Every finding on record at Cura of Willmar

Based on observation, interview, and document review, the facility failed to implement care planned interventions to prevent further falls for 1 of 2 resident (R22) reviewed for falls.Findings include: R22 quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate impaired cognition, had diagnosis which included cancer, non-Alzheimer's dementia. R22 required extensive assistance with activities of daily living (ADL's) which included toileting, transfers, and locomotion. R22 had one fall with no injury since the last required assessment. R22 quarterly Care Area Assessments (CAA) dated 05/22/2026, identified R22 had a terminal condition due to cancer, had hearing or vision impairment, and was on hospice care. The CAA indicated R22 was an increased risk for falls. Review of R22's current care plan revised 12/24/26, showed R22 was a fall risk. Care plan indicated R22 was at high risk for falls related to de-conditioning, cognitive deficits and history of falls prior to admission. R22's care plan listed various fall interventions which included anti-rollbacks placed on the back of wheelchair to prevent tipping, encourage resident to wear appropriate footwear/shoes. Ensure resident has wheelchair behind him when ambulating in case resident is weak so he can sit, remove mobile bedside table and place a non-movable bed side table next to bed for tripping prevention. R22's fall risk assessment dated [DATE], identified R22 was at risk for falls. Review of R22's most recent post fall assessment dated [DATE], identified new interventions to try: Reviewed current fall prevention interventions. Re-established the intervention to remove the resident's mobile bedside table, as it was not clearly visible in commonly referenced documentation by staff. Review of R22's progress notes dated 6/27/26 at 02:52 P.M., R22 was calling out for help when staff followed the noise, staff observed R22 on the floor by room [ROOM NUMBER] doorway, resting on L elbow and feet facing forward, mobile bedside table in hallway next to R22. R22 was asked what he was doing with his bedside table, he indicated he was using it as walker. R22 stated I was going to my room, when asked how he fell. During an observation on 07/13/2026 at 2:13 P.M., R22 was in bed with mobile bedside table alongside bed. During an observation on 07/14/2026 at 8:56 A.M., R22 was in bed with mobile bedside table alongside bed. During an observation on 07/14/2026 at 9:01 A.M., Staff was in R22's room with mobile bedside table alongside bed. Staff did not remove bedside table when they exited the room. During an interview on 07/14/2026 at 9:23 A.M., nursing assistant (NA)-A reported she was unaware of any fall preventions that are currently in place for R22. NA-A stated they use Tasks function on computer charting for specific tasks that need to be completed for R22. NA-A verified table along R22's bedside was movable. During an Interview on 07/14/2026 9:31 A.M., licensed practical nurse (LPN)-A verified mobile bedside table is alongside bed and is movable. LPN-A reports that mobile bedside table is present to facilitate meals that R22 eats in room. LPN-A stated R22's care plan stated Movable table was not to be at bedside but thought that it should be reassessed. At 07/14/2026 9:46 A.M., NA-A stated she verified on R22's care plan the mobile bedside table is not to be at bedside and removed bedside table from R22's room. During an interview on 07/15/2026 at 9:52 A.M., Director of Nursing (DON) reported they spoke with staff and confirmed mobile table was bedside on 7/14/26, and was removed after surveyor talked with staff. DON confirmed it is important to follow the care plan for patient and staff safety. DON confirmed residents have individualized care plans in order provide customized care for each resident. Review of a facility policy titled Fall Management - Long Term Care revised 6/2025, identified the facility assessed residents upon admission, after a significant change in condition and annually for falls and promptly began a falls prevention plan. Policy indicated a post-fall analysis was done after each fall and appropriate care planned interventions were to be followed.

Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 2 residents (R29) reviewed for pressure ulcers.Findings Include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact and had diagnosis which included; diabetes mellitus, coranary artery disease, and hypertension. R29's MDS identified R29 was dependent for dressing lower half, transfer, toileting and required substantial/maximal assistance with rolling in bed side to side. R29 had one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or with directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). R29's Care Area Assessment (CAAS) dated 12/19/25, identified R29 had alteration in skin integrity due to being admitted with chronic pressure ulcers and diabetic foot ulcers. R29's CAAS identified R29 was often noncompliant with repositioning and often refused to get out of bed. R29's Braden Scale For Predicting Pressure Sore Risk assessment dated [DATE], identified R29 was at moderate risk for pressure ulcers with a score of 13. R29's Tissue Tolerance Lying assessment dated [DATE], identified length of observation time was two hours. The assessment identified R29 had exhisting wounds to heels and coccyx, and based on observations R29 should be repositioned every two hours. R29's Wound Observation Tool dated 7/15/26, identified R29 had a stage 4 pressure ulcer on his coccyx, 2 centimeters (cm) lenght, 1 cm width and 3 cm depth. Summary identified wound stable, no change. No signs or symptoms of infection, with a small amount of serosanguineous drainage. Surrounding (peri) wound skin intact and within normal limits. R29's care plan revised 6/11/26, identfied R29 had alteration in skin integrity related to chronic pressure ulcer and diabetic foot ulcer. Interventions included air pressure mattress, nutritional supplements, and turn and repostion per tissue tolerance. R29's Visual Bedside Kardex Report dated 7/15/26, identified R29 was independent to make minor position changes but for turns and boosts up in bed required two assistance with lift sheet. Able to use trapeze (triangle bar above bed) independently. R29 unable to reposition self in bed, needed frequent encouragement to reposition due to wounds. Assistance of two to boost up in bed and assist to turn over in bed. May use trapeze to assist with bed mobility. R29s Kardex lacked instructions for how often to reposition R29. During continuous observation on 7/14/26 at 7:06 a.m to 9:51 a.m., identified the following:-7:06 a.m., R29 lying in bed on back, pillows on sides and under lower legs, head of bed slightly elevated. R29 was drinking water. R29 indicated his wound care was completed earlier that morning. -7:18 a.m., staff member entered R29's room with breakfast tray, then left room. -7:19 a.m., hospital staff member outside of R29's door, then left area.-7:20 a.m., facility staff member returned with a glass of milk she provided to R29. The hospital staff member entered R29's room to complete lab work. -7:26 a.m., hospital staff member left R29's room. -7:52 a.m., staff member entered R29's room and asked if could remove breakfast tray. Staff member obtained two containers of pudding out of R29's refridgerator, and placed on bedside table as requested, then left R29's room with breakfast tray. -7:52 a.m., a staff member entered room and asked if needed anything as R29's call light was on. R29 asked when could get pain medication, and staff member stated would inform nurse, sanitized hands, then left room. R29 remained in same position. -8:17 a.m., nurse in hallway with medication cart leaving area, staff member walked by stating daily chronical then entered R29's room. Staff member sat down in chair next to bed and began to read and visit with R29. -8:40 a.m. staff member left R29's room. R29 remained in same position. R29 held a paper in hand and appeared to be reading it. -8:58 a.m., R29 remained in same position. No staff members near R29's room.-9:07 a.m., R29 remained in same position, while looking out window. No staff members near R29's room.-9:31 a.m. R29 remained in same position, while on phone. No staff members near R29's room. -9:32 a.m. activity assistant (AA)-A entered R29's room and brought snacks. AA-A straightened R29's room asked about daily chronicels and appointment, then sat down in chair and began visiting. R29 remained in same position. -9:51 a.m. AA-A continued to sit in chair in R29's room visiting. R29 remained in same position. At no time during continouous observation did any staff offer to reposition R29. During observation on 7/15/26 at 9:54 a.m. surveyor informed clinical manager registered nurse (RN)-A that R29 had not been repositioned as care planned. At 9:56 a.m. RN-A went to R29's room and donned a gown and gloves. Assistant director of nursing (ADON) joined RN-A outside R29's room and donned gown and gloves then both entered R29's room. RN-A asked R29 if they could check his skin, and R29 agreed. ADON and RN-A removed pillows from both sides of R29, and two pillows from under R29's lower legs and assisted R29 to turn onto his right side. RN-A proceeded to perform incontinence cares for R29. RN-A confirmed R29's left buttocks and upper thigh was red in color, but blanchable. RN-A removed R29's socks and boots, checked R29's heels, then replaced the slipper socks and blue heel protection boots. No redness on heels were noted. ADON and RN-A proceeded with cares, then assisted R29 to return to previous position with a pillow on each of his sides of buttocks and trunk, and a pillow under each lower leg. During interview on 7/15/26 at 10:45 a.m., nursing assistant (NA)-C verified was working on R29's wing with NA-D. NA-C stated had not assisted R29 earlier that morning. NA-C indicated usual practice was to assist R29 with repositioning every 2-3 hours. NA-C indicated R29 did not like to be repositioned and liked two pillows under his bottom and legs. NA-C stated she thought R29 may be able to offload himself with use of trapeze as she had seen him use it while repositioning him, but was not certain. During interview on 7/15/26 at 10:50 a.m., RN-A confirmed R29's last tissue tolerance assessment indicated to reposition R29 every two hours. RN-A stated R29 could offload his upper body, but was not sure of his lower body. RN-A indicated it was important to reposition R29 for skin integrity and get the pressure off. RN-A stated R29 wanted to be returned to the same position after cares completed with the use of the pillows. During interview on 7/15/26 at 11:06 a.m., director of nursing (DON) indicated she had been informed of R29 not being repositioned timely and confirmed R29's tissue tolerance assessment instructed staff to reposition R29 every two hours. DON stated that was important because R29 was bed bound, for his skin integrity and to prevent R29's pressure ulcer from worsening. DON indicated they would educate on the proper way to complete a tissue tolerance, because it was stopped at two hours, and R29 may have been able to be repostioned less often. DON also indicated staff needed education to check on R29 and reposition him following care plan. During interview on 7/15/26 at 12:04 a.m., NA-D verified that morning she had assisted R29 with morning cares and repositioning shortly after 6:00 a.m., as he was the first person who liked cares at that time. NA-D indicated R29 now could assist them with turning onto one of his sides. NA-D stated they had pillows to support him and he had an air pressure mattress on his bed. The facility policy titled Pressure Ulcers/Injuries Overview dated 4/24, identified the purpose of the procedure was to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors. The policy referenced definitions from the MDS Resident Assessment Instrument User's Manual. The policy identified pressure ulcers/injuries occurred as a result of intense and/or prolonged pressure or pressure in combination with shear. The policy lacked interventions for care and prevention of pressure ulcers.

Based on interview, observations, and document review, the facility failed to provide nursing rehab services as ordered for 1 of 1 resident (R44) reviewed for rehab services.R44's Quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had intact cognition, did not reject care that is necessary to achieve the resident's goals for health and well-being. R44's diagnoses included hemiplegia (left side weakness), hypertension (high blood pressure), and diabetes. R44's care plan revised on 6/10/26, directing staff to the nursing rehab program as noted in tasks; the program is overseen by a nurse and periodically reviewed. R44's discharge recommendations, signed 11/26/25, identified range of motion program; skilled physical therapy was necessary to develop a passive range of motion (PROM) program with staff to maintain range of motion (ROM) in left upper extremity and lower left extremity due to patients dependent status with transfers and mobility. Prognosis: good with consistent staff flow through. R44's Rehab Follow-Up Recommendations, signed 2/11/26, identified an order from physical therapy for a maintenance program three times a week; maintenance program directions were to set R44 up with self-range of motion, provide R44 with a seven-pound dumbbell three times a week to continue and maintain strength. A passive range of motion and stretching program was attached to identifying staff to communicate with patients on intensity of stretch, being gentle, and move slow. Stretches could be held for 30 seconds and repeated two to three times. Then move through movements five to eight times, slowly. Directions were attached for left arm elbow straightening, below bending, forearm, hand opening, and arm overhead stretching. Left leg and left knee left hip stretching. R44's task tab dated 2/11/26, identified nursing rehab to set patient up with self-ROM handout three times a week and assist as needed. R44's task tab dated 6/10/26, identified nursing rehab to provide patient with power web flex gripper and/or seven-pound dumbbell three times a week to continue and maintain strength. R44's task tab dated 6/10/26, identified nursing rehab to provide patient with power web flex gripper and/or seven-pound dumbbell three times a week to continue and maintain strength. R44's Documentation Survey Report dated July 2026, identified web flex gripper and/or seven-pound dumbbell exercises were completed:-two out of three times in the first week of July,-two out of three times in the second week of July.R44 ROM was completed:-two out of three times in the first week of July,-one out of three times in the second week of July. R44's Documentation Survey Report dated June 2026, identified web flex gripper and/or seven-pound dumbbell exercises were completed:-two out of three times in the first week of June,-two out of three times in the second week of June,-two out of three times in the third week of June,-once out of three times in the fourth week of June .R44's ROM was completed:-two out of three times in the first week of June,-two out of three times in the second week of June,-zero out of three times in the third week of June,-two out out three times in the fourth week of June. R44's Documentation Survey Report dated May 2026, identified web flex gripper and/or seven-pound dumbbell exercises were completed:-two out of three times the third week of May,-one out of three times the fourth week of MayR44 ROM was completed:-one out of three times the third week of May,-one out of three times the fourth week of May. R44's Documentation Survey Report dated April 2026, identified web flex gripper and/or seven-pound dumbbell exercises were completed:-one out of three times the first week of April,-two out of three times the third week of April,R44's ROM was completed:-two out of three times the first week of April,-one out of three times the third week of April, R44's Documentation Survey Report dated March 2026, identified web flex gripper and/ or seven-pound dumbbell exercises were completed:-one out of three times the first week of March,-zero out of three times the second week of March,-two out of three times the fourth week of March.R44 ROM was not completed:-one out of three times the first week of March,-one out of three times the third week of March-one out of three times the fourth week of March. R44's Documentation Survey Report dated February 2026, identified a web flex gripper and/or seven-pound dumbbell exercise program started on 2/11/26 and was completed:-one out of three times the third week,-zero out of three times the fourth week.R44 ROM was completed:-two out of three times the third week,-one out of three times the fourth week. During an interview on 7/13/26 at 12:06 p.m., R44 indicated R44 requested an order for rehab, and the restorative nursing aide comes to work R44's arms as he didn't want to lose strength in his right arm or ROM in his left arm. R44 indicated ROM and strength exercises occur once a week and believes it's ordered more often than once a week. During an interview on 7/14/26 at 4:32 p.m., registered nurse clinical coordinator (RNCC) indicated that when the restorative nursing assistant (RNA) is not working, the trained medical assistant (TMA) will complete the restorative program for the residents. RNCC was unaware who was to finish restorative programs if the RNA was unable to see all the residents in a given day. RNCC was not aware the RNA was having difficulties completing the restorative program for all the residents. During an interview on 7/14/26 at 5:29 p.m., RNA indicated R44 had a ROM program on his left arm and leg, which is done in his room, and then R44 goes to the therapy room for the dumbbell exercise on his right arm three times a week, Monday, Wednesday, and Friday. R44 has stayed in bed in the past or had refused to get out of bed. If he refuses, then it would be documented in the restorative progress notes as refused or on the tasks as refused. If R44 is at an appointment, it would be documented as n/a in the task charting area. RNA indicated she was the only RNA and was unsure who covers the restorative program when she is gone. RNA indicated at one time there were two RNA's but has been doing the restorative programs by herself the past two years and feels like she is seeing more people than before. RNA indicated she is responsible for the whole building restorative programs and at times is unable to see all the residents on a restorative program each day depending on the time a resident wakes up, appointments, and activities a resident might be at. These things would impacts if they are seen or not. RNA indicated her normal practice was to let the nursing assistants (NA) know who was not seen. RNA indicated other nursing aides can do ROM but not the exercises in the physical therapy room. RNA indicated the nursing assistants can chart ROM but is unsure if all the NAs were aware that they can chart or were able to complete ROM after she leaves for the day. RNA was not aware if anyone was assigned to do restorative when she takes time off. RNA indicated she had informed the previous administrator, physical therapist, and director of nursing that she does not have enough time to see everyone depending on the daily schedule. RNA charting was shown from the previous month and the blank areas. RNA indicated she had time off the previous month; other blank days R44 might have refused, and RNA didn't have time to chart the refusals. RNA has not noticed a decline in R44 strength for ROM, but if there was a decline, she would relay that information to therapy, and they would ask the doctor for orders to evaluate R44. During an interview on 7/15/26 at 9:06 a.m., NA-B indicated training was not received regarding restorative programs. NA-B indicated training had been done with helping with walking and the exercise bike. During an interview on 7/15/26 at 11:07 a.m., TMA indicated she used to work part time as a restorative nursing aid and would do one hallway and the RNA would complete the other hallway, but was told she was no longer needed. Unsure who was to cover for RNA when she is off. TMA indicated when RNA leaves, and there is ROM to be completed, the charting tab would have to be switched over to chart in the tasks. TMA is unsure if NA's were aware of how to switch this tab or if all the NAs have access to chart under the restorative program. TMA was aware of R44 having a restorative program but was unsure what the program was without having to look in the chart. TMA had not noticed ROM or strength decreasing. During an interview on 7/15/26 at 10:01, certified occupational therapy assistant (COTA) indicated therapy does not oversee the restorative nursing assistant and was not aware of what her caseload was. COTA indicated nursing was to oversee the RNA. COTA indicated there were two RNA's in the past, but now there is one RNA. COTA was unsure if the nursing assistants were trained in ROM. COTA indicated therapy does not currently see R44 and is unaware if there has been a decrease in ROM. During an interview on 7/15/26 at 10:05 a.m., Physical therapist (PT) indicated R44 would have had an assessment for ROM; the person who did the assessment no longer worked for the company. PT indicated he had not met R44 and does not have orders to see R44. PT reviewed R44s chart and indicated R44 was a resident at the facility and left, and when R44 was readmitted in January 2026. R44 requested ROM as there were no orders for physical therapy. PT indicated recommendations for restorative program were in the restorative book in the therapy cupboard. PT indicated the therapy department does not oversee the restorative nursing program. PT indicated no measurements were done on extremities and would be unable to indicate if there was a decline in ROM. PT was not notified of a decline in strength or ROM for R44. PT would expect if the RNA saw a decline, the restorative aid to notify nursing, and nursing would notify therapy. Therapy would request an order from the physician for treatment. PT was unaware who oversees the RNA and if ROM was being completed as ordered. During an interview on 7/15/26 at 10:32 a.m., director of nursing (DON) indicated the process for physical therapy to evaluate a resident, put together a program, and give the program to the nurses. The programs are looked at routinely to ensure the program is still appropriate. The NAs are trained on how to perform ROM, and there were sheets in residents rooms on the programs. When RNA was not working, the programs were triggered on the Kardex for the NAs to complete. If there is a task that is blank, it cannot be assumed it was refused or completed. DON expectation would be for RNA to inform the care coordinator if a program was not completed. All NA's could document in the task section when the program was completed, refused, or NA if a resident is out for an appointment. DON indicated it was not brought to her attention that some of the restorative programs were not being completed as ordered. DON reviewed the documentation and confirmed that restorative programs were not being done as ordered for R44. DON indicated ROM is important for mobility and quality of life, pain reeducation, and prevention of contractors. A policy titled Nursing Rehab Services dated 4/26 identified residents will receive nursing rehab services as needed to help promote optional safety and independence. Rehab nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative service. Residents maybe started on a nursing rehab program upon admission, during the course of stay or when discharged from rehabilitation care. Rehab goals and objectives are individualized and resident- centered and are outlined in the residents plan of care. Rehab goals may include but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her physiological and psychological resources; maintain his/her dignity, independence, and self-esteem. And participating in their development and implementation of his/ her plan of care. Resident participation and effectiveness will be periodically reviewed for the continued appropriateness and/or need for further rehabilitation services.

Based on observation, interview and document review the facility failed to ensure infection prevention practices including hand hygiene were followed during wound cares for 1 of 1 residents (R29) observed for wound cares.Findings Include: R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact and had diagnosis which included; diabetes mellitus, coranary artery disease, and hypertension. R29's MDS identified R29 was dependent for dressing lower half, transfer, toileting and required substantial/maximal assistance with rolling in bed side to side. R29 had one stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or with directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). R29's Care Area Assessment (CAAS) dated 12/19/25, identified R29 had alteration in skin integrity due to being admitted with chronic pressure ulcers and diabetic foot ulcers. R29's CAAS identified R29 was often noncompliant with repositioning and often refused to get out of bed. R29's Wound Observation Tool dated 7/15/26, identified R29 had a stage 4 pressure ulcer on his coccyx, 2 centimeters (cm) lenght, 1 cm width and 3 cm depth. Summary identified wound stable, no change. No signs or symptoms of infection, with a small amount of serosanguineous drainage. Surrounding (peri) wound skin intact and within normal limits. R29's care plan revised 6/11/26, identfied R29 had alteration in skin integrity related to chronic pressure ulcer and diabetic foot ulcer. Interventions included air pressure mattress, nutritional supplements, and turn and repostion per tissue tolerance. During observation on 7/15/26 at 9:54 a.m., clincial manager registered nurse (RN)-A applied gown and gloves and was joined by assistant director of nursing (ADON) who also applied gown and gloves. RN-A and ADON entered R29's room and RN-A asked R29 if they could check his skin, and he agreed. ADON stood on R29's right side of bed, and RN-A was on R29's left side. R29's bed was raised up, and they removed R29's sheet and pillows under R29's sides and legs. They removed the tabs on R29's brief, and completed perineal cares to R29's front using wipes. They then assisted R29 to his right side. R29 had a large amount of soft grey stool on buttocks, whick RN-A began to cleanse off with wipes. RN-A removed gloves, and applied new gloves. RN-A placed R29's brief in garbage, rolled the soiled disposable chux up and placed a new chux on R29's left side. RN-A removed gloves, then placed new gloves on. RN-A removed R29's dressing over coccyx pressure ulcer, then noted more stool on R29's buttocks and upper thigh, so began again to cleanse area with wipes. RN-A removed gloves, then applied new gloves. RN-A did not once sanitize her hands after removing soiled gloves. RN-A then gathered wound care supplies and placed on new chux near R29's buttocks. RN-A removed wound packing from R29's wound, then began to measure the wound. RN-A then removed new packing from the small brown glass bottle and began to pack R29's pressure wound. RN-A used a scissors to cut of the strip, then applied a bandage over the coccyx pressure ulcer, using tape on the top edge of dressing. RN-A did not sanitize hands or change gloves prior to beginning packing wound and applying new dressing. RN-A then removed the soiled strip from the chux, placed in can and placed other supplies and scissors on the bedside table. RN-A and ADON then assisted R29 with new brief, checked skin on heels and abdomen then positioned R29 with pillows. RN-A removed gown and gloves and sanitized hands. During interview on 7/15/26 at 10:50 a.m., RN-A indicated was new to position and still learning. RN-A indicated her usual practice did not include R29's wound cares. RN-A confirmed she had not sanitized her hands after each time her gloves were changed. RN-A also confirmed she had not sanitized her hands or changed gloves after removing R29's soiled packing, before applying R29's new wound packing and dressing. RN-A indicated sanitizing hands when changing gloves was important. RN-A also indicated removing gloves and sanitizing hands was important between removing soiled dressings and applying new dressings for infection control. During interview on 7/15/26 at 11:06 a.m., director of nursing (DON) indicated her expectation was that every time gloves were removed staff should sanitize their hands. DON also stated after a wound was cleansed, staff should remove gloves, wash hands and apply new gloves prior to applying new dressings. DON stated it was important to prevent infection. DON indicated the facility planned to have a skills fair the next day, and they would be reviewing hand hygiene and glove use. The facility policy titled Handwashing/Hand Hygiene dated 9/25, identified all staff would be trained on the importance of hand hygien in preventing the transmission of healthcare-associated infections. All staff would the procedures to help the spread of infections ot other personnel, residents and visitors. The policy interpretation and implementation identified an alcohol-based hand rub should be used for the following situations:-handling clean or soiled dressings-before moving from a contaminated body site to a clean body site during resident care-after removing gloves-after handling clean or soiled dressings -after contact with a resident's intact skin-after handling used dressings, contaminated equipmentThe use of gloves does not repale hand washing/hand hygiene. The facility policy titled Wound Care dated 1/25, included the following instructions. Prepare a clean field on the resident's overbed table or another appropriate surface in resident's room. Place all items to be used during procedure on the clean field. Peform hand hygiene, don gloves. Cleanse the wound, discard disposable items and remove and discard soiled gloves. Perform hand hygiene. [NAME] gloves, proceed with dressing the wound as ordered. Remove and discard gloves, perform hand hygiene.

Based on observation, interview and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 3 of 3 (R10, R28, R42) resident council members interviewed. This had the potential to affect all 52 residents who resided in the facility. Findings include:On 7/14/26 at 11:00 a.m., a resident council meeting was held with three residents which included R10, R28 and R42. During the resident council meeting, all three residents indicated they were not aware how to file a grievance. During an observation on 7/14/26 at 11:40 a.m., a walk through was conducted on each unit of the facility which reveale no grievance forms or procedures were posted for residents or resident reprentativies to refer to. During an interview on 7/14/26 at 11:50 a.m., acitivity director (AD)-A indicated during resident council meetings she had informed residents they could have social services fill out a grievance form with them. AD-A indicated the grievance officer was social services and the administrator. AD-A confirmed was not aware of last time spoke to residents about filing grievances. AD-A indicated she did not have a copy of the grievance form and was not aware of which form to use since they had new owners. During interview on 7/14/26 at 12:16 p.m., licensed social worker (LSW)-A stated her usual process was to address the concern right away and document the results in the resident's progress notes. LSW-A indicated a resident could file a grievance with her, or complete one with the ombudsman. LSW-A stated residents could obtain a form from her if wanted to keep it annonyomous, and she would keep it confidential. LSW-A confirmed she was the grievance office, and no grievance forms had been completed for months, but could not remember when. Review of grievance log identified last grievance form was completed December of 2025. During interview on 7/14/26 at 12:21 p.m. administrator confirmed the grievance policy and grievance forms were not located in prominant locations through out the facility for residents or resident representatives to complete. Administrator indicated residents could ask social services for forms and assistance to complete them. Administrator stated all staff had access to the grievance forms. Administrator confirmed residents were not able to file a grievance anonymously. The facility policy titled Grievance Policy dated 4/26, identified the purpose was the resident had the right to vice grievances to any staff member or anonymouslyto the facility, or other agency or entity that heard grievances without discrimination or reprisal and with fear of discrimination or reprisal. Grievance information would be posted in the facility and would include, the right to file grievances, the right to file anonymously, and the contact information of the grievance official.

Based on interview and document review the facility failed to protect 1 of 1 resident (R1) from neglect when R1 experienced a fall from the toilet on 3/7/26 and unidentified staff assisted R1 back to bed without notification to nurse and assessment. This resulted in actual harm when R1 was later identified to be in pain, required emergency medical attention, and was diagnosed with closed fracture of left hip. R1 required surgical repair of the fracture. The facility implemented corrective action, and the deficient practice was corrected on 3/08/26, prior to the survey, and was issued at past non-compliance. Findings include: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's diagnoses included stroke, hypertension, end stage renal disease (ESRD) , diabetes mellitus and cerebrovascular accident (CVA). R1 was cognitively intact, with no behaviors or wandering, required use of wheelchair or walker for mobility and assist of one for toileting. R1 was dependent on staff for sit to stand, chair to bed transfer and had not attempted to walk 10 feet or more. The MDS further indicated R1 was frequently incontinent of bowel and bladder. The MDS indicated he had a fall within the last two-six months prior to admission, no falls since admission and rarely experienced pain or had no pain at all.R1's Care Plan dated 2/02/26, indicated R1 had localized edema, hemiplegia and hemiparesis (hemiplegia is severe, resulting in complete paralysis of one side of the body, while hemiparesis is a milder form characterized by weakness, tingling) following cerebral infarction (stroke) affecting left non-dominant side and required assistance of two staff with ambulation, transfers and toileting. R1's Brief Interview for Mental Status (BIMS) dated 3/16/26, indicated R1 had a score of 15 out of 15 meaning he was cognitively intact. R1's Post Fall Investigation dated 3/07/26, indicated R1's current fall interventions were in place: bed at appropriate height; encourage to wear appropriate footwear; call light within reach; call light pinned in place; referrals to physical, occupational and speech therapy as indicated; and reposition resident per tissue tolerances and as needed. The investigation further indicated to encourage commode use (riser above toilet) assistance of two with transfers and the only other fall was on 2/01/26, while attempting to self-transfer. The investigation indicated the root cause was resident was transferred incorrectly. R1 was moved back into bed without assessment, multiple staff were terminated as result of this action and staff education was posted via forms. In addition, R1's care plan and Kardex were updated. R1's Emergency Department Note/History and Physical dated 3/07/26, indicated R1 had left hip pain and was diagnosed with closed fracture of left hip, end stage renal disease and atrial fibrillation (high heart rate). R1 was sent to another hospital for surgery for his fracture.A Facility Reported Incident (FRI) dated 3/08/26, indicated on 3/07/26 at 1:29 p.m., R1 reported to nurse on duty he tipped off the toilet. During the evening shift at approximately 7:45 p.m., nursing staff entered residents' room to check his blood sugar and resident was complaining of left leg pain, which had progressed from earlier reports of left knee pain during the day. When asked where the pain was located, the resident stated the pain had spread to his entire left leg. During assessment, the resident yelled out in pain with repositioning. Nursing assessment noted old, scattered bruising to the lower extremities and swelling noted to the left hip area. No new redness or bruising was observed at that time. When asked what had occurred, the resident reported that he had fallen earlier off the toilet. The resident was unable to recall the names of the staff who assisted him. Earlier in the day the resident had complained of left knee pain, stating that the pain comes and goes. Tylenol was given due to leg pain. At approximately 3:00 p.m., R1 stated the pain had subsided. A cold compress was offered but declined. Nursing staff reviewed the morning shift report, which indicated the resident had earlier report he had tipped off the toilet however staff reported they had not witnessed a fall. At approximately 7:13 p.m. due to worsening pain the resident stated it hurt so bad and went to the emergency department (ED) and it was identified the resident had a left femur fracture and was transferred to a different hospital. Facility Investigation dated 3/13/26, indicated R1 was transferred to the toilet by one employee. The resident care plan indicated he needed assistance of two staff with transfers. R1 reported he was sitting on the toilet and fell forward onto the floor while attempting to wipe himself. R1 stated he was blind, and two individuals assisted him up from the floor but could not recall who it was and was unable to give many details. Further investigation indicated that his wife reported that the resident told her he fell off the toilet but again could not give many details and had difficulty describing what had happened, but she stated it sounded like someone helped him off the floor, though he could not identify who assisted him. R1's spouse noted that it seemed someone asked the resident if he should see the nurse before assisting him. The resident later complained of pain in his leg and knee, particularly during physical therapy exercises and received Tylenol, which provided some relief but did not fully resolve the pain. The investigation indicated hospital documentation included the patient had fallen off the toilet earlier today landing on his left side. Patient reports pain in his left hip. R1 was brought to the emergency department (ED) for evaluation. X-rays showed mild displaced (significant movement of bone fragments out of their normal anatomical position) and angulated (a bend or angle at the fracture site) intertrochanteric fracture (hip fracture) of the proximal (femoral head, neck and trochanters, forming the hip joint) left femur. R1denied loss of consciences or head trauma. R1 was transferred to another hospital and underwent orthopedic surgery. R1's Physical Therapy Treatment Encounter Note dated 3/07/26 at 11:55 a.m., indicated R1 was seen by physical therapy assistant (PTA)-B and had precautions due to high blood sugar, falls, left sided weakness and was legally blind. The note indicated patient reporting fall from toilet however staff report no fall noted on this date. Left lower extremity knee, hip and intertrochanter band area pain reported with all movement with this session. Attempted transfer training from out of bed x three however left lower extremity pain not allowing for rise in spite of bed raised for improved ease. Care coordination with nursing to report findings of today's session. During interview on 3/23/26 at 4:23 p.m., R1 stated he slid off of the toilet while he was trying to wipe his butt, and his left leg hit the floor, and two nurses entered his room and just pulled me up. R1 stated he didn't know who they were because he was blind but just knew it was two staff who helped him off the floor, back into bed.During interview on 3/26/25 at 4:31 p.m., administrator stated she had interviewed all of the staff who were working on Saturday 3/07/26, and the activity assistant /nursing assistant (AA)-A stated she put R1 on the toilet before she went on her lunch break. AA-A stated she was informed by other staff working, R1 required assist of one for transfers. AA-A left R1 on the toilet with his call light and informed the other staff working she was going on her break. The administrator stated after she had interviewed nursing assistant (NA)-A, NA-B and NA-C none of them reported a fall and also could not state they assisted R1 from the floor into bed. After they had suspended all three NAs, it was decided to terminate all of three them as it was known someone had put him back into his bed and he had a fracture. During interview on 3/23/26 at 6:26 p.m., NA-A stated she did not work with R1 the day of his fracture and was informed by NA-C via Snap Chat (social media messaging platform) message that evening about R1's fall and fracture. NA-A stated the snap chat message mentioned for her to stick to the story about R1's fall, and NA-C put him back into bed. NA-A stated the message immediately disappeared, so she was unable to show proof of the message. NA-A stated she does not recall telling AA-A R1 was assist of one and does not recall AA-A telling her he was on the toilet before AA-A went on break.During interview on 3/23/26 at 7:11 p.m., NA-B stated she received a phone call the day of the fall from the director of nursing (DON) around 8:00 p.m. and was informed she was suspended pending investigation. NA-B stated she answered R1's call light around 1:30 p.m., the day of the fall, when R1 asked for Tylenol for his headache and she informed licensed practical nurse (LPN)-A. NA-B stated the next thing she knew, the DON told me we were all mandated reporters and we would all be let go. NA-B stated she did not see R1 fall and did not assist him off of the floor back into his bed.During interview on 3/24/26 at 9:30 a.m., NA-C stated it has been two weeks since the incident occurred, so it was hard to recall the events but did remember she got R1 up on 3/07/26. R1 went to lunch, they had chili. After lunch NA-C and NA-B put R1 back into bed between 11:30 am and 12:30 p.m. NA-C did not recall telling AA-A that she could transfer R1 to the toilet from his bed with assistance of one. NA-C did not recall AA-A report she was then going to leave R1 on the toilet and take her break. NA-C stated she never transferred R1 off the floor and back into bed and was not aware of him falling. In addition, NA-C stated she did send a Snap Chat to NA-A later in the evening on 3/07/26, asking her if anyone called her about the fall and that was the only thing she sent via Snap Chat. During interview on 3/24/26 at 10:59 a.m., with R1 and family member (FM)-A, R1 stated before the fall he stood up and was trying to wipe himself when he slid to the floor and two nurses came in and picked him up under his arms, then put him into bed. R1 stated he could not identify who they were as he was blind, but he knew they were women. FM-A stated she arrived on 3/7/26 around 1:00 p.m. R1 told her the same information, and he complained of leg pain. R1 received Tylenol and later that day the pain worsened, and he was sent to the hospital and had surgery.During interview on 3/24/26 at 12:56 a.m., AA-A stated she was working on 3/07/26, doing activities. It was a Saturday. AA-A stated she also helped with meals and answering call lights. After assisting with meals AA-A was heading for her break she noticed R1 was in bed and had his call-light on. R1 requested to use the bathroom. AA-A asked the staff working what assistance R1 needed for transfers and was told he was assist of one and transfer belt to the toilet. AA-A was asked to transfer him and leave his call light with him. AA-A was told, the staff working would transfer him off of the toilet and back into bed while AA-A was on her break. AA-A stated after her break she continued with activities for the day and found out later in the evening R1 had fallen and had a fracture.During interview on 3/24/26 at 1:40 p.m., physical therapy assistant (PTA)-A stated prior to R1's fall with a fracture he was assist of one with a gait belt in therapy. PTA-A stated he does not think it would be possible for him to transfer himself back into bed after he had a fall and a fracture. PTA-A stated someone must have transferred him back into bed that day after his fall. During interview on 3/25/26 at 9:40 a.m., regional nurse consultant stated she knows something happened with R1 with his fracture and felt the staff working just wouldn't come clean. Their stories didn't match up with each other's and continued to deny what happened, even after termination.During interview on 3/25/26 at 11:10 a.m., LPN-A stated she was the nurse working on 3/07/26, and one of the NAs told her R1 wanted Tylenol. When LPN-A went into R1's room, R1 reported he had fallen from the toilet. When LPN-A interviewed all of the NAs working that day, none of them said they saw him fall. LPN-A thought R1 was confused. LPN-A stated she was new at the facility, and it happened right at the end of her shift so LPN-A passed the information on to the evening shift. Facility Fall Communication undated, indicated all fall events must be reported to the nurse immediately, including witnessed, unwitnessed, near, and suspected falls. If a resident reports a fall, this must be reported to the nurse immediately as well. Staff must never fail to notify the nurse if they are aware that a fall occurred, as prompt reporting is necessary for proper assessment and care. Failing to report a fall may result in preventable harm to a resident and may lead to a reportable event. The facility corrected the deficient practice, which began on 3/7/26, on 3/08/26, prior to survey entrance on 3/23/26, by NA-A, NA-B and NA-C were terminated, transfer audits completed, education completed on facility's transferring, ambulation and falls policy. Therefore the deficiency is being issued at past non-compliance.

Based on observation, interview and document review the facility failed to develop and implement a process to ensure the wander alert system was in working order. This had the potential to affect 2 of 2 residents (R1, R2) who utilized a wander alert device. Findings include:R1's admission Record indicated he admitted to the facility 2/23/24. Diagnosis included vascular dementia, Alzheimer's disease and bilateral below the knee amputations.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified a memory problem and delusions. The MDS indicated R1 did not wander during the assessment period and wore a wander alert device daily. R1's care plan dated 9/3/25, identified a high risk for elopement and directed staff to provided one to one supervision while awake and 15-minute checks while in bed. The care plan indicated R1 had wander device bracelets placed on his left wrist and on the back of his wheelchair.Facility incident report dated 8/24/25, indicated R1 was able to exit the facility via the front entrance doors, wander guard did not work. Nursing students observed R1 exiting the building and assisted him back inside and alerted staff. The report indicated the door had recently been open and had not locked which allowed R1 to exit the facility. Facility incident report dated 9/1/25, indicated Staff noted the wander guard alarm for R1's unit was sounding. Staff found R1 in the water in the tall grass in a culvert on the west side of the building with his wheelchair on top of him. The report indicated R1 was able to push and hold the exit door long enough for the emergency release to activate, allowing the door to open.During interview on 9/5/25 at 7:30 a.m., the administrator stated the facility did not currently have a maintenance director and had not for only about two weeks. The administrator said they had the maintenance staff from another facility come and look at the doors to ensure everything was working properly. She said everything was reported to be working fine. During interview on 9/5/25 at 7:52 a.m., the regional director of operations (RDO) stated the wander alert system was checked every Monday. The RDO stated there were two options for checking the doors, a testing device, handheld remote or using a FOB (transmitter). The RDO said the doors were checked using a handheld remote.During observation on 9/5/25 at 9:36 a.m., the RDO used the handheld remote to check the facility doors that had a wander alert system. The doors alarmed and locked when tested.During interview on 9/5/25 at 9:03 p.m., nursing assistant (NA)-A stated the doors alarmed when R1 was near but did not physically lock and said it had happened 4-5 times. During interview on 9/9/25 at 12:15 p.m., licensed practical nurse (LPN)-A stated she was working when R1 was found outside the facility. LPN-A said she felt the issue was the door had not been locking and said it had been reported to management.During interview on 9/9/25 at 12:39 p.m., NA-A stated it was pretty common knowledge the door had not been locking and said the issue had been going on for about 3-4 weeks. NA-A said it had been reported.During interview on 9/9/25 at 1:15 p.m., the administrator said the maintenance director from another facility had done an inspection of the doors to ensure they were working after R1 had eloped from the facility. During interview on 9/5/25 at 2:00 p.m., the maintenance director whom the administrator had been referring to, stated he had tested the doors at the facility on 8/26/25, but had not been out since. He said at that time the doors were functioning properly.During interview on 9/10/25, at 8:16 a.m., the former maintenance director said he did not think the doors would unlock if a wander alert device was near and said he never tested for that. The former maintenance director said the used a bracelet (transmitter) and checked the doors on Mondays to make sure they locked. He said the device checker never worked on the doors. The former maintenance director said he did not know who would be called if there were any technical issues with the wander alert system.During interview on 9/10/25 at 10:34 a.m., the RDO stated as far as he knew, the doors should not be able to unlock when pushed and held if the person was wearing a wander alert bracelet. The RDO said he had reached out to a third party who was going to send a technician to look at the system.DoorGUARDIAN Installation Manual dated 12/6/2023, indicated the following recommended weekly testing: Patient Escort Feature Test- Enter the monitoring zone with a transmitter on your ankle. The red light will turn on and the door will quietly lock. Enter the primary reset code and the light will turn green, and the door will unlock.Anti-tailgate Feature Test- With the door locked, apply pressure on the opening hardware of the door. The exit panel will begin to alarm, and the red light will remain on. The light will remain red and the audible alarm will sound. After 15 seconds the audible alarm will become a continuous tone and the door will release. Open the door and the audible alarm will change to a seagull sound. Close the door and enter the resent code. The panel will stop alarming, and the door will re-lock.Remote Keypad test- repeat the steps above.Push Button Test- Pass through the door from the exit panel side using the reset code. Close the door. Depress the push button. No alarm condition will be activated.Advanced Security Mode Test- Bring a transmitter into the monitoring zone. The green light will turn red; the yellow light will blink. Now enter the reset code. The red light will flash green momentarily indicating a valid code was entered while a monitored resident was nearby. Next, try to gain access via the indoor/outdoor push button if one is installed. With a transmitter in range, the door will remain locked, and an audible alarm will sound. Only by entering the secondary reset code will access be granted in this situation.

Based on observation and interview, the facility failed to ensure resident rights were maintained for 1 of 3 residents (R37) reviewed for dignity.Findings Include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with activities of daily living (ADL)'s. R37's diagnoses included non-Alzheimer's dementia, weakness and localized edema. MDS also indicated R37 had an indwelling external catheter. During observation on 8/4/25 at 2:21 p.m., R37's urinary catheter drainage bag, which was approximately half full of dark amber colored liquid, was hanging on the left side of bed. Drainage bag was visible to all residents and staff who walked past. During observation on 8/5/25 at 2:19 p.m., R37's urinary catheter drainage bag, which was approximately one-quarter full of dark amber colored liquid, was hanging on the left side of bed. Drainage bag was visible to all residents and staff who walked past. During observation on 8/6/25 at 8:50 a.m., R37's urinary catheter drainage bag, which was approximately half full of dark amber colored liquid, was hanging on the left side of bed. Drainage bag was visible to all residents and staff who walked past. During observation on 8/7/25 at 7:46 a.m., R37's urinary catheter drainage bag was hanging on the left side of bed. Drainage bag was visible to all residents and staff who walked past. During interview on 8/6/25 at 1:30 p.m., nursing assistant (NA)-C stated if a resident had a catheter bag it should always be covered so others could not see it. NA-C confirmed R37's urinary catheter drainage bag was not covered and was visible to all. During interview on 8/7/25 at 7:55 a.m., trained medication assistant (TMA)-A stated if a resident had a urinary catheter the drainage bag should be covered at all times for the resident's dignity. During interview on 8/7/25 at 8:13 a.m., registered nurse (RN)-C stated the catheter drainage bag should be hung on the side that would be more private for the resident and the bag should always be covered with a catheter cover bag to respect the resident's privacy and dignity. During interview on 8/7/25 at 8:17 a.m., licensed practical nurse (LPN)-C stated catheter drainage bag should be hung on whatever side where tubing is attached to the resident. LPN-C stated it was important to ensure drainage bag is placed lower than the bladder and cover the bag so no one can see bag for the resident's privacy. During interview on 8/7/25 at 9:49 am., director of nursing (DON) stated she would expect staff to place and cover urinary catheter drainage bag so it was not visible as it could be a dignity concern for the resident. DON confirmed she had noticed R37's catheter bag not covered and visible from hallway earlier this week. The facility Quality of Life - Dignity policy, last reviewed 1/2024, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist resident as needed by helping the resident to keep urinary catheter bags covered.

Based on observation, interview and document review, the facility failed to inform residents in the facility that all bird feeders, including personally owned bird feeders, were being removed, prior to doing so, for 1 of 1 residents (R34) in the sample. Findings include: In review of R34's electronic medical record diagnosis page, the following diagnoses were listed: Parkinson's disease, cerebral palsy, major depression with moderate recurrence, and anxiety disorder. R34's quarterly Minimum Data Set (MDS), dated [DATE], indicated resident required minimum - moderate assistance from staff for all activities of daily living. The MDS also indicated R34 was cognitively intact. A review of R34's assessments, the following was documented:6/20/25 Mood Interview (PHQ-9) R35 scored of 8 of 27 which indicated R35 was mildly depressed.6/20/25 Brief Interview for Mental Status (BIMS) R35 scored 15 out of 15 which indicated R35 was cognitively intact. R34's care plan printed 8/6/25, documented resident had been care planned for Mood / Psychosocial concerns with the following:Potential for adjustment concerns related to [long term care] placement. [Diagnoses of depression and anxiety. PHQ-9 score 8/27 on 6/20/25 indicating mild symptoms of depression/ [R34] loves all things cats and finds comfort with socializing with the household cat. {R34] dislikes the song Rocky Mountain High by [NAME] Denver as it reminds him of his dog when he was a child and requests that the song be changed when it plays in the dining room. During resident interview on 8/4/25 at 4:23 p.m., R34 and a family member (FAM)-A were sitting in his room visiting. R34 stated he was upset the facility had taken down his window bird feeders. R34 stated he has fed birds all his life and had actually built a bird feeder out of a bird cage, so that the black birds and squirrels could not get inside to take the food from the song birds. FAM-A interjected, R34's bird watching helped him with his anxiety and depression. It was something that he took pride in. As FAM-A was explaining how involved resident was with bird watching and bird feeding, R34 wiped his eyes with his shirt sleeve. R34 stated he was on an outing last week with his family. When he returned, he noticed the bird feeders were missing. R34 asked staff, who informed him corporate had informed the facility that all bird feeders (even the resident owned ones) were to be taken down due to a recommendation from the corporate contracted pest control provider. On 8/6/25 at 2:04 p.m., registered nurse (RN)-A stated staff heard the facility administrator had received a email from corporate which instructed [NAME] facilities were to remove all bird feeders from the properties. They were informed the pest control contractor (Plunkett's Pest Control) recommend this being done, for safety reasons of bird seeds on sidewalks, and pest mitigation. RN-A stated she was not aware rodents were an issue within the building. During interview on 8/6/25 at 3:59 p.m., the administrator and corporate RN (CorpRN) stated last week an email came from corporate to all facility administrators, to remove all bird feeds from their property, including ones hung by the residents/families themselves. Corporate was concerned about bird seed on sidewalks being a safety concern, as well as, the increased potential for rodent infestations. The administrator stated she requested the maintenance department remove all bird feeders on the property. Administrator didn't think about informing residents, while she thought all the bird feeders were facility owned. During a further interview on 8/7/25 at 9:47 a.m., CorpRN stated he had a telephone conversation with the corporate owner this morning. CorpRN verified the recommendation came from corporate, from the recommendation of the pest control provider, for the prevention of rodent infestation, and all administrators were informed to remove bird feeders from all facility properties. The facility was unaware R34's bird feeders were privately own when removed. CorpRN stated he would be meeting with R34 today to see if there is an acceptable alternate bird feeding system the facility could provide. The facility did not have policies for when facility systems / processes are changed which may directly impact residents.

Based on interview and document review, the facility failed to complete and implement a baseline care plan within 48 hours of admission for 1 of 2 residents (R22) reviewed for care plans.Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R22's diagnoses included: Type II diabetes mellitus with diabetic chronic kidney disease, heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), hypertension (high blood pressure), hemiplegia (a condition characterized by weakness or paralysis on one side of the body), malnutrition (a serious condition resulting from an imbalance in nutrient intake, leading to deficiencies or excesses that negatively impact health), depression, dependence on renal dialysis and hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream). MDS indicated R22 received dialysis services and was on a therapeutic diet. R22's electronic health record (EHR) indicated R22 was admitted to the facility on 12/2024. EHR lacked evidence a baseline care plan had been initiated within 48 hours of admission. EHR indicated baseline care plan was developed on 12/26/24 and indicated R22 was dependent on staff for transfers, toileting and grooming/bathing. During interview on 8/7/25 at 10:31 a.m., director of nursing (DON) stated baseline care plans should be completed within 48 hours of admission to the facility. DON confirmed a baseline care plan had not been completed with 48 hours of admission for R22. RN-A stated baseline care plans are important to complete for resident safety and so staff know how to care for the resident. The facility Baseline Care Plan facility, dated 11/21, indicated facility would develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission.

Based on observation, interview and document review, the facility failed to ensure a wheeled walker was not used as a wheelchair for 1 of 1 residents (R10) which placed resident at increased risk for a fall. Findings include: R10's quarterly minimum data set (MDS) dated [DATE], indicated R10 was cognitively intact and was independent with cares. R10s care plan dated 12/3/24, indicated R10 was up ad lib (allowed to get out of bed and move around as they please, without restrictions), ambulated and transferred slow and steady with four wheeled walker, and R10 was at risk for falls related to decreased functional strength, decreased activity tolerance and impaired standing balance. On 8/04/2025, at 10:57 a.m. was observed sitting on four wheeled walker using feet to propel walker backwards, two wheeled legs were observed to be bowed outwards from the walker. There was no wheelchair observed in R10s room. On 8/04/2025 at 11:30 a.m., R10 was observed entering the building sitting on four wheeled walker, propelled backward using feet. When interviewed on 8/07/2025 at 8:04 a.m., R10 stated no facility staff had spoken with him regarding potential risks related to using wheeled walker as a wheelchair. R10 stated he did not have a wheelchair and prior to admission to the facility he had a fall from the walker while propelling it backwards down a sidewalk, had hit head on the sidewalk after the walker had hit a bump and flipped out from under him. When interviewed on 8/07/2025 at 8:20 a.m., nursing assistant (NA)-B stated R10 normally used the walker as a seat and propelled backwards. NA-B stated R10 was told the wheels were flared out due to weight and was not safe to use. When interviewed on 8/07/2025 at 8:39 a.m., registered nurse (RN)-B stated R10 walked short distances when in room, when outside of room propelled walker backwards instead of using a wheelchair. RN-B stated R10 was informed sitting on the walker while propelled backwards was not safe, however, R10 continued to use the walker in that manner. When interviewed on 8/07/2025, at 9:56 a.m. director of nursing (DON) stated many things could happen to R10 when walker was used as a wheelchair, the walker could roll away or collapse, R10 or anyone that used a walker inappropriately was at an increased risk for a fall. DON stated R10 was bigger in size, would think the wheels would be bowed out. DON identified there was no risk/benefits located in R10's electronic record, nor was there a referral to therapy to ensure R10 had a proper and safe mobility device. Facility policy regarding resident safety and mobility devices was requested, however, none was received.

Based on interview and document review the facility failed to ensure coordination of dialysis care for 2 of 2 resident (R3 and R22) who required dialysis (treatment to filter blood when kidneys are no longer able). Additionally, the facility failed to ensure post-dialysis assessment and monitoring was completed for 2 of 2 resident (R3 and R22) reviewed for dialysis.Findings include: R3 R3's 5-day Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition and required assistance with all activities of daily living (ADL)'s. R3's diagnoses included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), hypertension (high blood pressure), renal failure (occurs when the kidneys are unable to adequately filter waste and excess fluid from the blood), diabetes mellitus (a metabolic disease where blood glucose levels are too high due to the body's inability to produce enough or properly use insulin), malnutrition (a serious condition resulting from an imbalance in nutrient intake, leading to deficiencies or excesses that negatively impact health), chronic obstructive pulmonary disorder (a progressive lung disease that makes it hard to breathe), dependence on renal dialysis and acquired absence of right leg below knee. R3's provider order printed 8/6/25, indicated R3 had dialysis treatments every Monday, Wednesday, and Friday. R3's electronic health record (EHR) identified R3 went to dialysis eleven times since admission with only two communication forms sent with. The facility's top portion of the communication form was not completed. Information on communication form to be completed by facility included:Resident NameDatedate of birth Code StatusMental StatusAccess Site LocationAccess TypeAccess Site BleedingSigns of InfectionMedications given pre-dialysis: Please not any pain meds or BP medsDiet/Fluid RestrictionVitals signs (temperature, pulse, respirations and blood pressure)New medications since last treatmentChange in medical condition since last treatmentAdditional commentsLTC Nurse signature with date R3's medical record lacked documentation of monitoring of shunt for bruit and thrill (bruit is an abnormal, swishing sound heard through a stethoscope, while a thrill is a palpable vibration felt over the same area. Both are associated with turbulent blood flow, often indicating a narrowing or other abnormality in a blood vessel). R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for reviewed dates 7/8/25 - 8/6/25 lacked directions for staff to check for bruit and thrill. In addition, MAR and TAR lacked evidence of monitoring of shunt for bruit and thrill. R22 R22's quarterly MDS dated [DATE], identified R22 had moderate cognitive impairment and required assistance with all ADL's. R22's diagnoses included: Type II diabetes mellitus with diabetic chronic kidney disease, heart failure, hypertension, hemiplegia (a condition characterized by weakness or paralysis on one side of the body), malnutrition, depression, dependence on renal dialysis and hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream). MDS indicated R22 received dialysis services and was on a therapeutic diet. R22's provider order printed 8/6/25, indicated R22 had dialysis treatments every Monday and Friday. R22's EHR identified. R22 went to dialysis 26 times since 5/12/25, only 10 communication forms were sent with. Eight Communication forms indicated facility's top portion of form was empty and not completed with two being completed fully. Information on communication form to be completed by facility included:Resident NameDatedate of birth Code StatusMental StatusAccess Site LocationAccess TypeAccess Site BleedingSigns of InfectionMedications given pre-dialysis: Please not any pain meds or BP medsDiet/Fluid RestrictionVitals signs (temperature, pulse, respirations and blood pressure)New medications since last treatmentChange in medical condition since last treatmentAdditional commentsLTC Nurse signature with date R22's medical record lacked documentation of monitoring of shunt for bruit and thrill. R22's MAR and TAR for reviewed dates of 6/1/25 - 8/6/25 lacked directions for staff to check for bruit and thrill. In addition, MAR and TAR lacked evidence of monitoring of shunt for bruit and thrill. During interview on 8/6/25 at 3:30 p.m., registered nurse (RN)-D stated communication forms are supposed to be sent back and forth to dialysis with the resident to communicate status and if there were any changes. RN-D stated she would expect the facility to complete the entire top section of the communication form, so they are aware of what is going on with the resident. RN-D stated the dialysis clinic would complete the bottom portion of the form to return to the facility with information regarding their dialysis run. If there were any pertinent changes the dialysis clinic would also call the facility and communicate the changes. RN-D stated both R3 and R22 had a fistula and would expect the facility to check for bruit and thrill. During interview on 8/7/25 at 8:17 a.m., licensed practical nurse (LPN)-A stated communication forms are expected to have the top portion completely filled out and sent with to the dialysis center. LPN-A stated communication forms should contain vital signs, diet, any medications changes or as needed medications received, dialysis port location, mental status, code status and any changes in resident's condition. LPN-A stated the monitoring for dialysis residents consisted of monitoring fluid restrictions, assess for redness or signs of infection at the port site and if the resident had increased edema. During interview on 8/7/25 at 9:35 a.m., LPN-B stated on resident's dialysis days a communication form was completed with resident's vitals, weight, medications, port location and any changes in condition and is sent with the resident to the dialysis clinic. Dialysis clinic would then complete the bottom portion of the form and return it to the facility. LPN-B stated R3 and R22 had fistulas and monitoring should include checking fistula for bruit and thrill. LPN-B stated she checked for bruit and thrill but does not document it anywhere as it is not on the MAR/TAR. During interview on 8/7/25 at 9:50 a.m., director of nursing (DON) stated the documentation regarding dialysis had been lacking. DON confirmed R3 only had two communication forms sent with that were not completed by the facility and R22 had 10 communication forms sent with eight of them not completed. DON stated the communication forms are important so there was communication between the facility and the dialysis clinic. DON stated she expected the top of the communication form to be completely filled out. DON stated she expected nursing to be monitoring the fistula site for bruit and thrill. DON stated it was important to ensure the fistula was patent and not infected especially when they return from dialysis. DON confirmed there is no monitoring for bruit and thrill in place for neither R3 or R22 but should be. The facility Hemodialysis, Care of a Resident policy, dated 8/25, indicated the facility will ensure that residents who require dialysis receive such services, consistent with professional standards of practice. - Licensed Nursing Staff will provide ongoing assessment of the resident condition and monitoring for complications after dialysis treatments received at a certified dialysis facility. - Licensed staff will monitor for complications related to post-hemodialysis which may include, but are not limited to:o Bleedingo Leg crampso Seizureso Nausea/vomitingo Unsteady [NAME] Headacheo Fatigueo Signs/symptoms of infectiono Hypotensiono Chest pain- The Charge Nurse will be responsible for ongoing communication with the dialysis facility including the following:o Sending current physician orders, lab reports, and vital signs to dialysis facility.o Advance Directives and code status; and any changes or need for further discussion with the resident/representative, and practitioners.o Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.o The identification of symptoms such as anxiety, depression, confusion, and/or behavioral symptoms that interfere with treatments.o Dialysis adverse reactions/complications, and/or concerns related to the vascular access site/PD catheter.o Changes and/or decline in condition unrelated to dialysis. This would include communication related to care concerns such as a resident who is at risk for or who has a pressure ulcer, receiving appropriate interventions; [NAME] The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.

Based on interview and document review, the facility failed to ensure tuberculosis (TB) testing was completed for 1 of 6 sampled residents (R68) reviewed for required baseline TB screening and testing. Findings include: The Centers for Disease Control (CDC) guidelines for preventing the transmission of mycobacterium tuberculosis (TB) in Health Care Settings, 2005, directed all residents and staff must receive a baseline TB screening. The baseline TB screening should consist of assessment for TB risk factors and history; assessment for current symptoms of active TB; and testing for the presence of infection with mycobacterium tuberculosis. R68's Minimum Data Set (MDS) entry tracking record dated 7/11/25, indicated he initially admitted to the facility on 7/2025. An initial baseline TB screening for signs and symptoms was completed 7/11/25, however R68'S electronic medical record (EMR) lack evidence of testing for the presence of TB infection. During interview on 8/5/25 at 1:12 p.m., the director of nursing (DON) stated all new residents were screened for TB and would be administered the first step tuberculin skin test (TST) upon admission or within 72 hours of admission. The DON stated the timeline from the administration to the reading of the results was 48 to 72 hours after administration. The DON stated TST's must be read during that period of time to ensure accuracy. The DON confirmed R68 did not receive the 1st TST before being re-hospitalized on [DATE]. The DON stated it was important to make sure resident TST's were administered and read within the timeframe of 48 to 72 hours with the second step occurring seven to 21 days after step one to verify resident's tuberculosis status and that it is accurate. The facility's Tuberculosis, screening residents policy dated 2025, indicated for all new admissions or re-admissions, residents would screened for TB infection in compliance with state regulations which includes the first step TST being performed within 72 hours of admission and read by a licensed nurse within 48-72 hours after administration. If the first step is negative, the second TST would be administered one to three weeks from date first step was read and be read by a licensed nurse within 48-72 hours after administration.

Based on observation, interview and document review, the facility failed to ensure the nursing staff posting (which included number of nurses and nursing assistants and the hours they were scheduled) was posted and available for all residents. families and visitors. This potentially effected all 20 residents residing in [NAME] House, all 20 residents residing in [NAME] House and their families / visitors. Findings include - Upon entering the facility on Monday 8/4/25 at 10:30 a.m., the survey team noted the posting of the Resident Rights and facility's survey results. However, in the front entrance of the facility, and in both front wings of the facility (Long Term Care units - [NAME] Cottage and [NAME] House) the lacked evidence the facility had posted the required staff posting of hours and nursing staff scheduled. After the initial walk through of the facility (on 8/4/25), the surveyors on the Transitional Care Unit (TCU - units 100 and 200) were unable to locate the posting as well. The long Term care (LTC) unit is separated from the TCU by means of a wing which included the administrative offices and therapy department. and one needed to walk through a set of closed fire doors to go between the two sections / levels of care. The survey team continued to observed for the postings, from 8/4/25 - 8/7/25. However, on 8/7/25 at 7:56 a.m., a surveyor on 100 unit noted the staff posting on a hallway wall dated 8/6/25 (the day prior), and was posted in an acrylic frame that was posted sideways. To read the posting, one would either have to take the posting out, or turn their head sideways to read the posting. During interview on 8/07/2025 at 11:17 a.m., the facility administrator verified the staff posting should be both on the TCU and the LTC units. Administrator stated the posting for the LTC wings should be on the receptionist desk, in that general area at the main entrance. The administrator stated the staff person responsible is currently on family medical leave, and the reassignment of that task had been over looked. The administrator stated she would have maintenance rehang and straighten the acrylic holder on the TCU.

Based on interview and document review, the facility failed to ensure as needed (PRN) medications were administered per physician's order for 1 of 1 resident (R20) reviewed for unnecessary medications. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R20's diagnoses included chronic diastolic congestive heart failure (type of heart failure that occurs when the heart's left ventricle is unable to fill with blood properly during the diastolic phase, when the heart relaxes), hypertension, peripheral vascular disease (chronic, progressive condition that occurs when blood circulation to a body part other than the heart or brain is reduced), Non-Alzheimer's Dementia, seizure disorder, anxiety disorder, asthma (inflammation and narrowing of the small airways in the lungs), respiratory failure (serious condition that make it difficult to breathe on your own), permanent atrial fibrillation (when atrial fibrillation is present all the time and no more attempts to restore normal heart rhythm will be made), and benign prostatic hyperplasia (non-cancerous condition in men where the prostate gland increases in size). R20's electronic health record (EHR) indicated a signed physician's order for Metolazone 5 mg (milligram) to be given by mouth as needed once daily for fluid retention/weight gain of three pounds overnight or five pounds in seven days related to chronic diastolic congestive heart failure. EHR lacked documentation of administration of PRN medication on 3/27/24, 3/31/24, 4/2/24, 4/10/24, 4/17/24 and 5/4/24. R20's weight documentation, in EHR, indicated increased weight gain overnight on the following dates: - 3/26/24 at 8:57 a.m., weight was documented as 165.6 lbs (pounds) - 3/27/24 at 9:04 a.m., weight was documented as 169.1 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. - 3/30/24 at 1:31 p.m., weight was documented as 167.8 lbs - 3/31/24 at 10:31 a.m., weight was documented as 183.4 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. - 4/1/24 at 8:47 a.m., weight was documented as 174.2 lbs - 4/2/24 at 9:30 a.m., weight was documented as 186.4 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. - 4/9/24 at 1:50 p.m., weight was documented as 175.2 lbs - 4/10/24 at 1:30 p.m., weight was documented at 186.4 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. - 4/16/24 at 9:13 a.m , weight was documented at 168.0 lbs - 4/17/24 at 12:39 p.m., weight was documented at 172.2 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. - 5/3/24 at 2:21 p.m., weight was documented at 171.0 lbs - 5/4/24 at 12:17 p.m., weight was documented at 175.0 lbs - based on order PRN metolozone should have been administered due to weight gain of over three pounds. R20's progress notes lacked documentation of increased weight and if R20 was experiencing any signs or symptoms related to the increased weight. During observation on 5/21/24 at 1:34 p.m., R20 did not have any edema noted in his lower extremities. During interview on 5/22/24 at 9:40 a.m., licensed practical nurse (LPN)-A stated R20 did not have a PRN order related to his daily weights. LPN-A stated if R20's daily weights were up three pounds in a day or seven pounds in a day they would notify the provider. LPN-A accessed R20's medical chart and stated that it does look like R20 has an PRN order for metolazone that should be used is weight is up. During interview on 5/22/24 at 9:47 a.m., registered nurse care coordinator (RN)-B stated residents with daily weights has the weights obtained and if they have parameters and/or PRN medications to be utilized, licensed nursing staff should administer PRN medication and then notify provider of weight gain and PRN usage. RN-B confirmed R20 had an order for PRN Metolazone to be administered for increased weight gain. RN-B stated licensed nursing staff probably do not know that R20 has this order as it is not linked to the daily weight task. RN-B stated that in the daily weight task it should prompt licensed nursing staff that resident has a PRN order that can be utilized. RN-B stated this was important because it is a provider's order and should be followed. RN-B stated medication is important due to fluid retention due to his congestive heart failure. During interview on 5/22//24 at 11:46 a.m., director of nursing (DON) stated she expected provider's orders to be followed with PRN medications. DON confirmed PRN medication should have been administered with the increased weight gain. DON stated this was important as R20 needs these monitoring/medications for his congestive heart failure and physician's orders need to be followed During interview on 5/22/24 at 12:38 p.m., consultant pharmacist (CP) stated metolazone should have been administered to R20 with the increased weight gain overnight. CP stated it is important to follow provider orders as they are ordered for management of congestive heart failure. On 5/22/24 at 2:07 p.m., call was placed to primary doctor with no return response. The facilities Medication Guidelines policy dated 5/24, indicated the facility would ensure the accurate storage and safe/effective administration of medications by qualified personnel. Medications are administered by qualified personnel who 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. Medication orders are to be administered as ordered by the provider.

Based on observation, interview and document review, the facility failed to perform hand hygiene after high contact direct cares for 1 of 3 residents (R114) reviewed for infection control. Findings include: R114's admission Minimum Data Set (MDS) and Care Area Assessment (CAA) dated 5/8/24, identified an admitted [DATE], moderately impaired cognition, diagnoses of end stage renal disease with need for hemodialysis, diabetes, and pressure ulcers. The MDS/CAA also identified R114 had a recent extensive hospital stay related to diabetic ketoacidosis and inflammation of the colon caused by the bacteria Clostridium difficile (C. Diff.), had frequent bowel incontinence, was very deconditioned and dependent for transfers and mobility. During observation on 5/20/24 at 12:29 p.m., a sign identifying the need for transmission-based precautions (TBP) was placed on the wall in the alcove outside R114's room with a cart of personal protective equipment (PPE). The sign specified contact enteric precautions (intended to prevent transmission of intestinal pathogens that are spread by direct or indirect contact with the resident or environment) and instructed staff to wash hands or use hand sanitizer, don gown and gloves prior to entry at the door and to wash hands upon leaving the room. During observation on 5/20/24 at 5:33 p.m., nursing assistant (NA)-B communicate the need for resident transfer assist via walkie, donned gloves and a gown then entered R114's room. NA-A arrived and donned gloves and gown and entered the room. NA-A and NA-B proceeded to assist R114 with sitting up in bed and then transferred her to the recliner using a sit to stand mechanical lift that was being stored in the resident bathroom. When finished NA-A doffed and disposed of her gown and gloves in the covered waste basket in R114's room near the door, opened the door and proceeded down the hall to the unit dining room, retrieved a meal tray off the kitchenette counter then walked back to R114's room and handed the tray to NA-B who was still in the room. No handwashing was observed after leaving R114's room. When interviewed on 5/20/24 at 5:41 p.m., NA-A stated she did not know why R114 required contact/enteric precautions and acknowledged she had not sanitized or washed her hands after assisting with R114's transfer but should have. NA-A stated usually staff could use the hand sanitizer when leaving a resident room until they could get to a nearby sink on the unit to wash their hands with soap and water. When interviewed on 5/22/24 at 7:46 a.m., registered nurse (RN)-A stated with residents on any type of infection precautions staff are informed of why and what control measure to take in shift-to-shift communications, through residents' electronic medical record and paper care sheets. RN-A stated hand sanitizer is available to use until staff can go to a sink to wash their hands with soap and water. When interviewed on 5/22/24 at 10:32 a.m., the director of nursing (DON) stated any need for TBP is tracked through the admission process and with any signs or symptoms of infection in residents and the licensed nurses can determine what type to implement then inform and communicate to other nursing staff. The DON stated all staff are educated on the importance of hand hygiene upon hire then routinely or as needed thereafter. The DON stated R114 was on contact enteric precautions related to C. Diff. diagnosis and a sign had been placed over the hand sanitizer dispenser in her room to wash hands with soap and water because hand sanitizer does not kill the C. Diff. organism. The DON stated routine hand washing by staff was important to protect residents and themselves from spreading infections. The facility policy Handwashing/Hand Hygiene dated 1/2023, identified the need for washing hands with soap and water after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. Diff.

Based on interview and document review, the facility failed to ensure 1 of the 5 residents (R55) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R55's significant change Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease and diabetes. R55's face sheet, dated 5/22/24, indicated he was [AGE] years old. The immunization record, dated 5/22/24, indicated he received a PPSV23 on 7/13/2017 and a PCV13 on 4/20/16. The record lacked evidence of shared clinical decision making with the physician for a PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R55 or representative was offered or received a PCV20. During an interview with the director of nursing (DON) who is also the infection preventionist (IP), on 5/22/24 at 10:32 a.m., the DON/IP indicated immunizations are verified upon admission through MIIC (Minnesota Immunization Information Connection) and resident medical records. The DON/IP stated residents and/or their representatives would be offered and educated on the risk/benefit of the PCV20, and consents are obtained if eligible. The DON/IP stated it is a collaboration for determining eligibility and administration of the vaccines including the facility pharmacy and resident providers. The DON/IP stated they follow their policies for immunization guidelines, and they are based on CDC recommendations. The DON/IP verified R55's pneumococcal immunizations as listed above. The DON/IP verified R55 had not been offered or provided education on PCV20. The facility policy Pneumococcal Immunization, Long Term Care dated 4/2024 identified Residents will be offered the pneumococcal vaccinations and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or the resident representative declines the vaccine.

Based on interview and document review, the facility failed to ensure education on benefits and potential side effects of COVID-19 booster vaccination and administration of the vaccination to 1 of 5 residents (R55) reviewed for COVID-19 vaccination status. Findings include: The most recent Centers for Disease Control (CDC) Covid-19 vaccine guidance dated 2/7/24, recommends everyone aged [AGE] years and older, including people who live in Long-Term Care (LTC) settings who received one dose of any updated 2023-2024 Covid -19 vaccine (Pfizer-BioNTech, Moderna or Novavax) should receive one additional dose of an updated Covid-19 vaccine at least four months after the previous updated dose. R55's significant change Minimum Data Set (MDS) dated [DATE] indicated moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease and diabetes. R55's face sheet indicated R31 had admitted to the facility on [DATE] and was [AGE] years old. R55's electronic medical record (EMAR) indicated he had last received a Covid-19 booster vaccination on 3/15/23. R55's lacked documentation of any additional COVID-19 booster vaccination and evidence of education regarding the benefits and potential side effects of additional COVID-19 booster vaccination. R55's EMR lacked evidence of any contraindication to Covid-19 vaccination. During an interview with the director of nursing (DON) who is also the infection preventionist (IP), on 5/22/24 at 10:32 a.m., the DON/IP indicated immunizations are verified upon admission through MIIC (Minnesota Immunization Information Connection) and resident medical records. The DON/IP stated residents and/or their representatives should be offered and educated on the risk/benefit of the Covid-19 booster, and consents are obtained if eligible. The DON/IP stated it is a collaboration for determining eligibility and administration of the vaccines including the facility pharmacy and resident providers. The DON/IP stated they follow their policies for immunization guidelines, and they are based on CDC recommendations. The DON stated this process was missed for R55. The facility policy Covid-19 Vaccine Policies and Procedures dated 10/2023, identified Covid-19 vaccinations will be offered to all staff and residents (or their representative if they cannot make health care decisions) unless such immunization is medically contraindicated, per CDC guidance, or the individual has already received all recommended doses.

Based on interview and document review, the facility failed to monitor for signs and symptoms of aspiration for 2 of 4 residents (R1, R2) reviewed who were not provided thickened liquid as ordered. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, dysphagia, hemiplegia/hemiparesis, and moderately impaired cognition. Further, R1's MDS identified R1 was independent with eating after setting up. R1's Physician Order Report, revealed R1's diet order dated 6/26/23, was mildly thick liquids. Review of facility report number 353673 to the State Agency (SA) dated 9/3/23, indicated R1 had reported choking on her old tea, and nursing assistant (NA) noted the tea was not thickened. R1 was immediately assessed by floor nurse and vital signs were within normal limits and lung sounds were clear in all lobes. Review of facility report number 353911 to the SA dated 9/25/23, indicated R1 reported she coughed on her tea and NA indicated the tea appeared to not be thickened. Review of R1's Medication Administration History dated 10/5/23, revealed there was no additional monitoring for signs and symptoms of aspiration following the incidents that occurred on 9/3/23 and 9/25/23. Review of R1's progress notes lacked evidence of assessment following 9/25/23 incident. R2's quarterly MDS dated [DATE], indicated R2 had diagnoses which included intellectual disabilities, dysphasia, and moderately impaired cognition. Further, R2's MDS identified R2 was independent with eating after setting up. R2's Physician Order Report, revealed R2's diet order dated 6/20/23 was moderately thick liquids. Review of facility report number 353907 to the SA dated 9/25/23, indicated R2 had reported to the nurse he was given the wrong liquids on 9/24/23. R2's progress note dated 9/25/23, revealed R2 notified the nurse that evening shift gave him regular liquids and that he understood they were not thick liquids but drank it anyway. Lung sounds were clear bilaterally. R2's medical record lacked evidence of any additional monitoring for signs or symptoms of aspiration. On 10/4/23 at 10:56 a.m. licensed practical nurse (LPN)-A indicated nursing staff were expected to monitor for signs and symptoms of aspiration by listening to the resident's lung sounds for 24 hours and place an order in the resident's treatments for oncoming shifts to continue. On 10/4/23 at 12:13 p.m., registered nurse (RN)-B indicated nursing staff were expected to assess the resident right away by listening to lung sounds taking vitals and initiating a treatment in the resident's orders for oncoming shifts to continue to monitor for signs or symptoms of aspiration following an incident of wrong diet given, however RN-B was unsure how long to monitor for aspiration. On 10/4/23 at 5:12 p.m. RN-C indicated nursing staff were expected to monitor for signs and symptoms of aspiration on each shift for 3 days following an incident of the wrong diet given. RN-C stated the nursing staff would implement an order in the resident's MAR for oncoming shifts to continue to monitor. Further, RN-C confirmed there were no additional monitoring treatments/orders in either R1 or R2's orders following the incidents and in addition no adverse outcomes. On 10/5/23 at 8:48 a.m., director of nursing (DON) stated nursing staff were expected to assess the resident immediately following an incident of the wrong diet and then plan a nursing treatment order into Matrix (electronic medical record system). Further, DON stated nursing should be assessing lung sounds, temperature, choking or coughing episodes every shift and when there are any changes identified, and closely monitoring the resident for 48-72 hours typically aspiration symptoms would be noted by then. Review of facility policy titled Vitals Signs dated 3/23, directed staff to obtain vitals signs at least weekly unless ordered more frequently by the provider or per nursing discretion. Further, unusual or irregular readings are brought to the attention of the charge nurse for further follow up, and if the vital signs are abnormal based on resident baseline, update the provider as necessary.

Based on interview and document review, the facility failed to notify resident representative/physician timely following an incident where residents therapeutic dietary order was not followed with the potential for aspiration for 2 of 4 residents (R1, R2) reviewed. In addition, the facility failed to update the physician for 1 of 4 residents (R4), who had continuous low blood pressures. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had diagnoses which included stroke, dysphagia, hemiplegia/hemiparesis, and moderately impaired cognition. Further, R1's MDS identified R1 was independent with eating after setting up. R1's Physician Order Report, revealed R1's diet order dated 6/26/23, was mildly thick liquids. Review of facility report number 353673 to the State Agency (SA) dated 9/3/23, indicated R1 had reported choking on her old tea, and nursing assistant (NA) noted the tea was not thickened. Further, facility report lacked evidence R1's representative/family was notified. Review of facility report number 353911 to the SA dated 9/25/23, indicated R1 reported she coughed on her tea and NA indicated the tea appeared to not be thickened. Further, facility report lacked evidence R1's representative/family was notified. R1's medical record lacked evidence R1's representative/family was notified. Review of R1's record lacked evidence R1's physician was notified of potential of aspiration after the two incidents occurred on 9/3/23 and 9/25/23. On 10/4/23 at 10:56 a.m. licensed practical nurse (LPN)-A indicated nursing staff were expected to notify the resident's representative/family/guardian right away if there was a possibility of aspiration following the incident. On 10/4/23 at 12:13 p.m., registered nurse (RN)-B indicated nursing staff were expected to notify resident's representative or emergency contact right away following an incident. On 10/4/23 at 5:12 p.m., RN-C confirmed R1's representative was not notified following the incidents that occurred on 9/3/23 or 9/25/23. On 10/5/23 at 8:48 a.m., director of nursing (DON) stated when an incident occurs or a vulnerable adult report had been submitted nursing staff have a thorough checklist to complete, and on the checklist, it directs staff to resident representative, but DON stated she would revise the checklist to include family and/or guardian to make it clearer for staff. R2's quarterly MDS dated [DATE], indicated R2 had diagnoses which included intellectual disabilities, dysphasia, and moderately impaired cognition. Further, R2's MDS identified R2 was independent with eating after setting up. R2's Physician Order Report, revealed R2's diet order dated 6/20/23 was moderately thick liquids. R2's progress note dated 9/25/23, revealed R2 notified the nurse that evening shift gave him regular liquids and that he understood they were not thick liquids but drank it anyway. However, R2's record lacked evidence R2's physician was notified. On 10/4/23 at 10:56 a.m. licensed practical nurse (LPN)-A indicated nursing staff were expected to notify the resident's physician right away if there was a possibility of aspiration following the incident. On 10/4/23 at 12:13 p.m., registered nurse (RN)-B indicated nursing staff were expected to notify the resident's physician right away following an incident. On 10/4/23 at 5:12 p.m., RN-C confirmed R1's physician was not notified following the incidents that occurred on 8/26/23, 9/3/23, or 9/25/23. RN-C also confirmed R2's physician was not notified following the incident that was identified on 9/25/23. Further, RN-C indicated nursing staff were expected to complete a physician communication form as soon as they were able to ensure the physician was aware of the incident and if there were any potential for an adverse outcome to the resident. On 10/5/23 at 8:48 a.m., director of nursing (DON) stated when an incident occurs or a vulnerable adult report had been submitted nursing staff have a thorough checklist to complete, and on the checklist, it directs staff to notify physician however it states notify if there is an injury. DON indicated staff are expected to notify physician whether there was an injury or no injury, and the checklist would be updated to be clearer for staff. AND R4's admission MDS dated [DATE], indicated R4 had diagnoses of atrial fibrillation, hypertension, wound infection and had moderately impaired cognition. R4 required extensive staff assistance with activities of daily living (ADLs) such as bed mobility, transfers, dressing and toileting. R4's medication administration record (MAR) dated 10/4/23, revealed R4 had orders for Losartan 25 mg once a day for essential hypertension start date of 9/22/23, Toprol X: extended release 100 mg twice a day for essential hypertension start date of 9/11/23, and Torsemide 10 mg once a day for essential hypertension start date of 9/12/23. Further review of R4's MAR revealed Losartan was not administered on 9/23/23, 9/24/23, 9/25/23, 10/1/23, 10/2/23, or 10/3/23 due to condition or low blood pressure (BP); Toprol was not administered 9/23/23, 9/24/23 AM or PM, 9/25/23, 10/1/23 AM or PM, 10/2/23, and 10/3/23 due to condition or low BP; and Torsemide was not administered on 9/23/23, 9/24/23, 10/1/23, 10/2/23, or 10/3/23 due to condition and low BP. R4's physician orders lacked perimeters for BPs and when to notify the physician and/or not administer blood pressure medications. Review of R4's BP record revealed R4 was noted to have low BP on 9/23/23, 9/24/23, 9/25/23, 9/26/23, 9/28/23, 10/1/23, and 10/2/23. R4's record lacked evidence R4 physician was notified of R4's continued low BP's or staff not administering blood pressure medications as ordered due to R4's low BP and condition from 9/22/23 until 10/2/23. Review of facility document titled Physician Communication dated 10/2/23, indicated R4 slipped down from the EZ stand while transferring from bed to bathroom. R4 became dizzy and was unable to hold on to EZ stand. R4 had been noted to not be feeling well, complaints of dizziness with standing, nausea, dry heaves and has frequent loose stools. However, document did not address R4's low BPs. On 10/5/23 at 9:42 a.m., registered nurse (RN)-D indicated since R4 admitted to the facility she continued to have hypotensive episodes. RN-D indicated since 9/13/23, R4 was noted to have low blood pressures and since have stayed low. RN-D confirmed there had been no further communication with R4's physician between 9/22/23 through 10/3/23, when R4 was discharged to the hospital. RN-D stated staff would be expected to notify and communicate with the resident's physician regarding changes with resident's condition. On 10/5/23 at 11:37 a.m. attempt to contact and interview medical doctor (MD)-A but unsuccessful. On 10/5/23 at 12:09 p.m., director of nursing (DON) nursing staff was expected to update the physician if they are holding any medications and reasoning as well as asking the physician for perimeters on blood pressure medications. Review of facility policy titled Incident Reports dated 10/23, defines incident as any adverse occurrence or allegation of an occurrence regardless of the presence of adverse outcomes. Occurrence may include by was not limited to choking episode, elopement, fall, abrasion, skin tear, bruise, burn, allegation of abuse of neglect. Further, policy revealed the resident's provider and/or their designee would be notified of incidents which have occurred as well as resident's representative was also to be notified. Review of facility policy titled Vital Signs dated 3/23, directs staff if vital signs are abnormal based on resident baseline, update provider as necessary.

Based on observation, interview and document review, the facility failed to investigate the cause of a skin injury and assess for appropriate treatment for 1 of 1 resident (R1) who sustained a burn from hot liquids served at the facility. This deficient practice resulted in actual harm for R1. Findings include: A Nursing Home Incident Report (NHIR) dated 4/28/22, indicated R1 had sustained a burn on her right thigh. R1 had told the staff member she had spilt her coffee. The burn was noted to be irregular shaped 1st degree (A mild burn injury of the outermost layer that make up the skin. Usually heals without scarring the skin) and had three small areas. The lateral area measured 6 centimeters (cm) by 3 cm wide. The middle area was 3 cm wide x 2.5 cm long. The inner most area measure 1.5 cm x 1 cm. The report indicated the facility had installed a new coffee machine on 4/20/22. The previous coffee machine was set to dispense liquids at 145 degrees Fahrenheit, however, the coffee machine was hot. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nutritional Care Area Assessment (CAA) dated 4/27/22, indicated R1 was to receive a soft diet with food cut into bite sized pieces. The CAA did not include an assessment of R1's ability to manage liquids. R1's Care Plan dated 4/29/22, identified R1 as being dependent on staff to obtain all fluids. The plan directed the staff to provide fluids but did not include any type of special instructions or adaptive equipment for hot liquids. The plan lacked direction related to [CONDITION(S)] or wound care. On 5/4/22, during continuous observation starting at 4:48 p.m. R1 was observed seated in the dining room waiting for the evening meal. -At 4:50 p.m. nursing assistant (NA)-H removed a standard plastic coffee cup from a storage drawer, added ice to the cup and then filled it with coffee. NA-H then placed the cup in front of R1. R1's cup was not observed to be equipped with any type of cover or other adaptive equipment. R1 was observed to pick up the cup and drank from it independently. -From 4:50 p.m. to 5:25 p.m. R1 picked up her coffee cup and drank from it independently. No staff members were observed to remain in the dining room while R1 drank and waited for the evening meal. On 5/5/22, during continuous observation starting at 7:02 a.m. R1 was observed seated in the dining room drinking a cup of coffee. The cup was a standard plastic coffee cup without any type of adaptive equipment. -At 7:42 a.m. R1 was served her breakfast meal consisting of scrambled eggs, a banana and toast. R1's meal was not observed to utilize any type of adaptive meal equipment. -At 8:06 a.m. R1 was observed to spill scrambled eggs on her clothing protector. -At 8:29 a.m. R1 stopped eating. She ate approximately 75% of her meal independently and drank 3/4 of the coffee. -At 8:43 a.m. R1 was wheeled to her room by NA-A and NA-B. The NA's utilized a standing mechanical lift to transfer R1 from the wheelchair into a standing position. NA-A pulled down R1's pants. R1's right thigh was observed to have a red area approximately three inches wide with three separate areas noted inside the red area. Two of the areas were noted to be covered with yellow/white slough. The third area was a fluid filled blister. -At 8:51 a.m. NA-A stated he noted the red area last week while transferring the resident after the breakfast meal. NA-A stated R1's clothing had been saturated with coffee, however, R1 had not vocalized to the staff she had spilt her coffee at the time it happened. R1 reported to NA-A she had split her coffee. NA-A stated he reported the red area to the nurse, and she had obtained a cream to be put on the area. NA-A also stated the yellow/white areas on the wound looked awful. Review of R1's Progress Notes (PN)/nurses notes revealed the following information: - PN 4/28/22, at 9:00 a.m. R1 had a red area discovered on her right thigh. Resident stated she spilt coffee with coffee stain noted on her shirt and pants. The burn area was irregular shaped 1st degree burn and had three smaller area. The lateral area was 6 cm long and 3 cm wide. The middle area was 3 cm wide and 2.5 cm long. The inner most area was 1.5 cm x 1 cm. -PN 4/28/22, at 10:00 p.m. indicated the burn on the right thigh had started to blister. -PN 4/29/22, at 9:48 a.m. indicated R1 had received an order to apply [MEDICATION(S)] 1% (medicated cream frequently used on [CONDITION(S)]) twice a day on the right thigh. -PN 4/30/22, at 11:22 p.m. indicated the staff had placed the [MEDICATION(S)] to the burn. -PN 5/1/22, at 11:41 a.m. indicated [MEDICATION(S)] was applied to the burn and R1 still had one blister intact. -PN 5/2/22, at 2:52 p.m. indicated [MEDICATION(S)] was applied to the burn. One blister was still intact. -PN 5/3/22, at 10:37 a.m. [MEDICATION(S)] applied to burn on right thigh. - PN 5/3/22, at 9:43 p.m. [MEDICATION(S)] applied to burn on upper right thigh. There is a blister area above the healing area that is still intact and a blister below the healing area that is intact. -PN 5/4/22, at 8:37 a.m. [MEDICATION(S)] applied to burn on thigh. There is still one blister that is intact. Healing slowly. -PN 5/5/22, at 3:49 p.m. the burn area has one blister that is intact no adverse side effects. -PN 5/5/22, at 10:31 a.m. [MEDICATION(S)] applied to burn. There is one blister that is intact. Healing slowing with scabbing over the middle light brown in color. Review of facsimile order dated 4/29/22, from nurse practitioner (NP)-A directed the staff to apply [MEDICATION(S)] cream 1% twice a day for seven days to the burn on the right thigh. Review of R1's medical record lacked an event/incident report related to the burn sustained on 4/28/22. It lacked, a comprehensive skin assessment which would include measurements, visual descriptions, and/or reactions to treatments. Finally, the medical record lacked a comprehensive assessment related to R1's ability to manage hot liquids. On 5/5/22, 8:55 a.m. RN-C stated she had completed R1's wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/22, at 8:58 a.m. licensed practical nurse (LPN)-A stated R1's burn area had been red last week, however, upon her return to work on 5/4/22, the center of the wound had started to turn yellow with one blister still intact. LPN-A stated R1's burn area looked worse. On 5/5/22, at 10:47 a.m. RN-D stated the facility had not completed an incident report (events report) related to the burn because the electronic medical record system did not have an established system to generate reports related to [CONDITION(S)]. Therefore, the facility had not completed an incident report. RN-D was aware R1 had a new order for [MEDICATION(S)] cream after sustaining a coffee burn; however, NP-A had not observed the wound. RN-D stated the burn was evaluated daily by the wing nurses and the progress notes were to reflect the status of the burn. RN-D confirmed the medical record did not contain a comprehensive skin assessment related to the burn, a care plan had not been developed and R1's ability to manage hot liquids had not been assessed. RN-D stated the electronic medical record normally directed the staff to complete assessments after an incident (event) report was completed. However, since the facility did not have an event report for [CONDITION(S)], no comprehensive assessment had been completed. RN-D stated she had not seen R1's burn area and she would depend upon the progress notes to reflect any changes in the wound. RN-D stated she was not aware of any changes to the burn area. On 5/5/22, at 11:13 a.m. RN-C and RN-D transferred R1 from the wheelchair to the bed via a standing mechanical lift. Once in bed, RN-D measured R1's burn area. The area was located on R1's upper right thigh just below her pantie line. RN-D measure the wound in three sections. The middle section was 6 cm x 2.25 cm and was 90%-100% covered with yellow/white slough. The portion of the wound closest to R1's groin area had a 2.25 cm x 2 cm intact fluid filled blister. The outer area of the burn measured 5.5 cm x 3 cm with a small open and slough covered areas. No significant drainage was noted. On 5/5/22, at 11:18 a.m. RN-C stated the wound appearance had changed in the last three days when the slough had started to cover the wound. On 5/5/22, at 11:25 a.m. RN-D confirmed R1's progress notes did not adequately describe the condition of R1's burn. The burn area was larger than it had been on the initial incident, no additional measurements or description of color had been recorded. In addition, R1 had not been evaluated by a physician to ensure appropriate care and treatment was being delivered for the wound. RN-D stated at minimum, the area required a weekly skin assessment. A skin/burn policy was requested, and none was provided. The Safety of Hot Liquids policy dated 2/2022, directed the staff to assess all resident safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions were to be implemented to maximize choice of beverage while minimizing the potential of injury. On 5/5/22, at 11:44 a.m. RN-A stated when an incident including a burn occurred in the facility, an event report was to be completed. However, the facility electronic medical record did not have a system for burn events, therefore, an event had not been completed. The staff members were to assess how the incident happened and develop a system for preventing future incidents. In addition, the staff members were to assess, document and care plan any treatments needed as a result of the event. RN-A confirmed R1's clinical record lacked a compressive assessment related to hot liquids and R1's current [CONDITION(S)]. RN-A added the facility did not have a policy related to [CONDITION(S)] sustained at the facility.

Based on interview and document review, the facility failed to ensure multiple allegations of physical and verbal abuse were appropriately and promptly reported to the required person(s) and agencies, investigated and adequate protection provided to ensure freedom from abuse for 3 of 4 residents (R2, R3, R4) whose allegations were reviewed. These findings constituted an immediate jeopardy (IJ) situation which had potential to affect 24 of 24 residents who resided on the [NAME] House unit as the alleged perpetrator (AP) continued to work despite witnessed, credible allegations of abuse towards residents. However, the facility had taken appropriate action(s) to correct the identified non-compliance and, as a result, the findings are being issued as past non-compliance. The IJ began on 7/23/20, when the AP (nursing assistant [NA]-A) was witnessed by multiple staff members to demean and verbally abuse R2 after she sustained a fall. This allegation was not immediately reported to the administrator or State agency (SA), nor was the allegation promptly investigated and protection provided to the resident(s) on the unit which lead to multiple other allegations being witnessed and also not acted upon, reported or investigated in a timely manner. The administrator and registered nurse unit manager (RN)-B were notified of the IJ on 8/7/20, at 3:03 p.m. However, the facility had already implemented several action(s) including implementing their abuse prevention policies and procedures, removing the AP from provision of resident care, and beginning shift-to-shift education 'huddles' to provide immediate re-education to staff to ensure all allegations are immediately reported to the proper personnel. As a result, the IJ was removed and the identified non-compliance was corrected as of 8/4/20. Findings include: A submitted SA incident report, dated 8/4/20, identified an allegation of Emotional or Mental Abuse was being submitted for R2. An incident date of 7/23/20 was listed, which identified R2 had fallen in the hallway due to her call light being on for an extended amount of time. A nursing assistant (NA)-A was then observed yelling and shaming R2 for falling in an annoyed and harsh tone. R2 was listed in the report as, . confused and crying saying that she is sorry to [NA-A]. R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had moderate cognitive impairment. On 8/7/20, at 9:50 a.m. R2 was interviewed and reported things were fine at the nursing home. R2 recalled falling in the hallway; however, could not recall any details of the fall or subsequent staff interactions when questioned saying, I don't remember. R2 voiced no further concerns with staff care or treatment since she fell on [DATE]. A submitted SA incident report, dated 8/4/20, identified an allegation of Emotional or Mental Abuse was submitted for R3. An incident date of 8/4/20, was listed, which identified NA-A was heard . yelling 'What do you want, I can't understand you fiercely, while [another staff] can hear the resident crying. R3's quarterly MDS, dated [DATE], identified R3 had severe cognitive impairment. On 8/7/20, at 10:01 a.m. R3 was interviewed using a staff member to interpret. R3 denied concerns with his care or treatment at the nursing home. A submitted SA incident report, dated, 8/4/20, identified an allegation of Emotional or Mental Abuse was being submitted for R4. An incident date of 7/29/20, was listed, which identified R4 preferred baths over showers as she did not like to get her hair wet. However, NA-A told her she needed to take a shower. R4 was hard of hearing, so NA-A had screamed at her and told her she needs [to] take the show [sic] whether she likes it or not. R4 then started crying according to the report. R4's annual MDS, dated [DATE], identified R4 had moderate cognitive impairment. On 8/7/20, at 9:56 a.m. R4 was interviewed. R4 could not recall any incidents of having to take a shower and denied concerns with her care or treatment at the nursing home. On 8/7/20, at 11:06 a.m. NA-B was interviewed and expressed she had heard of an incident which happened one or two weeks ago where a NA had been potentially verbally abusive to R2 after she fell . NA-B stated she thought the incident for R2 had been reported and voiced she had not heard of any other allegations regarding NA-A and other residents. NA-B stated she had worked with NA-A before and felt NA-A had a poor attitude; however, had never seen NA-A verbally or physically abuse a resident. NA-B stated her concerns with NA-A's attitude had been reported to a nurse before; however, the nurse was no longer employed at the nursing home and she was not sure if any follow-up had been done. On 8/7/20, at 12:03 p.m. registered nurse (RN)-A was interviewed. RN-A recalled R2's fall on 7/23/20, and stated she had been called to R2's room due to a fall. When she arrived, there were several NA staff present, including NA-A and NA-C. RN-A stated she did recall NA-A making a comment to R2, while she laid on the floor, where she told her she needed to wait for assistance; however, RN-A stated she could not recall the exact quote of what had been said anymore. However, RN-A expressed she did recall the tone NA-A used when making the comment and described it as a chastising manner. RN-A stated she felt the tone and overall comment was a dignified treatment concern as NA-A was someone who was young and mouthy. RN-A stated she did not report the incident to anyone, including the unit manager or administrator, as it didn't occur to me to go down that avenue. RN-A stated the facility' social worker (LSW)-A had just recently contacted her about the incident and expressed that was the first I heard there was an incident around the whole thing [7/23/20 allegation]. Further, RN-A stated she had worked with NA-A again in the days and weeks since 7/23/20, and voiced NA-A had never been placed on any formal monitoring for her cares to her knowledge. On 8/7/20, at 1:08 p.m. a telephone interview was completed with NA-C. NA-C voiced R2 had fallen on the evening of 7/23/20, and when she responded to the room to assist, she witnessed R2 laying on the floor covered in feces and appearing confused. NA-C stated NA-A was standing over R2 and pretty much like shaming her and being rude to her while scolding her for getting up unsupervised. NA-C stated R2 was crying and just kept voicing, I'm sorry, I'm sorry to NA-A as a result. NA-C reiterated NA-A was just being so awful to [R2] and it was upsetting adding she felt the interaction was abusive to R2 as NA-A was scolding R2 to make [R2] feel ashamed. NA-C verified RN-B was present for this interaction, and NA-C expressed she thought RN-B was going to follow-up on reporting the concern to management so she did not report it herself. NA-C voiced additional concerns were seen or heard involving NA-A, including an incident within the past week or so where she heard R3 crying in his room and NA-A yelling at him, [I] don't know what you want! NA-C voiced she was unaware of any details involving R4's allegation of being forced to take a shower, however, expressed NA-A worked after the 7/23/20, incident, and continued the same use of generally mean behaviors with residents with no formal monitoring of her cares being done to her knowledge. NA-C stated she felt NA-A was overall just rough with the patients as she would often rip off their clothes and things like that when helping them. NA-C stated all of these concerns and allegations had been reported to the nurses and she just figured every time I tell a nurse about it, they're supposed to report it. NA-C expressed she felt the staff needed to report these things and more people need to come forward when they see concerns. Further, NA-C voiced she had received some guidance and re-education on ensuring allegations are reported timely to the administrator or management team within the past few days. A series of e-mails and statements from other direct care staff were provided which demonstrated the facility's completed investigation, as of 8/7/20, into the multiple allegations of verbal abuse by NA-A. These identified the following: On 8/4/20, an e-mail from NA-C identified several concerns with staff and resident interactions pertaining to NA-A. The e-mail outlined NA-A had stated to her colleagues she was racist towards Somalians and verbalizing she wanted to . kill them all. The e-mail continued and NA-C outlined several allegations of verbal, and potential physical abuse, by NA-A which had been witnessed and/or heard. These included: - I have seen [NA-A] be rough in handling patients . jerking residents and not gently taking off their clothing to the point of the residents being confused about her behavior and her ignoring them to get her 'job' done, - I have heard outside of [R3's room], [NA-A] yelling What do you want, I can't understand you fiercely, while I can hear [R3] crying, and, - A few weeks ago [7/23/20] when [R2] had a fall in the hallway due to her light being on for an extended period of time, I came to help and saw [NA-A] yelling and shaming [R2] for falling and not waiting for her to answer her light. stating 'That's what you get, She needs to learn, Shouldn't have gotten up' she was scoffing and rolling her eyes at [R2] trying to ridicule her as she was laying on the floor covered in her own feces. [RN-B] told [NA-A] she fell because I asked you to get her light and you didn't.' . [R2] is confused and crying saying that she is sorry to [NA-A]. A statement was provided, dated 8/5/20, where homemaker (HMK)-A had described her interactions with NA-A. HMK-A outlined NA-A had like an anger issue, which was a concern along with, . She yells at residents. The statement was signed by LSW-A. A e-mail from RN-C, dated 8/4/20, identified a collection of statement pertaining to NA-A and her care of residents. A concern was listed which read, The way [NA-A] talks with residents . 'WHAT DO YOU WANT NOW!' . 'YOU WERE JUST TO THE BATHROOM! YOU NEED TO WAIT! . 'URG, It's [blank line] call light again! The concerns continued and included not answering call lights, using her telephone while at work and, . On Wednesday, July 28th, was [R4] bath night . [R4] did not receive her, what was supposed to be bath, until around 8 pm. [NA-A] had told her she was only giving her a shower, and [R4] had no say in it. [R4] had started crying, because she wanted her bath and not a shower. [NA-A] continued on with the shower, despite listening to what [R4] wanted. A provided untitled schedule, dated 6/30/20 to 8/7/20, identified NA-A's name at the top along with their worked and/or scheduled shifts. NA-A was identified as working on 7/23/20, 7/24/20, 7/25/20, 7/26/20, 7/28/20, 7/29/20 and 7/30/20 (before being removed from resident care on 8/4/20). Further, a provided Resident Bed List Report, dated 8/7/20, identified a total of 24 resident beds on the [NAME] House Unit. On 8/7/20, at 12:19 p.m. registered nurse unit manager (RN)-B, household coordinator (HC)-A and LSW-A were interviewed regarding R2, R3 and R4's allegation(s). RN-B stated a staff member had approached them on 7/31/20, and voiced NA-A was really rude and not very nice to anybody which caused them to start investigating so they could provide coaching or disciplinary action to NA-A. At that time, on 7/31/20, no allegations of abuse towards residents had been voiced to them. However, on 8/4/20, when they spoke to the initial NA who reported concerns on 7/31/20, they learned of multiple allegations of resident abuse. They immediately acted on them and reported them to the administrator and filed several vulnerable adult (VA) reports with the State agency. NA-A was then removed from resident care pending the investigations into the allegations, and the facility implemented shift to shift staff huddles to start re-educating direct care staff on abuse and the procedures for ensuring timely reporting. RN-B verified the allegations were not immediately reported when they happened which caused NA-A to continue working on the [NAME] House unit from 7/23/20 to 8/4/20, on an unsupervised basis despite the multiple allegations of abuse which had been witnessed or heard by direct care staff. RN-B stated on 7/23/20, when the first allegation of resident abuse was witnessed, NA-A should have been sent home immediately to remove them from the situation and the investigation process started in accordance with their facility's abuse policies and procedures. This was important as the facility's biggest priority was to keep residents safe and abuse should not be allowed to occur. At 12:39 p.m. the facility administrator joined the interview and verified she had not had any allegations of abuse reported to her until 8/4/20, despite the multiple allegations happening since 7/23/20 (12 days prior), which caused NA-A to continue working with residents unsupervised and without any monitoring from 7/23/20 to 8/4/20. The administrator stated when she learned of the allegations, they immediately reported them and started the shift to shift huddles to re-educate the staff. The administrator expressed they were still completing the investigation into the multiple allegations and were trying to figure out how direct care staff felt these were not reportable events when it was clearly reportable. Further, the administrator voiced she had spoke to NA-A the day prior who denied everything. A provided Abuse Prohibition Policy, dated 6/2019, identified all residents will be free from abuse, neglect and mistreatment. The policy outlined abuse can include physical harm, pain, verbal abuse or involuntary seclusion. A section labeled, Responsibilities, identified all staff, on an ongoing basis, would ensure residents are free from abuse and suspected cases of abuse would be, . thoroughly investigated and documented by the Administrator or designee. The policy directed suspected abuse must also be reported to the respective agencies, and, Staff members, volunteers, family members, and others must report incidents of abuse or suspected abuse . A provided Abuse and Neglect Reporting and Response Policy, dated 10/2019, identified a purpose of ensuring all staff follow the same procedures for reporting abuse and/or neglect. The policy outlined all employees of the nursing home were mandated reporters, and all allegations of abuse or neglect were to be promptly reported to the administrator who would then investigate the allegation(s). The policy continued, If the accused is an employee of the facility, he/she will be placed on a paid administrative leave pending investigation . The IJ, issued at past non-compliance began on 7/23/20, and was removed on 8/4/20, prior to the abbreviated survey as the facility had implemented sufficient step(s) to remove the immediacy and correct the identified non-compliance. These steps included implementing the facility's abuse prevention policies and procedures, removing the alleged perpetrator, NA-A, from resident care and implementing shift to shift huddles to begin re-educating the staff on abuse reporting procedures.

Based on observation, interview, and document review, the facility failed to ensure 1 of 3 residents (R19) with pressure ulcers, was assessed weekly to determine whether the current treatment was effective, and to ensure staff provided care to ensure current pressure ulcers were healing, and failed to prevent the development of new pressure ulcers, which caused actual harm for R19. Findings include: R19's quarterly Minimum Data Set ((MDS) dated [DATE] identified R19 had [DIAGNOSES REDACTED]. The MDS also indicated R19 had moderate cognitive impaired, was dependent on staff for bed mobility and was at risk for pressure ulcer development. Review of the pressure ulcer, Care Area Assessment (CAA), dated 7/29/14 identified that R19's risk factors included staff assistance to reposition, frequently incontinent of bowel and bladder, poor nutrition and non ambulatory. The CAA verified there were no current pressure ulcers identified for R19. Although R19 was identified at moderate risk for pressure ulcers, and had a pressure ulcer identified on 10/26/14. R19 developed two (2) additional stage 2 pressure ulcers on her coccyx on 12/18/14. The facility did not develop an individualized plan of care based on a comprehensive assessment to identify what interventions should be implemented or modified to help decrease the risk of R19 developing additional pressure ulcers and promote healing. There was no indication the pressure ulcers were re-assessed or consistently monitored on a weekly basis to determine staging, size, exudate, pain, wound bed and a description of the surrounding wound edges. This resulted in R19 having three stage 2 pressure ulcers, which resulted in actual harm. R19 was observed on 12/17/14 from 7:00 a.m. until 9:08 a.m. At 7:00 a.m. R19 was lying on her back, on an alternating pressure mattress in bed. R19 continued to lay in this position until 7:41 a.m. when registered nurse (RN)-A and licensed practical nurse (LPN)-B positioned R19 on her right side and provided R19 with cares for bowel incontinence. During the observation, there was an open area observed on R19's coccyx. LPN-B applied [MEDICATION NAME] (a skin barrier paste) to the open area and left the room. At 7:52 a.m. (11 minutes later) R19 was re- positioned onto her back by RN-A and LPN-B. R19 remained on her back until 8:33 a.m. when nursing assistant (NA)-B and NA-A came into the room, provided personal care and applied [MEDICATION NAME] and [MEDICATION NAME] powder to the open area on the resident's coccyx. NA-B and NA-A, assisted R19 into a wheelchair with a cushion and took her to the neighborhood dining room for breakfast. R19 was observed on 12/18/14 from 7:59 a.m. to 8:53 a.m. At 7:59 a.m., R19 was lying on her back on an alternating pressure mattress in bed. R19 remained in this position until 8:53 a.m. when NA-B provided R19 with incontinence care. At that time two open areas were observed to R19's coccyx. The NA-B applied [MEDICATION NAME] and [MEDICATION NAME] to both open areas. At 10:03 a.m. NA-B left the room and reported to LPN-B that R19 had a possible second open area. At 10:10 a.m. RN-A and LPN-B came into the room to provide wound care and to measure R19's coccyx open areas. LPN-B stated the coccyx measurements were 1.1 centimeters (cm) by 0.8 cm. In addition, LPN-B stated there were now two additional open areas to the resident's coccyx were not present the previous day (12/17/14). These open areas measured 0.8 cm by 0.5 cm and 0.3 cm 0.5 cm., for a total of three open areas on R19's coccyx. Review of the facility's Skin Risk Assessment (with Braden Scale) dated 10/26/14, identified R19 had a pressure ulcer on her coccyx, and that the Braden Scale (tool used to assess risk for pressure ulcers) score was 13. The score indicated R19 was at moderate risk for development of pressure ulcers. The assessment was a checklist and indicated R19 was completely immobile and had a problem with "Friction and shear, 1- Problem - Requires moderate to maximum assist in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assist. [DIAGNOSES REDACTED], contractors or agitation leads to almost constant friction." The assessment interventions that were checked included a turning and repositioning program, nutrition to manage skin problems, ulcer care and application of ointments and medications. R19's care plan identified a problem dated 11/14/ 2007 indicated a problem of reoccurring open area on coccyx related to moisture and abrasion from cleaning incontinent stool. The care plan interventions included: "Treat open areas as directed on buttock/coccyx as per directions of the WOCN (Wound Ostomy Certified Nurse). Chng (Change) per toileting schedule. Clean and dry skin after every toileting. Apply Remedy Skin Protectant BID (twice a day) to peri area. Apply [MEDICATION NAME] to coccyx area if skin breakdown present-PRN (as needed)." The care plan also directed staff to reposition R19 every hour when awake and during the night and to encourage to lay down on her bed to rest two to three times during the day to get off her buttocks. Additional interventions included air mattress on bed and a ROHO (a specialty cushion for pressure relief) cushion in her wheelchair. The care plan also identified R19 required "Bed mobility: Total assistance of two staff to assist with turning. Extensive assist of 2 to pull resident up to sitting position & balance on edge of bed." Review of R19's Physician order [REDACTED]. 10/3/14 (2) apply Remedy skin protectant with dimethicome to peri area if redness is present every shift as needed. 10/30/14 (3) may use [MEDICATION NAME] Lite or [MEDICATION NAME] 4x4 to coccyx PRN as needed for protection to open areas on peri areas/buttocks and No [MEDICATION NAME] Border. Review of the facility Wound Progress Sheet, dated 8/7/14 - 9/23/14 identified the resident had an open area stage 2 (partial thickness loss of dermis presenting as a shallow open ulcers with a red-pink wound bed without slough) "abrasion" on her coccyx on 8/7/14 which measured 1.0 centimeter (cm) by 1.0 cm. Review of the documentation indictaed the facility had completed measurements on a weekly basis, until the area healed on 9/23/14. R19's Resident Progress Notes dated 10/20/14, included: "Resident has chronic shearing issues on coccyx area R/T (related to) moisture, thin skin over tailbone & poor nutrition." On 10/31/14, R19's progress notes included: "She is at risk for skin breakdown.... Currently has a sm (small) open area on her coccyx - a reoccurring open area from moisture/abrasion related to when she is cleaned from her incont (incontinence) sticky BM's (bowel movements)." There were no additional notations about the open area on R19's coccyx until 11/22/14 (22 days later). The 11/22/14 progress note documentation from CNA/TMA-H (certified nursing assistant/trained medication aide), included: "Weekly Skin Assessment: General skin remains CDI (clean, dry and intact)." An 11/27/14 progress note from CNA/TMA-H identified, "Resident has a dime size open area on coccyx....writer placed a [MEDICATION NAME] boarder (sic) 3x3 on the open area." A progress note dated 12/7/14 identified that R19 had a [MEDICATION NAME] boarder applied to her coccyx. A progress note dated 12/12/14, included: "Resident has an open area to her coccyx that is getting larger in size." The next progress noted dated 12/17/14, documented by CNA/TMA-H identified, "Weekly Skin Assessment: General skin remains CDI. Has open sore on coccyx that has Mipilex boarder (sic) (absorbent foam dressing) in place." Even though the facility was using the [MEDICATION NAME] Border product, on 11/27/14, 12/7/14 and 12/17/14, there was a physician's orders [REDACTED].**NO [MEDICATION NAME] BORDER)". When interviewed on 12/18/14 at 11:23 a.m., RN-A stated the resident's last skin assessment had been completed on 10/26/14 when R19 had a pressure ulcer on her coccyx. RN-A confirmed the staff had not completed weekly assessment or monitoring of the coccyx pressure ulcer to determine if it was healing or not. The facility's Skin Care Policy, reviewed/revised 3/10, included a protocol for "Documentation on the wound progress sheet weekly." The policy directed staff to complete weekly documentation include: Drainage-amount, type, and color; Color, [MEDICAL CONDITION], temperature, induration and pain; size; any tunneling or undermining; specific location; stage of pressure ulcer; pain; [MEDICAL CONDITION]; periwound skin; residents' condition and response to treatment.

Based on observation, interview, and document review, the facility failed to ensure 3 of 4 residents (R79, R36 and R150) with pressure ulcers, were assessed, monitored and/or provided care to ensure current pressure ulcers were healing and to prevent the development of new pressure ulcers, which caused actual harm for R79. Findings include: R79's Minimum Data Set (MDS) dated 2/19/14 indicated R79 was cognitively intact, but required extensive assistance with transferring and repositioning in bed and was at risk for pressure ulcer (PU) development. The MDS also identified R79 had [DIAGNOSES REDACTED]. The 2/19/14 Pressure Ulcer Care Area Assessment (CAA) identified R79 was at risk for developing pressure ulcers, and needed extensive assistance for bed mobility, and had an unstageable PU due to coverage of wound by slough/eschar. The CAA also identified risk factors of immobility, incontinence, poor nutrition, and recent decline in activities of daily living (ADL). The Skin Risk Assessment (with Braden Scale) scale dated 3/21/14 identified R79 scored an 18, meaning he was at risk for the development of PU. He currently had PU "bilateral to feet, with no new sores." The assessment also indicated he had slight limited mobility, with potential problems of friction and shearing due to "skin probably slide to some extent against sheets, chair... Maintains relatively good position in chair or bed most of time but occasionally slides down." The interventions included pressure relieving devices for bed, ulcer care, application of dressing/ointments and other preventative or protective skin care and "prevalon boots." There was no indication a turning and repositioning scheduled was implemented even though R79 was at risk for PU, had limited mobility, and was at risk for having friction and shearing of his skin. R79's care plan dated 2/24/14 identified a problem with fragile skin, recurrent skin breakdown, circulatory disease and chronic wounds to lower extremities and skin tears easily. The care plan directed staff to "Dressing changes to open areas as per CNP (certified nurse practitioner)..." The plan also identified he had a decline in mobility and weakness, with the interventions of "Nursing will provide assistance with ADL's and mobility per therapy directives." Physical therapy (PT) and occupational therapy (OT) five times a week for improved mobility, endurance and strength. There was no mention of a turning and repositioning scheduled even though R79 needed staff assistance with mobility, was at risk for pressure ulcer development and had three current pressure ulcers which were not identified on the care plan. During an interview on 4/1/14 at 2:10 p.m. nursing assistant (NA)-L stated she gave R79 a bath this morning and noticed R79, "Had an open spot on the bottom so we put Calizone lotion it is on left cheek". The area was smaller than an eraser on a pencil. During an interview on 4/1/14 at 2:25 p.m. with registered nurse (RN)-C unit clinical coordinator stated R79 has some open areas on his legs, due to poor circulation. RN-C did not mention R79 had any pressure ulcers on his buttocks. R79 was observation on 4/1/14 from 12:58 p.m. until 4:41 p.m.. At 12:58 p.m. R79 was sitting in a regular high back chair with a cushion asleep with his feet firmly on the floor. R79 continued to sleep in this same position until 2:04 p.m. when an unknown NA entered the room and placed his feet onto a chair. The unknown NA did not repositioned R79, and only placed his feet onto a chair. R79 continued in the same positioned until 3:58 p.m. when an unknown physical therapy staff came into the room and did exercises with R79 legs. R79 remained in the same chair during this time and when the exercises were completed the unknown therapy staff, replaced R79's feet on top of the chair as before. The unknown therapy staff did not offer to assist R79 off the chair into a different position. At 4:41 p.m. R79 continued to sit in the same chair for 3 hours and 43 minutes without being repositioned during this time. An interview on 4/1/14 at 4:50 p.m. R79 said he had not moved from the chair since lunch. R79's family member (F)-A who was present during the interview stated R79 has a new open area and a scabbed area on his buttock. During an interview on 4/1/14 at 4:50 p.m. with licensed practical nurse (LPN)-A said R79's feet were sore so he doesn't move much any more but just sits there. On 4/1/14 at 4:52 p.m. NA-DD stated she was unsure when R79 was last repositioned and NA-DD and NA-S assisted R79 to a standing position. Near R79 scrotal area there was an open area approximately 0.3 cm X 0.3 cm. There was a scabbed area approximately 0.8 cm x 0.3 cm on R79's right tuberosity and an open area 0.8 cm x 0.3 cm on his left tuberosity. NA-DD and NA-S confirmed the open areas. NA-DD and NA-S verified R79 did not have a specific turning or repositioning schedule, even though he had three pressure ulcers in the same location. During continuous observation on 4/2/14 at 7:50 a.m. R79 was in his room again sitting in room on a regular chair with his feet up on a folding chair. He remained in this positioned until 9:55 a.m. when F-A came to visit. He continued to remain in this chair until 11:00 a.m. when he was assisted by NA-Y to ambulate to the dining room for the noon meal, a total of 3 hours and 10 minutes without being repositioned. During an interview on 4/2/14 at 1:45 p.m. RN-E measured the pressure ulcers on R79 buttocks. There was an open area that measured 0.9 x 0.5 on the right ischeal tuberosity and 0.7 cm x 0.4 cm on the left. The scrotal area measured 0.6 cm X 0.3 cm. RN-E stated R79 had an open area on the scrotum from "shearing" as well as two other open areas on his ischeal tuberosity. R79 skin was poor and agreed the shearing were considered pressure ulcers. She stated the RN clinical manager decides if a resident needs to be placed on a turning and repositioning schedule, which R79 did not have in place. Review of the facility Progress Notes and Wound Progress Sheets from 2/20 through 4/1/14 did not identify any pressure ulcers for R79's scrotum and bilateral ischeal tuberosity until 3/27/14, when the 3/27/14 progress note indicated, "Small open area on scrotum with a small amount of bloody drainage. Possibly from shearing." There was no mention of the bilateral pressure ulcers on the ischeal tuberosity, even though the right ischeal tuberosity was observed to be scabbed over on 4/2/14. These pressure ulcers had not been reassessed or monitored and measured on a weekly basis to determine location, staging, size, exudate, pain, wound bed and description of surrounding wound edges even though they were a stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). Although R76 was at risk for pressure ulcers development and developed three separate stage 2 pressure ulcers, one on his scrotum on 3/27/14, and one on each ischeal tuberosity, unknown date of development. The facility did not reassessed these pressure ulcer, to determine what interventions should be implemented to help decrease the risk of R79 from developing further pressure ulcers. Also there was no indication the pressure ulcers were consistently monitored and provided interventions to promote the healing of these pressure ulcers which caused actual harm for R79. R36's admission Minimum Data Set ((MDS) dated [DATE], included, she was cognitively intact, required extensive to total assistance with bed mobility, transfers and toileting and was frequently incontinent of bladder. R36 had [DIAGNOSES REDACTED]. R36's Pressure Ulcer Care Area Assessment (CAA) dated 2/14/14, listed R36 had risk factors for development of pressure ulcers including, requiring extensive assistance with bed mobility, frequent urinary and bowel incontinence, poor nutrition, slides down in bed, requires regular schedule of turning related to pressure, and moisture associated skin damage. The analysis of findings included, "(R36) needs extensive help to make position changes and do any offloading activity, she is a ceiling lift at present. Has a brace to her R (right) leg r/t (related to) knee fx (fracture)." The care planning decision was marked as yes, and "Proceed to care plan to assist with offloading and repositioning, provide thorough cleansing." R36 was observed in bed, on her back with the head of bed up approximately 45 degrees, on 4/1/14, from 1:00 p.m. until 2:15 p.m. At 2:15 p.m. R36's pressure ulcer with registered nurse (RN)-G was observed, on R36's buttock which was a shallow crater with redness surrounding the area. R36 stated, "I have had that sore for quite a while," and commented that she always sleeps on her back due to having problems breathing and this position was the most comfortable for her. RN-G stated the nurse aides would reposition R36 when ever they get her up for meals or therapy but R36 was not on a timed repositioning schedule. RN-G stated the pressure ulcer was from shearing from the use of the ceiling lift sling, which she was no longer using. However, R36 does slides down in bed, placing her at risk for further shearing, RN-G confirmed they had not implemented any interventions to prevent the potential shearing of R36, from sliding down in bed. R36 was observed in bed, on her back with the head of bed elevated approximately 45 degrees, on 4/2/14, from 6:45 a.m. until 7:53 a.m. and on 4/3/14, from 8:00 a.m. until 9:00 a.m. When interviewed on 4/1/14, at 2:15 p.m. nursing assistant (NA)-AA stated R36 was not on any repositioning schedule, she lays on her back when in bed, she will change positions when ever she gets up for therapy or meals. NA-AA stated R36 had been ill recently, and didn't always get up. During interview on 4/2/14, at 7:53 a.m. NA-A stated R36 was not on a repositioning schedule, she will mostly lay on her back in bed, with head of bed elevated a little. However, sometimes R36 will get up into her wheel chair. R36's progress note dated 2/12/14, included, "Crack in coccyx area, no drainage noted. [MEDICATION NAME] applied." This area was not identified as to if it was a pressure ulcer, or any further description including size, wound bed, drainage, wound edges, tissue surrounding wound, or if any pain was associated with it. The progress note on 2/19/14, indicated "Patient noted to have small area of shearing to middle of left buttocks measuring 2 cm (centimeters) x (by) 0.5 cm." R36's Wound Progress Sheet dated 2/19/14, included a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer, with a pink wound bed, scant amount of drainage, surrounding tissue pink, and wound edges normal. The progress note on 3/11/14, indicated, "Weekly skin assessment for high risk patient completed with the following results." Under "skin issues," number "1) Banmchable (sic) right buttock 1 cm x .75 cm." There was no way to determine if the 2/19/14, pressure ulcer on the left buttocks had healed or not, or if this was the same area as identified on 2/12/14. R36's progress notes dated 3/20/14, indicated she had been hospitalized with pneumonia, and on 3/24/14 had returned to the facility. R36's hospital return Skin Risk assessment dated [DATE], indicated she did not have any pressure ulcers or other skin issues on her buttocks or coccyx. A Skin Risk Assessment with Braden Scale assessment (a scale used to predict pressure ulcer risk) was completed on 3/24/14 which included risk factors for development of pressure ulcers that included: Cardiovascular disease, chronic incontinence, abrasions, bruises, cast/brace/splint, steroid use, occasional moist skin, bedfast, very limited ability to change and control body position, as well as a problem with friction and shear. The form indicated a plan of care would be initiated to prevent the development of pressure ulcers. The 4/1/14 progress note, indicated, "Observed wound to coccyx/buttock crease this evening. 1.75 inches x 3 inches, reddened areas surrounding multiple small areas of stage 2 or skin shearing." There was no staging, exudate, pain, wound bed, description of surrounding wound edges or if this was the same open area from the 3/11/14 progress note or if this was a new area. Review of R36's care plan updated 2/20/14, included nursing would provide assistance with ADL's (activities of daily living) and mobility per therapy directives." The care plan did not address the risk factors listed on the CAA and Skin Risk Assessment to determine appropriate interventions to help prevent the development of pressure ulcers even though R36 was at risk for the development of PU and currently had a stage two pressure ulcer. When interviewed on 4/1/14, at 1:55 p.m. the house supervisor, registered nurse (RN)-E, stated she was not aware R36 had any pressure ulcer at any time. RN-E was unsure if the 2/12/14, 2/19/14, and 3/11/14, pressure ulcers had healed during the hospital stay, or before R36's hospital stay or if they did not heal at all. When interviewed on 4/1/14, at 2:43 p.m. the clinical coordinator, RN-C verified there was no timed repositioning plan for R 36, staff would reposition her when ever she got up for therapy or meals even though R36 spent most of the time in bed on her back due to breathing difficulty. There was no toileting plan, even though R36's pressure ulcer CAA of 2/14/14, indicated urinary incontinence placed R36 at risk for development of pressure ulcers. RN-C stated she had no way to determine when the, "Crack in coccyx area," identified on 2/12/14, had healed, or when or if, the stage 2 pressure ulcer identified on 2/19/14, had healed, or if the area identified on 4/1/14, was the same area as had been identified on 2/12/14, 2/19/14, or 3/11/14. RN-C stated R36 should have been reassessed after R36 had returned from the hospital weaker, and was spending more time in bed. Although R36 was at risk for pressure ulcers and had developed a pressure ulcer on 2/19/14 to present, these ulcers had not been consistently monitored on a weekly basis to determine location, staging, size, exudate, pain, wound bed and description of surrounding wound edges. Also, a comprehensive assessment had not been completed to determine what interventions should be implemented to help decrease the risk of R36 from developing pressure ulcers. R150's, closed record review for pressure ulcers, indicated R150's admission MDS, dated [DATE], indicated R150 had no unhealed pressure ulcers and was at risk for development of pressure ulcers. The MDS also indicated the resident required limit ability for bed mobility and extensive assistance for transfers. In addition, the MDS indicated R150 had multiple [DIAGNOSES REDACTED]. R150's skin assessment, completed on 1/18/14, indicated the resident had a Braden Scale (scale of pressure ulcer risk factors) score of 16, identifying R150 was at risk for pressure ulcer development. The resident's pressure ulcer Care Area Assessment (CAA), dated 1/27/14, identified R150 was in therapy to improve ability to offload independently. R150's care plan, dated 1/27/2014, indicated "Skin: has rough, tender area to "L" buttock on admit. Needs help to offload from lower surfaces, i.e. recliner." The care plan directed staff to assist with offloading activities and "Cover offending (sic) area with [MEDICATION NAME] border and apply [MEDICATION NAME] PRN (as needed). A review of R150's, Resident Progress Notes, dated 1/25/14, identified the resident continued to have complaints of tenderness and discomfort to coccyx and area to left inner buttocks which measured 4 cm (centimeters) by 1.5 cm. The note indicated the area had "Calmo applied and covered with [MEDICATION NAME]." The resident's progress notes, dated 1/26/14, identified that R150 continued to complain of discomfort to coccyx area with "Calmo applied various times throughout shift. Calmo what effective for discomfort." Again, on 1/28/14, progress notes identified R150 had an "Area of raised, firm tissue on (L) (left) buttock noted to be macerated this a.m. Area cleansed, [MEDICATION NAME] applied, and covered with a [MEDICATION NAME] Border." The progress notes, dated 1/29/14, indicated the Nurse Practitioner (NP), observed the resident's buttocks, noted this was an area of shearing from sliding forward on seated surfaces. The NP ordered "Calizime to (L) (Left) butt TID (three times a day); do not cover with [MEDICATION NAME] border; software cushion in any chair surface he sits in." Although the facility had identified, on admission, R150 was at risk for pressure ulcer development and identified R150 developed a pressure ulcer to the left buttock, after admission; the care plan was not updated to reflect the current treatment as prescribed by the nurse practitioner (NP) to promote healing and prevent the development of additional pressure ulcers. Also, the assessment did not identify what interventions could be implemented to prevent R150 from developing pressure ulcers. When interviewed, on 4/3/2014 at 1:26 p.m., the RN-E stated the macerated area on the left buttock was a pressure ulcer. RN-E also stated the care plan was not updated to reflect the pressure ulcer treatment ordered 1/29/14 by the nurse practitioner. A policy entitled Skin Care, Rice Care Center, dated 3/10, included, a purpose of, "To maintain skin integrity, prevent skin breakdown, and to promote healing of non-intact skin." The procedure identified upon admission or hospital return, a skin assessment would be completed within 24 hours; a comprehensive risk assessment with Braden scale would e completed along with a tissue tolerance test (a test to see how long skin can withstand pressure) would be completed. If a resident was found to be at risk for skin breakdown, skin would be monitored weekly and documented in the progress notes. Residents with reddened, open areas, or ulcers would be entered on the treatment sheet, and documented on weekly to include: "treatment given, interventions to prevent further breakdown, size, depth, odor, and drainage." The policy further indicated the physician would be consulted with if there was any significant change in the ulcer. The policy contained a definition of an "Avoidable Pressure Ulcer," which included, "an ulcer that has developed because one or more of the following were not done: a residents clinical condition was not evaluated, risk factors were not identified, interventions were not implemented, or effectiveness of interventions not monitored or revised.