Every finding on record at Divine Providence Community Home

Based on interview and document review, the facility failed to have a system for employee surveillance based on national standards or identify specific criteria used in determining staff return to work (RTW) for 3 of 5 sampled staff (nurse aide (NA)-A, NA-B, and trained medication aide (TMA)-A).Findings include: Interview, employee surveillance review, and staff timecard punch review on 4/15/26 at 12:18 p.m., with registered nurse (RN)-A identified she is the interim infection preventionist (IP) while the IP was on vacation. When staff called in sick, facility process only dictated a return to work that was 3 days or longer required a physician Return to Work (RTW) note. They used no criteria to identify when staff would be able to safely RTW using national and State guidelines to ensure the safety of all residents and other staff in transmission prevention of potentially infectious disease. With the 3 sampled staff:Nurse aide (NA)-B called in ill on 2/8/26, 2/9/26, 2/13/26, 2/23/26 and 2/26/26. RN-A was allowed to return to work as soon as the next day. It was later discovered after 2/26/26 NA-B was pregnant and that was the cause of her vomiting, however it was unknown at the time of illness. NA-A called in on 3/31/26 with a sore throat and runny nose. It was not documented with a presence or absence of fever. NA-A RTW on 4/1/26. NA-A was known to call-in multiple times for illness. RN-A was unaware if NA-A had tested for COVID and was not cleared for potential respiratory infectious disease following CDC guidance of symptoms improving and fever free for at least 24 hours prior to RTW. Trained medication aide (TMA)-A left her shift on 4/2/26. TMA-A was seen by a physician and had a RTW clearance date of 4/6/26. The documented reason was RSV. On 4/6/26, TMA-A called in with continued symptoms of RSV. Timecards identified she had RTW on 4/7/26. There was no evidence that staff had ensured TMA-A was fever free or had improved symptoms for 24 hours before her return.RN-A stated she agreed there should be a system to vet staff prior to returning based off national guidelines and was unaware staff with unknown gastro-intestinal (GI) illness were to be kept off work for 48 hours after cessation of all symptoms per CDC and minimum 72 hours per State standards of the MDH to prevent highly potentially contagious GI illness such as Norovirus. Interview on 4/15/26 at 2:50 p.m. with the administrator identified the lack of employee surveillance was discussed. The administrator was unaware of staff needing to be vetted prior to returning to work to show national and/or state standards were followed, and employees were deemed appropriate to RTW as not to potentially expose other residents and/or staff to infectious disease. The documentation above showed no evidence of that occurring. Although she thought the DON may have screened employees prior to RTW, she agreed there was no evidence appropriate employee surveillance that had occurred. The administrator agreed with the findings and on the need to improve the surveillance and RTW vetting process and ensure documentation occurred. The administrator was unaware employee surveillance was not being discussed in QAPI. Review of the January 2026, Staff with Signs and Symptoms of Infectious Disease policy identified staff assessment protocols were to have been established in order for the facility to be notified if a staff member had symptoms of an infectious disease and must stay out of the facility. The goal was to prevent residents from contracting communicable disease and prevent an outbreak. Staff exhibiting any of the symptoms below need to call into DPCH and report the symptoms they are having. The staff member receiving the call were to document the employee's signs and symptoms such as: VomitingDiarrheaGeneralized body achesCoughRunny and or stuffy noseHeadachesChillsFatigueTemperature Sore Throat Once a staff's temperature had been normal for 24 hours without taking fever reducing drugs and other symptoms were absent, the employee was allowed to return to work, depending on the infection (testing may be requested). There was no indication the policy followed national standards of practice and/ or State guidelines, depending upon the symptoms. There was also no mention of how the process was to occur or that staff who were taking the call-ins had been appropriately trained per national and state standards for vetting employees in order to safely RTW. The policy did note staff were to be trained upon hire and annually on signs and symptoms of infectious disease.

Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee for 4 of 4 quarters submitted and reviewed, was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 47 residents. Refer to F657 and F880. Findings include: Review of the QAPI meeting minutes submitted for review identified for review of the past 4 Quarters of QAPI meeting minutes identified review of each quarter is as follows: Quarter 1 (April 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, dietary manager, facility director, vice president, maintenance supervisor, the administrator, and social services attended. Data submitted included:Falls: 4 with minor injury, none with major injury.Infections: 18. 15 were urinary tract infections (UTI), and 3 were skin.Medication errors: 3Elopements: 0Skin tears: 3Bruises: 12Abrasions/scrapes/lacerations: 1Admissions 13Discharges: 12. 8 residents went home and 4 were deaths.Social services: to review VA reportsEthics committee was to review any ethical concerns Pharmacy was to review pharmacy/trends or concernsPerformance Improvement projects were to be discussed. Social services documented 5 VA reports submitted to MDH and law enforcement. 2 residents had missing money. Residents were encouraged to use a lock drawer. There was no evidence of what was investigated, if the investigations were completed timely, or all staff/residents pertinent had been interviewed. 1 residents' money was found but details were not included. 2 residents were noted to have slapped one another. 1 resident's (unknown) care plan was updated, and medication was reviewed. A 2nd resident identified an (unknown) male resident touched a female resident (unknown) over their clothes inappropriately. QAPI documented there was a medication review to prevent similar incidents, and the resident was discharged to another facility. Neither resident was reported to be affected emotionally or physically. There was no indication QAPI reviewed if all the elements had been investigated thoroughly or if other residents with similar behaviors were reviewed. Bowel incontinence and medication error reductions were the PIP projects reviewed during that meeting. Analysis was occurring on PIP projects. The DON reviewed fall and infection statistics. QAPI noted the IDT team would continue to review falls weekly and interventions, however there was no indication of a comprehensive review by QAPI occurred of any benchmarks, goals or analysis of IDT data. There was also no indication employee surveillance was being reviewed or discussed. Survey results and updated policies were noted to have been reviewed and shared with the medical director. There was no indication what policies were reviewed, who reviewed the policies, or if the QAPI committee as a whole ensured those policies were appropriate and based on current standards of practice. The Pharmacist was noted to not have any trends to review at that time, however, there was no evidence the 3 medication errors noted above were discussed to identify what the benchmarks and goals were, if there were commonalities with the errors, or if they were significant to resident health. Although dietary, maintenance, and the RN staff development coordinator had attended, there was no indication that those departments nor others such as activities had data brought forth for review and analysis, to ensure all areas affecting patient care were being monitored. Quarter 2 (July 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the administrator, the vice president, and social services attended. Those areas included:Social services documented no VA reported were submitted. Administration discusses PIP projects which included benchmarks, goals and analysis.Falls were again submitted by the DON. There were 46 falls (8 minor injuries and no major injuries were noted). The IDT once again was to continue to review falls weekly and discuss strategies at that time. There was no evidence QAPI had ensured a comprehensive review of each resident's fall had occurred, what the benchmarks and goals were, or that analysis of IDT team findings and interventions had occurred. There was also no evidence QAPI had discussed or recognized the dramatic spike from the previous quarter as an area of high concern.Resident infection data was documented as reviewed. There were 18 total infections, with 9being UTI, 3 skin infections, and 6 respiratory infections. Staff were encouraged to utilize McGeer's criteria and follow antibiotic stewardship, however no benchmarks or goals were discussed, and no analysis of data was documented to have occurred to identify trends, or if tracking was occurring appropriately, if transmission-based precautions were needed or implemented timely etc. There was also no employee surveillance reviewed.Skin tears, bruises medication errors, elopements and discharges were documented as reviewed, however there was no documentation to support QAPI had provided appropriate oversight and monitoring.Pharmacy had no trends to review at that time, however, there were concerns brought forth of no open or expiration dates on insulin, expired medications, and missing signatures were noted in the narcotic book in her review. There was no indication QAPI had discussed these events reported to determine what were the underlying causes or had recommended actions to correct deficient practice. Quarter 3 (October 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the vice president, the administrator and social services attended. Those areas included:Social services documented 2 VA reports were submitted, 1 for an unwitnessed fall resulting in fracture, and another involving transferring a resident with an EZ stand. In that instance, QAPI documented the resident's (unknown) knees gave out resulting in bruising. No fracture was noted, and it was reported that resident was switched to a total body lift to prevent similar incidents. There was no indication QAPI had reviewed data surrounding the incidents to ensure appropriate monitoring occurred. Administration discusses PIP projects which included benchmarks, goals and analysis.Falls were again submitted by the DON. There were 20 falls (5 with minor injuries and 1 with major injuries). The IDT once again was reported to be reviewing falls weekly. There was no evidence QAPI had ensured a comprehensive review of each resident's fall had occurred, what the benchmarks and goals were, or that analysis of IDT team findings and interventions had occurred.Resident infection data was reviewed. 13 in total with 7 UTI, 4 were skin, and 2 respiratory. Again, McGeer's and antibiotic stewardship were encouraged, however there remained no evidence analysis or oversight by QAPI was occurring.Skin tears, bruises medication errors, elopements and discharges were documented as reviewed, however there was no documentation to support QAPI had provided appropriate oversight and monitoring.There were no concerns brought forth from pharmacy, however in the medication room review document submitted from pharmacy, there was a notation a cart was observed unlocked, the last shift of controlled drug count with dual signatures was on 8/11/25. This was not discussed or brought forth by pharmacy as a concern staff were not reconciling controlled meds appropriately. Open dates were still noted to be a continued concern. Quarter 4 (January 2026): Attendees included the medical director, director of nursing (DON), social services, the administrator, the Minimum Data Set (MDS) nurse, and pharmacist. No other departments were noted to have attended. Topics discussed were:UTI (urinary tract infections) (PIP): started on 7/1/25, which was noted to be in the implementation phase, whose purpose was to reduce UTI. Measures were Q1 9 UTI. Status was listed as increased testing. Changes initiated for actions identified were staff education, to improve resident hydration, add cranberry supplements, and ensure staff perform a clean catch (urinary collection to ensure no contamination occurred giving false results). A root cause analysis was completed, barrier identified, and specific education noted. Estimated completion dates were given. Other members weighed in such as pharmacist and infection preventionist, etc. Walking (PIP): a thorough analysis was completed and was similar to the above UTI section.VA (vulnerable adult) reports: staff noted they had no submissions for the previous quarter.Falls were notes as discussed. 38 for last quarter (9 with minor injuries and 0 major injuries). The interdisciplinary team (IDT) was noted to review falls weekly and discussed interventions and strategies. However, in the QAPI review, no residents were specifically discussed to ensure IDT was doing analysis of data behind falls. It was also not clear if this is a continued concern, th numbers were better or worse, what goals were, or if there was any analysis of data by QAPI to ensure IDT was reviewing their data appropriately.Resident infections were discussed in numbers but no there was no data documented as being reviewed, there were no benchmarks or goals, and no analysis identified. There was also no mention employee surveillance having been discussed. 6. Medication errors were noted as reviewed. 4 errors occurred. There was no documentation to support what the errors were, what the facility's benchmarks and goals were, or analysis of data. The QAPI committee notes documented There were no pharmacy trends to review at this time. There was no evidence to suggest the facility addressed and included all systems of care, such as dietary or maintenance, actual and/or potential staffing issues, or that other areas that would impact resident care were reviewed. There was also no evidence of a thorough review of data if the area was not part of a performance improvement project (PIP). Interview and document review on 4/15/26 at 3:45 p.m., with the administrator identified she was in charge of PIP and the director of nursing (DON) was in charge of the rest of discussion and documentation of QAPI. The administrator noted that whatever the DON documented in the QAPI meeting minutes was all they had. In review of the QAPI minutes provided, it was discussed with the administrator there was no evidence of oversight of analysis evident as only data brought forward with a brief overview of areas that weren't a PIP project. The administrator agreed there was a need for all data to have benchmarks, goals, actions, interventions and analysis of how well the plans worked and to ensure oversight was provided. The administrator agreed the QAPI committee needed more information to show those topics discussed were monitored appropriately to identify compliance or the need for further monitoring. Survey findings were discussed, specifically that one resident (R4) who was reviewed for falls failed to have their care plan revised after new interventions were identified to be implemented and would have been identified had the QAPI committee reviewed specifics around IDT review for falls and appropriate oversight would have occurred. The administrator agreed with that discussion and understood need for documenting the oversight. Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals. The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration.

Based on interview, and document review, the Quality Assurance (QA) committee failed to ensure they received reports from the infection preventionist relating to employee surveillance for 4 of 4 quarters reviewed. Refer to F865 and F880Findings include: Review of the QAPI meeting minutes submitted for review identified for review of the past 4 Quarters of QAPI meeting minutes identified review of each quarter is as follows: Quarter 1 (April 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, dietary manager, facility director, vice president, maintenance supervisor, the administrator, and social services attended. Data submitted included:Infections: 18. 15 were urinary tract infections (UTI), and 3 were skin. The DON reviewed infection statistics. QAPI noted the IDT team would continue to review falls weekly and interventions, however there was no indication of a comprehensive review by QAPI occurred of any benchmarks, goals or analysis of IDT data. There was also no indication employee surveillance was being reviewed or discussed. Quarter 2 (July 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the administrator, the vice president, and social services attended. Those areas included:Resident infection data was documented as reviewed. There were 18 total infections, with 9being UTI, 3 skin infections, and 6 respiratory infections. Staff were encouraged to utilize McGeer's criteria and follow antibiotic stewardship, however no benchmarks or goals were discussed, and no analysis of data was documented to have occurred to identify trends, or if tracking was occurring appropriately, if transmission-based precautions were needed or implemented timely etc. There was also no employee surveillance reviewed. Quarter 3 (October 2025): Attendees included the medical director, DON, RN staff development coordinator (RN-A), the pharmacist, facility director, the vice president, the administrator and social services attended. Those areas included:Resident infection data was reviewed. 13 in total with 7 UTI, 4 were skin, and 2 respiratory. Again, no employee surveillance was included. Quarter 4 (January 2026): Attendees included the medical director, director of nursing (DON), social services, the administrator, the Minimum Data Set (MDS) nurse, and pharmacist. No other departments were noted to have attended. Topics discussed were:Resident infections were discussed in numbers but no there was no data documented as being reviewed, there were no benchmarks or goals, and no analysis identified. There was also no mention employee surveillance having been discussed. Interview and document review on 4/15/26 at 3:45 p.m., with the administrator identified she was in charge of PIP and the director of nursing (DON) was in charge of the rest of discussion and documentation of QAPI. There was no evidence to support the IP had brought employee surveillance to QAPI for oversight. The administrator agreed with that discussion and understood need for documenting the oversight. Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals. The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration. There was no specific mention to the IP bringing all surveillance data to QAPI for review. Review of the January 2026, Infection Control Coordinator policy, identified the infection control coordinator was to report information related to compliance to Administrator and Quality Assurance and Assessment Committee. The IP was to collect, analyze, and investigate data and trends to nursing staff and health practitioners; maintain infection logs for staff and residents; consult on strategies for infection prevention; and implement evidence-based control practices. Infection logs -summaries of infections.

Based on observation, interview, and document review the facility failed to weekly assess and measure a pressure ulcer for 1 of 2 sampled residents (R5). Findings include: R5's 4/2/26, accepted quarterly Minimum Data Set (MDS) assessment identified R5 had severe cognitive impairment. R5 required partial assistance with activities of daily living (ADL). R5 had 1 unhealed stage 3 pressure ulcer (full thickness tissue loss subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) that was not present on admission and had moisture associated skin damage. R5 had a pressure relieving device on her bed and in her wheelchair. She took daily antidepressant and pain medication. R5's 4/14/26, diagnoses list identified dementia with anxiety, panic disorder, major depressive disorder, legal blindness, osteoarthritis, disorder of skin and subcutaneous tissue right buttocks cheek, and mixed incontinence of bladder. R5's 12/10/25, fax to physician identified communication that R5 had a pressure area measuring 3 centimeters (cm) x 3 cm on her right buttock with treatment set up to apply Mepilex every 3 days, and a note from staff asking if the physician would like to provide any further orders. R5's 12/23/25, provider communication identified staff were to report if R5's wound worsened or failed to resolve. R5's 4/14/26, printed care plan identified the nurse was to assist to reduce pressure and friction between R5 and her bed or chair. R5 had a pressure reducing mattress and cushions in her wheelchair and recliner. The nurse was to provide wound care to her right buttock and assess and measure the wound weekly. R5 would be monitored for nutrition and hydrating intake. Staff were to help R5 stay clean and dry and use a thin layer of barrier cream on red areas or previous problem areas. Staff were to report any redness to the nurse. Observation on 4/14/26 at 10:17 a.m., with registered nurse (RN)-A of R5's right buttocks wound identified RN-A prepped the supplies, washed her hands and donned gloves. RN-A removed the dressing and washed the wound. Observation of the wound identified a small open area with a pink wound bed. RN-A described the wound as stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed) with a thin layer of skin missing and measured the wound. RN-A identified interventions noted were for staff to promote healing and prevent further breakdowns including pressure relieving mattress and ensure a cushion was in her wheelchair and recliner. Interview on 4/14/26 at 12:07 p.m., with RN-A identified R5 had a treatment order to measure R5's wound every Monday. She revealed according to the documentation for February, March, and April of 2026 a measurement had only been completed on 3/9/26 and also what she had done earlier in the day. She confirmed the nurses had been charting that they had held the treatment and did not perform the task on all other Mondays. The nurse was to complete an assessment of the wound and measure every Monday until healed. R5's treatment administration record (TAR) identified an order to measure right buttocks open area one time a week on Monday until healed, start date of 2/2/26. Apply an Allevyn dressing and change every 3 days until healed, start date 2/7/26. Review of February, March, and April 2026 identified the following charting:2/2/26, was documented as held and not performed2/9/26, there was no documentation that the measurement was completed or not completed2/16/26, was documented as held and not performed2/23/26, was documented as held and not performed3/2/26, was documented as held and not performed3/9/26, was documented as completed3/16/26, was documented as held and not performed3/23/26, was documented as held and not performed3/30/26, was documented as held and not performed 4/6/26, was documented as held and not performed 4/13/26, was documented as held and not performed 4/14/26, documented as completed R5's wound assessment for February, March, and April 2026 identified the following documentation:2/2/26, R5's Allevyn (absorbent foam dressing) was intact on R5's right buttock.2/9/26, R5's Allevyn dressing was intact on R5's right buttock.2/16/26, R5's Allevyn dressing was as intact on R5's right buttock. R5's left buttock was noted, however, staff failed to document concerns with the left buttock.2/23/26, R5's Mepilex (absorbent silicone foam dressing) was intact on R5's right buttock.3/2/26, R5's Allevyn dressing was intact on R5's right buttock.3/9/26, R5 had 2 open areas measuring 0.5 cm around. The areas were cleaned and Allevyn dressings were applied.3/16/26, R5's Allevyn dressing was identified as intact on R5's right buttock.3/23/26, R5s right buttock was as opened and cleaned with an Allevyn dressing applied.3/30/26, R5's right buttock was not open however, an Allevyn dressing was applied4/5/26, R5's right buttock was opened and cleaned with an Allevyn dressing applied 4/6/26, R5's Allevyn dressing was intact on R5's right buttock 4/13/26, R5's Allevyn dressing was identified as intact on R5's right buttock 4/14/26, R5's right buttock had a stage 2 pressure ulcer with the wound tissue being pink and surrounding tissue identified as dark discolored. The right buttock wound measured 1 cm x 0.7 cm, the area was cleaned, and an Allevyn dressing was applied.Prior to the surveyor's observation of the wound and treatment with the RN-A on 4/14/26, there was no evidence to support the nurse appropriately assessed and measured R5's wound weekly to monitor for worsening, remaining the same, or if they showed improvement. Interview on 4/14/26 at 12:21 p.m., with RN-B confirmed the nurse should be following the treatment orders to assess and measure R5's wound weekly. She was unsure why this was not being completed. Interview on 4/15/26 at 4:14 p.m., with administrator identified she would expect the licensed nurses would follow the facility policy on wound monitoring and measuring. Review of April 2017, Pressure Ulcer Assessment policy identified pressure ulcers would be evaluated, measured and characteristics of the wound would be documented weekly to determine worsening or improvement.

Based on interview and document review, the facility failed to revise the care plan for 1 of 1 sampled resident (R4) reviewed for falls.Findings include: R4's 4/2/26, accepted admission Minimum Data Set (MDS) assessment identified R4's cognition was severely impaired. R4 required substantial assistance from staff for activities of daily living (ADL's) and was incontinent of bowel and bladder. R4 had a history of falls prior to admission, had 2 falls since admission (1 with minor injury and 1 with major injury). R4 was identified to have delirium, inattention, disorganized thinking, and altered mental status that fluctuated. R4 took scheduled pain, antipsychotic, antianxiety, antidepressant, diuretic, and opioid medication. She was also noted during the assessment period to take an antibiotic. R4 was receiving occupational and physical therapy. R4's diagnoses list identified dementia with psychotic disturbance, anxiety, cardia arrhythmia, high blood pressure, depression, osteoporosis, weakness and malnutrition. R4's fall reports identified on:2/17/26, R4 had an unwitnessed fall in her room, and was found next to the chair. R4 was assessed and assisted in her chair and then toileted. She reported she thought she bumped her head when she tried to walk. The call light was not on at time of fall. The Corrective action/solution was to place alarm on her bed, chair, and wheelchair.2/22/26, R4 had an unwitnessed fall in the facility living room and was found next to a recliner leaning on her right side. Her glasses were broken, and she had a laceration (cut) near her left eye. Prior to her fall R4 had been sitting on a chair near the window in the living room. At time of fall there were no staff in the area due to residents finishing up lunch and transporting residents out of the dining room. R4 had tried to walk and fell. The Corrective action/solution was to make sure she was sitting on her chair alarm, to not take her out of dining room until staff were around the living room area and have a staff member be in dining area when she was in dining area. Review of 3/10/26, interdisciplinary team (IDT) meeting note identified the IDT did a review of R4's 2/22/26 fall on 2/24/26 with a new identified intervention of having R4 in the living room area for supervision as much as able, and to continue with her therapy treatments. R4's current, undated care plan, identified R4 required 2 staff to assist with transfers and toileting. R4 did not understand instructions and was not able express her needs. R4 had a wander guard on her wheelchair. R4 could not safely transfer without assistance and had a bed and chair sensor alarm in place that connected to and turned on the call light and/or pager. The care plan lacked identification that R4 should remain in the dining room until staff were around the living room area and to ensure staff were in the dining room area while R4 was there or that R4 should be in the living room area as much as possible for supervision. Interview and care plan review on 4/15/26 at 2:17 p.m., with registered nurse (RN)-A identified R4 had been admitted to the facility for failure to thrive and dementia. R4 had 2 falls since admission in February 2026. RN-A identified the only intervention on her care plan was to have a bed and chair alarm. RN-A confirmed the interventions that had been identified on the 2/22/26, fall report had not been added to the care plan following R4's second fall that resulted in a fractured of her pelvis. RN-A identified when a fall occurred, that the charge nurse would complete a fall report and that person was to update the care plan with the new interventions. Then the IDT meets weekly and reviews any falls and would review interventions. The IDT also should update the care plan if the intervention was changed after review. RN-A stated the care plan should be updated any time care needs change for a resident. Interview on 4/15/26 at 4:14 p.m., with the administrator identified she would expect that R4's care plan would reflect her current care needs including identified fall interventions. Any time a new intervention or care need was identified to care for a resident that the care plan would be updated. Review of undated Fall and Post-Fall Assessment identified that following a fall the nurse would assess the resident and provide necessary medical attention. The environment would be evaluated for possible causes and necessary action would be taken to correct as needed. The family and medical doctor would be updated and notified of new interventions. Interventions would be added to the care plan and communicated to the staff.

Based on interview and document review, the facility failed to ensure care plans were appropriately developed for 1 of 5 sampled residents (R3) who received anticoagulant therapy.Findings include: R3's comprehensive MDS assessment, accepted on 9/11/25 identified she was admitted to the facility in August 2025. R3 had moderate cognitive impairment, with diagnoses of heart disease, cardiovascular and coagulation treatment, atrial fibrillation (heart's inability to appropriately contract, causing potential blood clots), and a history of heart attack. R3 required staff assistance with Activities of Daily Living (ADL) such as bathing, dressing and toileting. R3 used a walker, wheelchair, and cane or crutch for mobility and had a physical impairment on one side of her body. R3's current Medication Administration Record (MAR) indicated R3 received Xarelto, 15 milligrams (mg) daily related to their diagnosis of atrial fibrillation. R3's current, undated care plan identified R3 was at risk for falls as she was weaker and was known to be more fatigued than normal and may not remember to call staff for assistance. R3 had dementia and was known to be confused. R3 had muscle weakness and unsteadiness. R3's goal was to stay safe while out or moving about, transferring, and to avoid injury. There was no mention on the care plan R3 was at increased risk of bleeding and there were no bleeding precautions noted. Interview and care plan review on 4/15/26 at 12:18 p.m., with registered nurse (RN)-A identified she agreed there were no bleeding precautions listed on the care plan to alert staff what to monitor for since R3 was on an anti-coagulant. We probably haven't thought of that. RN-A agreed residents on anticoagulants should have increased monitoring related to increased risk of bleeding. Interview on 4/15/26 at 2:50 p.m. with the administrator identified she was unaware R3's care plan did not have any bleeding precautions. The administrator was unaware if any residents on anti-coagulants had interventions as they were at high risk for bleeding. The administrator agreed care plans needed to be developed as appropriate. Review of the current, undated Xaralto (anti-coagulant) patient safety information, located at: https://www.xarelto-us.com/what-is-xarelto/?utm_source=bing&utm_medium=cpc&utm_campaign=EG-DTCB-BR-NA-Xarelto-JJ-Priority/Top-Phrase-NA&utm_content=Core+Branded-TXT-National-NA-1-PH&utm_term=xarelto&gclid=8931e1615f0a13ed37da8886d53418dc&gclsrc=3p.ds&msclkid=8931e1615f0a13ed37da8886d53418dc, identified Xarelto was a blood thinner that treats and helps prevent blood clots that are related to certain conditions involving the heart and blood vessels. Anticoagulants lower your blood's ability to clot by stopping specific proteins and enzymes, also known as clotting factors, from doing their job to help blood clots form. Side effects of Xarelto included increased risk of bleeding. Patients were likely to bruise more easily, and it may take longer for bleeding to stop which can be serious and may lead to death. Patients were to notify a physician or receive medical attention if a patient developed signs or symptoms of bleeding such as:Unexpected bleeding or bleeding that lasts a long time, such as:Nosebleeds that happen often.Unusual bleeding from gums.Menstrual bleeding that is heavier than normal, or vaginal bleeding.Bleeding that is severe or you cannot control.Red, pink, or brown urine.Bright red or black stools (looks like tar).Cough up blood or blood clots.Vomit blood or your vomit looks like coffee grounds.Headaches, feeling dizzy or weak.Pain, swelling, or new drainage at wound sites.Left upper belly (abdominal) pain, pain below the left rib cage or at the tip of your left shoulder or diffuse abdominal discomfort (these may be symptoms of the rupture of the spleen). Review of the National Library of Medicine (NLM) article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12284669/, To anti-coagulate or not to anti-coagulate-that is the question in patients with fall risks, identified falls were associated with an increased risk of traumatic bleeding events and death. Another NLM article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11242576/, Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department identified the National Institute for Health Care Excellence (NICE) suggested considering conducting a head CT scan for people who have sustained a traumatic brain injury (TBI) [ex: hitting their head from a fall] and have no other indications for a head CT scan, except being on anticoagulant therapy. There was no policy related to anti-coagulation monitoring provided by the end of survey.

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for 2 of 5 sampled residents' (R3 and R8) on psychotropic medications. Findings include: R8's 3/27/26, accepted quarterly Minimum Data Set (MDS) assessment identified R8's cognition was severely impaired. R8 had inattention that fluctuated. R8 took scheduled pain, antianxiety, and antidepressant medication. R8's diagnoses list identified unspecified psychosis, depression, restlessness and agitation. R8's physician orders identified Zoloft 25 milligrams (mg) by mouth daily in the evening for depression with a start date of 6/6/23. Review of R8's GDR information provided by the facility identified on: 12/4/23, a fax to the provider by registered nurse (RN)-C that read, Resident was due for a 6-month review of psychotropic medications. She was currently taking Ativan, Lyrica and Zoloft. She has not had any adverse reactions to the medication. Okay to continue for another 6 months? The medical doctor responded ON 12/5/23, Patient is stable on above medications.will not change. 7/2/24, the medical provider notes identified an assessment and plan for cognitive decline was to continue sertraline (Zoloft). R8 had no behavior issues. Staff were to encourage participation with facility activities for increased engagement and interaction. 6/22/25, a fax to the provider by RN-C that read, Resident was due for a 6-month review of scheduled psychotropic medications. The resident has orders for Zoloft 25 mg daily in evening. The medication is effective and well tolerated. May we have orders to continue for another 6 months? She also has Ativan 0.5 mg daily in evening. This medication is effective and well tolerated. May we have orders to continue for another 6 months? The medical doctor responded on 2/24/25 with yes. 3/3/26, medical provider note identified the assessment and plan for cognitive was to continue sertraline (Zoloft). R8 had no behavior issues. Staff were to encourage participation with facility activities for increased engagement and interaction. 12/27/25, a fax to the provider by RN-C read, Resident was due for a 6-month review of scheduled psychotropic medications. The resident has orders for Zoloft 25 mg daily in evening. The medication is effective and well tolerated. May we have orders to continue for another 6 months? She also has Ativan 0.5 mg daily in evening. This medication is effective and well tolerated. May we have orders to continue for another 6 months? The medical doctor responded on 2/24/25, with yes. R8's pharmacy reviews for October, November, and December of 2025 and January, February, and March of 2026 had no mention of psychoactive medication review or a GDR recommendation. R8's undated, current care plan identified R8 had the potential to feel anxious, angry, sad, confused or forgetful, and have episodes of depression. Staff were to evaluate situational stressors and re-orient R8 unless it makes her agitated. Offer her choices and relaxation techniques. Interview on 4/15/26 at 4:14 p.m., with the administrator identified she would expect the regulations would be followed and gradual dose reductions (GDR) would be attempted as required. R3's comprehensive MDS assessment, accepted on 9/11/25 identified she was admitted to the facility in August 2025. R3 had diagnoses of depression, restlessness and agitation, unspecified dementia without behavioral or psychotic disturbance. She had moderate cognitive impairment, and her Patient Health Questionnaire-9 (PHQ-9) score was 1, indicating little to no depressive symptoms with no behaviors noted during the lookback period. R3's last physician's orders in September 2025, identified she received: Sertraline HCL (anti-depressant) 50 milligrams (mg), 1.5 tablets daily. Seroquel (antipsychotic) 12.5 mg in the a.m., and 25 mg in the evening. R3's pharmacy recommendations identified on: 9/26/25, pharmacist (RPh)-A made recommendations for lab tests. 10/27/25 and 11/24/25, RPh-A noted no problems with medications were identified. 12/11/25, review of allergy medication and cholesterol medications were reviewed and recommended to be discontinued. 1/23/26, Tylenol was recommended for a dose reduction from polypharmacy (multiple-like) medications. Seroquel 12.5 mg dose was as needed (prn) at that time and RPh-A recommended it to be discontinued as it was overdue for a 14 day face to face review. The physician was encouraged to discontinue that prn dose at that time. 2/19/26, and again on 3/19/26, RPh-A indicated no problems were identified. There was no indication RPh-A recommended a GDR attempt within her 1st 6 months of admission. R3's nursing progress notes identified on 12/1/26, staff noted R3 was due for 6 month scheduled psychotropic medication evaluation upcoming on 5/30/26 for her Seroquel. There was no indication nursing staff identified R3 should have had a GDR attempt requested within 6 months of admission. Interview on 4/11/26 at 3:22 p.m., with registered nurse (RN)-B identified nursing listed the medications for physicians when completing rounds and only asked if they would like to continue them. They made no mention to the physician if a resident was due for a GDR to be attempted. Interview on 4/15/26 at 10:15 a.m., with RPH-A identified GDR are listed in her notes as a review of medications. She does not specifically recommend GDR's. RPh-A identified she had recommended a review of medication in May 2026, as she made an error as she thought R3 had been admitted in January. She felt the nursing staff were to inquire about GDR's. RPh-A thought R8 had a GDR done and would check. Interview on 4/15/26 at 12:18 p.m., with RN-A identified she was under the understanding the RPH would ask about GDR in their medication reviews and was unsure if GDR's were discussed or mentioned at that time. Interview on 415/26 at 2:50 p.m., with the administrator identified she was unaware GDR were not being performed and/or documented for R3 or R8, only mediation reviews were being requested to either continue or discontinue the medication. The administrator agreed GDR must be requested and attempted as required. If the request from the physician was denied, a rational for the denial was required and must be documented. Review of the December 2022, Pharmaceutical Services, Psychotropic Drugs policy identified residents who use psychotropic drugs were to receive GDR's unless contraindicated in an effort to discontinue the drug. Review of the undated, Psychotropic Medication policy, identified a psychotropic drug review would be completed by the consulting pharmacist with a collaborated goal of reduction or discontinuation of psychotropic medication. The purpose of the gradual dose reduction was to find an optimal dose or to determine if the continued use of the medication was beneficial to the residents. Accepted standards of practice for GDR were within the first year of a resident admission on a psychotropic medication or after the start of a psychotropic medication the facility must attempt a GDR in two separate quarters with at least one month between the attempts, unless clinically contraindicated. After the first year a GDR must be attempted annually, unless clinically contraindicated.

Based on observation and interview, the facility failed to ensure oxygen administration was consistently monitored according to physician orders for 2 of 4 residents (R18, R19) observed during dining. Findings include: R18's facesheet printed on 3/5/25, included diagnoses of multiple fractured ribs and congestive heart failure (when the heart doesn't pump blood as well as it should). R18's admission MDS assessment dated [DATE], indicated R18 had moderately impaired cognition, clear speech, could usually understand and be understood. R18 required substantial assistance with ADL's and did not walk. R18 used continuous oxygen therapy. R18's physician orders dated 2/28/25, indicated chronic oxygen at 2 LPM (liters per minute) at HS (bedtime) PRN (as needed) and 1 LPM during the day to keep [oxygen saturation] above 90%. R18's care plan dated 2/12/25, did not include oxygen therapy. During an observation on 3/4/25 at 8:10 a.m., R18 was seated at the table in the dining room in her wheelchair. R18 had an oxygen cannula in her nares. Her oxygen tank on the back of her wheelchair indicated R18 was receiving 1 liter of oxygen, however, the arrow on the oxygen gauge was in the red REFILL section. LPN-A who was sitting next to R18 while R18 was taking her pills, looked at the gauge and stated, oh, it's empty. LPN-A obtained a new oxygen tank and changed it out. R18 denied feeling short of breath. During an interview on 3/4/25 at 10:14 a.m., NA-A stated she had helped R18 get up that morning. NA-A stated she turned the portable oxygen tank on and saw there was hardly any oxygen left. NA-A stated she knew there would be enough oxygen to quick weigh R18 and bring her back to her room for breakfast. However, after being weighed, R18 decided she would eat in the dining room. NA-A stated at that point, she had totally forgot about the oxygen tank being almost empty. (NA)-A stated whoever put a resident in a wheelchair with their portable oxygen tank was responsible to ensure there was oxygen in the tank. NA-A stated nurses and nursing assistants had training on how to use and change an oxygen tank. R19's facesheet printed on 3/4/25, included diagnosis of chronic obstructive pulmonary disease (COPD), (a disease that blocks airflow making it difficult to breathe). R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R19 was cognitively intact, had clear speech, could understand and be understood. R19 required partial assistance with activities of daily living (ADLs) and could walk short distances with supervision. R19 received oxygen therapy. R19's physician orders undated, indicated administer oxygen per cannula 1-4 liters as needed for shortness of breath (per standing order). Order dated 11/18/24, indicated to monitor O2 (oxygen) saturation and chart how often using oxygen. R19's care plan dated 9/3/24, indicated R19 had respiratory problems; got short of breath with exertion, but currently did not use oxygen. During an observation on 3/3/25 at 5:59 p.m., R19 was seated at the table in the dining room in her wheelchair. R19 had an oxygen nasal cannula in her nares. The oxygen tank on the back of her wheelchair indicated R19 was receiving 1.5 liters of oxygen, however the arrow on the oxygen gauge was in the red REFILL section. During an interview and observation on 3/3/25 at 6:04 p.m., licensed practical nurse (LPN)-B verified the arrow was in the red REFILL section and stated the tank was empty. LPN-B turned the handle on the tank to the open position to make sure it was open, and the arrow remained in the REFILL section. During an observation on 3/3/25 at 6:07 p.m., LPN-B changed out the oxygen tank. During an interview on 3/3/25 at 6:14 p.m., R19 stated she had not felt short of breath while eating her meal, adding, she was only eating, not walking. During an interview on 3/4/25 at 2:31 p.m., the director of nursing (DON) stated in the morning, staff usually changed out the portable oxygen tanks if needed, and whoever was taking the resident with the portable tank should look at the level of oxygen remaining in the tank. Facility Oxygen Concentrator and Cylinders policy with revised date of 4/24, indicated oxygen would be provided to residents for whom oxygen had been ordered by a physician; oxygen concentrators would be used whenever possible and tanks only as needed. The policy described the steps for setting up an oxygen cylinder (tank). The policy did not include periodic checking of the amount of oxygen in the tank when in use.

Based on interview, observation and document review, the facility failed to ensure staff provided a walking program to meet the assessed needs for 1 of 1 residents (R35) reviewed for restorative services. Findings include: R35's face sheet printed on 3/4/25, indicated primary diagnosis of chronic obstructive pulmonary disease (lung disease causing breathing difficulty), type two diabetes mellitus, chronic kidney disease, and heart failure. R35's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, use of a walker, wheelchair, and limb prosthesis, substantial assistance for bathing, partial assistance for upper and lower body dressing, partial assistance for personal hygiene, setup assistance for transfers, supervision for walking 50 feet, and no restorative nursing program. R35's care plan dated 9/27/24, indicated R35 walked independently with one helper providing setup assistance and use of four wheeled walker with gait belt. R35's goal was to continue to be able to walk and transfer safely. R35's document titled [NAME] Therapy Referral to Nursing dated 12/20/23, indicated R35's physical therapy recommended ambulation/walking program instructed to walk with R35 with four wheeled walker, gait belt, contact guard assistance of one staff, wheelchair to follow to and from all meals (three times daily). During interview on 3/3/25 at 3:53 p.m., R35 stated he had not been walking as much he wanted to and stated staff did not always have the time to help him walk. R35 stated he would walk more if staff were available, and he could not walk on his own due to past falls. During observation on 3/3/25 at 5:35 p.m., R35 was observed propelling himself in his wheelchair in the hallway and was not observed walking to or from supper. During interview on 3/4/25 at 10:49 a.m., nursing assistant (NA)-B stated she was supposed to walk the residents on her assigned hallway during her shift and usually had time to get all of her assigned walks done. NA-B further stated completed walks would be documented in the electronic health record (EHR). During interview on 3/4/25 at 12:26 p.m., NA-C stated the restorative nursing assistant (RNA) did most of the walking of residents, but the NA would assist with walking when able. During interview on 3/4/25 at 12:39 p.m., NA-D stated both the RNA and NA are responsible for walking the residents on their assigned hallway. NA-D stated when walks were completed they were documented in the EHR and resident refusals would also documented in the EHR. During interview with the director of nursing (DON) on 3/4/25 at 2:42 p.m., she stated she would expect that R35's walks were completed as recommended and if R35 refused to walk she would expect that to be documented in the EHR. DON further stated R35 had not declined from not walking, but walking would be important to maintain his current level of function and prevent any decline in function. Review of an untitled facility provided document from the EHR printed 3/4/25, indicated from 2/16/25 through 3/2/25, R35 did not walk three times daily as recommended. Documented walks included the following: 2/16/25- one time 2/17/25- no walk 2/18/25- one time 2/19/25- no walk 2/20/25- two times 2/21/25- one time 2/22/25- two times 2/23/25- one time 2/24/25- one time 2/25/25- no walk 2/26/25- no walk 2/27/25- no walk 2/28/25- no walk 3/1/25- one time 3/2/25- one time Review of a facility policy titled Assisting with Transfers and Walks revised 5/24, did not include anything regarding walking residents based on therapy recommendations.

Based on interview and record review the facility failed to use the appropriate type of mechanical lift sling according to the care plan for 1 of 3 residents (R1) reviewed for mechanical lift transfers. This resulted in harm when R1 was transferred with with a toileting sling resulting in subsequent pain, brusing and diagnosed humoral fracture to left arm. Findings include: A facility reported incident (FRI) submitted to the State Agency on 5/6/24, indicated R1 had an unexplained injury that staff became aware of on 5/4/24 when a nursing assistant (NA) reported R1 had dark black and blue bruising on her upper arm. R1 was sent to the hospital for further evaluation. R1's face sheet identified R1 had diagnoses that included wedge compression fracture of T7-T8 vertebra, unilateral primary osteoarthritis, impingement syndrome of left shoulder, unspecified fracture upper end of left humerus, chronic pain, and abnormalities of gait and mobility. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, moderate difficulty with hearing, unclear speech, rarely/never understood, but usually understood others. R1 had upper and lower extremity impairment on both sides that required staff assistance with all activities of daily living (ADLs). R1's care plan dated 2/13/24, indicated R1 had a progressive decline in strength and use of extremities, and had muscle weakness in right hand, and a [NAME] left shoulder from non-use. For toileting the care plan directed 1 to 2 helpers with ARJO (brand name) blue medium sized sling -resident can use this sling for toileting- please do not use sling that goes under the arms. R1's Therapy/Restorative-Plan of Care dated 4/30/24, for transfers directed assist of 1-2 staff with ARJO Hoyer/EZ body sling, Blue/medium sling- can use this sling for toileting- do not use sling that goes under her arms. Ensure full body sling under bottom for transfers. During an interview on 5/10/24 at 9:45 a.m., trained medication aide (TMA)-A indicated R1 had decreased range of motion in her shoulders/arms and R1 could not raise her arms up. TMA-A indicated the facility had two types of lift slings, a regular full sling and the toileting sling which went under the arms. TMA-A stated R1 had been using a full body sling for approximately 1.5 years and would not be able to use the toileting sling because the sling would cause R1's arms to go up. TMA-A stated she worked the day shift on Friday, 5/3/24, and transferred R1 from the wheelchair to her bed after lunch using the full sling. TMA-A did not notice anything abnormal and did not recall R1 having any increased pain anywhere. During a phone interview on 5/9/24 at 2:27 p.m., NA-C indicated R1's arms were difficult to move because they were stiff and rigid; washing under her arms was hard because of her decreased range of motion. R1 was transferred with a mechanical full body lift by two staff. NA-C indicated she worked the night shift and did not routinely transfer R1. NA-C stated she worked the overnight shift Thursday (5/2/24) and stayed late on the day shift Friday (5/3/24). NA-C explained when she and NA-D transferred R1 from her bed to wheelchair Friday morning they used the ARJO toileting sling because that was the one in R1's room. The toileting sling shape is different from the full sling because the toileting sling goes under the arms instead of fully encompassing the upper body. The toileting sling also had a buckle that went across the upper chest at shoulder level that would cause some pressure. NA-C stated it was difficult to put the sling on R1 because they had to move R1's arms so that they were outside of the sling for the transfer. R1 made moaning noises when she was moved. NA-C indicated she had questioned at the time of the transfer if the toileting sling was the right one because of the difficulty applying it. NA-C stated R1 should have been transferred with a full sling but did not know that at the time. Calls were placed to NA-D on 5/9/24 at 2:24 p.m. and 5/10/24 at 9:37 a.m., no return call from NA-D was received. R1's progress note on 5/3/24 at 9:30 p.m., R1 had yelled out when arm was touched or moved with cares. The note did not identify which arm. During a phone interview on 5/10/24 at 10:51 a.m., licensed practical nurse (LPN)-A stated on Friday 5/3/24 she worked the evening shift. LPN-A stated the NA called her to R1's room because she was having increased pain in her right arm. LPN-A did not notice any bruising on R1's right arm and there was no change in R1's shoulder/arm range of motion. LPN-A added the increased pain into the computer and passed along her findings in her report to the next shift. During an interview on 5/9/24 at 10:55 a.m., NA-A stated she assisted R1 with morning cares on the morning of 5/4/24. NA-A stated R1 was always tight and constricted on her right arm but that morning the whole arm felt loose and was easily lifted compared to the left side. NA-A stated she told the nurse of her findings R1's late entry progress note dated 5/5/24 at 2:20 p.m. for 5/4/24, identified nursing assistant (NA)-A called nurse to room due to (d/t) R1's right arm hurting with movement. No bruising. Hospice nurse in the building checked her out. During a phone interview on 5/10/24 at 11:10 a.m., LPN-B stated she worked 5/4/24 during the day. LPN-B verified NA-A had her go to R1's room for R1's right arm moving more than normal. LPN-B stated she did not notice any abnormalities and had the hospice nurse look at it. LPN-B stated she looked at the arm on 5/5/24 (Sunday) morning, it had bruising on it that was not present of 5/4/24. During a phone interview on 5/10/24 at 2:47 p.m., hospice nurse (H)-A stated she examined R1 on 5/4/24 because facility staff were concerned with flaccidness of R1's right arm. I didn't think it was a huge, big deal, maybe she [R1] was more relaxed and she is pretty non-verbal. She looked comfortable. H-A was at the facility 5/5/24 and examined the change with the bruising on the right arm. H-A then notified the hospice doctor who advised the desision to send R1 to the hospital was up to R1's family. H-A stated I think that using the toileting sling that was the only thing that I could come up with that may have caused it [the injury to R1's right arm]. During an interview on 5/9/24 at 1:21 p.m., registered nurse (RN)-A stated R1 did not move her arms or legs independently on a good day. Normally, R1 liked her arms down and bent at the elbow and resting on her abdomen. RN-A explained she worked during the day on 5/5/24. That morning, (NA)-B had her come to R1's room to examine bruising. RN-A stated when she arrived to R1's room, she told NA-B don't touch, don't move [R1]. RN-A assessed R1's bruising and then called family member (FM)-A to come to the facility. H-A who was in the building examined R1 and FM-A requested R1 be sent to the emergency department. R1's progress note on 5/5/24 at 9:14 a.m., identified R1 moaned a lot for unknown reason and had right upper arm anterior (front) and posterior (back) dark purple bruising and pain with movement. At 11:23 a.m., R1 was transferred to the emergency department. At 2:46 p.m., R1 returned from the emergency department. R1's emergency department note on 5/5/24 signed at 1:37 p.m., identified R1 presented to the emergency department due to a change in the patients humeral area with significant increase in pain with movement as well as bruising. Exam consisted of significant bruising on the central aspect of the humeral area and the posterior aspect of the humeral area. Swelling and decreased range of motion noted along with pain when moving extremity away from body. R1's X-ray identified diffuse osteopenia and angulated nondisplaced proximal right humeral fracture with subluxation of the humeral head relative to the glenoid (common fracture often seen in elderly patients with osteoporotic (weak and brittle) bone usually from an outstretched arm). During a phone interview on 5/10/24 at 10:00 a.m., medical doctor (MD)-A stated with R1's condition, any kind of a pressure could cause a fracture. During an interview on 5/10/24 at 11:25 a.m., physical therapist (PT)-A reviewed emergency department notes and stated considering R1 had osteopenia, an upward force like that of using a toileting sling could be related to a dislocation or fracture, especially with R1's frailty. During an interview on 5/9/24 at 10:04 a.m., with administrator and director of nursing (DON), DON explained when R1 first transitioned from the sit-to-stand, the toileting sling was first tried, however that pulled too much on her shoulders, so it was determined R1 should use the full sling, instead. During an interview on 5/10/24 at 12:32 p.m., the administrator stated it was her expectation staff followed the care plan. The facility policy titled assisting with transfers and walks reviewed 3/2022, identified that care plans and caregiver worksheets offer guidance regarding level of assistance required by each resident. Employees will perform all transfers in compliance with these tools.

Based on observation and interview staff failed to ensure a mechanical transfer lift was cleaned after resident use for 1 of 1 resident (R10), observed for infection control practices. Findings Include: R10's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact, dependent on staff for toileting, required substantial/maximal assistance with transfers, personal hygiene, and dressing and used a wheelchair for mobility . R10's care plan dated 2/12/24, indicated when R10 was transferred to use standup lift if left prosthetic was on and use the full body lift, Arjo (mechanical patient transfer device) if prosthetic was off. On 2/12/24 at 7:18 p.m., nursing assistant (NA)-C removed a mechanical lift from R10's room placed the mechanical lift near a wall in the hallway. NA-C then was observed to walk down the hallway and there was no cleaning of the mechanical lift observed. NA-C confirmed he did not disinfect the mechanical lift after use with R10. NA-C further stated R10 was the only resident on the hall that used the lift and that is why he did not disinfect the lift after use with R10. NA-C stated other residents in the facility might use that same mechanical lift on other halls throughout the facility. On 2/14/24 at 7:56 a.m.,observed NA-D remove a mechanical lift from R10's room and placed by the wall in the hallway and no cleaning of the lift was observed. On 2/14/24 at 8:12 a.m., NA-D confirmed the mechanical lift used for R10 was not disinfected prior to removing or once removed from R10's room and had not disinfected the lift prior to use. NA-D stated it was not the facility policy to clean mechanical lifts after each use, unless the resident was in precautions for COVID or another type of transmission based precaution. On 2/1/24 at 10:28 a.m., the director of nursing stated it was the expectation staff were to clean mechanical lifts after each resident use and between uses to prevent the spread of infection. The DON stated other residents in the facility use the same lift R10 used and was expected to be cleaned after resident use. Facility document checklist titled 16 hr. (hour) Nursing Assistant Orientation dated 3/21, indicated: -Disinfecting lifts/vital machines or any other shared equipment with Sani-wipes between residents. The facility Infection Control Program policy dated 3/21, did not address mechanical lift cleaning.

Reviewed- LS-done Based on observation, interview and document review, the facility failed to ensure routine personal hygiene (toenail care) was provided for 1 of 1 resident (R7) reviewed for activities of daily living (ADLs) and who was dependent upon staff for care. Findings include: R7's Diagnosis Listing printed on 2/14/24, included diagnosis of Alzheimer's disease. R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had severe cognitive impairment and was dependent upon staff for personal hygiene. R7's care plan printed on 2/12/24, and otherwise undated, indicated R7 needed help with all ADL's including personal hygiene, and that she liked her nails clipped after bathing. Progress notes regarding bathing provided by the director of nursing (DON) indicated R7's previous baths were on 2/7/24, 1/31/24, 1/24/24 and 1/10/24. During a telephone interview on 2/12/24 at 2:34 p.m., family member (FM)-B stated she saw R7's toenails one time and almost threw up because they were long and thick. FM-B had not told staff about her concerns and did not know if podiatry saw R7. FM-B stated she doubted R7 was aware of the length of her toenails, but wondered if the length of the nails bothered her when she had shoes on. During an observation and interview on 2/13/24 at 8:37 a.m., R7 was seated on the side of her bed. Nursing assistant (NA)-A was getting R7 dressed. During observation of R7's feet, noted toenails to be long on the right foot. The great toenail was long and thick; the nail exceeded the top of the toe by approximately one quarter inch. The third and fourth toenails were long and starting to wrap around the toes. The fifth toenail was long .about one eighth inch past the top of the toe. NA-A stated NA's trimmed resident toenails on their bath day unless the resident was diabetic, then a nurse trimmed nails. NA-A stated R7's bath day was scheduled for the next day, 2/14/24. NA-A did not know why R7's toenails had not been trimmed and stated she did not usually work with R7. During an observation and interview on 2/13/24 at 8:44 a.m., together with registered nurse (RN)-B, looked at R7's toenails on her right foot. RN-B stated the toenails were long and needed to be trimmed. RN-B stated due to the length, it was obvious they not been trimmed for a while. RN-B stated NA's were supposed to trim resident toenails on bath day unless the resident was diabetic. RN-B stated R7 was not diabetic. RN-B stated she would have expected a NA to trim R7's toenails or report the long toenails to a nurse, just like they would report a bruise or skin issue. RN-B stated she would trim R7's toenails. During an interview on 2/13/24 at 10:43 a.m., the director of nursing (DON) was informed of the length of R7's toenails. The DON stated she would expect a NA to trim the toenails if the resident was not diabetic, or tell a nurse if not comfortable trimming them. The DON stated nail care was a regular part of a residents bath day routine. The facility A.M. (morning) Cares policy with revised date of 12/22, indicated on bath day, residents would have nail care. Licensed nurses were to trim nails on diabetic residents. If the toenails were too thick to be trimmed, report to the charge/cart nurse. The cart nurse assigned to the resident would observe that nail care had been provided per resident preference.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R15) reviewed for hospice. Findings include: R15's Face Sheet indicated admitted was 1/3/24, and diagnoses of heart failure and chronic kidney disease. The advanced directives section indicated R15 had a physician order for hospice and was on hospice 12/8/23 while in hospital. R15's admission Minimum Data Set (MDS) dated [DATE], section O, K1 under special treatments and programs, did not include hospice care services . Section J 1400 Prognosis: conditions or chronic diseases that may result in a life expectancy of less than 6 months was left blank (no yes or no answer). During interview on 2/13/24 at 9:19 a.m., registered nurse (RN)-A, also identified as MDS coordinator, indicated R15 was admitted to the facility on hospice. Upon review of admission MDS, RN- A confirmed section 0 was not coded as R15 receiving hospice services. During interview on 2/14/24 at 9:17 a.m., the director of nursing stated the MDS should have been completed accurately and hospice services should have been indicated on the admission MDS.

Based on observation, interview and document review, the facility failed to notify the physician for 1 of 1 resident (R14) reviewed for nutrition when R14 showed a significant weight loss within a six-month period. Findings include: R14's Diagnosis Listing printed on 2/13/24, included diagnosis of congestive heart failure (when the heart doesn't pump blood as well as it should). According to family member (FM)-E, R14 had a stroke in 2017 which affected her right side. R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R14 was cognitively intact, had clear speech, could understand and be understood. R14 could eat independently with set-up help. R14's physician orders dated 2/5/24, indicated a diet of regular, small portions, and daily weight. R14's care plan printed on 2/12/24, and otherwise undated, indicated R14 had the potential to lose more weight and become malnourished; had a low meal intake and did not want nutritional supplements. Had weight changes since recent removal of biliary stone. During record review, the electronic medical record (EMR) indicated R14 sustained a 14.63% weight loss in six months, from 8/24/23, to 2/12/24. R14's weights per EMR: - current - 2/12/24 - 105 pounds - one month ago - 1/15/24 - 110.4 pounds - six months ago - 8/24/23 - 123 pounds - one year ago - 2/17/23 - 117.6 pounds A progress note dated 10/12/23, written by dietician (RD)-C indicated R14 had not experienced any significant weight changes. Meal intake records showed R14 ate 100% at breakfast, 50-75% at dinner and 50% at supper. Nutritional supplements had been offered but refused by R14. R14 had no problems chewing or swallowing regular texture diet with her natural teeth. R14 fed herself. Her MNA (Mini Nutritional Assessment) score was 12 indicating normal nutritional status. A progress note dated 1/4/24, written by RD-C indicated R14 weighed 113 pounds which represented an unplanned, significant weight loss of 6% in the last 30 days. R14 continued to receive a regular, small portion diet. Meal intake records showed a decline in intake since last evaluation on 10/10/23. R14 was eating 50% at breakfast, 25% at dinner and 50-75% at supper. R14 did not want any nutritional supplements so it would be difficult to increase her caloric intake. The dietician placed R14 at risk status and to continue to monitor weight and intake. A progress note dated 1/18/24, written by RD-C indicated R14's weight was 110.4 pounds, representing a 10.2% weight loss in 180 days and 8% in 30 days, both considered unplanned, significant weight losses. Meal intake showed a slight decrease at 25-75% at breakfast, 25-100% at dinner, and 50-100% at supper. R14 was at nutritional risk status due to weight loss and intake. It will be difficult to meet R14's needs due to her food preferences. Her MNA score was 9 indicating risk of malnutrition. Goal is for weight to stabilize and improved oral intake. A progress note dated 2/12/24, written by RD-C indicated R14's weight was now 105 pounds which represented an unplanned significant change weight loss of 9.5% in 90 days and 14.6 % in 180 days. R14 had been hospitalized recently and had a biliary stone in her gall duct removed. Prior to that her intake had declined and she was not eating well. Current intake was 25-75% at breakfast, 25-50% at lunch and 50% at supper. Nutritional supplements had been offered in the past and R14 took them for a short period of time and then wanted them stopped. Dietician note indicated they would try adding pudding to her supper meal and recommended starting a MVI (multivitamin). The note also indicated it was difficult to meet R14's nutritional needs due to her preferences. An internal message had been sent to nursing regarding MVI and to dietary manager to get the pudding started. MNA score was eight, indicating risk of malnutrition. During record review, the following three provider visit notes were reviewed and did not indicate awareness of R14's significant weight loss: --Provider note dated 11/7/23, for nursing home exam and update --Provider note dated 12/5/23, for hospital follow up --Provider note dated 2/7/24, for nursing home exam and update During an interview on 2/14/24 at 9:07 a.m., registered nurse (RN)-B stated she was not aware of R14's significant weight loss. RN-B looked in the EMR and noticed an internal message from the dietician about R14, dated 2/12/24, which indicated dietary would be adding pudding to meals and recommended starting a multivitamin due to R14's weight loss. RN-B stated when staff, usually a nursing assistant (NA), entered a residents weight in the EMR, a pop-up box with a yellow caution symbol would appear if the resident gained or lost a certain amount of weight. When this occurred, the NA would notify the cart nurse (nurse assigned to a medication cart). RN-B stated the cart nurse would notify the charge nurse, who would notify the provider. RN-B looked in the EMR and was not able to identify a provider had been notified of R14's weight loss. RN-B stated when a provider made rounds to see residents, he/she were given residents weights, but didn't know if R14's weight loss had been pointed out to the provider. RN-B stated she would fax the provider regarding the weight loss and ask if there were any new orders. During an interview on 2/14/24 at 9:34 a.m., the director of nursing (DON) stated she had not been aware of R14's weight loss, and stated she thought R14 had gained weight. The DON read the dieticians note in the EMR dated 2/12/24, which indicated significant weight loss. The DON could not determine by reading notes in the EMR if a provider had been informed. The DON stated when a provider made rounds, he/she were given resident weights for review. The DON stated typically the charge nurse would inform a provider of a residents weight loss and did not know why that had not occurred for R14. The DON stated residents with weight loss were discussed at IDT (interdisciplinary team) meetings, but could not recall if R14 had been discussed. The DON acknowledged a provider should be informed when a resident experienced a significant weight loss. During an interview on 2/14/24 at 9:45 a.m., NA-B stated when a NA entered a residents weight in the EMR, if they got a pop-up indicating weight loss or weight gain, they were to communicate that to the cart nurse or the charge nurse. NA-B was not aware of R14's weight loss as she does not always weigh her -- depended on her assignment. During a telephone interview on 2/14/24 at 10:48 a.m., RD-C stated each week she was at the facility, she communicated resident weight loss via the message board in ECS - internal communication via the facility EMR. RD-C stated messages were sent to all nurses and the DON, and staff were responsible to read it. In addition, RD-C stated she also sent weight loss reports (titled Consultant Dietician Report) to the DON, food service director and administrator. RD-C stated she did not typically notify a provider of weight loss unless there was concern for protein calorie malnutrition. RD-C stated she had not done that for R14 since R14 had recently been in and out of the hospital and her weight variations were likely a result of that, such as a weight increase due to receiving intravenous fluids while in the hospital. RD-C acknowledged R14's weights had been trending down over the past months prior to being hospitalized . R14 had been hospitalized from 1/29/24 to 2/5/24, for removal of biliary stone via ERCP (a procedure to look at biliary ductal system). Documents titled Consultant Dietician Report, hand-written by RD-C, were provided by the food service director (FSD)-D and indicated the following regarding R14's weight: 1/4/24 - R14 placed at risk status due to unplanned significant weight loss in 30 days 1/18/24 - R14 at nutrition risk status due to weight 1/25/24 - review of weights for significant change: R14 down 10.6% in 180 days 2/1/24 - R14 was not included on the report The facility Significant Weight Loss policy dated 2013, indicated appropriate members of the IDT would identify individuals with significant/severe weight losses. Significant weight loss was defined as 5% weight loss in one month, 7.5% weight loss in three months, and 10% weight loss in six months. The policy outlined measures to take for weight loss and continued weight loss, but it did not include notification of a provider at any point. During an interview on 2/14/24 at 12:40 p.m., the DON stated the facility did not have a policy regarding significant change.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R1) reviewed who was at risk for pressure ulcer development. The facility's failure resulted in R1 sustaining harm when the resident developed a Stage IV (extend into the muscle, tendon, ligament, cartilage or even bone) pressure ulcer to the sacral/coccyx (triangular bone found between end of lumbar 5 of the spine and coccyx (end of spine area) area. Findings include: R1's face sheet printed 11/7/22, included diagnoses of chronic obstructive pulmonary disease (airflow limitations), anxiety disorder, heart failure, peripheral vascular disease (narrowing, blockage or spasm in any vessels outside of the heart), and personal history of COVID-19. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 as having intact cognition, understands and is understood and moderate hearing loss. The MDS further indicated R1 had no rejection of cares, required no staff assistance with mobility needs and used a walker and wheelchair. The MDS included R1 was at risk for pressure ulcers, currently had no skin issues and had a pressure reducing device for bed and chair. R1's discharge MDS assessment dated [DATE], identified R1 as requiring limited assist with transfers, was independent with bed mobility and required extensive assistance with dressing, personal hygiene and toileting. R1's Care Area Assessment (CAA) dated 5/30/22, indicated R1 had no pressure ulcers but had a history of healed pressure ulcers and the head of the bed is elevated all or most of the time. The CAA further stated R1's skin in good condition but remains at risk due to frail and fragile condition, weight declining but able to continue with activities of daily living and walking. R1 rests most of the time in bed, doesn't change position in bed and just keeps the same position on the right edge of bed so she can get up to the bathroom as she desires and chooses. R1's Braden Scale (the gold standard used to identify risk of developing a pressure injury) dated 5/23/22, indicated a score of 19/23 (indicating no risk). However, added text indicated R1 was at risk due to age, due to always laying on the same area on back and side and never alternated her position in bed, weight is low and bony prominence's at risk. R1's care plan dated 3/21/22, for skin care indicated nursing assistants (NA) was to use pressure redistribution devices on the bed, pillows to reduce pressure and friction between R1 and the bed or chair with cushion in wheelchair when used. Keep R1 clean and dry by providing pericare when needed and noting when incontinence pad needs changing. Report redness, check skin folds, keep dry, and treat as ordered. The goal was to keep skin healthy and intact and avoid injury. Record review revealed the following weekly skin assessments: 9/9/22: no open areas on skin. 9/16/22: bruise present on right knee and top of head which is resolving. 9/23/22: no open areas. 9/30/22: no open areas 10/7/22: red area under chin. 10/21/22: no new skin issues 10/13/22: no current skin lesion or problems. Skin is within normal limits A progress note dated 10/17/22, at 7:41 a.m., indicated R1 tested positive for COVID-19. A progress note on 10/17/22, at 12:08 p.m., indicated R1 refused meal and acetaminophen. Oxygen saturation was 90% on 1 liter of oxygen. A progress note on 10/17/22, at 2:25 p.m. indicated R1 had been unresponsive a couple times during shift, refused meds and meal but refused to go to the hospital. A progress note dated 10/18/22, at 4:34 a.m., included R1 continued to refuse to be treated at the hospital and required assistance to the bathroom. A progress note dated 10/22/22, at 10:34 p.m. indicated R1 was feeling tired with very little energy and slept for most of the shift. A progress note dated 10/24/22, at 1:47 a.m. indicated acetaminophen 325 mg tablet was given for pain on R1's bottom and rated the pain at a 6. At 7:54 a.m., R1 was transferred to acute care hospital by ambulance for evaluation of breathing pattern that is fast, breath sounds abnormal, crackles heard, diminished. Cough was congested. Temperature was 99.6 degrees Fahrenheit. A History and Physical dated 10/24/22, from hospital admission indicated a 3 centimeter (cm) sacral ulcer was present with surrounding erythema (superficial reddening of the skin, as a result of injury or irritation) present. Wound not deep enough to see the bone but extends through the subcutaneous fat. Inside the wound, the tissue is gray and black and foul smelling. Assessment and plan included sacral decubitus ulcer (pressure ulcer), stage IV. The nursing home reported they were unaware of this. Will clean the wound with microsyne wound spray (safe hypochlorous acid based antimicrobial treatment for the cleansing, irrigation and moistening of wounds) and bandage as appropriate. Nurses will frequently reposition. A hospital discharge summary dated 10/28/22, included sacral decubitus ulcer (pressure ulcer) stage 4: R1 was found to have a large sacral ulcer with surrounding erythema and severe tenderness. Area is very painful. PU has a small opening on the surface but is quite deep. There is a large amount of necrotic (death of cells) tissue within the wound. R1 is not a candidate for surgical debridement. Cleaning of the wound is done daily with microsyne wound spray and covering with Mepilex border dressing (absorbent, dressing that acts as a barrier to liquid and microorganisms). R1 will need ongoing wound care after discharge. It is extremely important to have an appropriate mattress and assist her to off load the sacral area. Physician orders dated 10/28/22, included: Cleanse wound on sacrum/coccyx with microsyne and change Mepilex on sacrum/coccyx daily until healed. Measure PU, explain condition, treatment, stage 4 on sacrum/coccyx 1 time per week starting Friday until healed. During observation and interview on 11/6/22, at 12:58 p.m., nursing assistant (NA)-D assisted R1 to the bathroom. R1 had Mepilex on sacrum/coccyx. NA-D indicated R1 was in the hospital and returned with a pressure ulcer. R1 refused to be interviewed. During observation on 11/6/22, 5:55 p.m. R1 was brought to the dining room in her wheelchair. R1's bottom was in the center of the chair and R1 was leaning back casing her to appear slouched in the wheelchair with pressure on sacral/coccyx area. R1 was able to sit up to eat and then would lean back again. R1 took her medications, ate 1/2 of her chicken noodle soup and requested to go back to her room. R1 was assisted back to her room, toileted with Mepilex still in place and settled into bed on her back with head of the bed observed to be at 30 degrees. During observation on 11/7/22, at 12:41 p.m., R1 was laying in bed on her back with head of the bed at 30 degrees. Air mattress was present on bed. During observation and interview on 11/7/22, at 1:32 p.m., registered nurse (RN)-B entered R1's room to complete a dressing change. RN-B indicated R1 returned from the hospital with wound at the end of October when she had COVID-19. RN-B indicated R1 had no redness or signs of a pressure ulcer prior to her transfer to the hospital. Trained medication assistant (TMA)-B rolled R1 onto her left side. RN-B removed Mepilex covering wound and per RN-B a moderate amount of serosanguinous drainage was present with a yellow-greenish tint. RN-B indicated the wound had increased redness around the edges and inside the wound, bone was visible with exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation) present. RN-B cleansed wound with microsyne and gauze. RN-B measured tunneling of the wound which was 6.5 centimeters (cm). Wound length was 5 cm and 4 cm wide. Depth of wound was 1 cm. RN-B indicated the wound was larger, had more drainage and redness than previous on 11/4/22. A new Mepilex was placed on the wound. RN-B indicated the air mattress was placed on R1's bed when she returned from the hospital. RN-B said they have educated R1 about getting off her back and bottom but R1 refuses and prefers to lay on her back. A progress note on 10/28/22, at 11:49 a.m. indicated R1 was readmitted to the facility at 11:40 a.m. via ambulance from the acute care hospital. Hospital orders included wound care for stage 4 ulcer/coccyx and to cleanse wound with microsyne and cover with Mepilex daily and as needed. A transfer assessment completed on 10/28/22, at 1:05 p.m. indicated R1 could assist with standing, bear full weight for a least 4 seconds and follows directions. Transfer instructions included standing pivot with assist of 1 and gait belt. Stand in front of resident, pull resident to feet with both hands and gait belt and feet in a staggered stance. Pain present on buttocks. R1 is usually understood by others and usually understands others, but misses some part or intent of message but comprehends most conversation. A progress note dated 10/29/22, at 10:21 a.m. indicated PU stage 4, full thickness of skin and subcutaneous tissue loss, exposing muscle and or bone. Tissue type is slough (dead skin tissue yellow or white in appearance) with wound tissue white. Light drainage, yellow in color noted on Mepilex when removed. Surrounding tissue is cyanotic (bluish discoloration of the skin resulting from poor circulation). Wound length was 4 cm, width, 3 cm and depth 2 cm. A Braden Scale completed on 10/31/22, indicated score of 17/23, meaning no risk. No mention of current pressure ulcer present. A progress note dated 11/4/22, indicated PU stage 4 with wound tissue yellow, surrounding tissue reddened, and no change with healing progress. Length of wound is 4 cm, width is 6 cm and depth 0.3 cm. A progress note dated 11/5/22, indicated PU stage 4, area was painful with dressing change and cleansing of the area. Brown drainage on changed Mepilex and has a foul odor. R1's care plan revised 11/7/22, indicated R1 had the potential for skin injury, bruise easily and developed a pressure ulcer due to poor tissue perfusion, saggy skin and wanting to lay in the position R1 chooses not be moved or have things in bed unless R1 requests it. In the past R1 had a history of open areas, bruises, moist skin folds and had lost so much weight that bony prominence's was at a great risk, also risk of slow healing because of minimal intake. R1 needs extra protection to prevent skin injury. R1 has a pressure reducing mattress to prevent and reduce risk of skin breakdown. R1 needs PU care and to stay off area, but doesn't like others to position her, as always R1 doesn't want anything changed in her cares. Keep good padding around bony areas as needed, report redness, check skin folds, keep dry and treat as ordered. Keep wrinkles out of sheets as best as possible. Nurses need to reduce pressure and friction between R1 and the bed or chair, monitor nutrition, check skin weekly, monitor pressure areas especially the left hip due to always lying the same way in bed. During interview on 11/8/22, at 9:25 a.m. the director of nursing (DON) indicated R1 did not have a pressure ulcer when she was transferred to the hospital. The DON indicated she returned with a stage IV sacral ulcer. The DON indicated R1's last skin assessment at facility was normal prior to R1 discharging to the hospital and R1 is very independent and does her own thing. During interview on 11/8/22, at 9:40 a.m. RN-C indicated R1 had a history of PU but on her right hip. RN-C indicated she completes the quarterly assessments and always puts R1 as high risk even though her Braden Scale doesn't show she is high risk. RN-C indicated R1 always lays on her back, and has a history of PU on her right hip over 5 years ago, which is not the same area as this PU. RN-C indicated R1 has always wanted to maintain her independent and wants to be left alone. R1 had toileted, transferred and got around the facility by herself. RN-C added since R1 got COVID-19 in October, she now requires assistance for all her activities of daily living including transfers and toileting. During interview on 11/8/22, at 11:10 a.m. the DON indicated R1 had been at the facility a long time and had been independent with bed mobility, transfers and ambulation until she got COVID-19. The DON indicated there would not be any documentation about her refusing assistance with turning or education on risks and benefits of refusing to stay off her bottom due to her length of stay at the facility. During interview on 11/08/22, at 11:13 a.m., RN-B indicated prior to, and after R1's hospitalization she had educated R1 about not laying on her bottom, but R1 refuses the use of pillows for positioning, or assistance with position changes, which is probably how she got the PU to begin with. RN-B indicated R1 was independent with all her activities of daily living, but when she got COVID-19 in October, she needed assistance with transfers, bed mobility and toileting. RN-B did not think any barrier cream was used on R1 and indicated the air mattress was new when she returned following hospitalization . During interview on 11/8/22, at 11:29 a.m., nursing assistant (NA)-J indicated she cared for R1 throughout her isolation period for COVID-19. NA-J indicated R1 was very weak and required assistance with transfers and toileting. NA-J indicated she laid on her back in bed throughout her isolation until she went to the hospital. NA-J indicated she did notice redness on her sacral/coccyx area when assisting her with toileting but doesn't remember if she notified anyone about the redness. During interview on 11/8/22, at 12:25 p.m. RN-C indicated when R1 returned from hospitalization , she went into observe wound care and noted very saggy skin which required pulling up of the skin to visualize the wound. RN-C indicated obviously we missed this. During interview on 11/8/22, at 12:36 p.m., NA-G indicated she cared for R1 while in isolation for COVID-19 while still at the facility. NA-G indicated R1 had loose stools, was weak requiring assistance and wasn't eating. NA-G included R1 was normally independent but with COVID-19 required assistance to the bathroom and with all her cares, including eating, but refused to let us help her with eating. R1 wasn ' t patient with staff and would start to stand up before staff was ready for her to do so, therefor, NA-G didn't get a good look at R1's bottom. NA-G added she had never been aware of a repositioning program for R1. During observation and interview on 11/8/22, at 12:35 p.m., R1 returned to her room and with staff assistance laid down in her bed with head of bed at 30 degrees, oxygen on at 2 liters per nasal cannula. R1 indicated she just does not feel good and is so tired. R1 was asked if she would lay on her side and R1 stated No. R1 was asked if staff ask her to lay on her side and R1 responded I'm not going to. Continuous observation on 11/8/22 included: 12:35 p.m., laid down in bed on her back with head of the bed at 30 degrees. 12:54 p.m., no change in position. Room was dark and R1 is resting. 1:20 p.m., no change in position. 1:36 p.m., no change in position, no staff have checked on R1. 1:48 p.m., no change in position, room remains dark and R1 appears to be sleeping. 2:02 p.m., no change in position. 2:14 p.m., no change in position. 2:26 p.m., no change in position and no staff into room. 2:43 p.m. - no change in position. 2:56 p.m. - no change in position and no staff into room. R1 continued to rest in bed. During interview on 11/8/22, at 3:06 p.m., the DON indicated when R1 had COVID-19 she was weak, always laying on the left side of the bed. The DON confirmed R1 had a change in condition when she had COVID-19 and does not believe she was reassessed during that time. The DON indicated a discussion was held on placing an air mattress on her bed but was worried as people have rolled off of them so choose not to implement prior to R1's hospitalization . The DON added that R1 will not turn and reposition even a slight tilt. Throughout the past the facility has tried protein supplements, including Magic Cup, Great Shakes and concentrated protein drinks but R1 refuses them. The DON confirmed the stage IV pressure ulcer was discovered on admission to the hospital per documentation and likely was present while she was at the facility but was not discovered. During interview on 11/8/22, at 12:47 p.m., the certified dietary manager (CDM) indicated R1 is on the registered dietician's risk list and being seen monthly. The CDM indicated monitoring R1's intake which varies from 0% to 100% of her meals. CDM indicated having tried Resources, Magic Cup and Arginade (supplements to support the unique nutritional needs of wound care) but she refuses to drink them. CDM did indicate R1 will eat ice cream with each of her meals but have not tried shakes with supplements because R1 likes things her way and likely will not drink those. Facility policy and procedure for prevention of pressure ulcers was requested and none was received. Facility policy and procedure titled Wound Care, Dressing Guidelines, last revised 12/2017 included care for skin tears, minor cuts or abrasions, surgical wounds, but did not include pressure ulcer wound care. A policy and procedure on Wound assessment dated ,d+[DATE] (Copyright: NPUAP) - Pressure ulcer definition as a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated pressure ulcers. -Stage I: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tone. May indicate at risk person. - Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling of the wound. Stage IV: Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling. The depth of stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Based on observation, interview and document review, the facility failed to ensure use of personal protective equipment (PPE) was implemented to prevent the spread of Covid-19 per guidance by the Centers for Disease Control (CDC) when during a Covid-19 outbreak, residents and visitors were observed not wearing masks, and staff not wearing masks correctly. Further, the facility failed to ensure PPE and transmission based precautions (TPB) were used in accordance with the CDC guidance for Covid-19 for 1 of 1 resident (R20) reviewed for transmission-based precautions (TBP). Findings include: A sign was observed on 11/9/22, at approximately 12 noon, at the entrance to the facility, taped to the Covid-19 check-in station that indicated the facility was in Covid-19 outbreak status. R20's diagnosis listing printed on 11/7/22, indicated a diagnoses of personal history of Covid-19, dated 11/7/22. According to an interview with the director of nursing (DON) on 11/8/22, at 9:30 a.m., R20 tested positive for Covid-19 on 10/28/22. R20's annual Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment. R20 had adequate hearing, had visual impairment, clear speech, usually was understood and usually could understand. R20 required extensive assistance of one staff for most all activities of daily living (ADLs). R20's care plan dated 6/13/22, indicated R20 would be protected from exposure to Covid-19 and would need staff to follow all policies and procedures set forth by the facility and governing agencies to prevent exposure to Covid-19. The care plan did not indicate measures such as PPE and TBP's for R20's diagnosis of Covid-19 During an observation on 11/06/22, at 12:43 p.m., observed signage on the outside of the door to R20's room indicating he was in enhanced precautions. The sign instructed to keep the door closed if able, to wear a gown, N95 or higher level respirator, eye protection (goggles or face shield) and gloves when entering the room. R20's door was wide open. In addition, there were signs on the door outlining steps for donning and doffing PPE. A three-drawer plastic isolation cart was outside the room. During an observation and interview on 11/06/22, at 12:45 p.m., observed nursing assistant (NA)-K prepared to enter R20's room to bring in his lunch. NA-K stated the facility had an outbreak of Covid-19 a few weeks ago and R20 had been in precautions because he had tested positive for Covid-19. Observed NA-K don gown, gloves and face shield before entering R20's room, but not a N95 mask. N95 masks were observed in ample supply in the isolation cart outside R20's room. Upon exiting the room, NA-K stated she did not need to wear a N95 mask if she wore a face shield over her surgical mask. Together looked at the enhanced precaution sign on the door which indicated staff should wear an N95 mask and eye protection (goggles or face shield). NA-K acknowledged the sign and stated she had not been wearing a N95 mask when entering R20's room. In addition, NA-K did not change her surgical mask upon exiting R20's room. During an observation on 11/06/2, at 2:40 p.m., observed and followed four family members (FM)-E enter the facility though the employee entrance in the back of the facility. They did not have masks on. They walked through the entire facility to the front entrance, past staff and residents in the hallways. No staff stopped them to ask them to put on masks or to question where they were going. Once they reached the main entrance, which was a significant distance from resident rooms/nurses station, and therefore no staff close by, they were informed by the surveyor they would need to put masks on. The Covid-19 check-in station with masks at the facility entrance was pointed out to them. FM-E stated they came in the back door, they were from a neighboring state and did not know they needed to wear masks. Following this encounter, (NA)-D was informed of the observation and interaction. NA-D stated she did not see FM-E enter the facility and confirmed they needed to wear masks. During an observation on 11/06/22, at 4:00 p.m., multiple residents were in the dining room playing bingo. Ten residents did not have masks on. Residents were sitting two or three to a table with other residents and visitors. During an observation on 11/06/22, at 4:01 p.m. in the common area between resident hallways and by the nurses station, observed unmasked (FM)-F talking to an unidentified NA. During the same observation, new admission from 11/2/22 -- R140, did not have a mask on, nor did R7. All were sitting either in side chairs or wheelchair in less than six feet from each other. (NA)-E was wearing mask below the nose. Did not observe staff remind or encourage residents to wear masks, despite some residents having masks hanging from the handles on the back of their wheelchairs. During an observation on 11/06/22, at 4:04 p.m., unmasked R2 and R9, returned from bingo, self-propelling in wheelchairs. Observations of the main entrance visitor Covid-19 check-in point and mask availability: 11/06/22, at 5:44 p.m. -- box of masks was empty. 11/07/22, at 9:04 a.m. -- masks replenished. 11/07/22, at 3:17 p.m. -- no masks. 11/08/22, at 6:50 a.m. -- no masks. During an observation on 11/06/22, at 6:39 p.m., unmasked R7, R2, R9, and R26 was observed returning to their rooms from supper via wheelchairs through resident hallways. Did not observe staff remind or encourage residents to put on masks. Care plans did not indicate the resident refused or was not able to tolerate a mask. During an interview on 11/07/22, at 1:37 p.m., when asked if residents were supposed to wear masks since the facility was in outbreak status, (NA)-A stated she didn't know for sure, she would need to ask someone. During an observation 11/07/22, 4:08 p.m., maintenance (M)-A, housekeeping (H)-A, (NA)-L, (NA)-I, all had masks below nose. During an observation on 11/07/22, at 6:13 p.m., (NA)-I did not don PPE to deliver the evening meal to R20 who was in isolation for Covid-19. NA-I stated he did not don PPE if just delivering a meal to residents in isolation. NA-I stated he was aware of the PPE requirements posted on R20's door. During an observation and interview on 11/08/22, at 7:00 a.m., the following residents were observed sitting in the common area by the nurses station in wheelchairs or side chairs, closely together (less than three or four feet) without masks: R34, R140, R7, R28, R4, R33 and R9. During an interview, (NA)-G, stated she didn't know why residents were not wearing masks, adding maybe they didn't want to. Did not observe staff remind or encourage residents to put on masks despite some residents having masks hanging from handles on the back of their wheelchairs. During an interview on 11/8/22, at 7:41 a.m., licensed practical nurse (LPN)-C stated she thought residents were supposed to be wearing masks since R20 was still in precautions for Covid-19, but did not know why they were not, adding that guess it hasn't been enforced. During an interview on 11/8/22, at 9:30 a.m., the DON was informed that while facility was in outbreak status, only a few residents were observed wearing masks at various times. Also informed new admissions R140 and R191, who according to CDC guidance should be masked for 10 days following admission were not masked. The DON stated staff encouraged residents to wear masks and that most residents wore masks. The DON was informed the majority of residents observed had not been wearing masks, and care plans did not identify if a resident was unable to wear them. The DON stated she had not noticed residents had not been wearing masks. The DON stated she was aware some visitors and family members always had to be instructed to wear masks. The DON was also informed of observations of staff entering R20's room without a N95 mask, without gown, gloves and eye protection, and exiting and re-entering the room without removing gown. The DON stated she was not aware of this and stated no auditing of staff to ensure compliance with appropriate use of PPE had been done recently. The DON stated she was aware of the CDC guidance related to Covid-19, including masking and proper use of PPE, and as infection preventionist acknowledged it was her responsibility to ensure regulations were adhered to in order to prevent further spread of Covid-19. During an interview on 11/09/22, at 10:25 a.m., the DON stated when community transmission level was high, per regulation, facility had required visitors to wear masks except when in a residents room or if in a designated location. Further, the DON stated new admissions were not required to wear masks outside of their room for 10 days following admission .adding they had not been requiring it and had no policy on that. During an observation on 11/09/22, at 11:05 a.m., many residents in the TV area were being led in singing by activities staff. Nine residents were unmasked and three had masks under chin or nose. New admission from 11/3/22, ---R191, had mask below chin. All were sitting closer than six feet apart. During an observation on 11/09/22, at 1:09 p.m., RN-D was observed showing a new agency staff around the building, walking through resident hallways. The agency staff was unmasked. The DON was informed at 1:14 p.m. During an interview 11/09/22, at 2:23 p.m., RN-D was was asked for documentation NA-I had training on donning and doffing PPE. RN-D stated staff completed online learning modules for infection control upon hire and annually. The content of this training titled Infection Control and Prevention was provided and dated 2016, and included two short paragraphs on TBP, along with definitions of three types of TBP. It did not include specifics on donning and doffing for TBP. Documentation was provided by RN-D indicating NA-I completed this one-hour learning module on 11/5/22. The content of those modules were not provided. Evidence of training to ensure NA-I had received training on proper donning and doffing of PPE was requested, but not received. During an interview on 11/09/22, at 2:45 p.m., the administrator was informed of infection control observations related to lack of resident masking during the Covid-19 outbreak, lack of residents masking who were new admissions, staff wearing masks inappropriately, and staff not following donning and doffing requirements when entering and exiting a Covid-19 positive resident room. The administrator was not aware of these findings and stated she thought they had been following the recommended regulatory guidance. The administrator acknowledged the importance of following the guidelines to prevent further Covid-19 outbreaks, and stated the findings would be addressed. Facility policy titled Indoor Visitation During Covid-19 Pandemic, with two revision dates of 3/10/22 and 4/22, indicated visitors would adhere to infection prevention and control safety practices in order to enter the setting for indoor visitation. Visitors that chose not to follow the practices may be asked not to visit. Visitors would be screened at the front entrance. Visitors must wear a well-fitting mask. Visitation would take place in designated areas such as resident room, snack shop, or outdoor courtyard. All visitors must maintain 6 feet social distancing. If the county Covid-19 community level of transmission was high, all residents and visitors, regardless of vaccination status would wear face masks and physically distance at all times. Facility policy titled Infection Control Program, with revision date of 3/22, indicated before any employee was asked to perform a new task, and before being assigned to care for a resident under isolation precautions, the employee would be trained in how to perform the assigned task safely. The DON, or designee, was assigned responsibility as the infection control coordinator. All employees would be trained in infection control practices. Department managers were responsible for monitoring infection control compliance in their departments. All employees were expected to be familiar with policies and procedures, as well as standard practices and best practices for their particular positions. Failure to comply would be addressed by immediate supervisor and employees may be required to undergo retraining. Facility policy Interim Policy: A Response to Covid-19, with revised date of 6/22, had a section titled new admissions, however it did not include information on masking for 10 days following admission, as recommended by the CDC. Facility policy titled Isolation Procedures, with revised dated of 6/21, indicated nursing would be adequately instructed and trained in caring for residents in isolation areas. The policy described steps for donning and doffing PPE, but was not specific for Covid 19; N95 masks were not mentioned. In the event of epidemic or pandemic, guidance from the Minnesota Department of Health and/or CDC would over-ride the policy.

Based on observation, interview, and document review, the facility failed to date opened containers of food stored and failed to ensure expired food were identified and removed in one of three standup kitchen refrigerators, two of two walk-in coolers, and one of two walk-in freezers. This had the potential to affect all 39 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on [DATE] at 12:59 p.m., with dietary aide (DA)-A, observed food items in the standup refrigerators, walk-in coolers, walk-in freezer, and dry goods room that were not dated or marked and/or were expired. DA-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators, freezers, dry good room should be gone through daily to check for expired or damaged food. DA-A indicated if any food or drink was not dated when opened, it should be removed immediately. DA-A indicated all left-over prepared food and beverages when marked were good for 3 days from date opened per facility policy. The following items were observed during tour: Stand-up refrigerator: 1. Glenview Farms sour cream; 5lb container; ,d+[DATE] full, unmarked/undated; expiration date [DATE] 2. Glenview Farms liquid whole eggs with citric acid; 2lb container; ,d+[DATE] full; unmarked/undated; expiration date [DATE] 3. Apricot halves; covered in facility plastic bowl, ,d+[DATE] full, dated [DATE]; appeared dry and shriveling in center 4. Applesauce; covered in facility container; 2L full; dated [DATE] 5. Diced pears; covered in facility container; 1.5L full; dated [DATE]; diced pears appeared dry 6. Diced pears; covered in facility container; 2.5L full; dated [DATE]; diced pears appeared dry, had root formation, had foul odor Stand-up refrigerator: 1. pickles; approximately ,d+[DATE] full; placed in facility plastic container, dated [DATE]; no expiration date 2. sauerkraut; approximately ,d+[DATE] full; placed in facility plastic container, dated [DATE]; no expiration date 3. sour cream; 4 oz. placed in facility plastic container; dated [DATE]; no expiration date Walk-in cooler: 1. Kozyshack Smart gels fruit cup- single serve (13); unopened; expiration date [DATE] 2. Shredded cheese in plastic bag; ,d+[DATE] full; not unmarked/undated; no expiration date; appeared clumped together, dried out in some areas Walk-in cooler: 1. 10 oz wholesale produce grape tomatoes; in original plastic container- unopened; no expiration date; skin of tomatoes appeared shriveled with small areas of dark discoloration 2. Head of lettuce (5); in original plastic wrapping; unmarked/undated; no expiration date; appeared to have increased moisture, leaves turning brown 4. Baby carrots in original small plastic bag; unopened; expiration date [DATE] appeared; to have increased moisture 9. Cross Valley Farms fresh tomatoes (17); appeared soft, mushy, shriveled, dark discoloration in areas Walk-in freezer: 1.Country fried chicken breasts in zip lock bag- (6); opened [DATE]; no expiration date; appeared freezer burned When interviewed, on [DATE] at 1:23 p.m., DA-A indicated when food and beverage items were delivered to facility, staff would rotate food items, placed older food items towards the front, newer food items towards the back, older food items to be used up first. DA-A stated when food items were opened, staff were to mark date when opened so staff could be aware of when to discard items if beyond facility policy expiration date. DA-A indicated staff should be checking fresh produce daily, if food appeared dry, discolored, had increased moisture, or was foul smelling, food should be discarded immediately. DA-A stated when food items opened, typically had 7 days to use then needed to discard. During an interview, on [DATE] at 11:20 a.m., certified dietary manager (CDM)-A indicated had worked at facility for [AGE] years, was unaware of any unmarked/undated or expired food/beverage found during kitchen tour, would expect all food/beverage items to be labeled/dated when opened, discarded within 7 days after opening or per expiration date if sooner per facility policy. Facility policy titled, Storage of Perishable Food Items, revised date ,d+[DATE], included leftover foods are put in the refrigerator in a shallow pan (,d+[DATE] deep) so food may chill quickly to less than 40 degrees F; covered, dated, labeled, not mixed with fresh or raw foods; fruits and vegetable resorted regularly, and damaged or spoiled pieces are discarded; all food items in refrigerator are to be properly dated, labeled, and placed in containers with lids, or are loosely wrapped; all frozen foods dated, labeled, and wrapped in moisture-proof materials to prevent freezer burn. Facility policy titled, Food Storage Areas, revised date ,d+[DATE]; indicated stock is rotated- first in, first out; items are dated and marked when not sealed in original containers.

Based on observation, interview, and document review, the facility failed to ensure staff were educated and following fall risk intervention implemented for 1 of 3 (R34) residents identified at risk for falls to prevent further falls. Findings include: R34's facility Diagnosis Listing, printed 11/7/22, indicated R34 had diagnosis of dementia with behavioral disturbance (brain dysfunction causing abnormal behaviors, memory loss, impaired judgement), overactive bladder, macular degeneration (condition causing vision loss), and osteoporosis (condition causing weak and brittle bones). R34's admission Minimum Data Set (MDS) assessment dated [DATE], identified R34 had severely impaired cognition, had behaviors and would occasionally be physical towards others, occasionally rejected cares, occasionally wandered, needed 1 staff member to assist with transfers, toileting, and personal hygiene, needed 2 staff members to assist with walking in room or hallways, and was incontinent of bowel and bladder. , R34's admission fall risk assessment, dated 9/12/22, indicated R34 was at high risk for falls due to impaired cognition, was ambulatory with assistive devices, required staff assistance for elimination needs, had medical conditions, and took medications which may attribute to falling. Facility incident and fall investigation report, dated 11/4/22, indicated R34 had an unwitnessed fall on 11/3/22 at 4:35 p.m. Report indicated R34 was found on floor in living room area, was lying on stomach, had bleeding from left side of head, was alert, would not respond to questions asked by staff. Report further indicated R34 was sent to emergency room (ER) for further evaluation of injury sustained from fall. ER report from 11/3/22 fall indicated R34 sustained a hematoma (pooling of blood) to left side of head. Facility incident and fall investigation report, dated 9/25/22, indicated R34 had an unwitnessed fall on 9/25/22 at 8:06 p.m. Report indicated R34 was found without injury on floor in living room area, legs stretched a foot away from wheelchair. IDT meeting notes indicated, fall prevention interventions consisted of settling R34 into bed after supper due to increased agitation after supper and attempting to self-transfer, if unable to put to bed, staff to place R34 in recliner in living room. R34's baseline care plan, printed on 11/7/22, indicated R34 required staff assistance with activities of daily living (ADL), including personal hygiene, dressing, bathing, and toileting; needed staff assistance with transfers and ambulation. R34's baseline care plan further indicated R34 was unaware of safety risks, would sometimes transfer self without help, required frequent checks for safety, needed staff assistance to guide R34 to room, recliner in room, or bathroom, required staff to anticipate needs and assess for unmet needs including behaviors of agitation, anxiety, aggression, delusions, hallucinations, and/or decreased inhibitions. R34's updated care plan, dated 11/7/22, included fall prevention measures of keeping an eye on behaviors, reporting any behaviors that might cause harm, frequent checks, take for walks, report signs of pain to nurse, explaining needs to others, discuss safety at IDT PRN (as needed). During an observation, on 11/06/22 at 2:14 p.m., R34 was observed in recliner chair in room, semi-reclined position, eyes closed, resting comfortably. R34 had call-light within reach, room appeared free of clutter, had fall mat next to bedside, bed in low position. While interviewed on 11/07/22 at 2:10 p.m., nursing assistant (NA)-I indicated awareness of R34's care needs, and indicated could find information for care needs on R34's care plan, also on NA assignment sheet. NA-I stated R34 was known to be impulsive and self-transferred. NA-I indicated R34's fall prevention measures included having a fall mat next to bedside and bed in lowest position. NA-I stated awareness of falls at facility, believed R34 had 1-2 falls, unsure if anything was updated in care plan since falls. NA-I indicated R34 was on a walking program at one time, but R34 often refused to walk. NA assignment sheet reviewed, NA-I indicated cares listed for R34 included if walking, stand-by to 1 staff assist with use of 4-wheeled walker and wheelchair to follow behind, always know where R34 was at due to wandering and gets up on own. During an observation on 11/07/22 at 2:15 p.m., R34 was observed sitting in wheelchair, rocking back and forth calmly, by nurse's station. R34's left eye was noted to be slightly swollen, had reddish-purple discoloration surrounding entire left eye, had yellow discoloration over left cheekbone, and a hematoma approximately 2.5cm in diameter to left temporal region. While interviewed on 11/07/22 at 2:22 p.m., trained medical assistant (TMA)-B indicated R34 was at high risk for falls, would occasionally self-transfer, could be resistive with cares provided by staff. TMA-B stated awareness of R34's care needs, could be found in the care plan located in the electronic medical record (EMR) system. TMA-B indicated R34's fall prevention measures prior to her falls included toileting schedule every 2 hours, bed in lowest position. TMA-B stated unawareness of fall prevention measures put in place following 9/25/22 fall, thought a fall mat next to bedside was implemented following 11/3/22 fall. During an interview on 11/07/22 at 2:29 p.m., NA-B indicated awareness of R34's care needs; could find care information in R34's care plan, NA daily assignment sheet, and shift report. NA-B stated R34 was at risk for falls due to self-transferring and need for staff assistance. NA-B was aware of R34's recent falls, unaware of fall prevention measures put in place following falls. NA-B indicated prior to R34's falls, staff would toilet R34 every 2 hours, keep R34 involved in activities, closely supervised R34. NA-B stated R34 was on a walking program but became resistive towards staff, was no longer receiving restorative nursing services. While interviewed on 11/07/22 at 2:58 p.m., licensed practical nurse (LPN)-D indicated awareness of resident care needs, would look in care plan, medical administration record (MAR), treatment administration record (TAR). LPN-D stated R34's cognition was impaired, especially when trying to express needs; was impulsive with self-transfers, could be resistive to staff cares being provided. LPN-D indicated R34 was at risk for falls, aware of 2 falls since admission. LPN-D stated R34's fall prevention measures included wander guard, bed alarm, close supervision, and toileting every 2 hours. LPN-D indicated with recent falls, re-education was provided to staff reminding R34's need for close supervision, hard to supervise R34 closely as impulsive and self-transfers. LPN-D stated process for resident falls included assessing resident immediately post fall, notifying physician and resident family member of fall, completing a fall incident report, putting in a fall intervention immediately post fall to prevent further falls, updating staff of fall incident and fall intervention put in place. During an interview on 11/07/22 at 3:17 p.m., the director of nursing (DON) indicated process for residents that fall, includes nursing immediately assessing resident condition, completing a post fall incident report and implementing a fall prevention measure to prevent further falls, and management review of incident and appropriateness of fall prevention measure at weekly IDT meeting. The DON stated R34 was at risk for falls due to dementia with behavioral disturbance, could be resistive with cares, occasionally impulsive with self-transfers. The DON indicated R34 had fall prevention measures in place and listed in care plan. The DON stated after R34's fall on 9/25/22, fall prevention measure implemented was to settle R34 in bed after supper due to increased agitation after supper and attempting to self-transfer, if unable to put to bed, staff to place her in recliner in living room. The DON indicated R34's fall intervention following 11/3/22 fall had not been implemented yet, as R34 was sent to the ER and returned same day, and planned to discuss at scheduled IDT meeting tomorrow 11/8/22. The DON stated fall prevention measures implemented should be communicated with staff immediately upon fall, discussed during shift report, reviewed during IDT meeting and prevention measures communicated to MDS coordinators, MDS coordinators update new fall interventions in care plan within 7 days post fall. The DON reviewed R34's care plan, confirmed fall interventions for 9/25/22 were not updated in care plan, DON indicated it was her expectation fall interventions for 9/25/22 to have been in place, as MDS coordinators were responsible for creating resident care plans and ensuring updated when needed. While interviewed on 11/07/22 at 4:07 p.m., registered nurse (RN)-C indicated for residents at risk for falls, fall prevention measures should be care planned. RN-C stated if fall prevention was care planned, all staff would be able to see prevention measures in place in care plan by checking resident's EMR. RN-C reviewed R34's care plan, had safety care planned, included measures of; wander guard, reporting behaviors that could cause R34 harm, frequent checks, take for walks, report signs of pain, explain needs to others, redirect, discuss safety at IDT PRN. RN-C stated all staff should know R34 was at risk for falls, indicated R34 required staff assistance and use of gait belt with transfers and mobility. RN-C confirmed upon review of R34's care plan, fall prevention measures implemented following 9/25/22 fall consisting of, settling R34 in bed after supper due to increased agitation after supper and attempting to self-transfer, if unable to put to bed, staff to place her in recliner in living room; had not been updated in care plan. RN-C indicated R34 had recliner care planned for in baseline care plan, dated 9/9/22, stated since recliner already in care plan, did not need to update following 9/25/22 fall. RN-C confirmed R34 had a recliner in her room, verified 9/25/22 fall prevention interventions entailed R34 to be placed in recliner in living room. Facility policy titled, Fall and Post-Fall Assessment, revised 7/18 consisted of; Policy: It is the policy of [NAME] Providence Community Home to assess each resident after a fall to assess condition, investigate cause of fall, develop strategies, and implement to prevent further falls/injury. Procedure included interventions will be added to the care plan and communicated to staff via NAR worksheets (if applicable), through shift report, and on the 24-hour flow sheet; the post fall assessment will be reviewed and evaluated by the interdisciplinary team at the first meeting following the fall. Periodic review will take place to monitor the effectiveness of interventions.

Based on observation, interview and document review, the facility failed to provide services to maintain and prevent further loss of range of motion (ROM) for 1 of 1 residents (R26) reviewed for hand contractures and limited ROM. Findings include: R26's face sheet printed on 11/9/22, indicated R26 was admitted on [DATE], and had a diagnoses of osteoarthritis. R26's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R26 was cognitively intact, had adequate vision and hearing, clear speech, could understand others and be understood. R26 required extensive assistance of one staff for all activities of daily living (ADL's), except eating for which he was independent with set-up help. R26's care plan dated 8/31/22, indicated R26 had arthritis that affected his hands, and could do very little with his hands. No interventions were identified for arthritis of hands. Care plan dated 10/4/22, indicated R26 wanted to restore his ability to maintain independence and care for himself as much as possible. R26's physician orders did not include an order for therapy services. During an interview on 11/06/22, at 1:56 p.m., R26's fingers were observed bending away from the thumb on both hands. In addition, R26 had a dupuytren contracture (finger bent toward the palm and unable to straighten) of the middle finger of right hand. R26 was not able to straighten his fingers. R26 stated his fingers where like this when he was admitted to the facility. R26 stated he did not receive exercises to his hands to keep them limber and from tightening further. R26 stated, I can feed myself now, but if it gets worse, I won't be able to hold my spoon. R26 stated he wanted to maintain as much independence as possible. During an interview on 11/07/22, at 1:37 p.m., nursing assistant (NA)-A verified she performed restorative services to residents. NA-A displayed a list of residents who received restorative services and R26 was not on the list. NA-A stated R26 did not require restorative services. Therapy documents provided by director of rehabilitation (DOR)-C dated 2/3/22, indicated R26 had a HEP (home exercise program) and would require 50% cues to complete the program accurately. The document indicated the goal had not been met due to lack of compliance with OT (occupational therapy) interventions. However, while the document indicated OT to BUE (bilateral upper extremities), it was in relation to R26 lifting small hand weights; there was nothing specific to maintaining and preventing loss of ROM to R26's fingers/hands. During an interview and observation on 11/08/22, at 2:44 p.m. in R26's room with DOR-C, observed R26's hands. R26 demonstrated how he himself decided to roll up a washcloth in his right hand and used that at night for comfort. DOR-C asked R26 if he would be interested in therapy recommendations for his hands to help to maintain and improve strength and flexibility of his fingers, and R26 stated he would, adding he wanted to maintain the ability to feed himself. During an interview on 11/09/22, at 10:38 a.m., (NA)-B stated R26 never had exercises for upper extremities or hands. If he was supposed to have exercises, the therapy department would have given the restorative aides a sheet of paper indicating what exercises should be done. NA-B stated they had never received an exercise sheet for R26. During an interview on 11/09/22, at 10:55 a.m., the director of nursing (DON), stated she was aware of R26's arthritic hands and hand contractures. The DON was not aware if R26 had a therapy consult upon admission, but was aware he had not been receiving restorative services for his hands. The DON acknowledged a ROM program for R26's hands may help reduce his fingers from further contracting. The DON stated they should have done something .we missed that .should have talked about it at his care conference .ROM would definitely be helpful for him. Facility policy titled Rehabilitative Nursing Care, with revised date of 8/21, indicated the facility had a rehabilitative nurse care program directed toward assisting each resident to achieve or maintain an optimal level of self-care and independence. The residents care plan would reflect rehabilitative needs for each resident as needed. Rehab (rehabilitation) aides would assist residents to perform ROM exercises as developed by the physical therapist (PT), occupational therapist (OT) or speech therapist (ST) and to carry out prescribed exercises. Residents were referred to PT/OT/ST on admission if the RN assessment or physician orders so indicated.

Based on observation, interview and document review the facility failed to ensure activities of daily living (ADLs) were provided, including trimming of fingernails for 1 of 2 residents (R27) reviewed, who needed staff assistance to maintain good personal hygiene. Findings include: R27's quarterly Minimum Data Set (MDS) assessment, dated 10/5/22, indicated R27 had intact cognition and required assistance from staff to maintain personal hygiene. R27's care plan dated 10/24/22; indicated R27 required staff assist of 1 with dressing and to maintain personal hygiene. During an observation and interview on 11/06/22 at 3:20 p.m., R27 was sitting in recliner chair in room, fingernails long and jagged. R27 indicated he was becoming more independent with activities of daily living (ADL), and staff have him do more for himself, but still needed some assistance with dressing and hygiene cares. R27 stated trimming fingernails was difficult to complete independently, and had not asked for staff assistance with fingernail trimming, and staff had not offered to trim fingernails. R27 indicated would like staff assistance with nail cares. During observation on 11/07/22 at 1:02 p.m., R27 was sitting in recliner chair in room, long, jagged fingernails remained. During an interview on 11/08/22 at 7:15 a.m., nursing assistant (NA)-I indicated had worked at facility for 2 years. NA-A stated resident nail care was completed on bath day, indicating NAs able to trim resident fingernails unless diabetic or had difficulty trimming, would then have licensed nurse complete. While interviewed on 11/07/22 at 6:21 p.m., the director of nursing (DON) indicated resident nail care was completed on their bath days. DON stated NAs typically would trim fingernails and toenails needing to be trimmed if not diabetic, if diabetic or had difficulty with trimming nails, licensed nurse would complete. DON indicated R27 was independent with some cares, needed staff assistance with fingernail trimming, could be completed by NA as R27 was not diabetic. DON reviewed bath schedule for R27, and noted R27's fingernails should be checked for trimming on Saturdays. DON reviewed nursing documentation for R27's bath cares completed from 10/8/22-11/5/22, and verified there was no documentation for nail trimming over past month. DON was shown R27's fingernails, and confirmed fingernails were dirty, longer in length, and jagged. DON stated her expectation for staff was to check fingernails/toenails during resident scheduled bath, trim nails as appropriate and per resident request. During an observation and interview on 11/08/22 at 7:24 a.m., R27 appeared clean in appearance. R27's fingernails was observed to be clean and trimmed some. R27's right 4th fingernail observed to have continued jagged edges. R27 stated staff had trimmed fingernails last evening, right 4th fingernail remained slightly jagged due to crooked finger. R27 indicated he preferred staff leave right 4th fingernail alone. Facility policy titled Policy A.M. Cares, revised 11/22, indicated cares are given daily to each resident requiring assistance, supervision is provided for residents able to self-care and assistance is given as needed, purpose of cares to promote cleanliness. Procedure consisted of residents on the bath list should be given a complete tub bath or shower including a shampoo and nail care per resident preference, licensed nurses will trim nails on diabetic residents, if toenails are too thick to be trimmed this will be reported to charge nurse.