odontoid process, closed. Other diagnoses include [hypertension],chronic A-fib, cognitive impairment. Resident is alert and oriented, with short-term forgetfulness. Vital signs stable. Vision adequate with use of eyeglasses, minimal difficulty hearing, some wax present in bilateral ears on admission. No dental issues noted. Resident has no ROM limitations except for his neck, C-collar in place to keep resident from moving neck until it is healed. Resident is independent with eating, rolling left and right; set up assist needed for oral hygiene; supervision needed for toileting hygiene, upper body dressing, personal hygiene, sitting to lying, lying to sitting, sit to stand, chair to bed to chair transfers, ambulation, substantial [maximum] assist for putting on/taking off footwear. Resident is continent of bowel, utilizes MiraLAX 17 grams daily and senna-docusate 2 tabs twice daily due to narcotic use, has BM?s 4-6X weekly. Resident is continent of bladder, voids 3-4 times daily. Staff provide A1 with toileting tasks. Resident is at risk for falls d/t history of falls, medication use. Does have history of X2 falls at home. No falls in facility at this time. Falls prevention interventions in place, see care plan. Resident is at risk for pressure ulcer formation d/t potential for bladder incontinence, decreased activity, pain and narcotic use, use of C-collar. Resident is independent with mobility in bed, has pressure reduction mattress on bed, dressings in place under edges of C-collar for padding and skin breakdown prevention. Resident does [complained of] pain that varies at times dependent on position of neck even with C-collar on. Describes pain as aching, sharp, tender, shooting and dull at times. He does report difficulty sleeping and waking often due to pain. Pain relief includes scheduled and prn pain medication, frequent position changes, cold packs, distraction which seem to be effective. Will continue to monitor for any issues or complaints. Will proceed to care plan.During interview on 3/02/26 at 3:58 p.m., R48 stated prior to admission he was home doing laundry in the basement. When R48 took his laundry basket to the top of the stairs, he threw the basket onto a shelf causing him to loose balance and fell backwards down the stairs. R48 stated he felt sore, but needed to get to a family gathering in Sauk Centre. R48 stated he drove himself to the reunion, afterwards driving himself to the emergency room in Sauk Centre, where was diagnoses with the shoulder and neck fractures. R48's Medication Review Report (print date of 3/05/26) included the following medications: Tizanidine HCL (Zanafex) 2 milligrams (mg) 1 tablet orally every 8 hours as needed (short-acting, centrally acting skeletal muscle relaxant) for displaced DENS fracture with routine healingVoltaren External Gel 1% (diclofenac sodium) topical cream apply to all joints three times a day (nonsteroidal anti-inflammatory topical cream)Acetaminophen 500 mg - 2 tablets orally three times a day for displaced DENS fracture with routine healingLidocaine External Patch 4% - apply to right shoulder as needed (PRN)- removed after 12 hourscholecalciferol 25 micrograms (mcg) give one tablet every day - displaced DENS fracture with routine healingAscorbic acid oral tablet 500 mg chewable (vitamin C) once a day - displaced DENS fracture with routine healing R48's medication administration records (MAR) for February 2026 and March 1-5, 2026 documented R48 had only been taking the the ascorbic acid, acetaminophen, and cholecalciferol. R48's MARs indicated resident had not been requesting his as needed (PRN) medications of Tizanidine HCL, Lidocaine External Patch 4%, nor Voltaren External Gel 1%. R48's Pain Evaluation - Assessment - V3 (dated 1/23/26), indicated R48 was currently experiencing pain, described as sharp and tender, which varied during the day, with the facility comments as follows:resident has had decrease in pain with healing of fracture, worked with PT [physical therapy] on right shoulder pain. Resident is in process of weaning brace from fracture and occasionally gets a sharp pain when turninghead at night. Pain goes away with repositioning. R48 stated no longer needing narcotic pain medication. Has PRN medication available. No referrals indicated. R48's comprehensive care plan (print date 3/04/26) lacked evidence the facility had comprehensively developed R48's care plan to include his pain concerns. During interview on 3/04/26 at 12:51 p.m., care manager (RN)-A, after reviewing R48's care plan stated R48's care plan lacked documentation of resident's pain issues. The MDS coordinator (RN)-B stated when R48 was admitted to the facility, he was on a different unit and assessed and care planned by a newer care manager. RN-A stated when R48 was transferred to her unit in January 2026, she should have reviewed R48's care plan more closely. RN-B stated R48's care plan did mention resident was on pain medications, however after further review, pain [medications] were mentioned was under R48's nutritional problem. In an interview on 3/5/26 at 9:27 a.m., director of nursing (DON) stated it was the expectation, when residents have been comprehensively assessed, all areas of concerned identified, would be comprehensively care planned, so that facility staff would be aware of the issues of each resident. In review of the facility policy, entitled: Care Plans, Comprehensive Person-Centered (effective date 02/2025) indicated the following in section 8:8. The Comprehensive, person-centered care plan will:a. include measurable objectives and timeframes;b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;c. describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;d. describe any specialized services to be provided as a result of PASARR [Preadmission Screening and Resident Review] recommendations;e. include the resident's stated goals upon admission and desired outcomes;f. include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such desire;g. incorporate identified problem areas;h. incorporate risk factors associated with identified problems;i. build of the resident's strengths; j. reflect the resident's expressed wishes regarding care and treatment goals;k. reflect treatment goals, timetables and objectives in measurable outcomes;l. identify the professional services that are responsible for each element of care;m. aid in preventing or reducing decline in the resident's functional status and/or functional level;n. enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. reflect currently recognized standards of practice for problem areas and condition.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented to prevent potential contamination of oxygen equipment when oxygen tubing was observed lying on the floor with the nasal cannula prongs touching the floor for 1 of 2 residents (R3) reviewed for infection control.Findings include:R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required assistance with all activities of daily living (ADLs). R3's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by physical injury), hypertension (high blood pressure), diabetes mellitus (high blood sugar due to insulin problems), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), chronic pain (long-lasting pain), and obstructive sleep apnea (breathing repeatedly stops during sleep). During observation and interview on 3/02/26 at 2:42 p.m., R3 stated she wore oxygen only at nighttime and required staff assistance to apply and remove the nasal cannula. The nasal cannula was observed lying on the floor with the prongs, which are inserted into the resident's nose when in use, touching the floor. During observation on 3/03/26 at 11:14 a.m., oxygen tubing was observed on the floor at the end of R3's bed with the nasal cannula prongs touching the floor. During observation on 3/03/26 at 2:15 p.m., oxygen tubing remained on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor. During observation on 3/04/26 at 8:30 a.m., oxygen tubing noted on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor. During observation on 3/04/26 at 12:16 p.m., oxygen tubing remained on the floor at the end of R3's bed next to the oxygen concentrator with the nasal cannula prongs touching the floor. R3's order summary report, dated 3/5/26, indicated an order initiated on 12/10/25 for supplemental oxygen at 2 liters per minute (LPM) at NOC (bedtime) for nocturnal hypoxia identified during a sleep study. During interview on 3/04/26 at 1:46 p.m., nursing assistant (NA)-A stated R3 required assistance removing the oxygen in the mornings as R3 only wore oxygen at night. NA-A stated the nasal cannula should be draped over the end of the bed or the oxygen concentrator when not in use and should not touch the floor. During interview on 3/04/26 at 2:50 p.m., licensed practical nurse (LPN)-A stated oxygen tubing should never touch the floor due to infection control concerns. During a joint interview on 3/04/26 at 3:41 p.m., registered nurse case manager (RN)-A and MDS registered nurse (RN)-B stated R3 wore oxygen at night, and the oxygen tubing should not be on the floor. RN-A and RN-B stated allowing oxygen tubing to touch the floor was an infection control concern. During interview on 3/04/26 at 3:52 p.m., the director of nursing (DON) stated oxygen tubing should not be placed on the floor when not in use due to infection control concerns. Review of the facility policy titled Infection Prevention and Control, dated 1/2026, indicated the facility was to maintain equipment in a sanitary condition and implement appropriate infection control practices to prevent contamination and the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were revised to reflect current conditions and interventions for 1 of 2 residents (R13) reviewed for Enhanced Barrier Precautions.Findings include:R13R13's annual Minimum Data Set (MDS), dated [DATE], identified R13 had moderate cognitive impairment and required assistance with some activities of daily living (ADLs). R13's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by physical injury), non-Alzheimer's dementia (cognitive decline not related to Alzheimer's disease), strength), low back pain (pain in the lower spine), obesity (excess body weight), and nonrheumatic mitral valve insufficiency (leakage of the mitral heart valve). The MDS indicated R13 was at risk for developing pressure ulcers/injuries and did not have an unhealed pressure ulcer at that time. R13's comprehensive care plan, with a print date of 2/24/26, included the following interventions, which were initiated on 11/5/25 and remained active:Resident was on Enhanced Barrier Precautions per CDC recommendations for a Stage 2 pressure ulcer.Remain free from multidrug-resistant organisms (MDROs).Use gown and gloves for high-contact resident care activities.Make personal protective equipment (PPE) available outside of the room.Post clear signage indicating required precautions and PPE.Provide education to the resident and visitors. Review of progress notes indicated:On 1/8/26 at 4:07 p.m., R13 was evaluated by the MNDOTA Health Wound Clinic Nurse Practitioner, and right and left ischial tuberosity wounds were identified as healed.On 1/15/26 at 2:12 p.m., skin assessment revealed no open areas, with reddened but blanchable skin.On 1/22/26 at 12:00 p.m., previously affected areas remained healed with intact, blanchable skin and no new concerns identified. Review of R13's electronic medical record (EMR) identified R13 previously had wounds to the right and left ischial tuberosities, which had resolved on 1/8/26. However, review of the comprehensive care plan revealed continued inclusion of interventions for enhanced barrier precautions (EBP) related to wound care, despite the wounds being resolved and EBP no longer being implemented. During observation on 3/2/26 at 1:16 p.m., no EBP precautions were in place for R13, including no signage posted outside the resident's room and no personal protective equipment (PPE) cart present. During an interview on 3/3/26 at 12:52 p.m., R13 stated prior sores to the buttocks had healed approximately one month earlier and confirmed no current open areas. During a joint interview on 3/4/26 at 3:37 p.m., the registered nurse case manager (RNCM) and infection preventionist (IP) stated R13 had no current wounds and confirmed the wounds had resolved on 2/5/26. They further stated R13 was no longer on EBP precautions and acknowledged the care plan should have been updated to remove these interventions. They indicated it was important for the care plan to accurately reflect current interventions to ensure staff followed appropriate care and understood the resident's overall needs. During an interview on 3/4/26 at 3:49 p.m., the Director of Nursing (DON) stated care plans were to be updated with any changes in a resident's condition or care needs. The MDS process, including quarterly assessments, should prompt review and revision of the care plan. The DON further stated updates should be reflected in the care plan and any related signage should be removed immediately when no longer applicable. The DON indicated the care plan was an ongoing document intended to guide staff in providing appropriate care based on the residents' current needs. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated 2/2025, indicated a comprehensive, person-centered care plan with measurable objectives and timelines was to be developed and implemented for each resident. The policy further indicated resident assessments were ongoing and care plans were to be revised as the residents' condition changed.

Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 1 resident (R35) reviewed for medication errors. This failure resulted in actual harm for R35 when she had a fall, sustaining a minor head injury, developed tachycardia (abnormally fast heart rate) and became hypertensive (abnormally high blood pressure) which required ongoing monitoring in the emergency department (ED). The facility had implemented appropriate corrective action prior to the onsite investigation, therefore the deficiency is being cited at past non-compliance. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R35's diagnoses included non-traumatic brain dysfunction, hypertension, diabetes mellitus, non-Alzheimer's Dementia, anxiety disorder, nocturia, and generalized edema. A facility report to the State Agency (SA) on 3/24/25, indicated on 3/24/25 at 7:45 a.m., R35 received another resident's medications, and had been sent to the hospital. On 3/24/25 at 8:30 a.m., a progress note indicated R35 had an unwitnessed fall at 8:15 a.m., where R35 obtained a laceration above her left eyebrow. R35 was sent to the emergency room (ER) for further evaluation based on recent received medication that was intended for another resident. On 3/24/25 at 8:45 a.m., a progress note indicated R35 was administered wrong medications. Order written for evaluation and treatment at the ER. R35's Blood Pressure and Pulse Summary dated 4/8/25 indicated on 3/24/25, R35 had a blood pressure (BP) of 179/123, and heart rate (HR) was 129 at 8:05 a.m. At 8:15 a.m. R35's BP was 169/105 and HR was 114 beats per minute (bpm). Normal blood pressure is 120/80 and normal pulse is 60-100 bpm. R35's Emergency Department Note dated 3/24/25, indicated R35 was given the following medications the morning of 3/24/25: acetaminophen 650 milligrams (mg) - two tabs, aspirin (blood thinner) 81 mg , calcium 600+vitamin D 600-400 mg, citalopram hydrobromide 20 mg (selective serotonin reuptake inhibitor), lisinopril 40 mg (blood pressure medication), metoprolol succinate ER 200 mg (blood pressure medication), omeprazole 20 mg (heartburn medication), primidone 250 mg (seizure medication), torsemide 20 mg (diuretic), and vitamin D 1000 units. R35's hospital History and Physical Summary dated 3/24/25, indicated R35 was accidentally given the wrong medications on the morning of 3/24/25. R35 had the following symptoms: weakness and hypertension. Computed tomography (imaging test that detects injuries) of head was performed with no abnormalities noted. Per note, pharmacy was updated and advised the metoprolol would peak at about 2:00 p.m. that afternoon so R35 needed to have her blood pressure and heart rate monitored frequently. ER doctor indicated monitoring of vitals should be able to be accomplished at the care center and parameters were given for when to notify if needed. ER final diagnoses included: minor head injury and accidental drug ingestion. On 3/24/25 at 1:15 p.m., a progress note indicated R35 returned from the ER at approximately 11:00 a.m., vital signs were obtained upon her return with BP being 193/103 and 191/118 and her HR was 75 and 76 bpm. New orders indicated for staff to administer morning scheduled doses of duloxetine, potassium, preservision, and sucralfate; staff to hold morning doses of Tylenol, lisinopril (ACE inhibitor- heard medication), protonic (for gastric reflux, and furosemide (diuretic) and resume usual medications orders on 3/25/25; and for staff to check BP and HR hourly until 4:00 p.m., then every four hours for the next 24 hours - and to notify on call provider if R35's heart rate is less than 50 bpm or systolic blood pressure (SBP) is less than 100. On 3/25/25 at 9:48 a.m., registered nurse (RN)-B sent a message to nurse practitioner stating Resident was given another residents medications yesterday and following meds had a fall in the bathroom. We sent her to the ER; Resident per ER was to have BPs every hour until 4:00 p.m. and then every four hours for 24 hours. BPs and HRs were not consecutively gotten. Staff was to update MD on call is SBP was less then 100 or HR was less then 50 bpm. All SBPs that were taken were greater then 140 and all HRs were greater than 65. BPs and HRs were taken hourly upon readmission at 11:00 a.m. until 2:00 p.m. then not again until 10:40 p.m., then has been every four hours since then. On 3/25/25 at 1:03 p.m., nurse practitioner responded that staff could go back to standard vital checks with no further monitoring needed. On 4/9/25 at 3:36 p.m., RN-C stated on 3/24/25, during the morning medication pass, she set up multiple residents' medications in med cups that she initialed with their first and last name initials and placed them in the top drawer of the medication cart to administer at a later time. RN-C stated when she went to administer R35's medications, she gave R35's another resident medications as she had mislabeled the medication cup. RN-C stated when she realized the error, she notified the RN clinical coordinator immediately who instructed her to wait 30 minutes and to then obtain R35's vital signs as that would be when the medications could start working. RN-C stated R35 then fell approximately 30-40 minutes after she had administered her the wrong medications. RN-C was removed from passing medications and had to complete an education module on medication administration. RN-C was told she needed to leave the facility pending investigation. RN-C had since been re-educated and was now aware that pre-preparing medications was not an acceptable practice, and she would not be doing it in the future. On 4/9/25 at 4:47 p.m., consultant pharmacist (Pharm D) stated after she reviewed the medications R35 received in error, she was concerned about R35's blood pressure as she received high doses of blood pressure medications and seizure medication. Per email from Pharm D to the facility: Based on the medications received, particularly higher doses and multiple medication classes, I do think it is likely that the fall was a result of the medication error. Primidone alone has an onset of as little as 30 minutes. Many of the other medications have a peak within an hour. Pharm D stated it would not be acceptable for nurses to prepare more than one person's medications at one time ever. Pharm D stated due to the multiple significant medications that were not R35's, she would consider this a significant medication error. On 4/10/25 at 10:11 a.m., the director of nursing (DON) stated the process of passing medications staff was to follow the medication rights, and to prepare medications for one resident at a time. The policy was not followed by RN-C on 3/24/25. The facility had reviewed the medication administration and medication incident policy, revised the medication administration standards policy, reviewed R35's care plan, started medications administration audits, and education was provided to nurses in regard to medication pass expectations. DON stated it was not appropriate for staff to pre-set-up medications and place them in the top drawer of the medication cart to administer at a later time as that can lead to a medication error. The facility Medication Administration policy dated 2/2025, identified staff administering medication would perform ongoing monitoring of the resident's response to medications administered. Medications are to be administered in a timely manner, accurately and in a way to allow for maximum benefit. Personnel administering medications practice safe medication administration including the correct process for resident identification. Medications will not be prepared without the intent to administer, known as pre-pouring or pre-setting. The facility implemented corrective action to prevent recurrence by 3/28/25 when the facility completed the following: Reviewed and revised medication administration policies, provided education to all staff members responsible for medication administration, which included administration of medications and ensuring the six rights of medication administration was being followed, and completed medication administration audits. Verification of corrective action was confirmed by observation, interview, and document review on 4/10/25.

Based on observation and document review, the facility failed to ensure the required nurse staffing information was posted daily for 3 of 3 days reviewed. This had the potential to affect all 48 residents residing in the facility, visitors and staff who may wish to view the information. Findings include: During observation on 4/7/25 at 11:32 a.m., the nurse staffing information was posted on wall inside the entrance of the facility. However, the posted nurse staffing information was dated for 4/7/25 and 4/8/25. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted on specific units of the facility labeled Team Leader LPN [licensed practical nurse] [NAME] Oaks and Charge Team Lead LPN Whispering Pines During observation on 4/8/25 at 8:00 a.m., same nurse staffing information remained posted on wall from 4/7/25. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted under the section labeled Team Leader LPN [NAME] Oaks and Charge Team Lead LPN Whispering Pines During observation on 4/9/25 at 8:15 a.m., the nurse staffing information dated for 4/9/25 and 4/10/25 was posted. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted under the section labeled Team Leader LPN [NAME] Oaks and Charge Team Lead LPN Whispering Pines During interview on 4/10/25 at 8:52 a.m., business office manager (BOM) confirmed she completed the daily staff postings and posts them to let staff know where they are working and she tried to keep it updated as much as possible. BOM stated she posts two days at a time. BOM confirmed there were TMA's listed under the Team leader LPN section, the facility name was not included on posting and the current census was not reflected on posting. BOM stated it was important to have the correct information so families and resident know the numbers of staffing the facility was running with, ensures we had the correct number of staff on so if something happened, we would have proof that we were properly staffed. BOM stated it was important to have staff listed under the correct titles because it could be false information and give off the wrong information as there are many things an LPN could do that a TMA could not legally do. During interview on 4/10/25 at 10:11 a.m., director of nursing (DON) stated the daily staff posting was for compliance. DON stated TMA's should not be listed under the LPN section as that was false documentation and families could think the TMA was able to do things that an LPN should do. DON confirmed posting did not contain the facility name or the current census. The facility's Posting of Nursing Hours policy, dated 4/25, indicated the facility posted nursing staffing data was to make staffing information readily available for resident and visitors at any given time. Staffing personnel and/or their designee will post the following daily information in a prominent area of the facility: 1. Facility name 2. Current date 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

Based on interview and document review, the facility failed to ensure medication regimens were free of unnecessary psychotropic drugs for 3 of 6 (R20, R43 and R6) residents reviewed who had orders for antianxiety medications beyond 14 days without documented rational. Findings include: R20's significant change Minimum Data Set, dated [DATE], identified severely impaired cognition with diagnosis of Alzheimer's dementia. R20's order listing report dated 4/10/25, identified an order for prn (per requested need) for Ativan (an antianxiety medication) oral tablet 0.5 mg (milligrams) to be given by mouth every 4 hours as needed for terminal agitation with a start date of 2/28/25 and an end date of 2/21/26. R20's care plan dated 2/5/25, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety medication and directed staff to ensure minimum effective therapeutic dosing. R20's February 2025 medication administration record (MAR) indicated she had not used prn Ativan. R20's March 2025 MAR indicated she had used prn Ativan one time. R20's April 2025 MAR indicated she had not used prn Ativan. When reviewed on 4/10/25, R20's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. R43's quarterly MDS dated [DATE], identified intact cognition and a diagnosis of anxiety. R43's order listing report dated 4/10/25, identified an order for prn Ativan oral tablet 0.5 mg by mouth one time a day for anxiety and give 0.5 mg by mouth as needed for anxiety with a start date of 4/7/25 and an end date of 10/3/2025. R43's care plan dated 8/27/24, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety and directed staff to ensure minimum effective therapeutic dosing. R43's April 2025 MAR indicated she had used prn Ativan two times. When reviewed on 4/10/25, R43's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. R6's significant change Minimum Data Set, dated , 1/31/25 identified severely impaired cognition, diagnoses of Alzheimer's dementia. R6's order listing report dated 4/9/25, identified an order for prn (per requested need) for Ativan (an antianxiety medication) oral tablet 0.5 mg (milligrams) to be given by mouth every 4 hours as needed for terminal agitation with a start date of 2/13/25 and an end date of 1/12/26. R6's care plan print date of 4/9/25, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety medication and directed staff to ensure minimum effective therapeutic dosing. R6's February medication administration record (MAR) indicated she had not used any prn Ativan. R6's March 2025 MAR indicated she had not used any prn Ativan. R6's April 2025 MAR indicated she had not used any prn Ativan. When reviewed on 4/10/25, R6's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. When interviewed on 4/9/25 at 4:47 p.m., the pharmacy consultant (Pharm D) stated a review of resident medications was completed monthly including any psychotropic (drugs that affect thoughts, behaviors, mood and perception) medications. The Pharm D stated any prn psychotropic medication including antianxiety medications such as Ativan were to be ordered only for a 14-day period and any continuation beyond that timeframe required review by and a statement of clinical rationale by the resident's provider. The Pharm D confirmed there was no documented clinical rationale for the extended prn Ativan orders for R20, R43 and R6 and she should have made this recommendation to their providers. When interviewed on 4/10/25 at 9:29 a.m., the director of nursing (DON) stated the facility process for review of psychotropic medications was done by the facility interdisciplinary team (IDT) monthly. The DON stated her expectation for R20's, R43's and R6 prn antianxiety medication orders would have been to have had a 14-day end date or review and provider clinical rationale for continued use and acknowledged this had been missed for R20, R43 and R6. The facility policy Psychotropic Medication Management-Long Term Care dated 10/2023, identified As needed orders for psychotropic drugs (with the exception of anti-psychotics) are limited to 14 days. Unless, the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days in which case he/she should document their rationale in the resident's medical record and indicate the duration for the as needed order.

Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R6) reviewed for urinary tract infections (UTI). Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R6's diagnoses included hypertension, renal insufficiency, thyroid disorder, arthritis, non-Alzheimer's dementia, depression, respiratory failure, chronic respiratory failure with hypoxia, mononeuritis multiplex, morbid obesity and dependence on supplemental oxygen. R6's face sheet, print date of 4/9/25, included a diagnosis of urinary tract infection (UTI). R6's electronic health record indicated the following UTI history: 10/30/24 - was diagnosed with a UTI and was started on Cephalexin (antibiotic) 500 mg every 12 hours for seven days. 11/15/24 - was diagnosed with a UTI and was started on Bactrim (antibiotic) 800-160 mg twice daily for ten days. 12/10/24 - was started on methanamine hippirate (antibacterial medication)- one gram twice daily for recurrent UTI's. 1/9/25 - diagnosed with a UTI and was started on Cephalexin 500 mg every 12 hours for seven days 2/11/25 - was started on a cranberry supplement 500 mg twice daily for recurrent UTI's 3/20/25 - diagnosed with a UTI and was started on Cephalexin 500 mg every 12 hours for seven days. R6's physician orders, print date of 4/9/25, indicated an order for methenamine Hippurate (antibacterial medication used primarily to prevent and treat urinary tract infections) - one gram by mouth twice daily for recurrent UTI's. R6's care plan, print date of 4/9/25, did not include R6's urinary tract infection, R6's history of urinary tract infections, goals of treatment, and interventions allowing the nurse to assess the intervention's outcome and potentially revise care based on the resident's status. During interview on 4/10/25 at 9:58 a.m., registered nurse (RN)-A clinical coordinator stated the clinical coordinators are responsible for updating the resident's care plans. RN-A stated if a resident had an history of UTI's it should be included in the care plan so staff are watching for signs and symptoms and could recognize them earlier to treat the UTI sooner. RN-A stated it was important to include history of UTI's on the care plan to help with implementation of interventions or staff being aware so symptoms could be recognized and acted on. RN-A confirmed R6's care plan did not include that R6 had a history of UTI's or goals/interventions to prevent and treat UTI's. During interview on 4/10/25 at 10:06 a.m., director of nursing (DON) stated each discipline of practice completes their section on the resident's care plan. DON stated medical or nursing related issues were completed by the clinical coordinators. DON stated she would expect staff to update the RN clinical coordinator with any changes with the resident. DON stated if a resident had a history of UTI's, she would expect that to be included in their care plan. DON stated it was important so staff can know that R6 is susceptible to UTI's and that all steps are taken such as, thorough cares, increasing fluids and noticing the symptoms that R6 displays with UTI's so we can respond quickly with treatment. The facility Care Plans, Comprehensive Person-Centered policy, dated 2/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practical able physical, mental, and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. d. Incorporate identified problem area. e. Incorporate risk factors associated with identified problems f. Reflect the resident's expressed wishes regarding care and treatment goals. g. Reflect treatment goals, timetable and objectives in measurable outcomes. h. Identify the professional services that are responsible for each element of care: i. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. j. Reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on interview and document review, the facility failed to provide timely results of x-rays services for 3 of 3 residents (R1, R2, R3) reviewed for timely diagnostic services. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnosis of Alzheimer's disease. R1's MDS indicated R1 had severe cognitive impairment with memory loss and a history of falls. R1's care plan dated 12/10/24, indicated R1 had a history of falls. On 1/7/25 at 4:46 a.m., a progress note indicated R1 had an unwitnessed fall with a 1.5 centimeter (cm) x 1.5 cm laceration noted to the left side of her head. On 1/8/25 at 9:41 a.m., a progress note indicated R1 had swelling to her left forearm. R1 was observed to use her left hand less than usual. On 1/9/25 at 5:23 p.m., a progress note indicated R1 had a bruise on her left arm around the elbow measuring 5.5 x 9.7cm x 9.7cm. R1 denied pain, and was able to complete range of motion (ROM). On 1/9/25 at 6:05 p.m., a progress note indicated the on-call provider was contacted, and an x-ray was ordered to be completed 1/10/25. On 1/9/25, a Physician's Order directed R1 to have an elbow x-ray. On 1/10/25 at 3:55 p.m., a progress note indicated R1's x-ray was completed at 1:30 p.m., with her daughter present. On 1/15/25 at 4:10 p.m., a progress note indicated R1 had increased swelling over the past two days. The clinic was called requesting the provider to review x-ray results. The clinic nurse informed registered nurse (RN)-A it might take up to two weeks to get the x-ray results. On 1/15/25 at 4:33 p.m., a progress note indicated R1's medical doctor (MD)-A personally reviewed R1's x-ray and recommended evaluation in the emergency room (ER). On 1/15/25 an After Visit Summary indicated R1 had diagnoses of closed fracture dislocation of left elbow, and closed displaced fracture of medial epicondyle of left humerus (bony prominence located on inner side of the elbow joint). On 1/29/25 at 9:20 a.m., registered nurse (RN)-A stated it took the facility five days to receive R1's x-ray results. R1 had increased swelling on 1/14/25 and 1/15/25. She called the clinic on 1/13/25, 1/14/25 and 1/15/25 requesting x-ray results. R1's physician looked at the x-ray himself on 1/15/25 and sent her to the ER due to a fracture to the left elbow, indicated by the x-ray. R2's significant change MDS dated [DATE] indicated R2 had a diagnosis of non-traumatic brain dysfunction and dementia. On 1/16/25 at 5:42 p.m., a progress note indicated MD-A ordered an x-ray of R2's right foot, and the x-ray was completed. On 1/21/25 at 1:55 p.m., a progress note indicated MD-A reviewed R2's foot x-ray and did not see any fracture. On 1/22/25, a Final Result Report indicated R2's x-ray of the foot indicated no definitive findings to explain symptoms. R3's significant change MDS dated [DATE] indicated R3 had diagnoses of debility, heart failure and respiratory failure. On 11/21/24 at 11:49 a.m., a progress note indicated MD-A ordered a chest x-ray for R3 following a clinic visit. On 12/2/24, a Final Result Report for R3's chest x-ray indicated R3 had cardiomegaly (enlarged heart), central vascular congestion, a large left pleural effusion (buildup of fluid between the tissues that line the chest), negative for pneumothorax (a condition where air leaks into the space between the lungs and chest wall), and calcified arteries. On 1/29/25 at 1:35 p.m., the assistant director of nursing (ADON) stated she did not find it acceptable to wait five days for x-ray results. On 1/29/25 at 2:00 p.m., the director of nursing (DON) stated she was told x-ray readings were delayed due to a shortage of radiologists. She expected to have x-rays read within 24 hours. On 1/29/25 at 2:33 p.m., the administrator stated the facility should have been made aware of R1's fracture within a couple of hours. The timeframe for x-ray results should be communicated to the facility. On 1/29/25 at 3:27 p.m., MD-A stated R1's x-ray was ordered by another provider in his absence on 1/9/25. He looked at the x-ray himself on 1/15/25 and observed a fracture. R1's x-ray from 1/10/25 was not formally read by radiology until 1/19/25. R2's foot x-ray was not read in a timely fashion. R2's x-ray was ordered on 1/16/25 and formal results were not available until 1/23/25. R3's chest x-ray was ordered on 11/21/25 and formal results were not available until 11/30/24. MD-A stated it is not unusual to wait 7-10 days for x-ray reports, which is not ideal. On 1/30/25 at 9:19 a.m., the director of regional hospital imaging department (DOR) stated he did not think there was formal process for the expectation of time for providing x-ray results. The delay was due to staffing shortages. General x-ray results were taking 5-7 days to review, unless they were marked STAT (immediate). The ordering provider should be looking at the images after they were completed, and they should not be waiting for the radiologist to provide their findings. On 1/30/25 at 1:50 p.m., via email, the DON stated the facility did not have a diagnostic testing policy via email. A facility document Contract for Radiology Services dated 1/18 directed to complete medical records in a timely and legible fashion.

Based on interview and document review, the facility failed to document assessments that occur during pressure ulcer dressing changes to include measurements and visual data and have a system to ensure appropriate reporting with findings and follow up occurred when the need for a more thorough assessment was identified for 1 of 1 resident (R1). Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of osteomyelitis of vertebra (infection in a bone), extradural and subdural abscess (area of pus located in brain), severe protein-calorie malnutrition, acute infarction of spinal cord (stroke within the spinal cord), and a pressure ulcer. R1's care plan dated 9/5/24, indicated R1 had a deep tissue pressure ulcer to coccyx. Staff were to administer pain medications as directed, observe for signs and symptoms of pain with treatments, ensure an air mattress was on his on bed, assist/encourage R1 to float his heels while in bed, ensure a foot cradle was in place to offload pressure, provide nutritional supplements as ordered, observe for signs or symptoms of infection, and reposition side to side every 2 hours. There was no mention staff were to document findings when providing ordered dressing changes. R1's Weekly Complex Wound assessment dated [DATE], identified R1 had an unstable pressure wound located on coccyx measuring 11 centimeters (cm) long, 2.7 cm wide, and depth was 0.3 cm. Further assessment identified moderate amount of serous (thin, watery, clear drainage) exudate, slight odor present, 10% granulation tissue (pink or red tissue with shiny, moist, granular appearance), 40% slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or mucinous), and 50% necrotic tissue (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges). R1's wound was noted to have 0.3 millimeters (mm) tunneling at 6 o'clock. R1 was scheduled to have a wound consult on 8/22/24. R1's physician was notified. R1's Medication Administration Record (MAR) for August 2024, revealed R1 had a wound treatment order which was Mepilex 6x6 to coccyx ulcer three times a week and as needed if soiled. R1's Treatment Administration Record (TAR) identified dressing changes and wound treatments were completed on 8/16/24, 8/19/24, and 8/21/24. R1's progress notes identified no corresponding treatment note, originating for the TAR was made on 8/16/24, 8/19/24, or 8/21/24 that would identify characteristics of the pressure ulcer, changes that were identified by licensed staff, or notification for the need for a formal assessment due to changes in the wound. R1's medical record lacked evidence of a any wound assessment on 8/16/24, 8/19/24, or 8/21/24, when R1's wound treatment was completed. On 9/17/24 at 1:08 p.m., licensed practical nurse (LPN)-A stated as a licensed nurse if she was made aware there was a change with a resident's wound, she would complete an assessment and notify the director of nursing (DON) with the information as well as informing the resident's physician. LPN-A stated upon notifying management, they would complete a comprehensive assessment on the wound and assess the wound more thoroughly. LPN-A stated R1 was admitted to the facility with a sacral wound. LPN-A stated she observed R1's wound on Friday 8/16/24, and again on Sunday 8/18/24, and LPN-A stated the wound looked worse and notified registered nurse (RN)-A and DON via email. LPN-A was unsure what happened after that but assumed RN-A re-assessed R1's wound on Monday 8/19/24. In addition, LPN-A could not recall if she documented the wound in R1's medical record regarding identified changes she made during her observations while providing wound care. RN-A was no longer employed by the facility at the time of survey and was unavailable for interview. On 9/17/24 at 4:25 p.m., DON stated R1 was admitted to the facility with the wound on his coccyx. The DON was made aware the need for a formal assessment via email from LPN-A regarding a concern of R1's wound potentially worsening but could not recall what the email said specifically. It was addressed to RN-A and the DON had been cc' d on the email. DON stated there was no evidence in R1's record of R1's wound being re-assessed after the change was identified by LPN-A, nor was there documentation to support her visual assessments at the time dressing changes were performed had been documented. Staff were expected to re-assess a change in a wound, document the assessment, and add progress notes identifying changes or current status of wounds. Further interview on 9/17/24 at 5:07 p.m., with LPN-A identified she sent the email to RN-A and the DON on 8/18/24 at 4:34 p.m On 8/16/24, when she saw R1's wound the wound bed appeared to be red in color but on 8/18/24, the wound bed now appeared to have white slough in the wound bed and an area that appeared to be brown in color, and another area at the 5 p.m. mark (like on a clock) that appeared to show muscle involvement in the wound. In her opinion, the wound had appeared worse as she recalled that was a change from 8/16/24, when she observed it and provided the dressing change. LPN-A had not documented her finding from wound care or dressing changes to identify characteristics of the wound, in order for staff to determine if changes were occurring that would warrant a more formal assessment or the need to update the physician. On 8/18/24 at 10:04 a.m., family member (FM)-A stated R1 was admitted to the facility with the wound on his tailbone area. FM-A stated R1 was sent to the hospital on 8/21/24 for another concern, and the non-visible wound was debrided surgically, and a wound VAC (vacuum) was placed. On 8/18/24 at 12:26 p.m., the medical director (MD) stated he would expect the facility to follow policy and procedures and if needed, notify him if a wound had deteriorated or showed signs and symptoms of infection. On 8/18/24 at 1:00 p.m., DON confirmed there was no documentation to support that assessments were documented, or a more thorough assessment had been performed. Review of facility policy titled Pressure Injury Management, dated April 2024, indicated a resident who had a pressure injury received necessary treatment and services to promote healing, prevent infection, and prevent the development of new pressure injuries. Upon performing dressing changes, staff were to have necessary supplies, practice goof infection control technique, inspect the wound, noting location and color, amount, and odor of any drainage or necrotic (dead tissue) debris. Staff were to note these characteristics, measure the wound, notify the physician for signs of infection or wound deterioration, and document the procedure.

Based on interview and document review, the facility failed to ensure resident's physician and responsible parties were notified in a timely manner for 1 of 1 resident (R1) reviewed for notification of change, who had increasing depression and had attempted to harm self. Findings include: A Vulnerable Adult Maltreatment Report dated 8/15/24, identified a report had been submitted for R1 which alleged resident's increasing depression, anxiety and attempt to strangle self with resident's nasal cannula (tubing attached to an oxygen source to deliver oxygen). These included increased comments voiced by R1 of telling family members she would rather die than stay here, and on 8/13/24 that she was going to kill herself. On 8/13/24 at 9:55 p.m., licensed practical nurse (LPN)-A, documented in R1's medical record, Resident stated she was going to kill herself and had her oxygen cannula wrapped around her neck. Staff removed the cannula around the neck. [Daughter] [family member (FM)-B], is currently visiting with her to help her sleep. Resident states she sees people outside her window as well. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was moderately cognitively impaired, fed self after set up, but required extensive assistance for transfers, dressing, grooming and toileting. Further, the MDS documented diagnoses of chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, hypertension, cirrhosis, insulin dependent diabetes, major depression, and arthritis. R1's Care Area Assessment (CAA) for Cognitive Loss / Dementia, (from the admission MDS - dated 6/27/24), the facility documented the following: Resident does have a diagnosis of cognitive decline as well as delirium. She also has mild recurrent major depressive disorder. In regard to respiratory, she has a diagnosis of chronic respiratory failure with hypoxia, chronic interstitial lung disease and a [history] of pneumonia. Resident also has liver cirrhosis and fatty liver disease. In regards to possible incontinence she has a diagnosis of bladder cancer . R1's Preadmission Screening and Resident Review (PASARR) dated 6/18/24, indicated R1 did not have any developmental disability, mental illness, suicidal ideation nor civil confinement for mental illness. R1's Clinical Resident Profile from her electronic medical records (print date of 8/21/24), listed R1's primary physician's name and contact number, as well as the contact information for three family members. The family members were listed in order of who was to be contacted first. R1's electronic medical record (EMR) from the time of LPN-A's entry on 8/13/24 at 9:55 p.m., lacked what interventions and safety measures the facility staff implemented, until 8/14/24 at 8:48 a.m., when social services assessed R1 and contacted resident's primary physician and daughter. In a telephone interview on 8/20/24 at 11:35 a.m., LPN-A stated one of the nursing assistant (NA)-A came up to her and stated R1 voiced she wanted to die. LPN-A suggested to the NA-A to bring R1 out of her room to the day room and offer her coffee and a snack (the dayroom was across from the nurse station) to be more easily observed. At approximately 9:00 p.m., LPN-A stated the NA's (NA-A and NA-B) offered to get R1 ready for bed and R1 agreed. At approximately 9:30 p.m., LPN-A stated NA-A came to get her and said R1 was wrapping her nasal cannula around her neck. LPN-A entered the room noting NA-B holding R1's hands. LPN-A and NA's removed the cannula. While LPN-A was settling R1, she sent one of the NA's to call R1's daughter to see if she would come in and sit with R1 until she fell asleep. LPN-A stated family member (FAM)-B came in and sat with R1 until she fell asleep, leaving at 2:00 a.m. LPN-A verified neither she nor the NA informed family (FAM-A and FAM-B) of R1 wrapping the nasal cannula around her neck. Nor did the facility contact R1's primary physician or any on-call physicians. LPN-A stated the only conversation she had with FAM-B was FAM-B wanting the nurse to give R1 something to knock her out. LPN-A stated they did not have any orders for that type of intervention. LPN-A was asked if during that conversation, had she mentioned to FAM-B about R1's incident. LPN-A stated: no I didn't, she was kind a stand-off-ish. LPN-A stated from the time FAM-B left until morning staff came on (2:00 a.m. - 6:30 a.m.), she and the two NAs checked on R1 every 30 minutes, finding her sleeping until 6:30 a.m., when R1 requested to be toileted. During telephone interview on 8/20/24 at 11:51 a.m., the reporter (Report) stated the facility did not do enough to monitor R1's safety after finding R1 with the nasal cannula around her neck. Report stated the staff should have called the primary MD, on-call physician or brought her to the adjoining emergency room . An interview on 8/20/24 at 12:22 p.m., director of nursing (DON) stated after review of R1's EMR documentation during and after the incident, LPN-A lacked appropriate documentation to fully understand what occurred. DON verified the record lacked evidence that R1's primary physician / on call physician and family were contacted. During telephone interview on 8/20/24 at 2:05 p.m., FAM-A verified someone from the facility had called her around 9:30 p.m. on 8/13/24. However, she was only told that R1 was upset and wanted family to come in to visit. FAM-A stated she called FAM-B and requested FAM-B to go in and sit with R1. When asked if R1 would have the ability to follow through on harming herself, FAM-A only stated, R1's actions were not purposeful. An interview on 8/21/24 at 8:11 a.m., social work designee (SWD) stated she had not been informed of R1's attempt to harm self until the next morning during stand-up meeting with the interdisciplinary team. SWD performed a PHQ-9 (a depression assessment) and found R1's score greatly increased from admission over a month ago. SWD then performed a Columbia Suicide Assessment and found R1's score high. The facility then contacted R1's primary physician and FAM-A and transferred R1 to the adjoining emergency room for further assessment. During a telephone interview on 8/21/24 at 9:48 a.m., R1's primary physician (PP) verified neither he nor the on-call physician had been contacted about R1's incident of wrapping the nasal cannula around her neck until the morning of 8/14/24. PP stated he has known R1 for about [AGE] years and did not feel she was capable of mentally or physical strength to following through on the act. PP stated the facility staff should have contacted him or the on-call physician immediately for orders and further assessment. PP mentioned labs and CT scans were completed the day prior and found R1's liver function and ammonia levels were elevated. PP stated this could be root cause for the change in mental disturbance and her actions. When asked about facility staff monitoring R1 only every 30 minutes from 2:00 a.m. until 6:30 a.m., PP responded at least they did that. On 8/21/24, between 10:07 a.m. and 10:18 a.m., attempted to make contact with the two NAs (NA-A and NA-B) on the relief shift of 8/13/24, and the two NAs (NA-C and NA-D) on the night shift (scheduled from 8/13/24 until the morning of 8/14/24), receiving no return calls or messages. During an interview on 8/21/24 at 11:03 a.m., the facility administrator stated during general orientation all staff were educated in Vulnerable Adult regulations. In that education suicide was briefly discussed. Since this incident, all staff were provided copies of the facility's policy on Suicide Prevention. Furthermore, all staff have been assigned an online course in EDUCARE on Vulnerable Adult with a section on suicide prevention. Staff are to have it completed by Wednesday August 28, 2024. In review of the facility's policy, entitled: Suicide Prevention (effective date 01/2024) indicated in the following sections: A. Staff will notify Social Services of a resident making suicidal comments. If Social Services is not available, will notify the charge nurse. D. Social Services and/or the nurse will document investigation with the resident in the progress notes section of the medical record. E. If a resident is found to be actively suicidal, with the intent to harm self and meaningful plan the resident will not be left unattended. G. The resident's provider or provider [on-call] will be notified of situation, provider orders obtained as to what staff should do for resident. Orders will be followed. I. Responsible party of resident will be updated on resident's situation.

Based on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 1 resident (R10) reviewed for MDS' accuracy. Findings include: The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, . Hospice Care, and outlined, Code residents identified as being in a hospice program . where any array of services is provided for the palliation and management of terminal illness . R10's quarterly MDS dated [DATE], identified diagnoses included non-Alzheimer's Dementia, diabetes mellitus, end stage renal disease and hypertension (elevated blood pressure). The MDS failed to identify R10 received hospice care in section O- Special Treatments and Programs. Face sheet printed 2/14/24, identified R10 was admitted to hospice services on 8/8/23. During an interview on 2/14/24 at 9:45 a.m., registered nurse (RN)-A verified he had reviewed R10's MDS (dated 11/17/23) and stated hospice care should have been coded adding, That was a mistake. During an interview on 2/14/24 at 12:10 p.m. the director of nursing (DON) stated R10 was on hospice for some time. The DON stated MDS assessment accuracy was important because it drove reimbursement rates, staffing needs and was basis for everything long term care related. The facility policy Minimum Data Set, Management of, Long Term Care policy, revised 3/2023, identified the purpose to ensure the Minimum Data Set (MDS) is accurately and comprehensively completed. All MDS assessments and records will be completed and electronically encoded into the facility's electronic medical record and transmitted to the state database in accordance with current regulations. OBRA tracking records and assessments will be completed as defined per the RAI manual.

Based on observation, interview and document review the facility failed to maintain a lift chair in good repair for 1 of 1 residents (R13) reviewed who utilized an electronic lift chair. Findings include: R13's face sheet printed 1/26/23, indicated R13's diagnoses included Parkinson's, anxiety, osteoarthritis, dorsalgia (low back pain) and weakness. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 was able to communicate her needs. R13's cognition was intact. On 1/23/23, at 1:26 p.m. R13 was observed seated in the electronic lift chair in her room with the footrest elevated. The plastic covered wires for the remote were seen coming out of the remote. On 1/24/23, at 9:36 a.m. R13 demonstrated use of the remote for the electronic lift chair by lowering her legs. R13 stated she had no concerns with use of the remote, it worked each time she has tried it. R13 owned the chair. On 1/26/23, at 10:31 a.m. head of maintenance (HOM) stated all requests for repair of either resident owned items or facility owned items are submitted through the same process. HOM was not aware of R13's electronic lift chair needed repair. HOM confirmed the coated wires for R13's electronic lift chair were pulling out of the remote. HOM considered exposed, coated wires to be a high priority and should be repaired immediately. R13 was at risk for injury if the coating on the wires cracked or pulled off the wires. Facility policy, Electric Lift Recliners- Long Term Care revised 12/2021 indicated repair of privately owned lift chair is the responsibility of the resident but failed to provide direction regarding responsibility or a process to check the lift chair for need to be repaired.

Based on observation, interview, and document review, the facility failed to assess an increase in behaviors, failed to implement nonpharmacological interventions to ensure adequate medical justification prior to increasing an antipsychotic medication for 1 of 5 residents (R3) reviewed for unnecessary medication use. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with a diagnoses of heart failure and schizophrenia. R3 required extensive assistance for most activities of daily living (ADL's) and R3 is usually understood. R3's MDS identified a life expectancy of less than six month. R3 took antipsychotic medication for seven of the seven-day assessment period. Gradual Dose Reduction (GDR) has been documented as clinically contraindicated. R3's Mood State Care Area Assessment (CAA) for assessment reference date 3/11/22, identified a psychiatric disorder and was on antipsychotic medication. The CAA was not signed and there was no indication that this care area would be care planned. R3's Behavioral Symptoms CAA for assessment reference date 3/11/22, identified long standing mental health problems but this area would not be care planned. The CAA was not signed. R3's Psychotropic Drug Use CAA for dated 3/18/22, resident admitted to Hospice 3/3/22 due to decline in overall health condition. Other diagnosis includes Schizophrenia. He is on a scheduled antipsychotic for this diagnosis. Proceed to care plan. Nurses give psychotropic medication per order. Monitor for effectiveness and for any adverse effects. Staff to monitor behaviors/mood, interventions and outcomes per Care Center protocol. Allow resident to vent/provide reassurance. DISCUS [ screening for antipsychotic side effects] as warranted. Titrate medication as warranted and per M.D. order. Update primary M.D., Hospice and [power of attorney (POA)] with changes. Care planning to be completed for this area. R3's care plan dated 9/3/22 included psychotropic drug use: potential for an alteration in cognition function/thought process r/t diagnosis of Schizophrenia. Resident has a history of delusions and hallucination. Zyprexa is given per order scheduled. Staff were directed to monitor mood and to titrate with physician as needed. R3's care plan failed to identify any behaviors toward others and failed to direct staff on how to prevent them from happening, or how to manage them when they occur. R3's Hospice Admission Note dated 3/1/22, lists, [AGE] year-old patient with history of Chronic Diastolic Congestive Heart Failure (CHF), type II diabetes and coronary artery disease (CAD). Hospice admission completed today with R3 in his room at the facility. His POA was updated following the admission who was in full agreement with comfort focused cares and the hospice admission as well. R3 was not very verbal, which is his baseline per the facility, but was quite clear in expressing his wishes to be comfortable and being ready to die. The staff reported to me, that he has also been giving away some of his most precious items to the POA over the course of the last weeks. R3 has been experiencing a slow decline over the past month per documentation. R3's DISCUS assessment dated [DATE] indicated no facial tics or grimaces. No eye blinking. No lip smacking or chewing, nor puckering, sucking, or thrusting of the lower lip. No tongue thrusting or tongue in cheek, nor tonic tongue, tremor, nor lateral movements noted. No head, neck or trunk abnormalities/movements. No upper or lower limb movements of concern noted. Antipsychotic Medication Evaluation Follow Up completed 12/6/22 indicated two episodes of behaviors of R3 yelling out at staff, hitting at staff, kicking at staff and one episode of pushing against the straps for the lift making it had for staff to unhook device. Review also indicated R3 has been on the current dose of 15 mg of Zyprexa (antipsychotic medication) once a day in the evening since 6/17/21. Also noted was Olanzapine (antipsychotic medication) has been trialed. R3's Care Conference Note dated 12/16/22, identified care plan reviewed and remained the same. R3's Orders Administration Note dated 1/21/23, Zyprexa tablet Resident had a hard time getting medication down and stated that he did not want to take it. R3's Behavior Note dated 1/22/23, included, Resident was upset after supper because he noticed his 24 pack and 12 pack of pop was taken out of his room. Staff labeled pop with residents name and put in the fridge. Resident stated that it belonged in his room and that he was going to call the cops if we didn't bring it back. Resident was yelling at staff and wouldn't let them explain that we shouldn't keep that much in his room so staff let resident calm down and came back later. Last time resident had 2- 12 packs in his room he drank both of them within 2 days. Resident did not drink water during that time and was always incontinent through his (overnight) brief and pants even though he was toileted every two hours. Resident is also a diabetic and was previously on fluid restrictions. For the residents well being staff decided his pop should be put away and resident can then ask for one. When writer visited with resident after he was calm, he then understood that his pop has his name on it and is only for him, he just has to ask and staff can get it for him. No further behaviors. R3's Behavior Monitoring dated 1/23/23, Behavior Exhibited Initially refused to toilet and was upset with staff although he did toilet and had voided, upset that staff had taken pop out of his room but then had calmed down once staff explained his name was on it and he just needed to ask for it and then this evening resident continued on about his pop not being in his room so staff did put his pop back in his room this evening. Frequency and impact to self or others indicated no risk at physical injury to self or others interfered with cares x1, Non-pharmacological Approaches/Effectiveness states, Educated resident on importance of letting staff do cares. Pharmacological Interventions/Effectiveness lists Zyprexa 15 mg daily for Schizophrenia. R3's Behavior Note dated 1/23/23, Resident was upset that his pop was not in his room. Writer tried to talk with resident and let him know that we have it with his name on it and that he just needs to let us know when he would like one. Resident continued to be upset and said 'If I want my pop in my room I can have my pop in my room.' Staff did bring pop back into residents room. R3's Nurses Note dated 1/24/23, In an unpleasant mood this morning. Not being very cooperative with NA [nursing assistant] as they reported. Pushing back on staff when trying to hook him up in the lift then wouldn't stand and when staff trying to adjust his leg so Hes standing properly on lift pad. Then getting angry at NA for assisting him with his positioning. Also reported that housekeeping staff asking resident if ok to mop the floors in his room. Resident stating that is ok so housekeeper starts to mop the floor and while she is doing these [sic] resident proceeds to run into her on purpose with his wheelchair multiple times. R3's Orders Note dated 1/25/23, lists new orders per Hospice, start Zyprexa 7.5 mg once daily in the morning. R3's Behavior Note dated 1/25/23, resident was resistive with toileting this afternoon yelling at aid when she had to change his pants and socks due to being soaking wet aid finally got him changed and tried to hook him back up to the EzStand (lift) resident shoved it toward her and told her she was being mean. R3's Hospice Note dated 1/25/23, It is also reported that patient is having more behaviors. He has been resistive with cares. It is documented that he is trying to push the lift machine away when staff trying to hook him up also it is documented yesterday that housekeeping staff asked him if they could come and mop his floor which he agreed but then was purposefully running his wheelchair into the housekeeper multiple times. Last month on 12/14/22 we tried increasing his morphine thinking behaviors were possibly related to pain as he does have ongoing foot wound however his behaviors seem to be getting worse and his foot wound is looking better. I did update [primary physician] on behaviors and requested to possibly start a morning Zyprexa 7.5 mg and continue with the Zyprexa 15 mg at night awaiting response. R3's Behavior Note dated 1/26/23, Writer followed up with resident regarding his pop. Asked if he approved where his pop currently is at in his room, He stated yep, I like it right where it is. Verified he was ok with having it at room temp, he stated yep. Encouraged resident to ask for ice if he wanted it cold. Resident was smiling ear to ear with no further concerns. Care plan updated. When interviewed on 1/25/23, at 1:45 p.m. hospice registered nurse (RN)-B stated she was in to see R3 yesterday and reviewed the notes regarding recent mood/behavior of resident as well as the recent upset regarding his pop. RN-B stated they previously increased pain medication due to his behaviors and difficulty with communication. RN-B stated she requested an increase in Zyprexa due to recent increase in behavior frequency. She reported she has communication with R3's POA and they are ordering diabetic shoes as resident insists on wearing his shoes and they are ill-fitting due to foot wound. Stated she does speak with the nurses and nursing assistance when she is on site but all provider orders are requested by hospice nurses from the physician. She had reached out to the physician to request an increase in Zyprexa. Discussed possibility that behaviors were due to patient care rather than need for medication dose change and RN-B stated she will review R3's information. When interviewed on 1/25/23, at 3:53 p.m. R3's POA stated there is good communication with the care center staff as well as the hospice nurses in which she receives calls or texts with any information or updates. POA stated R3, likes things his way or he gets mad. When asked about the recent removal of patients personal supply of soda, she was not aware of this and stated this would, upset him greatly. When discussing the recent behaviors reported POA stated, I'm sure it is about the pop. She stated she has seen him in one of his manic moods and he usually becomes very quiet and sullen. POA stated she is consulted regarding medication changes usually after the fact and has not had any discussions about a medication change at this time. When interviewed on 1/26/23, at 9:04 a.m. nursing assistant (NA)-B stated, resident behavioral education is provided for all staff in upon hire and in general. She stated NA's pass on behavioral incidents to the nurses, who document in the resident record. NA-B states every resident has rights and they all should be kind to one another. NA-B stated she learned how to work with R3 with experience. NA-B stated she knows R3 doesn't mean what he says. She stated R3 loves his pop, and she can offer that to help diffuse a situation. NA-B stated R3 likes music and listening to the radio as well as crossword puzzles. NA-B stated this is all in the computer along with toileting and repositioning. When interviewed on 1/26/23, at 9:48 a.m. DON stated staff is to Monitor mood and behavior per facility policy. DON stated they do not have target behavior monitoring or interventions. DON stated she is trying to implement this. DON informs that she has started monthly behavior meetings with the nurses a couple of months ago this review not documented in the resident chart. The nurses verbally discussion their resident concerns to collaborate. DON reviewed R3's medical record and was unable to find a comprehensive behavioral assessment or care planned interventions. DON also confirmed there was no interdisciplinary team (IDT) meeting completed to determine increased frequency or change in severity and no new nonpharmacological interventions were attempted prior to new hospice order for increase in antipsychotic medication. When interviewed on 1/26/23, at 11:07 a.m. RN-C stated, there is a verbal update with hospice staff while in the facility which is usually daily, or facility staff will call the hospice nurse if they feel it is urgent. Facility staff does not call the physician directly, but hospice staff does take concerns to the physician and report back to the facility. Additionally, a verbal report is completed daily with the hall staff during walking rounds as well as the recently implemented monthly meetings with the DON. Monitoring for mood and behavior triggers on the Kardex (system of communication and organization used in nursing to relay important patient information and needs) if order is entered in the chart. This allows the staff to check off boxes accordingly while interacting with the residents. RN-C states they are working on transitioning to resident specific targeted behaviors with the specific patient needs and prevention as well as interventions. Hoping to change system wide to be more patient specific rather than broad as it currently is. When interviewed on 1/26/23, at 11:22 a.m. NA-A states she was not really trained on behavior management and this was overwhelming at first. NA-A states that training upon hire was very broad addressing behaviors and how to respond. NA-A states that she feels more comfortable now as she knows the residents more. NA-A states she has not had issues with R3 on being physically aggressive toward her and he is usually only grumpy or verbally upset at times. NA-A states R3 has specific staff that he seems to not like and be more physically aggressive with. NA-A states she usually gets a verbal pass on during walking rounds updating on resident condition, mood, and behaviors. NA-A states that if there were an issue with any resident, she passes this on to the nurse right away and the nurses makes a note in the chart, as she can only click the appropriate boxes. NA-A states if a resident is visibly or verbally escalating, she speaks calmly with the resident to try to calm them down. A policy for psychotropic medication requested but not provided by the facility.

Based on observation and interview the facility failed to ensure proper gloving and hand hygiene was implemented during incontinent cares for 1 of 8 residents (R1) observed for personal cares. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was fully dependent on another person for physical assistance with toileting and personal hygiene. R1 was always incontinent of bowel and bladder and had a diagnosis of dementia. R1's care plan with last review date 12/5/22, indicated R1 required assist of one to two staff with peri cares and changing incontinent products. On 1/24/23, at 10:12 a.m. during observation of incontinent cares, nursing assistant (NA)-C clean bowel movement from R1's buttocks with her right hand and removed the soiled brief from under R1 with her left hand. Without changing her gloves, NA-C reached into R1's bedside table for a clean brief and placed it under R1. NA-C reached into the top drawer of R1's bedside table for a tube of barrier cream, then applied the barrier cream to R1's buttocks with her right hand. NA-C with assistance from NA-D rolled R1 side-to-side to adjust the brief, then assisted R1 with dressing upper and lower extremities. NA-C brought the wash basin to the bathroom and dumped the water into the sink. NA-C then assisted to straighten R1's sheet over him. NA-C removed the garbage with the soiled brief in it and placed it into a larger garbage can in R1's room. NA-C continued touching various items in R1's room including his tray table and bed controls. NA-C removed gloves when removing other personal protective equipment (PPE), the used hand sanitizer when leaving R1's room. On 1/24/23, at 10:30 a.m. NA-C confirmed she did not change her gloves or clean her hands after assisting R1 with peri care following bowel incontinence. NA-C stated she knew she was expected to change her gloves after cleaning bowel, before touching clean items and to clean her hands each time she changed her gloves. On 1/26/23, at 11:50 a.m. director of nursing (DON) stated she expected gloves were changed after removing a soiled brief, especially after bowel incontinence. Hands should be cleaned anytime gloves are changed and when visibly soiled. Education has been provided to staff so they do not touch items in the resident's room after cleaning a resident up after incontinence, but especially bowel incontinence. DON stated it was important for staff to change their gloves and wash their hands to prevent possible spread of infection and to prevent contamination of other items in the resident's room. A facility policy for hand hygiene was requested but not received.

Based on observation, interview and document review, the facility failed to ensure resident choices were honored for storage and access to personal property brought in to meet the residents' fluid intake preferences for 1 of 1 resident (R3) reviewed for choices. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with a diagnosis of heart failure. R3 required extensive assistance for most activities of daily living (ADL's) and R3 was usually understood. R3's MDS identified a life expectancy of less than six month. R3's Hospice Admission Visit note dated 3/1/22, indicated discontinuation of fluid restriction to promote comfort and quality of life. R3's care plan dated 12/12/22, identified, Hospice: I am diabetic, I can make my own food decisions, Exercise the right to not always follow my diet. R3's care plan dated 9/3/21, included to provide with a choice of snacks, like diet coke. R3's Behavior Note dated 1/22/23, included, Resident was upset after supper because he noticed his 24 pack and 12 pack of pop was taken out of his room. Staff labeled pop with residents name and put in the fridge. Resident stated that it belonged in his room and that he was going to call the cops if we didn't bring it back. Resident was yelling at staff and wouldn't let them explain that we shouldn't keep that much in his room so staff let resident calm down and came back later. Last time resident had 2- 12 packs in his room he drank both of them within 2 days. Resident did not drink water during that time and was always incontinent through his (overnight) brief and pants even though he was toileted every two hours. Resident is also a diabetic and was previously on fluid restrictions. For the residents well being staff decided his pop should be put away and resident can then ask for one. When writer visited with resident after he was calm, he then understood that his pop has his name on it and is only for him, he just has to ask and staff can get it for him. No further behaviors. R3's Behavior Note dated 1/23/23, Resident was upset that his pop was not in his room. Writer tried to talk with resident and let him know that we have it with his name on it and that he just needs to let us know when he would like one. Resident continued to be upset and said 'If I want my pop in my room I can have my pop in my room.' Staff did bring pop back into residents room. R3's Nurses Note dated 1/24/23, In an unpleasant mood this morning. Not being very cooperative with NA [nursing assistant] as they reported. Pushing back on staff when trying to hook him up in the lift then wouldn't stand and when staff trying to adjust his leg so Hes standing properly on lift pad. Then getting angry at NA for assisting him with his positioning. Also reported that housekeeping staff asking resident if ok to mop the floors in his room. Resident stating that is ok so housekeeper starts to mop the floor and while she is doing these [sic] resident proceeds to run into her on purpose with his wheelchair multiple times. When interviewed on 1/24/23, at 11:15 a.m. nursing assistant (NA)-A stated, R3's pop had not been returned to his room at this time. R3 was to request from staff. When interviewed on 1/24/23, at 2:05 p.m. registered nurse (RN)-A. stated, R3 had a case of pop and drank it in two days. R3 Now usually gets about one a day. He is not able to keep in room due to lack of water consumption. RN-A was unsure if he prefers it to be cold. R3 does not have a refrigerator in his room. RN-A stated R3's pop is probably brought in by his power of attorney (POA) that is his good friend. It is R3's right to do so. However, RN-A identified that R3's is currently in the refrigerator down the hall. When interviewed 1/24/23, at 3:45 p.m. director of nursing (DON) stated she was aware likes to drink Diet Coke but does not drink water. In a recent interdisciplinary team (IDT) meeting it was noted that he went through a case in a few days. He is on hospice, and it was discussed to let him have his Diet Coke if he wants was the consensus with dietary staff present. DON stated it is noted that it helps his moods which can be major at times. The DON stated, unless the doctor ordered it to be taken away it should not be taken from him. DON indicated that she was not aware that it had been removed from R3's room. DON stated it should not have been removed. DON stated that if a resident is not cognitively intact we would need to discuss with the POA and physician prior to limiting his access or consumption. When reading R3's behavior notes DON stated, that's awful. R3's Behavior Note dated 1/24/23, included, Writer followed up with resident regarding his pop. Asked if he approved where his pop currently is at in his room, He stated 'yep, I like it right where it is.' Verified he was ok with having it at room temp, he stated 'yep.' Encouraged resident to ask for ice if he wanted it cold. Resident was smiling ear to ear with no further concerns. Care plan updated. When interviewed on 1/25/23, 03:53 p.m. R3'S POA stated, she brings pop in for him when she visits ever since he was taken off of the fluid restriction in March 2022. She brings in enough to allow him two cans a day but states he does not have any self-control when it comes to his pop. So there are times that he will run out. The POA stated R3, likes things his way or he gets mad. The POA was not aware that his pop had been removed from his room and stated it would, upset him greatly. When discussing the recent behaviors reported the POA stated, I'm sure it is about the pop. A resident choice policy was requested, but not provided by the facility.

Based on interview and document review, the facility failed to provide restorative nursing programs as care planned to maintain abilities for 5 of 5 residents (R28, R40, R18, R20 and R4) reviewed who were to receive a restorative nursing program. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], included cognitively intact with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28 required extensive assistance with transfers, did not ambulate at all in the corridor, but ambulated in room once or twice with one person physical assistance during the look back period. R28 did not receive any therapy, nor did she receive any restorative nursing program. R28's functional maintenance program care plan dated 3/5/21, and revised 6/30/21, included, Restorative nursing, ambulate distance as tolerated with 4 WW [wheeled walker] with gait belt and one ext [extensive] assist 5x/week [five times per week]. W/C [wheelchair] to follow. Restorative nursing: Functional maintenance program for Nustep [elliptical work out machine] use Nustep resistance 2 for 5-8 minutes or as tolerates at seat 9 and arms at 10. When interviewed on 8/17/21, at 3:13 p.m. R28 stated she is supposed be offered the Nustep 3 time per week and ambulation 5 times per week, but has only been offered about once a week. R28 stated, she enjoys doing these exercises as it keeps, her legs moving, and is good for her. R28 stated the reason she is not getting her exercises in is, They don't have enough help. R28's Walk in corridor documentation for 7/17/21 through 8/18/21, identified R28 had only ambulated on 7/20/21 and 8/11/21. She had refused to ambulate 4 times during the past 30 days. The documentation did not show if ambulation was offered five times a week as directed in care plan. R28's Restorative nursing documentation for the Nustep use indicated R28 used the Nustep on 7/20/21, 8/11/21, and 8/17/21 and refused 3 days. There was no indication why R28 had not received the program three times per week as directed. When interviewed on 8/18/21, at 1:26 p.m. nursing assistant (NA)-B stated R28 should receive assistance with the Nustep every Tuesday, Wednesday and Friday and ambulate in hall five times a week. However, the restorative nursing aide gets pulled from duties to assist with nursing assistant duties when they are short staffed, or someone calls in sick. When this happens, which is several times a week, the restorative programs do not get done. If this happens, she does not document the program in any way. R28 does not normally refuse to participate in the program. When interviewed on 8/19/21, at 9:12 a.m. registered nurse (RN)-B stated, the restorative aide often gets pulled when they need staff to work on the floor. R28 should be getting on the bike 3 times per week and confirmed by looking in the computer that this was not being done. RN-B stated that it is important for all residents to be getting restorative care as they do not want a decline in the residents functional ability. When interviewed on 8/19/21, at 9:18 a.m. the director of nursing (DON) stated, R28 should be getting restorative care three times a week but only has received it twice in month of august and should have received it at least 6-8 times by now. DON further stated it was important for all residents to get their restorative nursing programs to maintain their current abilities and to prevent decline, if they can. R40's quarterly MDS dated [DATE], included severe cognitive impairment with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Therapy had ended 4/12/21, and did not receive a restorative nursing program. When interviewed on 8/16/21, at 1:57 p.m. family member (FM)-A stated, R40 was not receiving the exercise program that therapy ordered for him. FM-A stated, R40 has been weaker lately, but felt it was medication related. R40's care plan revised 7/27/21, indicated R40 required extensive one to two assist with bathing, bed mobility, dressing and walking. R40's care plan further indicated weights two times per week on Tuesday and Friday and walk with staff in room/hallway one to two times per day with front wheeled walker and wheelchair to follow. R40's restorative documentation dated 7/17/21 through 8/17/21, directed staff to compete exercises once a day 3-5 days per week. R40's exercise was documented as being completed on 8/2/21 and 8/12/21 only. The documentation indicated R40 was either not available or refused on 2 days also. There was no indication R40 had been offered the exercise program any other days. When interviewed on 8/18/21, at 1:26 p.m. NA-B stated, R40 is supposed to be working with the theraband, lower legs, and walking and reports this was not getting done because the restorative aide was always getting pulled to work on the floor and there was no time to complete the exercise program for R40. When interviewed on 8/18/21, at 9:11 a.m. LPN-A stated therapy no longer works with R40 but he is on a walking program 1-2 times a day if he allows. However, this was not getting done because of staffing issues. When interviewed on 08/18/21, at 9:17 a.m. LPN-A stated that the restorative aide gets pulled when there is a call in or they are short staffed. LPN-A stated they try to get all of the cares done but can't really say what isn't getting completed. However, the restorative nursing programs are often the first to go when they don't have enough staff. When interviewed on 08/18/21, 12:49 p.m. RN-A stated that R40 participates with the rehab program but not sure if this is getting completed all the time. RN-A stated that the restorative aide does get pulled when staffing is short and they try to get the rehab program completed. R18's annual MDS dated [DATE], included, cognitively intact, did not reject cares, required extensive assistance for most ADL's and did not ambulate. R18 did no receive a restorative nursing program. R18's care plan dated 5/19/21, included to walk in room/corridor with extensive assist of one short distances with a walker. In addition, the care plan identified a functional maintenance program, staff were directed to: Restorative nursing: Complete 15 reps [repetitions] of the following exercises to BUE [bilateral upper extremities] with yellow theraband. Complete 3-5 days a week. Please walk patient as far as she tolerates with FWW [front wheeled walker] and CGA [contact guard assist]/Min [minimum] A [assist] of 1 and wc follow once a day to increase strength and endurance. R1's Functional Maintenance Program from physical therapy dated 1/4/21, directed: Please walk patient as far as she tolerates with FWW and CGA/Min A of 1 and WC follow once a day to increase strength and endurance. When interviewed on 8/19/21, at 11:07 a.m. R18 stated, she does her exercises and walks, but is only offered maybe once a week. The exercises have helped her keep her arms moving and she enjoys it. She did not know why she was not being offered the program more often. Documentation of R18's restorative nursing program with exercises and ambulation was requested from the facility, but not provided. R20's quarterly MDS dated [DATE], indicated severe cognitive impairment with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 did not receive a restorative nursing program. R20's care plan dated 9/18/20, indicated R20 needs extensive one assist with bed mobility, dressing, and walking. R20's care plan further indicated restorative nursing related to weakness with interventions of seated exercises, ankle pumps, hip exercises and glut sets (buttocks muscles) 10-20 reps, walking program in hallway along with upper extremity functional maintenance program. R20's Functional maintenance program by occupational therapy, dated 10/12/20, indicated rehab aide to complete bilateral upper extremities with yellow theraband 3 days a week. Functional maintenance program by physical therapy dated 12/30/20, indicated R20 to do seated exercises ankle pumps, hip exercises and glut sets (butt muscles) 10-20 reps, walking program in hallway 1 time a day and 3-5 times per week due to weakness after COVID. During interview on 8/19/21, at 11:10 a.m. R 20 stated she likes doing the exercises when the staff come and help her but they do not come all the time. R20 stated it helps her keep moving. Documentation of R20's restorative nursing (functional maintenance program was requested, but not provided by the facility. R4's annual Minimum Data Set, dated dated dated (MDS) dated [DATE], indicated moderate cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 did not receive a restorative nursing program. R4's care plan printed 5/19/21, identified R4 restorative nursing related to weakness with interventions of upper extremity functional maintenance program three times per week. Staff were to encourage walking in hallway with FWW independently. When interviewed on 8/19/21, at 11:47 a.m. R4 stated the restorative aide comes in most the time but unsure how many times a week she actually comes. R4 stated that the aide misses some times but doesn't feel like she is declining. Documentation of R4's restorative nursing program was requested, but not provided by the facility. When interviewed on 8/19/21, at 10:28 a.m. assistant director of nursing (ADON) stated, it was important for residents to be getting their restorative care and the residents should be having this done to prevent decline and to maintain strength. ADON further stated that the restorative aide typically gets pulled when there is a call in or when she was on vacation they tried to fill the shifts. When interviewed on 8/19/21, at 10:34 a.m. NA-B stated with P4, P18, and P20 they are all on restorative program as well, and stated when the restorative aide is pulled, the program for all the residents are not getting completed. NA-B further stated they try to walk the residents when time allows, but it is not always being completed due to staffing. NA-B further stated that it was important for residents to participate in the restorative program to prevent freeze up of joints and decrease in strength of the resident. Restorative hours printed 8/19/21 for the past 30 days was provided and identified 5 times (excluding weekends) the restorative aide was pulled to work the floor, or not filled. In addition the rehab aide was on vacation and not replaced 8/9/21 through 8/12/21. A facility Restorative Nursing Program-long term Care policy dated 2/21, included, A restorative nursing program defines nursing interventions that promote the resident's ability to live as independently and safely as possible. The restorative nursing program will be carried out by a nursing assistant that has been trained in the techniques to promote resident involvement. The restorative nursing program is overseen by a licensed nurse.

Based on observation, interview, and document review, the facility failed to ensure an oxygen machine was kept in a safe and sanitary condition to ensure proper function for 1 of 2 residents (R21) observed to use oxygen on the survey. Findings include: R21's annual Minimum Data Set (MDS), dated [DATE], identified R21 had intact cognition. Further, the MDS outlined R21 demonstrated shortness of breath with exertion and while at rest, and used oxygen therapy while a resident at the nursing home. On 8/16/21, at 10:24 a.m. R21 was observed laying in bed in his room. R21 had a visible nasal cannula in place which was connected to a NewLife Elite AirSep oxygen concentrator positioned along the wall. This machine was inspected which identified a single, approximately six inch filter on the back of the machine which was covered with copious amounts of dark gray, clumping dust and debris. R21 denied being short of breath at this time; however, he was not really sure who cleaned the machine's filter or monitored it to ensure proper function. During subsequent observation, on 8/18/21 at 11:59 a.m. R21's oxygen concentrator continued to have the same visible, copious dust and debris present on the single filter. R21 was not using the oxygen at this time. On 8/18/21, at 12:13 p.m. licensed practical nurse (LPN)-A was interviewed and verified she was assigned to care for R21 and often worked with him several days a week. LPN-A stated R21 had [CONDITION(S)] ([CONDITION(S)]) and [CONDITION(S)] which required him to use his oxygen from the concentrator primarily during the night hours when he was sleeping to avoid becoming short of breath. LPN-A explained the nurses were responsible to ensure resident's oxygen equipment, including the filters on the concentrators, were kept clean and it was tracked through the resident Treatment Administration Record (TAR). However, LPN-A reviewed R21's TAR and voiced there had been no intervention or direction set-up on the record to ensure this was done for some reason. LPN-A then observed R21's oxygen concentrator in his room and voiced the filter was heavily soiled and needed to be cleaned. LPN-A stated she would ensure the intervention for routine cleaning was added to the TAR and added it was important to ensure the machine's filter was cleaned and free of debris otherwise the machine [isn't] going to filter the air properly and R21 would not get the best oxygen he could. LPN-A expressed she was unaware the last time the machine had been checked or the filter had been cleaned. An undated NewLife Elite Oxygen Concentrator Service Manual identified a section labeled, Patient Instructions, which directed the Air Intake Gross Particle Filter should be cleaned on a weekly basis using soap and water. Further, an attached Troubleshooting Chart outlined some potential issues which could occur due to air intake and/or filtration issue(s). These included restricted airflow through the unit which could cause the machine's compressor to shut down intermittently or the compressor not staring due to excessive heat. When interviewed on 8/18/21, at 1:06 p.m. the assistant director of nursing (ADON) stated R21 used oxygen mostly at night for [CONDITION(S)], and the nurses should be cleaning his oxygen equipment, including the concentrator filter, according to the facility policy. The ADON stated this should be completed and tracked on the resident's TAR. The ADON expressed it was important to ensure oxygen equipment was kept in a clean and safe condition to help prevent respiratory infections and because soiled equipment was just gross. Further, the ADON stated the facility had no formal audit system in place to ensure these items and equipment were being cleaned in accordance with their policy. A provided Oxygen Administration - Long Term Care policy, dated 3/2021, identified a section labeled, Oxygen Concentrators, which directed, Filters for the oxygen concentrators (if applicable) will receive cleaning as recommended by the manufacturer.

Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to address a repeatedly voiced lack of activities on the weekend for 1 of 2 residents (R2) reviewed for activities. Findings include: R2's annual Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition and required extensive assistance for most activities of daily living (ADLs). Further, the MDS outlined R2 considered having magazines, books or newspapers to read as, Not Very Important; however, listening to music, doing things with groups of people, and doing her favorite activities was recorded as being, Very Important. R2's most recent Activity Admission Assessment V2, dated 8/27/19, identified a section labeled, Activity Interests, which outlined several questions answered with radio-button style responses to indicate R2's activity interests. R2 was recorded as enjoying several card games, board games, Bingo, word games, people watching, television, radio listening, parties, music events, 'happy hour', and visiting with friends. The assessment outlined R2 desired small group and independent activities in the evening hours, and listed places R2 preferred to do activities including her own room, activity room, lobby, outside and on community outings. R2's care plan, dated 5/3/21, identified R2's activity preferences included listening to music, being around animals, keeping up on the news, doing things with groups of people, and doing her favorite activities (cards, bingo, baking/cooking, painting, large print word searches). The care plan listed a goal which read, Resident to make choices about her daily activity involvement through the review date, along with several interventions to help R2 meet this goal including offering pet visits, assisting to go outside as COVID-restrictions allowed, and reminding R2 about activities of interest. The care plan last had activities-based interventions added on 5/19/20. On 8/16/21, at 1:20 p.m. R2 was interviewed. R2 explained she enjoyed bingo and dice games, and she routinely attended the activities programs at the nursing home. However, R2 expressed there needed to be more activities for residents, including herself, to do on the weekends as the weekends were, pretty dead and, as a result, caused her to spend a majority of her time on weekends just watching television. R2 stated she had voiced concerns about the lack of organized activities on the weekends to the staff but added there was, not much they can do as she thought they, don't have enough help. When interviewed on 8/17/21, at 5:57 p.m. nursing assistant (NA)-C stated R2 attended most of the activities offered in the facility; however, NA-C acknowledged R2 had voiced there was a lack of activities on the weekends, especially Sunday. NA-C stated she had last heard R2 voice such concern just the weekend prior and, as a result, the staff attempted to provide her with puzzles or listen to music. However, NA-C voiced, at times, R2 would just have to sit in her room and watch television as there was no structured activities on some weekends. Further, NA-C stated the activities department staff were aware R2 had voiced comments and concerns about a lack of weekend activities. On 8/17/21, at 6:47 p.m. R2 was observed seated in her motorized scooter seated at a dining room table in the main dining room. Rosary was in progress and R2 was actively participating in the activity with several other residents present. On 8/18/21, at 8:32 a.m. NA-D and NA-E were interviewed. They described R2 as someone who, goes to a lot of activities and typically was able to attend them herself without staff needing to provide assistance to or from them. NA-E voiced R2 had made comments about a lack of organized activities on the weekends before, and NA-E expressed it was due to a lack of activities staff on the weekends as they were only present from 8:00 a.m. to 2:00 p.m. on Saturdays and 12:00 p.m. to 4:00 p.m. on Sundays. NA-E explained the nursing staff often wanted to help R2 find some activities to do, however, there was rarely time given their other duties and the, skeleton crew on the weekends. NA-E voiced it was hard, at times, to even provide R2 with board games or other self-involved activities as the nursing staff, don't have the keys to the activity room. Further, NA-D and NA-E both expressed the activities department was aware of R2's concern with a lack of activities on the weekend but they were unaware what, if any, actions were being done to help develop more activities or address R2's repeatedly voiced concerns. R2's medical record was reviewed and lacked evidence R2 had been comprehensively reassessed to help determine what activities could be altered, changed, or added to R2's regimen, both for group-based or individual-based activity programming, despite these ongoing and repeatedly voiced complaints of a lack of activities on weekends to the direct care staff members. On 8/18/21, at 11:43 a.m. activities assistant (AA)-A was interviewed. AA-A explained the activities department only have one staff member on the weekends who often helps pass meals trays in addition to their activities-based duties. AA-A stated a group of residents is then assisted to the laundry folding and, at times, get a conversing group organized with coffee and cookies. Afterwards, AA-A stated she tries to catch up on doing visits with other residents but added, If I have time. AA-A stated the resident population, including R2, really don't get a whole lot of activity in on the weekends due to the minimal staff. AA-A stated the weekdays often have three staff members present to help organize and lead activities and added she was unaware why there was only one person on the weekends adding, I guess that's a good question. AA-A expressed she had heard R2 voice concerns about the lack of activities on the weekends and stated she responded to them by asking R2 what she had done on weekends when you were at home. R2 responded with saying they used to have company over to the house, and AA-A voiced the COVID-restrictions in place were hard to accommodate that desire but acknowledged the facility had recently started allowing volunteers back inside which could help with this. AA-A stated they did have various games or more individual-based activities present in a cabinet on the floor which the nursing staff could offer residents, including R2, when they were bored; however, AA-A voiced the cabinet likely could be reviewed to ensure it had up-to-date items inside and added possibly the floor staff needed to be re-educated on the cabinet and how to address these complaints of residents. Further, with R2's complaints of a lack of activities and their staffing situation on the weekends, AA-A expressed, Maybe we need to look at things a little differently. An August 2021 activities calendar was provided which outlined the scheduled activities for the nursing home for the month listed by each day. On the weekend of 8/7/21 to 8/8/21, a total of six activities were offered between the two days including laundry-games, Bingo, and 1:1 visits. On the weekend of 8/14/21 to 8/15/21, a total of five activities were offered including laundry, horse day, Bingo, and 1:1 visits. On the weekend of 8/21/21 to 8/22/21, a total of four activities were offered including laundry-games, Bingo, and 1:1 visits. Further, on the weekend of 8/28/21 to 8/29/21, again only four activities were offered which included laundry-games, Bingo, Catholic mass (televised), and 1:1 visits. R2's corresponding Follow Up Question Report(s), dated August 2021, identified R2's activities involvement for the month period. On the weekend of 8/7/21 to 8/8/21, R2 was recorded as watching television, visiting with other residents, attending Rosary, attending Mass, and playing Bingo. Further, on the weekend of 8/14/21 to 8/15/21, R2 was recorded as attending Bingo, attending an animal event, attending Mass, watching television, and reading a magazine or book. When interviewed on 8/19/21, at 9:09 a.m. the activities director (AD) stated the pandemic restrictions had hit activities hard as it didn't allow them to have large group activities. AD described R2 as someone who was very social and outlined R2's activity attendance as eight to 16 activities per week. AD stated she felt the activities department was doing the best we can with their staffing limitations; however, acknowledged R2 had voiced comments about a lack of activities on the weekends. As a result, they did discuss things R2 could do on her own in her room. AD expressed, in her opinion, that R2's complaints of a lack of activities were her grieving and just wanting the activities to be back to what it used to be prior to the pandemic. AD verified R2 had not been comprehensively reassessed for her activities preferences, including what options could be attempted, tried or addressed on the weekend hours, since her last assessment in 2019, nor had there been any grievances or anything completed for R2's concerns. Further, AD stated they could re-visit the situation with R2 and possibly add her to one-to-ones again to help resolve her concerns but expressed activities on the weekend were not just the activities people responsibility as the nursing staff were capable of providing things for the residents to do in their absence, too. A provided Activity Admission Assessment V2 policy, dated 8/2020, identified an activity interest survey is conducted and maintained for each resident to promote their physical, mental and psychosocial well-being. The policy directed each resident would be assessed upon admission to help develop an activity-based care plan to help allow the resident to attend activities of their choosing and interest. This would be maintained by the activity department and are reviewed as necessary, but at least annually and with significant change.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R36) who used a mechanical standing lift and needed assistance for transfers was left alone at the edge of the bed while staff retrieved a mechanical lift. R36 fell resulting in a fractured right humerus (long bone of upper arm) and facial bruising that required medical attention. Staff subsequently placed R36 back into bed without first being evaluated and did not report this fall until 24 hours after the incident occurred. These actions resulted in actual harm for R36 who suffered a right humerus fracture and facial bruising while left unattended at the bedside. Findings include: R36's diagnoses, as identified on the Admission Record printed 6/7/18, included Alzheimer's dementia. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R36 was severely, cognitively impaired. The MDS indicated R36 was dependent upon staff for transfers, and did not walk. The MDS indicated with transfers R36 was not steady, and only to stabilize with human assistance. The MDS further indicated during sit-to-stand transfers (for example from sitting on bed to standing) or surface to surface transfers (for example from bed to wheel chair seat), R36 was unsteady and required human assistance. During observation on 6/5/18, at 6:04 p.m nursing assistant (NA)-C and NA-F began evening cares for R36. NA-C placed the lift sling tabs onto the metal arms of the lift, then NA-F activated the arm which lifted R36 from the wheel chair, and NA-C guided R36 into bed as the lift arm lowered. NA-C and NA-F rolled R36 side to side to remove the lift sling from underneath R36. During the movement back and forth, R36 had verbalizations of pain. NA-C and NA-F began to remove R36's clothing and shoulder to wash under R36's arms and upper body. As NA-C and NA-F removed the Velcro from the immobilizer, all the while R36 was grimacing. When NA-F took the immobilizer off, R36 began to cry out in pain, and several times cried and verbalized Ow in pain. During the provision of cares, NA-C and NA-F talked to R36 continuously, giving encouragement and frequently stated we're almost finished. R36's expression of pain stopped when NA-C and NA-F stopped moving R36. NA-C and NA-F reported R36 had a humerus fracture from a recent fall. When interviewed on 6/5/18, at 7:12 p.m., NA-C stated R36 definitely has pain when doing the HS (evening) cares. NA-C stated you try to be a gentle as you can, and try to roll R36 as little as possible, but in order to clean under the immobilizer, it has to come off, and I'm sure its painful for R36. NA-C also stated R36's mostly showed pain upon movement. R36's care area assessment (CAA) for activities of daily living (ADLs) dated 8/11/17, indicated a history of developmental delay, late onset [MEDICAL CONDITION], with a significant decline and weight loss over past 6 months (prior to nursing home admission) and significant physical deconditioning and weakness. The CAA indicated R36's baseline indicated she answers some questions appropriately and others inappropriately, responded to simple structure and was severely cognitively impaired. The CAA indicated R36 required extensive assist to being dependent with cares, and transferred with assist of 1 and a PAL lift; R36 used a wheel chair for locomotion and was non-ambulatory. A fall risk assessment dated [DATE], indicated R36 had long and short-term memory loss, was easily distracted, and mental functions varied over the course of the day. There assessment identified R36 was at risk for falls, and summarized R36 transferred with extensive assist of one and PAL lift, and did not communicate needs effectively or consistently. R36's care plan, revised 11/8/17, identified R36's potential for falls related to impaired cognition and mobility, and potential for poor safety awareness, and inability to voice needs adequately. The care plan also identified an ADL/mobility self care deficit. The care plan indicated for bed mobility R36 was extensive to being dependent with assist of one to two, and for transferring, R36 required extensive assist of one with PAL lift or two staff assist. R36's nursing progress note dated 5/12/18, indicated: Writer is called into R36's room with report of a large bruise on right temple area. Nursing assistant (NA) getting R36 dressed and shows me a very firm hematoma (bruise) It's reported when the NA entered the room. The area measure 6.5 cm (centimeters) by 6 cm x 2 cm raised. R36's right eye is watering and does seem to track my voice as R36 usually does. Gaze is fixed forward, but does have some grimacing or moaning with repositioning and turning. Respirations are short, but not dyspneic (difficulty breathing). Pupils are round and responsive, and R36 does move all 4 extremities actively but does favor right arm. R36 is flushed and diaphoretic (sweating). R36 did have a very large, watery bowel movement this morning after receiving a suppository. Vitals are as follow 97.4 (axillary temperature); 117 (pulse) 24 (respirations) and blood pressure 175 over 84. Ice pack applied to right temple area. A nursing progress noted dated 5/12/18, indicated primary care provider (PCP)-A evaluated R36 in her room and indicated new area of bruising on right shoulder and elbow. R36 winced and moaned with attempts to move her arm. PCP-A ordered a right shoulder, elbow and abdominal X-ray for evaluation of R36. A review of facility document, Imaging Services, dated 5/12/18, indicated R36 had a Oblique, angulated, non-displaced fracture proximal right humerus (diagonal [MEDICAL CONDITION] humerus non displaced the near end right humerus). A physician's progress note dated 5/14/18, indicated primary care provider (PCP)-A was asked to evaluate R36 due to some new areas of bruising identified this morning. The progress note indicated R36 is non-verbal, and completely dependent on others for transitions and mobility. PCP-A's assessment indicated, with attempted movement of the right shoulder and elbow, R36 has grimacing and guarding, and new soft tissue contusion of the right frontal parietal (right side of head above the ear) area with areas of ecchymosis (area of bleeding below skin) that is also developing on the anterior lateral aspect (front side). PCP-A provider's note indicated current areas of bruising are very concerning for injury and trauma, and evening nursing staff were questioned directly by the morning nursing supervisor and deny any falls out of bed, accidents, or injuries. The report indicated staff were unsure how these areas of bruising developed. Night nursing supervisor likewise reports no accidents or injuries reported to her by staff overnight. An untitled facility incident summary report, dated 5/12/18, indicated the facility self reported an allegation of physical abuse, unexplained injury to the State agency on 5/12/18. The report indicated on 5/12/18, at 7:10 a.m. nursing assistant (NA)-A called licensed practical nurse (LPN)-B into R36's room to report a large hematoma (measuring 6.5 centimeters x (by) 6 cm x 2 cm) on R36's right temple shortly after coming on shift. R36 was also favoring her right arm. The report indicated the writer arranged for another staff member to care for R36 in case the present nursing assistant (NA)-A was involved with the injury. A follow up Investigation Summary report was submitted to the State Agency and dated 5/17/18, which indicated R36 had X-rays of the right shoulder, right elbow and abdomen done on 5/12/18. The X-rays revealed R8 had a nondisplaced [MEDICAL CONDITION] (closest to shoulder) right humerus. A shoulder immobilizer was placed on R36. The investigation summary report indicated on 5/12/18 licensed practical nurse (LPN)-B was called into R36's room by NA-A at 7:10 a.m. to report bruising to R36;'s right temple area. NA-A told LPN-B she found R36 that way and did not know what happened to R36. The following day, LPN-C reported NA-A had confessed to what really happened. After getting R36 partially dressed, she sat her up at the side of bed to transfer using a standing lift. The lift was not at bedside, so the aide turned her back to grab the lift and R36 fell forward onto the floor. NA-A panicked and picked R36 from off the floor, cradled R36 like a baby and placed her back into bed. The NA-A call the nurse. The report indicated NA-A was educated on having the mechanical lift closer to the bed, so that you don't have to turn your back on a resident that is sitting up at the bedside. NA-A was also educated on the importance of not moving a resident before getting a nurse to assess the resident. When interviewed on 6/6/18 at 10:33 a.m., licensed practical nurse (LPN)-B stated she was working the day R36 had the fall (5/12/18), it was on Saturday. LPN-B stated NA-A led me into R36's room and showed me R36 had this big bruise on her face. LPN-B stated NA-A had no idea what happened to R36 but found her that way. LPN-B stated NA-A maintained all during the shift she did not know what happened to R36 or how. LPN-B stated my immediate reaction was R36 must have suffered some kind of trauma because the bruise was so large. LPN-B stated she immediately informed the charge nurse, began a set of vital signs and neuro checks, got the doctor involved, who ordered X-rays. LPN B stated during her assessment R36 was sweaty, and I thought maybe had a [MEDICAL CONDITION]. LPN-B stated NA-A was re-assigned work groups and did not take care for R36 for the rest of the day. LPN-B stated she suspected NA-A may have known more than was letting on, because of interviews and questions that were asked of NA-A during the shift. LPN-B stated she learned NA-A confessed to what occurred with R36 prior to the start of morning shift the next day, on Sunday (5/13/18). LPN-B stated it was 24 hours before NA-A fessed up to what really happened with her and R36. LPN-B stated R36's fall occurred on Saturday, (5/12/18) between the start of the morning shift at 6:00 a.m. and when she was called to the room, around seven or seven-thirty by NA-A. NA-A told her was getting ready to transfer R36 but the lift was not right at the bedside. LPN-B stated R36 fell when NA-A turned to get the lift. NA-A picked R36 up off the floor and placed her back into bed without telling the nurse. LPN-B stated she questioned if placing R36 back to bed caused or made R36's injuries more severe. LPN-B stated NA-A should have reported what happened to R36 immediately and not pick R36 off the floor back into bed after the fall. LPN-B stated residents, like R36 need a standing lift for transfers, and cannot be left alone at the side of the bed because you're never sure if they are stable. LPN-B stated there's a reason why a resident requires a lift and added I would not feel comfortable leaving R36 sit up on her own at the edge of the bed while NA-A got the lift. When interviewed on 6/6/18, at 10:54 a.m. nursing assistant (NA)-A stated she was working when R36 had the fall, and was responsible for what happened to R36, and lied about it by not telling the nurses what happened right away. NA-A stated she worked that Saturday morning (5/12/18) and was getting R36 up at her usual time, and sat R36 up at the edge for the bed. NA-A stated R36 used a mechanical (PAL) lift for transfers and assistance of one staff. NA-A stated when she was ready to transfer R36, the lift was not in arm's reach. NA-A stated R36 was not supported at the bedside, and she turned her back on R36 to retrieve the lift and left R36 unsupported, which was only three or four steps away, and R36 fell . NA-A stated R36 should not be left alone at the side of bed, and she should have had the lift right at the bedside. NA-A stated she then panicked, and put R36 back into bed because I was nervous, scared, panicked, and thought I would get into more trouble for what really happened. NA-A stated she did not immediately tell staff what happened to R36 on the day, but instead, I picked R36 up after the fall and put her back into bed. NA-A stated she did not admit to what happened with R36 until the next day, on Sunday (5/13/18). NA-A stated after letting staff know what really happened, she was removed from work and had to meet with the director of nursing. NA-A stated she was suspended without pay for three days, was given a written disciplinary notice, and re-educated on proper use and supervision using a lift with a resident. When interviewed on 6/6/18, at 1:58 p.m. NA-E stated R36 could not sit up alone at the side of bed, and would likely fall back. NA-E stated that while R36 would not be one to move too much when using the stand lift, R36 just was not safe to be left alone. When interviewed on 6/6/18, at 2:02 p.m. NA-B stated if she had to move R36 with a pal lift, and the lift was not right at hand, she would lay R36 back down on the bed, then move the lift into position. NA-B stated many residents could sit up on their own at the edge of the bed, but R36 was not very stable. When interviewed on 6/7/18 at 6:53 a.m., registered nurse (RN)-A stated R36 suffered injures from the fall. RN-A stated R36 had a right shoulder fracture, and extensive bruising on her right side, required X-rays for diagnosing, and some [MEDICAL CONDITION] (swelling) on the right side from the immobilizer R36 now has to wear. RN-A stated R36 did not fracture her wrist, and had some resulting pain, which now seems more under control. NA-A's personal file was reviewed and indicated NA-A received education of Workplace accident and Injury Reduction Program and Abuse Prevention, training both dated 3/1/18. When interviewed on 6/7/18, at 8:47 a.m., the director of nursing (DON) stated she felt R36's fall was an accident, but stated R36 could not be trusted and left sitting up, unattended. The DON stated leaving a resident unattended was not what nursing assistants are taught. The DON stated in her meeting she spoke with NA-A that moving R36 after the fall may have caused more harm, and emphasized to NA-A nurses need to make assessment before a resident was moved after any fall and re-education was provided to NA-A. The facility was also monitoring NA-A while she provided transfers and cares to resident, so this incident would not reoccur.

Based on interview and document review, the facility failed to adequately monitor the effectiveness of insulin for 1 of 3 residents (R1) who had recent insulin dosage changes and experienced elevated blood sugars. Staff failed to report the elevated blood sugars to the physician per the facility protocol. R1 required hospitalization for a [DIAGNOSES REDACTED]. Findings include:R1's medical record was reviewed. R1 was admitted in July 2015 and was diagnosed with [REDACTED]. R1's care plan dated 8/7/15, indicated R1 was on a diabetic diet with carbohydrate counting, and did not have good control. The care plan directed staff to update the physician as indicated and observe for signs/symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. (low and high blood sugars). The care plan did not identify parameters for staff as to what levels were considered high or low. R1's diabetic protocol directed nursing staff to notify the attending or on-call physician for a blood sugar over 300 milligrams/deciliter. In addition, R1 was to have his blood sugars checked before meals and at bedtime. R1 had physician orders [REDACTED]. Nursing staff to administer units of insulin based on the blood sugar reading. On 10/8/15, the physician ordered [MEDICATION NAME] 15 units at bedtime was ordered. Another physician order [REDACTED]. R1 saw the endocrinologist on 11/4/15, who ordered to discontinue the [MEDICATION NAME] 15 units at bedtime. The endocrinologist also ordered to check glucose at 3:00 a.m. and treat if less than 50. The order further directed staff to call or fax glucose levels to endocrinologist every 2 weeks. The endocrinologist ordered to start [MEDICATION NAME](long acting insulin to control blood sugar levels) 10 units in a.m. on 11/6/15. Medical record revealed R1's blood experienced low blood sugars: (normal blood sugar when fasting should be 70-110 and 135-140 after eating a meal). On 9/24/15 the blood sugar reading was 42 at 7:31 a.m. On 9/25/15 the blood sugar reading was 60 at 7:06 a.m. On 9/26/15 the blood sugar reading was 66 at 7:30 a.m. On 9/27/15 the blood sugar reading was 67 at 9:20 a.m. On 10/3/15 the blood sugar reading was 48 at 7:22 a.m. On 10/4/15 the blood sugar reading was 40 at 3:00 a.m. On 10/4/15 the blood sugar reading was 52 at 7:32 a.m. On 10/7/15 the blood sugar reading was 40 at 7:07 a.m. On 10/8/15, the blood sugar reading was 34 at 7:30 a.m. On 11/2/15 the blood sugar reading was 51 at 7:08 a.m. On 11/3/15 the blood sugar reading was 52 at 7:10 a.m. R1's November 2015, Medication Administration Record [REDACTED]. A progress noted on 11/5/15, at 8:00 a.m. by registered nurse (RN)-D indicated RN-D called R1's medical doctor (MD)-E to report the blood sugar reading at 3:00 a.m. of 358 and the pre breakfast blood sugar of 425. MD-E did not order any additional insulin coverage for the blood sugar readings. R1's November 2015, MAR indicated [REDACTED]. A nursing progress note on 11/6/15, at 7:15 a.m. by RN-D indicated she was updated by LPN-H that R1 had an elevated blood sugar at 6:30 a.m. of 505. R1 appeared confused and weak so LPN-H had checked the blood sugar prior to the pre-breakfast blood sugar check. R1 received his sliding scale Humalog insulin 6 units and [MEDICATION NAME] 10 units. R1 was sleepy but did arouse with touch. R1 did open his eyes but they appeared glossy. R1 was able to answer questions, however, R1 was disoriented and quickly went back to sleep. RN-D called the on-call MD-F and updated on R1's blood sugar, changes in cognition and recent insulin changes. MD-F ordered to give 2 additional units of [MEDICATION NAME], and to update MD-F on R1's blood sugar after 1 hour. A nursing progress note on 11/6/15, at 7:25 a.m. identified while RN-D was giving R1 the 2 additional units of [MEDICATION NAME] she checked his blood pressure which was 64/32. R1's normal blood pressure was 140-150 over 70-90. R1 was also snoring. RN-D updated MD-F on the low blood pressure and snoring and ordered R1 to be evaluated at the emergency department and was admitted to the hospital for diabetic ketoacidosis and a [MEDICAL CONDITION]. On 12/1/15, at 3:04 p.m. the director of nursing (DON) was interviewed. The DON stated she interviewed LPN-A and LPN-B and asked the nurses why they had not notified the medical doctor (MD) when R1's blood sugar was over 300. Both LPN-A and LPN-B stated since the doctor had ordered to treat if the blood sugar was less than 50, they felt that order superceded the diabetic protocol. R1's diabetic protocol directed nursing staff to notify the attending or on-call physician for a blood sugar over 300 milligrams/deciliter. In addition, R1 was to have his blood sugars checked before meals and at bedtime. On 12/1/15, at 5:25 p.m. LPN-B was interviewed. She stated there was a book for each diabetic resident which indicated when the MD should be called to report blood sugar values. LPN-B stated R1 had been having issues with low blood sugars. LPN-B stated on 11/6/15, when she checked R1's blood sugar at 3:00 a.m. and it was 414 she knew the order was to treat if below 50. LPN-B stated she looked at the 3:00 a.m. blood sugar result for 11/5/15, which was over 300 and LPN-A had not notified the MD, therefore LPN-B did not notify the MD. LPN-B stated she was aware R1 had a diabetic protocol to notify the doctor for a blood sugar over 300. On 12/2/15, at 10:10 a.m. R1 was interviewed and stated he did not remember the incident with his elevated blood sugars. On 12/10/15, at 3:25 p.m. LPN-A was interviewed. LPN-A stated R1 was eating candy prior to having his blood sugar checked at 3:00 a.m. on 11/5/15. LPN-A stated she reported R1's blood sugar on the taped nursing report in the morning that RN-D would listen to. LPN-A stated the doctor's order was to treat if under 50, and stated the doctor should have been notified according to R1's protocol. On 12/17/15, at 10:05 a.m. MD-F was interviewed. MD-F stated the nurses should have called the physician to report the elevated blood sugars per facility protocol on 11/5/15. MD-F stated R1 had a lot of problems with low blood sugars. MD-F stated she was not the MD that was called on 11/5/15, but if she had been notified of the 3:00 a.m. blood sugar on 11/5/15, she would have ordered additional insulin and not transferred R1 to the emergency department. MD-F stated she became concerned when R1 experienced the change in condition on 11/6/15, and ordered R1 to be transferred to the emergency department for evaluation. On 12/2/15, at 9:00 a.m. a policy for diabetic management was requested and the DON stated the diabetic protocol for each resident would be the policy and was considered part of the resident's care plan.