Every finding on record at Ebenezer Integrated Care & Rehab

Based on observation, interview, and document review, the facility failed to ensure fasting blood glucose (BG) testing was performed before a meal for 1 of 2 residents (R28) observed who required insulin (medication used to lower blood glucose) based on a sliding scale.Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact, dependent on staff for most activities of daily living (ADLs), required insulin injections every day of the seven-day lookback period and had a diagnosis of diabetes mellitus (disease that leads to elevated blood glucose). R28's care plan revised 3/12/26, indicated R28 had diabetes mellitus type 2 and instructed staff to monitor blood sugars per provider order and as needed. R28's provider order dated 11/21/25, instructed, Monitor BG-Levels QID AC and HS [four times a day before meals and at bedtime]. R28's provider order dated 11/24/25, instructed, Insulin Aspart Pen-injector 100 units/milliliter (ML) inject as per sliding scale: if BG 0-139 = 0 units; 140-189=1 unit; 190-239=2units; 240-289=3units; 290-339=4units; 340-439=5units; 440+=7units, subcutaneously with meals for diabetes. During observation on 3/31/26 at 8:28 a.m., licensed practical nurse (LPN)-B entered R28's room to administer morning medications. R28 was sitting up in bed with his bedside table over the bed and a breakfast tray on the table. R28's breakfast included scrambled eggs, blueberry muffin, cereal, milk and juice. R28 had eaten approximately ninety percent of the scrambled eggs and had taken some of each of the beverages. LPN-B told R28 to go ahead and finish his eggs and then she handed him a cup containing his oral medications, which he took and swallowed. LPN-B then prepped the BG meter and pricked R28's finger and obtained a sample of blood to test for the level of blood sugar in his blood. R28's BG was 175. LPN-B reviewed R28's orders and stated he needed 1 unit of insulin as indicated by the ordered sliding scale and proceeded to inject the insulin. During interview on 3/31/26 at 8:45 a.m., R28 stated his BG should be checked prior to eating meals since the amount of one of the insulins he received was based on the BG result and a sliding scale. During interview on 3/31/26 at 8:49 p.m., LPN-B stated R28's BG should have been tested by 7:30 a.m., to ensure it was before breakfast. LPN-B stated testing prior to a meal would have provided a more accurate fasting BG. During interview on 4/1/26 at 7:14 a.m., registered nurse (RN)-C stated insulin administered per sliding scale should be based on a fasting BG (before a meal) in order to ensure an accurate amount of insulin was provided. During interview on 4/1/26 at 10:42 a.m., RN-A stated staff were expected to be checking BG before meals to get an accurate fasting BG result. RN-A stated a BG taken after a resident already started eating or completed a meal, could provide an inaccurate level and the amount of insulin provided based on the result and per sliding scale could be incorrect. During interview on 4/1/26 at 1:21 p.m., director of nursing (DON) stated expectation for fasting BG to be taken prior to a meal and that a BG taken during or after a meal could potentially indicate a wrong dose of insulin administered per sliding scale. Facility policy Blood Sugar Monitoring dated 4/25, instructed staff to monitor resident BG levels per provider order.

Based on interview and record review, the facility failed to assist in obtaining routine dental services for 1 of 1 resident (R1) reviewed for dental services. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, dependent on staff for oral hygiene, and did not exhibit rejection of care behavior. R1's diagnoses included hemiplegia and hemiparesis (weakness and paralysis affecting one side of the body). R1's care plan revised on 3/4/26, identified R1 had a self-care performance deficit and required substantial to dependent assistance with personal hygiene and oral care. R1's Oral/Dental Assessment ([NAME]) dated 9/23/25, indicated R1did not have any oral concerns, but was considering partials for his edentulous (lacking teeth) upper and lower premolars. R28's [NAME] indicated R28 had not seen a dentist in over two years and neither R28 nor a responsible party declined offer for routine dental appointment. R1's [NAME] dated 12/22/25, indicted R28 had no dental concerns, but had not seen a dentist in over two years and neither R28 nor a responsible party declined offer for routine dental appointment. R1's medical record lacked evidence of a dental appointment or any reference to an offer for dental referral. During interview on 3/30/26 at 12:43 p.m., R1 stated had not seen a dentist in at least a year and a half and had not been offered to see a dentist since admission. During interview on 3/31/26 at 12:35 p.m., registered nurse (RN)-B stated the MDS nurse would schedule the quarterly oral assessment, and the assigned nurse or charge nurse would complete the assessment as identified on the treatment administration record (TAR). If it was identified that the resident needed a dental referral due to oral issues or lack of routine dental evaluation, they would notify the provider to have a dental referral placed. RN-B further stated if the resident had a dental appointment while a resident, there would be documentation in the electronic medical record (EMR) indicating a summary of the appointment. RN-B stated if documentation could not be located, she would consult the health unit coordinator (HUC) who could determine if a referral had been made and/or an appointment scheduled or completed. RN-B stated regardless of a resident's dental status, if a resident had not seen a dentist in over two years and they did not decline an appointment; a referral should be made. During interview on 4/1/26 at 9:49 a.m., family member (FM)-B stated could not remember the last time R28 had seen a dentist and could not recall any discussion with the facility regarding offering dental services. FM-B further stated would expect R28 to be offered routine dental care and neither she nor R28 would decline those services. During interview on 4/1/26 at 10:13 p.m., HUC stated if a resident wanted to see a dentist, and did not have their own dental clinic, she would arrange for an appointment and transportation when she received a referral from their provider. HUC looked in R28's EMR and confirmed R28 did not have a dental appointment scheduled and had not seen a dentist since his admission. During interview on 4/1/26 at 10:42 a.m., RN-A stated if a resident was assessed and found to need or desire to see a dentist, the nurse would request a referral from the provider, and the facility would get a consent and make the arrangements. RN-A further stated R18 should have been offered a dental referral regardless of his dental status and that routine dental care could prevent oral issues in the future. During interview on 4/1/26 at 1:21 p.m., director of nursing (DON) stated dental referral should be recommended and arranged per resident preference. DON expected staff to address R28's lack of dental visits and offer to arrange a dental appointment. Facility policy Consultant Visit Policy - Audiology, Optometry, Podiatry, and Dental Services dated 6/25, identified the facility was responsible for scheduling and coordinating dental consultations for residents. The policy further indicated, Within 90 days of admission, staff will refer the resident for an initial dental examination, unless the resident has had a dental exam within six months before admission. After the initial exam, staff will offer an annual dental exam within one year of the previous exam.

Based on observation, interview, and document review, the facility failed to ensure active interventions were implemented to reduce the risk of falls for 1 of 2 residents (R46) who had repeated falls and was reviewed for accidents.Findings include:R46's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors. A walker and wheelchair were used, and substantial/maximal assist was required for transfers, ambulation, toileting, lower body dressing, and bed mobility. R46 had a diagnosis of vascular dementia (nontraumatic brain dysfunction). One fall occurred since the last assessment with two or more injuries.R46's annual Care Area Assessment (CAA) dated 6/2/25, identified falls triggered due to falls since previous MDS. R46 had two falls without injury due to poor balance, poor judgement, and wearing inappropriate footwear. Fall risk score was 12 and indicated high risk for falls. Dementia with severe cognitive impairment contributed to poor safety awareness and decision-making. He demonstrated shuffling gait and poor balance. Staff supervised his activity, provided reminders and redirection, and ensured he was wearing appropriate footwear. Additional contributing factors were incontinence and heart failure. R46 was at risk for further loss with all areas due to advancing disease process. Interventions were in place and the plan was to continue assisting with cares for R46 at present level. Reference care plan for goals and interventions.R46's Fall Risk assessment dated [DATE], identified he was at high risk for falls.R46's falls care plan dated 3/31/26, identified he was at risk for falls related to cognitive impairment, deconditioning, gait and balance instability, crisscross gait pattern, incontinence, incomplete bladder emptying, history of falls, and history of low blood pressure. Interventions effective 2/18/26, were to remove R45's feet from the footrests and place wheelchair footrests in upright position when not propelling.R46's progress notes dated 1/18/26 through 3/31/26, identified three falls from his wheelchair.On 1/18/26 at 8:27 p.m., R46 was found on the floor in TV lobby at 6:15 p.m., with no injury. R46 said he tried to get up to use the bathroom. The nursing assistant last checked on R46 10 minutes before the fall and denied toileting R46 after the evening meal. The root cause analysis included was standing up unassisted to try and use the bathroom without locking wheelchair brakes, and misjudgment of ability. The NA last checked on him 10 min ago and R46 was not toileted after the meal. Immediate interventions included frequent checks and to encourage R46 to ask for help before transferring.The Post Fall IDT note dated 1/19/26 at 11:41 a.m., identified new Interventions included cue resident after every meal to go to the bathroom and offer assistance, and a request was sent to therapy to evaluate for strengthening.On 2/17/26 at 9:51 p.m., R46 had an unwitnessed fall to the floor from his wheelchair in the dining room at 7:15 p.m., and sustained a laceration to the left upper eyelid. R46 was toileted around dinner, and the root cause analysis included misjudgment of ability. Immediate interventions included staff to constantly check on R46.The Post Fall IDT note dated 2/18/26 at 10:07 a.m., identified R46's wheelchair footrests were in the down position, and R46 likely tripped when attempting to stand and walk from his wheelchair. A new intervention was placed for wheelchair footrests in upright position when not propelling R46 to destinations.On 3/3/26 at 4:15 p.m., R46 was witnessed by staff standing up in the dining room, his body leaned to the left, the wheelchair tipped over and he fell to the floor. The root cause analysis included misjudgment of ability and cognitive impairments. Lapses in memory about R46's physical limitations resulted in attempts to transfer/ambulate without assist. R46 had actual repeated falls due to weakness, deconditioning, poor balance, poor insight into deficit, and antiarrhythmic medication use. Immediate interventions included increased rounding and staff presence, especially before and after dinner time which were high risk times.The IDT Follow Up Incident progress note dated 3/4/26 at 10:22 a.m., identified occupational therapy would assess additional wheelchair safety. The note did not identify if the footrests were positioned up according to the care plan.During an observation on 3/30/26 at 1:52 p.m., R46 was observed to be lying face down on the floor next to his bed. R46's bed was in a low position, and his call light was on the bed and not activated. Surveyor went to alert staff and nursing assistant (NA)-A and NA-B alerted the nurse and both NAs came down to R46's room to check on him. At 1:54 p.m., licensed practical nurse (LPN)-A arrived at the room, saw he was waking up, and left to get the vital signs machine. At 1:55 p.m., R46 got up onto his knees and got back into bed independently, despite NA-A and NA-B advising him to be still until LPN-A returns to assess for any injuries. At 1:57 p.m., LPN-A re-entered the room with the vital signs machine. LPN-A stated R46 could not communicate well so staff had to look for non-verbal signs. LPN-A assessed range of motion, skin condition, and vital signs which were within normal limits. LPN-A stated R46 had been up most of the morning and was assisted into bed shortly before he fell out of bed.During an interview on 3/30/26 at 4:39 p.m., R46's family member (FM)-A stated she had concerns about R46 having repeated falls.During a continuous observation on 4/1/26 starting at 7:45 a.m. to 10:15 a.m., R46 was seated at the dining room table alone. Licensed practical nurse (LPN)-A was at the medication cart approximately 10 feet away. R46's feet were placed on the wheelchair footrests which were not in an upright position, which conflicted with the care plan intervention to place wheelchair footrests in upright position when not propelling.At 8:14 a.m., R46's breakfast tray was placed in front of him and began eating and drinking independently. One other resident was at the table along with a nursing assistant. R46's feet were still on the footrests which were not in an upright position. At 8:45 a.m., R46 finished with breakfast and was brought to the commons by nursing assistant (NA)-B to watch TV. R46's feet remained on the footrests while propelling and after being stopped near the television. NA-B was intermittently close to R46 but escorted residents to other places and intervened with other residents. R46 was awake and alert with his feet on the footrests which were not in the upright position. At 9:19 a.m., NA-B left the unit and LPN-A remained at her medication cart about 10 feet away from R46. At 9:22 a.m., LPN-A walked by R46 and had not corrected the position of his footrests. At 9:24 a.m., NA-B re-entered the dining room which was approximately 15 feet away from R46 and LPN-A left the area. R46 remained in his wheelchair with his feet in the footrests that were not in the upright position. At 9:33 a.m., NA-A took R46's shoes off, put on gripper socks on both of his feet, and then put his shoes back on while his feet remained on the footrest, then NA-A left the area. R46 remained in the commons area with intermittent staff in the area but no staff right next to him to intervene quickly if he attempted to self-transfer. Staff in the area had not corrected the position of the footrests.At 10:00 a.m., NA-A brought R46 from the commons area back to his room. Once in R46's room NA-A flipped up R46's footrests and angled them off to the side away from the front of the wheelchair and assisted R46 to transfer into bed using a gait belt and one staff assist. When NA-A was asked how she knew which fall interventions R46 had in place, she stated interventions showed up on their charting iPad, and the nurse would update them on new interventions. NA-A acknowledged she put R46's gripper socks on while the footrests were not in an upright position but R46 was not propelling.At 10:10 a.m., after NA-A left R46's room, NA-A was asked to show surveyor a list of R46's fall interventions from their iPad to verify if all interventions were visible on the NA's charting iPad. NA-A would not answer. R46's Kardex (list of cares) was shown to NA-A with the fall intervention of keeping feet off the footrests unless propelling in wheelchair. NA-A would not answer and deferred surveyor to LPN-A who was also in the hallway. LPN-A reviewed the Kardex and stated that fall intervention to keep feet off footrests unless propelling was in place because when R46 would stand up, he would trip over the footrests and had falls in the past related to this issue. LPN-A stated R46 had been calmer the last couple of days and that might by why R46's footrests remained in place with his feet on top, even though he was not propelling. NA-A then stated yes that was the reason why his footrests remained in use. During an interview on 4/1/26 at 10:15 a.m., (RN)-A stated fall interventions listed on the Kardex and care plan should be followed as written for safety reasons. All nursing staff had access to the interventions. RN-A stated R46 had a fall in the past from tripping over his footrests and since the intervention of keeping the footrests up was implemented, he has not had falls from tripping over the footrests. RN-A stated R46's vascular dementia was challenging because he could not process the dangers of self-transferring.During an interview on 4/1/26 at 2:28 p.m., the director of nursing (DON) stated staff should review the care plan or Kardex at the start of their shift. Fall risk interventions should be implemented as written for safety. Following a fall, the interdisciplinary team (IDT) would review any resident falls and see if the care planned interventions were in place. If documentation was lacking, the IDT would follow up with the staff working during the fall.During a follow up interview on 4/1/26 at 2:58 p.m., The DON stated keeping R46's feet off the footrests unless propelling was still an active intervention that should have been implemented.The facility's Fall Risk, Post Fall Investigation, Follow Up, and Care policy dated 1/26, identified Universal fall precautions are used for all patients based on individual patient needs. Interventions should be selected based on individual patient needs. Document interventions in the medical record. Falls risk and interventions should be noted on the plan of care.

Based on interview and document review the facility failed to follow care plan interventions required to provide safe transfers for 1 of 3 residents (R1) who required the use of a walker, gait belt, wheelchair and assist of one staff for transfer assistance. This resulted in actual harm when R1 was ambulated without contact guard assist and a wheelchair behind her, fell, and sustained a fracture of the shoulder. The facility implemented corrective action prior to the start of the survey, so therefore, the deficiency was issued at Past Noncompliance.Findings include:R1's face sheet dated 12/4/25, indicated R1 had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease affecting right dominant side, acute on chronic diastolic heart failure, chronic obstructive pulmonary disease, type II diabetes, and atrial fibrillation.R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact and was dependent on staff for assistance with activities of daily living (ADL) including transfers and toileting.R1's ADL care plan focus last revised on 10/9/25 identified R1 had a self-care performance deficit due to weakness, deconditioned and stroke with left side hemiparesis. R1's transfer care plan dated 8/26/25 directed staff to transfer R1 with an assist of one with a transfer belt and two wheeled walker.R1's therapy to nursing communication, dated 10/7/25 directed R1 required the assist of 1 with the gait belt and the wheelchair to follow. Comments included contact guard assist and bilateral knee braces. Walk 1 time day to dining room and back with one seated rest break, contact guard assist and bilateral knee braces on. R1's progress note dated 11/10/25 at 2:05 p.m., indicated that a nursing assistant reported to a nurse that while assisting R1 with toileting, the resident lost balance and fell while being assisted to sit in the wheelchair using a gait belt and a walker. The new intervention identified staff is now using the current care plan. The nurse practitioner was notified and an order for an x-ray of the left shoulder was placed.R1's imaging results, dated 11/10/25 identified R1 had acute comminuted fracture (severe fracture with several breaks) of the proximal humerus (upper arm bone) which involves the surgical neck and greater tuberosity prominent bony landmark of the humerus), with mild displacement. There is normal joint alignment. Mild glenohumeral (shoulder joint) and severe acromioclavicular joint degeneration (where the shoulder meets the clavicle) changes. Osteopenia aortic atherosclerosis.R1's progress note dated 11/10/25 at 11:35 p.m., indicated the x-ray results were received and included the results as identified per the imaging result. R1 progress note dated 11/11/25 at 9:52 a.m., indicated the interdisciplinary team met to discuss R1's fall. The note indicated the care plan was not followed. The resident was transferring from toilet to her wheelchair by ambulation when care plan designates the resident is pivot stand transfer (sic-inconsistent with the care plan). The wheelchair was not positioned next to the resident during the attempted transfer. Resident's legs became weak when attempting to ambulate to her wheelchair outside the bathroom door and resident fell. Fall resulted in shoulder fracture. The new intervention included educating staff about current care plan, R1's walking program was discontinued. Requested and received orders for physical therapy to evaluate transfers, fall and pain management.R1's transfer intervention last revised 11/11/25 directed staff R1 required assist of two with a mechanical lift, medium sling size. The care plan had a focus section about R1's limited physical mobility due to weakness, deconditioned, poor balance, unsteady gait and a history of stroke with left side hemiparesis. Interventions included:-Ambulation: resident does not walk. Not dated.-Escort in wheelchair to destinations. Not dated.-Non-weight bearing left shoulder, at least x 6 weeks. Not dated.-Non weight bearing left arm. Dated 11/10/25.-Shoulder Immobilizer to left arm at all times, remove daily for hygiene. Dated 11/26/25. During an interview on 12/5/25 at 8:31 a.m., nursing assistant (NA)-C stated she was taking R1 to the bathroom Around 2:00 p.m., NA-C said she was new, and it was her first solo day on the unit. NA-C explained on 11/10/25 R1 was in bed and needed to use the bathroom. NA-C put the gait belt around R1's waist, R1 stood up, pivoted and transferred to the wheelchair, was brought to the toilet, R1 stood, pivoted and transferred onto the toilet. R1 was provided privacy, five minutes later NA-C returned. NA-C couldn't get the wheelchair to fit in the bathroom with the walker. NA-C held her gait belt, R1 stood up and NA-C pulled the walker closer. R1 had to take a few steps while NA-C pulled the wheelchair closer. While NA-C was pulling the wheelchair closer R1 became unsteady. NA-C helped lower her to the ground and went to get help. NA-C was re-educated to follow the care plan and to ask for help if needed. NA-C stated she was re-educated that the wheelchair would fit in the bathroom when the foot pedals were removed. NA-C stated she felt really bad and apologized to R1 and R1's family member.During an interview on 12/5/25 at 9:03 a.m., the nurse manager (NM)-A stated she did the staff re-education following R1's fall and was in the interdisciplinary team meeting. The education that was provided to the nursing assistant and other staff was about following the care plan and completing safe transfers. There were ongoing audits to observe staff completing transfers beginning 12/5/25 and were ongoing at the time of the survey. During an interview on 12/5/25 at 10:00 a.m., the administrator stated R1 was transferring from the toilet to the wheelchair and there was not an option based on where the wheelchair was positioned for her to complete the stand pivot transfer which is what was in her care plan. R1 took a few steps, lost her strength when trying to get to the wheelchair and fell. The nursing assistant helped lower her to the floor with the gait belt. Nurses were alerted and staff got her up from the floor with a full body mechanical lift. The nursing assistant was pulled from the schedule following the incident, was interviewed and re-educated one where to find the care plan and to make sure she understands what she was doing before she does it. Further education was provided to a wider group of staff. Audits were implemented for transfer statuses.The facility policy Vulnerable Adult Abuse Prohibition last revised 10/24, directs that Ebenezer skilled nursing facilities have zero tolerance for resident or patient abuse, neglect or exploitation or mistreatment. The goal is to provide residents with a safe and secure environment free from maltreatment.The facility policy Transfer Techniques Patient Assist last revised 4/2025, directs that staff should follow the care plan or the Kardex when transferring patients. The Past Noncompliance began on 11/10/25. The deficient practice was corrected by 11/11/25, after the facility implemented a systemic plan that included the following actions: immediate education on safe transfers and following the care plan. Audits completed by nursing leadership for review of safe transfers. Interviews with staff on 12/4/25 confirmed knowledge of facility policies. Observation of transfers on 12/4/25 demonstrated compliance with following the care plan for transfers.

Based on document review, interview and observation, the facility failed to implement proper infection control when three staff were observed not following enhanced barrier precautions or hand hygiene during direct care for 2 of 4 (R3, R4, R5) residents reviewed for infection prevention. Findings include:Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be infected with multi-drug-resistant organisms as well as those at increased risk of multi-drug resistant organism acquisition (residents with wounds or indwelling medical devices)R2's face sheet dated 12/4/25, indicated R2 had diagnoses of cellulitis of unspecified part of limb, lymphedema (swelling), need for assistance with personal care, type II diabetes and rhabdomyolysis (breakdown of skeletal muscle tissue).R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was moderately cognitively impaired and dependent on staff for activities of daily living, including transfers.R2's care plan dated 12/4/25, had a focus section, Enhanced barrier precautions indefinitely due to wounds. The interventions listed included gloves and gown prior to the high-contact care activity. High-contact resident care activities such as but not limited to: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use for central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care. R2's order set lacked orders for enhanced barrier precautions.During an observation on 12/4/25 at 8:54 a.m., R2 was in bed and was waiting for assistance with a transfer to his wheelchair. R2 had an EBP sign on his door that indicated when staff should practice EBP, and which PPE should be worn. Three staff, nursing assistant (NA)-A, NA-B and physical therapist (PT)-A were already in the room. They all had gloves on, but no gowns. R2's brief had leaked, and urine had soaked the bed linens. NA-A assisted R2 to change into a clean gown, the clean gown became soaked with urine immediately. NA-A left to get R2 a beverage, returned to the room and put on new gloves. NA-B and PT-A were working on obtaining a functioning mechanical lift, NA-B had left the room. At 9:03 a.m., NA-A removed R2's gown and placed a new one on without changing gloves or completing hand hygiene. NA-A adjusted the foot pedals on R2's wheelchair, changed her gloves and then adjusted the call light button. PT-A assists R2 in sitting up at the side of the bed. NA-A applied the mechanical lift sling. PT-A put on another gown to cover R2's back side. PT-A and NA-A both adjusted the sling and were questioning the size of the sling for the resident. R2 says he doesn't think the sling is the right size. At 9:10 a.m., PT-A left the room to obtain a different sling. R2 requested his morning supplement drink, NA-A shook the drink and opened it for R2. NA-A removed R2's gown on his back and put a larger size on to cover his back side. At 9:17 a.m., NA-B returned with a new sling, NA-B was not wearing gloves or a gown. NA-B operated the mechanical list and NA-A removed the soiled linens. NA-B transfers R2 to the wheelchair, adjusted his oxygen tubing and removed the sling. NA-A started opening cabinets, adjusted the bedside table and set up R2's breakfast on the bedside table. NA-A removed the soiled linen from the room, removed her gloves and used hand sanitizer. PT-A and NA-B left the room. R3's face sheet dated 12/4/25, indicated R3 has diagnoses of type II diabetes, traumatic subdural hemorrhage with loss of consciousness, need for assistance with personal care, chronic pancreatitis and repeated falls.R3's Medicare 5-day MDS assessment dated [DATE], indicated R3 was cognitively intact and required partial moderate assistance with some activities of daily living.R3's care plan dated 12/4/25, had a focus section, Enhanced barrier precautions indefinitely due to wounds. The interventions listed included gloves and gown prior to the high-contact care activity. High-contact resident care activities such as but not limited to dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use for central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care. R3's order set lacked orders for enhanced barrier precautions.During an observation on 12/4/25 at 11:35 a.m., R3 was in her room sitting in a recliner. R3 had an EBP sign on her door that indicated when staff should practice EBP, and which PPE should be worn. NA-B was in the room tidying up for R3. NA-B was not wearing gloves or a gown. NA-B removed the dirty linen from R3's bed and placed it in a trash bag. NA-B then touched R3's walker, emptied the trash and put a new trash bag in. NA-B took the trash, soiled linen bag, nursing assistant tablet and exited the room. NA-B disposed of the trash and then washed her hands.During an interview on 12/4/25 at 1:01 p.m., NA-B stated hand hygiene should be completed when entering or leaving a resident room. Gloves should be changed anytime contact with a resident is stopped. EBP means that anytime personal cares or transfers are done, a gown and gloves should be worn. Staff know which residents require EBP because there are signs on the doors and in the Kardex. When asked why she did not wear a gown during R2's transfer, she stated she was called in while doing other things and it was her mistake.During an interview on 12/4/25 at 1:10 p.m., NA-A stated hand hygiene should be completed if there is body fluid involved. Gloves should be changed after changes briefs or before touching something else. EBP means staff should wear a full gown when changing or transferring a resident to avoid infection. Signs on the door indicate if a resident requires EBP or not. NA-A stated she didn't know why she wasn't wearing a gown during R2's transfer.During an interview on 12/4/25 at 1:19 p.m., PT-A stated hand hygiene should be done before and after entering a room. Gloves should be changed during an exit or if they get wet or soiled. EBP means staff should be wearing gown and gloves and it is indicated on the resident's door. PT-A stated she wasn't doing direct cares, so she didn't need to wear a gown during R2's transfer.During an interview on 12/4/25 at 4:04 p.m., registered nurse (RN)-A who was also the infection preventionist, stated staff are educated about EBP upon orientation and there are annual in-services. EBP means staff must wear gowns and gloves during high contact care activities. High contact care activities would include patient transfers and changing bed linens. Gloves should be changed anytime perineal cares are done or when going from dirty to clean.During an interview on 12/5/25 at 9:03 a.m., nurse manager (NM)-A stated EBP means a patient has a preliminary disease or diagnosis that could be transmitted. The resident may have an indwelling catheter, device, wound or intravenous line. Gowns and gloves should be worn. A linen change would require a gown and gloves. Hand hygiene should be done all the time, when entering a room, when doing something dirty and going to clean. Gloves should be changed when going from clean to dirty.During an interview at 12/5/25 at 10:00 a.m., the administrator stated EBP means staff should wear a gown and gloves and maybe a face shield when providing close contact cares to prevent spread of infection. Hand hygiene should be completed when entering a room, and going from any clean to dirty task.The facility policy, Enhanced Barrier Precautions last revised 1/22/25 directs EBP to be practiced when completing the following high-contact resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, assisting with toileting, device care or use and wound care.

Based on observation, interview, and document review, the facility failed to ensure residents with food allergies received the appropriate tray for 1 of 1 resident (R23) reviewed who had a listed anaphylactic reaction (a severe, potentially life threatening allergic response) to ginger. This resulted in an immediate jeopardy (IJ). The IJ began on 12/14/24, when R23 was served a meal tray which included honey ginger chicken and after a few bites experienced an anaphylactic reaction. R23 had an order for epinephrine to be used in the case of an anaphylactic reaction however, R23 was not given the epinephrine. This resulted in R23 requiring transfer to the emergency department for treatment. The administrator and director of nursing (DON) were informed of the IJ on 2/25/25 at 3:46 p.m. The facility implemented corrective action and the IJ was removed on 2/26/25 at 7:20 p.m. However, non-compliance remained at the lower scope and severity of D, isolated, no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and required setup assistance for eating. R23's diagnoses included acute ischemia of small intestine (decrease in blood flow), type 2 diabetes, and [NAME]-[NAME] syndrome [a condition affecting appetite and causing one to always feel hungry). R23's care plan dated 12/9/24, indicated set up assistance to eat, diet as ordered, monitor food intake at meals, and offer alternatives for meals if refusing. R23's care plan lacked evidence of any food allergies. R23's diet order/dietary communication dated 11/29/24, indicated food allergies, ginger, bee pollen. R23's allergy list printed 2/25/25, indicated the following food allergens: ginger, bee pollen/royal jelly. R23's admission nutrition assessment dated [DATE], indicated, Allergies .Diclofenac, metformin, Bee pollen/royal jelly, Ginger. R23's physician order history indicated the following: -Epinephrine injection solution auto-injector 0.3mg/0.3ml. Inject 0.3 mg intramuscularly as needed for anaphylaxis, allergy to ginger, daily - start date 11/29/24 at 5:00 p.m. -11/29/24 at 9:29 p.m. on hold, insurance does not cover. -12/18/24 at 3:19 p.m. resume, ordered per provider. -Date received-12/23/24, on hand. R23's December 2024 medication administration record (MAR) indicated, EPINEPHrine Injection Solution Auto-Injector 0.3 MG/0.3ML (Epinephrine [Anaphylaxis] Inject 0.3 mg intramuscularly as needed for anaphylaxis, Allergy to ginger. Daily - Order Date- 07/27/2014 .-Hold Date-from 12/01/2024 .to 12/18/2024. R23's MAR indicated H from 12/1/24 through 12/17/24, and did not indicate any epinephrine administration. During interview on 2/24/25 at 11:51 a.m., R23 stated a few months ago she was provided a meal consisting of a piece of chicken and stir fry vegetables. R23 stated her meal ticket did not indicate chicken; therefore, did not know what type of chicken was provided. R23 asked several unidentified staff members if the food items contained ginger, and all said no. After a couple bites, R23 stated she thought she bit into a piece of ginger and within a few seconds her lips started tingling and she felt her throat beginning to tighten. R23 notified staff she was having an anaphylactic reaction and requested epinephrine. R23 was told her epinephrine order was on hold due to insurance not covering it and staff did not have epinephrine in the emergency medication kit (E-kit). Review of facility week 2 menu for Saturday was honey ginger chicken thighs and Asian stir fry vegetable mix. R23's progress note dated (Saturday) 12/14/24 at 10:56 p.m., indicated R23 reported to staff of having a food allergy after eating part of her dinner and on assessment discovered R23 having a stick [sic] throat, and does not feel well. R23 started having shortness of breath and was put on oxygen at 4 liters/min. Resident had an order for epinephrine but it was on hold and the medication was not available. Staff called 911 and resident was sent to the hospital. R23's progress noted dated 12/14/24 at 11:05 p.m., indicated, This writer re email [sic] resident diet order to kitchen because one of the dietary stated that they don't have the food allergy in their file. R23's emergency department after visit summary (AVS) dated 12/14/24, indicated, Reason for Visit ALLERGIC REACTION Diagnoses -Shortness of breath - Anaphylaxis, initial encounter. The AVS instructed, You were seen today for an allergic reaction. Your symptoms improved after an epi pen. Return to the emergency department with any new or worsening symptoms. During observation on 2/25/25 at 9:00 a.m., R23's meal tray ticket lacked evidence of any food allergies. During interview on 2/25/25 at 9:21 a.m., dietary staff (DS)-A stated each resident had diet orders and allergies uploaded to the nutrition program. DS-A stated dietary staff would go room to room and enter residents' requests for all three meals for the following day. The nutrition program would identify a contraindication due to an allergy and would not allow the specific food item to be ordered. DS-A further stated resident allergies should also print out on the meal tray ticket and staff should check ticket prior to providing resident their meal. During interview on 2/25/25 at 9:41 a.m., licensed practical nurse (LPN)-A stated all resident allergies should be listed in the nutrition program and should display on the resident's meal tray ticket. LPN-A further stated epinephrine was stocked in the E-kit and available to be used in emergency situations. LPN-A further stated if a resident had epinephrine ordered for an anaphylactic reaction and did not have the medication available in their medications, the epinephrine in the E-kit should be used in the case of an allergic reaction. During interview on 2/25/25 at 10:06 a.m., kitchen manager (KM) and director of nutrition services (DNS) stated nursing communicates diet orders and allergies to dietary services using a specific communication form which was completed then scanned and emailed to nutrition. KM stated the information was then uploaded into the nutrition program (Healthtouch) and the system had safety measures built in to not allow a resident to order a food item that was listed as an allergy. During interview on 2/25/25 at 10:34 a.m., registered nurse (RN)-A stated would expect dietary services would have the correct allergy information for each resident and that they would not provide a meal containing food that a resident was allergic to. RN-A stated each resident's meal tray ticket should indicate any food allergies. RN-A further stated if a resident had an order for an emergency medication and it was not covered by insurance, that the facility would purchase the medication within 24 hours of denial and preferably before their first meal in the case of a food allergen. During follow up interview on 2/25/25 at 11:37 a.m., DNS provided list of all available allergies in the nutrition program and confirmed ginger was not included. DNS stated an undefined allergy could be added to the comments area but that did not display on the meal tray ticket. During interview on 2/25/25 at 10:55 a.m., director of nursing (DON) stated expectation that the process would correctly identify a resident's food allergies, and that information would be communicated to nutrition services. DON stated the food allergy should print on the meal tray ticket. DON further stated in a situation of a non-covered emergency medication the facility would purchase the medication to have on hand. DON stated the facility E-kit does contain epinephrine, but was not sure it was the corrected dosage. DON could not explain why there was not a change of condition, safety event or risk management completed on this event and stated lack of such report did not allow for proper follow up, education or resolution. During interview on 2/25/25 at 11:25 a.m., consultant pharmacist (CP) stated epinephrine was stocked in the facility E-kit and was unaware of any shortage around 12/14/24. CP stated if a resident was experiencing an anaphylactic reaction due to a food allergen ingestion, should be given epinephrine if ordered as anaphylaxis is a medical emergency. CP stated a resident in anaphylaxis who does not receive epinephrine could experience inability to breathe and would need emergency services. Facility policy Patient Meal Service Procedure dated 8/8/23, indicated, food allergies would be entered appropriately into HealthTouch and HealthTouch computer system will automatically omit designated allergens from the patient's menu choices. All foods listed as allergen in the HealthTouch system will not be served to the patient .If the patient has an allergy that is not identifiable in Health Touch the menu will be hand checked by the diet clerk or designee. The policy further indicated, A designated Nutrition Aide will check each meal tray for accuracy before the tray leaves the department. This check includes, but it [sic] not limited to: confirming all items are in place and all quality standards are met. The immediate jeopardy that began on 12/14/24, was removed on 2/26/25 at 7:20 p.m., when it could be verified through observation and interview that the facility had implemented a process to ensure residents would receive appropriate food items and not receive identified food allergens. A whole house audit was conducted by nutrition services and verified all residents' allergies listed in the medical record was accurately listed in the nutrition system and that those allergies would accurately print on the residents' meal tray ticket. Meal service observation identified staff confirmed the meal served matched the meal tray ticket and any food allergies listed on the meal ticket were not served. In addition, R23's orders and stocked medication included epinephrine. The E-kit contents were reviewed and included epinephrine as well. Nutrition staff education started on 2/25/25 included allergy information communication and entry into the nutrition system, meal service, meal ticket and allergy review and tray assembly. Nursing staff education started on 2/25/25 included verification that the meal delivered matched the tray ticket and did not contain any food allergens. Nursing education further included E-kit contents, use of epinephrine via a vial, standing house orders, signs and symptoms of anaphylactic reaction, procedure for allergic and anaphylactic reactions, and incident reporting. The plan was to educate all staff prior to their next shift. Continued compliance monitored via meal service audits completed daily for two weeks, then weekly for four weeks and monthly thereafter. Audit results would be reviewed by the quality committee.

Based on interview and document review the facility failed to ensure 4 of 4 residents (R15, R33, R54, R110) were offered and/or provided updated vaccinations for pneumococcal disease and 2 of 5 residents (R33, R110) for influenza in accordance with the Centers for Disease Control (CDC) vaccinations. Findings include: R15 R15's discharge Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of diabetes which puts him at higher risk for pneumococcal diseases. R15's Minnesota Immunization report dated 2/7/25, indicated R15 received the pneumococcal polysaccharide vaccine (PPSV23) on 7/17/12 and the pneumococcal conjugate vaccine (PCV13) on 4/26/19. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R15's age and vaccine history: Give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of which vaccine is used (PCV20 or PCV21), their pneumococcal vaccinations are complete. R15's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal vaccination. R33 R33's admission Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of diabetes which puts her at higher risk for pneumococcal diseases. It further indicated her pneumococcal vaccinations were up to date. R33's Minnesota Immunization report dated 1/10/25, indicated R33 received the pneumococcal polysaccharide vaccine (PPSV23) on 10/10/19 and the pneumococcal conjugate vaccine (PCV13) on 11/211/16. It further indicated R33's most recent influenza vaccination was administered on 10/1/2020. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R33's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or 21 is administered, their pneumococcal vaccinations are complete. R33's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal and/or influenza vaccination. R54 R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of intracerebral hemorrhage (brain bleed). R54's Minnesota Immunization report dated 11/20/24, indicated R54 received the pneumococcal polysaccharide vaccine (PPSV23) on 9/19/19 and the pneumococcal conjugate vaccine (PCV13) on 10/28/15. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R54's age and vaccine history: though the vaccines were considered complete, based on shared or clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or PCV21 was administered, their pneumococcal vaccinations are complete. R54's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal vaccination. R110 R110's discharge Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted on [DATE], was currently [AGE] years old, had moderately impaired cognition and of diagnosis of hepatic encephalopathy and alcoholic cirrohosis of the liver (with ascites). It further indicated his pneumococcal vaccinations were up to date. R110's Minnesota Immunization report dated 2/20/25, indicated R110 received the pneumococcal conjugate vaccine (PCV13) on 4/30/1997. It further indicated R110's last influenza vaccine was administered on 4/30/1956. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R110's age and vaccine history: Give one dose of PCV15, PCV20 or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least 1 year. The minimum interval is 8 weeks and can be considered in adults with immunocompromising conditions, cochlear implants, or cerebrospinal fluid leaks. R110's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal and/or influenza vaccination. During interview on 2/27/25 at 10:00 a.m. the infection preventionist (IP) stated the process regarding vaccinations for new admissions was to print of their Minnesota Immunization Information Connection report (MIIC) in order to determine what vaccinations the resident had already received and which ones they needed. Then the facility would ask the resident if they are interested in receiving those vaccines and give them a Vaccine Information Sheet (VIS), and request a physician's order. If the resident refused, they sign a declination form, were educated on the risk versus (vs) benefits, and it was documented in their medical record. The facility offered COVID, influenza, RSV, and pneumococcal vaccinations. The IP verified R15, R33, R54, R110 lacked documentation of vaccines being offered, refused, or educated on risk vs. benefits and was still following up on those residents. The nursing staff try to offer the residents vaccinations in the first day or two following admission. The IP also stated influenza vaccinations are offered from October 1st-March 31st each year. During interview on 2/27/25 at 12:49 p.m., the director of nursing (DON) stated when there was a new admission, the nursing staff were responsible for putting in an order set which would populate the vaccinations and schedule a Tuberculin blood test at the lab. Then the results would be documented. The nursing staff and IP were responsible for following up and ensuring the residents were offered and/or received the vaccinations. Documentation for refusals was not put in Point Click Care (computer program) it was tracked internally. The facility's policy regarding influenza (11/7/24) and pneumococcal vaccinations (11/5/24) indicated, all patients including those admitted during the influenza season, will be offered an influenza immunization, September 1st through March 31st annually, unless the immunization is medically contraindicated, or the resident had already been immunized during this time period. All residents or resident representative will receive information regarding the benefits and potential side effects of immunization prior to a vaccine being offered. In the case of a refusal, staff will discuss the risk and benefits of the influenza vaccine and return later to re-offer, preferably having another nurse offer, and if the resident refuses, document the refusal in the medical record. In regards to the pneumococcal vaccination the policy indicated all residents are encouraged to receive a pneumococcal vaccine as defined by the Minnesota Department of Health or CDC unless medically contraindicated, refused, or already immunized or due to circumstances outside the facility's control. The resident will be give the opportunity to refuse the vaccine and refusals will be documented in the medical record. All residents or legal representatives will receive information regarding the benefits and potential side effects of the immunization prior to a vaccine being offered. In the case of a refusal, the staff will discuss risks and benefits of the pneumococcal vaccine, return later to re-offer (preferably having another nurse offer), if the resident refuses, it will then be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure hand hygiene was completed during incontinent cares for 2 of 4 residents (R31 and R9) who were observed for cares. Furthermore, the facility failed to ensure urine was cleaned in a manner to prevent infection for 1 of 1 residents (R31) reviewed for clean environment. Findings include: R31 R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 had cognitive impairment and diagnoses of dementia and heart failure. R31's care plan revised 11/27/24, indicated R31 was had bladder incontinence and tended to void in available garbage cans or receptacles. R31 requires assist of one staff to find the bathroom and assist with incontinent cares. Furthermore R31's care plan indicated R31 would urinate in inappropriate places. An observation on 2/25/25, at 7:07 a.m., R31's door was open with the commode moved away from the wall and placed in front of the R31's door. R31 was laying in bed and then started getting up from bed. R31 walked to the bathroom doorway, stood there for a moment before returning to bed. At 7:33 a.m., nursing assistant (NA)-B entered the room and asked R31 if wanted to go down for breakfast. R31 declined. NA-B then took the commode bucket out of the commode and went into the bathroom and rinsed it out. NA-B then took the commode bucket, now filled with soap and water and poured the soapy water onto R31's floor. NA-B placed the commode bucket back into the commode and then took towels and using their feet, wiped up the soapy water from the floor. A disposable pad and towel were placed on the floor and NA-B then put the commode on top of them. At 7:42 a.m., writer entered the room as R31 was now getting out of bed. Without glove exchange or hand hygiene, NA-B assisted R31 by the arm to the bathroom to urinate NA-B stated the floor may be wet as R31 goes all over the place. After R31 urinated, NA-B obtained a wipe and wiped the toilet seat as R31 walked back to the room. NA-B moved clean towels from the sink in R31's room to his bed and asked R31 to come to the sink. Still without removing gloves or performing hand hygiene, NA-B took R31's toothbrush, added toothpaste and prompted R31 to brush their teeth. When R31 was done, NA-B took the toothbrush and rinsed it off in the sink, using a gloved thumb to rub the bristles. NA-B prompted R31 to wash their hands while NA-B took some clean towels from the bed and placed them back onto the sink. Without hand hygiene or glove exchange, NA-B placed body soap on the towel and got it wet. Assisted resident to wash face. NA-B placed towel in garbage bag. NA-B then lowered R31's soiled pants and took a clean towel placed soap on it and got it wet. NA-B cleaned R31's front groin side and with the same towel wiped down R31's legs to the knees before coming back up to wipe the backside. The wet towel was placed in the garbage bag before NA-B opened a drawer to obtain a dry towel and dried off R31. R31 sat down on the bed. Without hand hygiene or glove exchange, NA-B went to R31's closet and obtained clean clothing. NA-B assisted R31 with a clean sweatshirt and clean pants. R31 put on shoes and NA-B prompted R31 to walk down for breakfast. NA-B finished up with collecting the dirty linens and clothes before removing gloves and performing hand hygiene. When interviewed on 2/25/25 at 8:05 a.m., NA-B verified hand hygiene and glove exchange was not completed after handling soiled towels and the commode bucket and before working with R31. NA-B further acknowledged hand hygiene and glove exchange was not completed in between cleaning soiled areas and working with clean areas. NA-B explained R31 would just get up an urinate anywhere in the room. NA-B used the soapy water from the commode bucket to help keep the smell of urine out of the room. NA-B verified the soap used in the water was a Dial men's 3 in 1 soap. When interviewed on 2/25/25 at 2:02 p.m., universal services staff (USS) stated all resident rooms were cleaned daily. USS stated they just started at one end to the next end. USS stated staff had not informed them of any room needing cleaning due to urine being spilled. USS stated they had not cleaned R31's room yet and left that one for last. USS said R31 urinates on the floor often so that room was saved for last as rooms were completed only once a day. When interviewed on 2/27/25 at 8:33 a.m., universal services manager stated nursing staff should clean up any bodily fluids and then environmental staff should be notified to sanitize the floor. It was expected the USS would clean the floor right away and after each occurrence. Furthermore, body soap would not properly disinfect the floor and would not be used and should not be dumped from a commode bucket. R9 R9's quarterly MDS dated [DATE], indicated R9 had cognitive impairment and diagnoses of dementia, stroke, and dysphagia (difficulties swallowing). Furthermore, R9 was dependent on staff for toileting and bed mobility. R9's care plan revised 12/19/24, indicated R9 was incontinent of bowel and bladder and dependent on staff for toileting. An observation on 2/26/25 at 3:45 p.m., nursing assistant (NA)-E and NA- B assisted R9 back to bed with a lift. R9's was assisted with turning back and forth in bed to remove sling and pull down pants to change brief. NA-A tucked in the left side of brief and then turned R9 to the right. R9 has a small bowel movement. NA-E used a wipe to clean R9 and removed the soiled brief. NA-E then placed the soiled brief on the floor. NA-E then looked at their gloves and took an incontinent wipe and wiped their soiled gloved hands. Without hand hygiene or glove exchange, NA-E assisted with placing R9's clean brief. NA-E and NA-A then assisted with R9's pants. NA-E lowered R9's bed and placed the call light within reach. NA-E moved R9's wheelchair and then picked up R9's soiled brief from the floor and placed in the garbage. NA-E doffed the gloves, tied up the garbage and took to the soiled utility room where hand hygiene was then completed. When interviewed on 2/26/25 at 1:00 p.m., NA-E verified she had not performed hand hygiene or changed gloves after handling R9's soiled brief. NA-E stated since R9's brief was only a little dirty, glove change was not needed. NA-E further verified the soiled brief should not have been on the floor and should have been placed in the garbage right away. When interviewed on 2/27/25 at 10:00 a.m., the infection preventionist (IP) stated hand hygiene and glove exchange was required after handling soiled or potentially dirty items and moving to clean areas during resident cares. IP further stated nursing staff were responsible to clean up any bodily fluids that were on the floor and notify the universal workers to come disinfect the floor. The floors can be cleaned as often as needed. When interviewed on 2/27/25 at 11:49 a.m., the Director of Nursing (DON) expected staff to change gloves and perform hand hygiene when moving from soiled cares to clean cares. Dirty briefs should not be placed on the floor and should be placed in the garbage right away. DON further expected staff to clean up any bodily fluids from the floors and then seek out environmental services to clean or disinfect the floor. All of these were important to prevent infection. A facility policy titled Environmental Cleaning revised 3/2024, was received and did not outline cleaning procedures for bodily fluids. A facility policy for hand hygiene was requested however not received.

Based on observation, interview and record review the facility failed to ensure adaptive equipment was used for 1 of 1 residents reviewed for adaptive equipment. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had cognitive impairment and diagnoses of dementia, stroke, and dysphasia (difficulties swallowing). R9 had was dependent for eating, had difficulty swallowing and required a mechanically altered diet. R9's nutritional assessment dated [DATE], indicated R9 required varying level of assistance with meals and required a nosey cup for drink. R9's Kardex printed 2/25/25, indicated R9 required honey thick liquids and adaptive equipment of a nosey cup. (cup that assists resident with drinking fluids) R9's care plan revised 12/13/24, indicated R9 had severe nutrition deficit related to demean, dysphasia and history of weight loss. Interventions included honey thick liquids and use of nosey cup. R9's meal tickets dated 2/24/25 and 2/26/25, directed staff to provide a nosey cup with meals. An observation on 2/24/25 at 11:47 a.m., lunch started to be served. R9's tray had three cups of juice, however did not have a nosey cup. Nursing assistant (NA)-B placed R9's tray in front of him and set it up before delivering other resident trays. R9 was able feed self with spoon a few bites of pureed diet. R9 reached for cup, but did not pick up. After delivering trays, NA-B sat down and assisted R9 with lunch. NA-B assisted with the juice and NA-B had not obtained a nosey cup. R9 was not able to tip head back to drink all the juice and NA-B poured juices together. When interviewed on 2/24/25 at 12:24 p.m., NA-B stated R9 was dependent with eating and was not able to do eat or drink on their own. NA-B verified R9's meal ticket indicated R9 required a nosey cup however R9 liked to hold the normal cup and sometimes refused it. The cup would be sent up from the kitchen and NA-B stated there were not any on the unit. When interviewed on 2/24/25 at 12:24 p.m., dietary aide (DA)-A verified if adaptive equipment was listed on the ticket, the kitchen would send it up on the tray. When observed on 2/26/25 at 12:16 p.m., NA-E assisted R9 with lunch. R9's tray did not have a nosey cup. When interviewed on 2/26/25 at 12:30 p.m., NA-E verified R9's meal ticket indicated R9 required a nosey cup, however, did not use one during lunch. NA-E stated the cups do not always come on the trays from the kitchen. When the cup was not available, NA-E would see how R9 was doing with drinking out of a normal cup and if there was not a lot of coughing, then the normal cup would be used. If R9 wasn't doing well with the normal cup, then the kitchen would be notified to bring a nosey cup. When interviewed on 2/27/25 at 8:30 a.m., kitchen manager (KM)-B expected adaptive equipment that was included on the meal ticket to be sent with the residents tray. KM-B further stated if it was not, nursing staff should reach out. When interviewed on 2/27/25 at 10:55 a.m., registered nurse (RN)-D stated if adaptive equipment was needed, it should be available and used. RN-D stated the nosey cup was needed to assist with fluid intake and make it easier to swallow. When interviewed on 2/27/25 at 11:55 a.m., the Director of Nursing (DON) expected resident adaptive equipment to be provided by the dietary staff. If the equipment was not provided, nursing staff should reach out to the kitchen to obtain what was needed. A facility policy titled Adaptive Equipment effective 4/5/23, directed staff to assure all residents were assessed and provided the special equipment necessary for them to reach their highest level of functioning.

Based on interview and document review the facility failed to notify the physician of a change in condition for 1 of 1 resident with congestive heart failure (CHF) and a significant weight gain. The facility further failed to ensure appropriate wound care orders were followed for 1 of 1 resident (R35) reviewed for wound care. Findings include: R40 R40's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of CHF, acute and chronic respiratory failure with hypoxia, acute kidney disease, and fluid overload. It further indicated R40 required partial/moderate assistance with most activities of daily living (ADL) and mobility. R40's physician's orders dated 1/20/2025, indicated daily weights and to update the provider of a weight gain of 2 pounds (lbs.) in one day and/or 5 lbs. in one week, every shift. R40's care plan dated 1/3/25, indicated R40 had CHF, peripheral heart disease (PAD), and hyperlipidemia (HLD). Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Notify provider of abnormalities. It further indicated the following interventions: -Daily weights, call medical doctor (MD)/nurse practioner (NP) for weight gain of more than 2 pounds per day and/or 5 pounds per week. -Encourage adequate nutrition. Offer small frequent feedings. -Give cardiac medications as ordered. -Monitor lab work; potassium (K+), sodium (NA), blood urea nitrogen (BUN), and creatinine. -Monitor/document sleeping pattern. Inform physician of any insomnia or anxiety. Give sedatives as ordered. Monitor/document/report (as needed) any signs or symptoms of CHF: dependent edema of legs and feet, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. Report to provider as indicated. R40's treatment administration record (TAR) for January and February of 2025 indicated, during the week of 1/20/25-1/26/25 R40 had a weight gain of 11.4 lbs., from 1/25/25-1/26/25 a weight gain of 8.8 lbs., and from 2/6/25-2/27/25 a weight gain of 13 lbs. as evidenced by the weights below: -1/20/25 443.4 lbs. -1/24/25 443.8 lbs. -1/25/25 446.0 lbs. -1/26/25 454.8 lbs. -1/27/25 445.6 lbs. -2/6/25 433.0 lbs. -2/7/25 446.0 lbs. -2/10/25 442.0 lbs. -2/11/25 448.0 lbs. R40's progress notes for the month of January and February of 2025, lacked any indication the doctor had been notified of a change in condition regarding weight gain During interview on 2/26/25 at 4:40 p.m., RN-F verified R40's weights on her January and February TAR were more than 2 lbs. in one day and 5 lbs. in one week (as referenced above) and stated the physician should have been notified and documentation should have occurred. During interview on 2/26/25 at 4:46 p.m., RN-G verified R40's weight gain of more than 2 lbs. in one day and 5 lbs. in one week (as referenced above ) and stated the nurses were responsible for calling the provider and documenting in the progress notes. RN-G further stated if a resident needed to be re-weighed, they should document it in the progress notes. During interview on 2/27/25 at 9:45 a.m. the nurse practioner (NP) stated the only time she had been notified of R40's weight gain was when she sent her to the hospital for hypervolemia on 2/12/25. The NP further stated she was in the facility 4 days per week and reviewed the weights of the patients she planned to see that day. She didn't see every resident every time she was there, therefore the order indicated to notify the physician and that's what the nursing staff were expected to do. The nurses were responsible for re-weighing a resident if there was an issue with the weight. The NP also verified the order was intended to be for a 7 day period typically from Monday to Sunday. During interview on 2/27/25 at 12:45 p.m. the director of nursing (DON) stated the nurses were responsible for notifying the provider of a change in condition and the provider should have been notified regarding R40's weight gain. This was important because R40 had CHF and was at risk for fluid overload which could have negative effects on her cardiac health. The facility's policy regarding weight and height dated 10/2021, indicated to document resident weight in PCC and update the provider of weight increases or decreases as needed and per physician's orders. 49617 R35 R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was dependent on staff for toileting and personal hygiene cares as well as mobility and transfers. The MDS identified R35's diagnoses of dementia (a loss of memory, language, problem-solving and other thinking abilities) and indicated she was unable to complete the mental status assessment interview. Additionally, the MDS identified she was at risk for developing a pressure injury and had moisture-associated skin damage (MASD, or skin irritation or breakdown caused by prolonged exposure to moisture such as urine, saliva, sweat, or wound drainage). R35's Care Area Assessment (CAA) for pressure ulcer/injury dated 10/31/24, identified her MASD to left gluteal fold with treatment. The CAA directed staff to the care plan for goals and interventions. R35's care plan revised on 2/5/25, identified her impaired skin integrity and risk for further breakdown as evidenced by MSAD to her buttocks. The care plan directed staff to provide treatment and wound care as ordered. R35's signed order summary dated 1/6/25, included the wound order: - wound care 1. Facility staff to perform every other day and as needed 2. Cleanse open areas to buttocks and upper thigh. Allow to dry. Apply Mepilex over open areas every day shift every other day for MASD, dated 12/17/24. R35's TAR dated 2/25, reflected the following wound care orders: - wound care to buttocks: cleanse open areas with wound cleanser. Pat dry. Cover with Mepilex dressing, change every evening shift every other day for MASD, dated 2/26/25 at 7:08 p.m. - wound care for left heel: cleanse with wound cleanser. Pat dry. Apply Medihoney and cover with Mepilex dressing. Change daily and PRN (as needed) every evening shift, dated 1/23/25. During observation on 2/26/25 at 6:14 p.m., registered nurse (RN)-C and RN-D were at R35's bedside during evening cares. RN-D stood at the head of the bed and talked to R35 while RN-C performed wound cares. RN-C sprayed a wound cleanser over R35's buttocks to cleanse the area before patting it dry with gauze. RN-C applied a dark, honey-colored gel from a tube to her gloved fingertips and dabbed it onto each of the opened and red areas on her buttocks, and then applied more from the tube to her fingertips and dabbed it onto the fluid-filled sacs on R35's buttocks. RN-C then applied foam dressings to cover the areas and dated each dressing. During interview on 2/26/25 at 6:42 p.m., RN-C reviewed R35's wound care orders and TAR dated 2/25 and was unable to find current or active wound treatment orders for her. RN-C verified the wound treatment orders for R35's pressure ulcer to her left heel, which included Medihoney, and confirmed applying it to R35's buttock during wound cares. During interview on 2/27/25 at 2:26 p.m., RN-D verified the MSAD treatment order should have been cleanse with a wound cleanser, pat dry with gauze and cover with a Mepilex. RN-D confirmed witnessing RN-C applying the Medihoney to R35's MSAD on her buttocks and stated, I thought I saw RN-C doing that. RN-D expected staff to verify and double check orders before applying treatments if staff were unsure. Per interview on 2/27/25 at 3:13 p.m. with the director of nursing (DON), staff were expected to review treatment orders if they were unsure of an order before administering the treatment or order. Per facility policy titled Management of Skin Alterations dated 9/11/24, residents with wounds would have at minimum weekly monitoring for appropriateness of treatment/care plan, signs of healing and would report to the provider as needed. Education would be provided to staff as needed on alterations in skin integrity.

Based on interview and document review, the facility failed to investigate an incident of anaphylactice reaction and need for emergency services for 1 of 1 residents (R23) reviewed for anaphylactic reaction. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and required setup assistance for eating. R23's diagnoses included acute ischemia of small intestine (decrease in blood flow), type 2 diabetes, and [NAME]-[NAME] syndrome [a condition affecting appetite and causing one to always feel hungry). R23's diet order/dietary communication dated 11/29/24, indicated food allergies, ginger, bee pollen. R23's allergy list printed 2/25/25, indicated the following food allergens: ginger, bee pollen/royal jelly. R23's physician order history indicated the following: -Epinephrine injection solution auto-injector 0.3mg/0.3ml. Inject 0.3 mg intramuscularly as needed for anaphylaxis, allergy to ginger, daily - start date 11/29/24 at 5:00 p.m. -11/29/24 at 9:29 p.m. on hold, insurance does not cover. -12/18/24 at 3:19 p.m. resume, ordered per provider. -Date received-12/23/24, on hand. During interview on 2/24/25 at 11:51 a.m., R23 stated a few months ago she was provided a meal consisting of a piece of chicken and stir fry vegetables. R23 stated her meal ticket did not indicate chicken; therefore, did not know what type of chicken was provided. R23 asked several unidentified staff members if the food items contained ginger, and all said no. After a couple bites, R23 stated she thought she bit into a piece of ginger and within a few seconds her lips started tingling and she felt her throat beginning to tighten. R23 notified staff she was having anaphylactic reaction and requested epinephrine. R23 was told her epinephrine order was on hold due to insurance not covering it and staff did not have epinephrine in the emergency medication kit (e-kit). Review of facility week 2 menu for Saturday was Honey Ginger chicken thighs and Asian Stir fry vegetable mix. R23's progress note dated 12/14/24 at 10:56 p.m., indicated R23 reported to staff of having a food allergy after eating part of her dinner and on assessment discovered R23 having a stick [sic] throat, and does not feel well. R23 started having shortness of breath and was put on oxygen at 4 liters/min. Resident had an order for epinephrine but it was on hold and the medication was not available. Staff called 911 and resident was sent to the hospital. R23's progress noted dated 12/14/24 at 11:05 p.m., indicated, This writer re email [sic] resident diet order to kitchen because one of the dietary stated that they don't have the food allergy in their file. R23's emergency department after visit summary (AVS) dated 12/14/24, indicated, Reason for Visit ALLERGIC REACTION Diagnoses -Shortness of breath - Anaphylaxis, initial encounter. The AVS instructed, You were seen today for an allergic reaction. Your symptoms improved after an epi pen. Return to the emergency department with any new or worsening symptoms. Review of facility risk management lacked evidence facility completed an investigation or safety incident report for R23's anaphylactic reaction event. During interview on 2/27/25 at 2:29 p/m., director of nursing stated expectation for staff to initiate a safety event or risk management entry, both process include the required report of the event to the administrator and DON regardless of date, time or shift. DON stated either herself or the administrator would then file a report with the SA and initiate an investigation. DON confirmed that this did not happen following R23's anaphylactic reaction. During interview on 2/27/25 at 3:13 p.m., administrator stated expectation of any adverse event would be reported via a group text which included herself, the DON, unit managers and the manager on call. Administrator stated either herself or DON would submit a report to the SA and initiate an investigation. Administrator confirmed that the event involving R23's anaphylactic reaction that occurred on 12/14/24, was not reported to the SA until 2/26/25. Facility policy Incident/Accident Reports dated 1/24, indicated, When the incident/accident involves a resident, nursing is responsible for notation in the medical record Risk Management and progress note describing the incident /accident, as well as, prompt follow-up action, intervention and notification of family and physician. The policy further indicated, DON or designee would review and ensure documentation was complete and when appropriate ensure incidents were reported in accordance with state and federal law. The policy further indicated, Designated staff member [designated by the administrator or DON] will initiate an internal investigation as needed to determine the root cause of the incident. Facility policy Vulnerable Adult-Abuse Prohibition Plan dated 10/24, indicated all incidents involving abuse, neglect, exploitation or mistreatment would be reported immediately to the SA. The policy defined neglect as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further indicated, All incidents requiring medical intervention or follow-up are documented in the resident record and DON, Administrator or other designee would immediately institute an internal investigation of the reported allegation or incident. The policy indictated the investigation may include but not limited to the following: -Interviews and written statements with staff and any witnesses -Resident and resident representative interviews -Care observations -Environmental review -Resident health status and medical record review.

Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 residents (R44) observed with medications at bedside. Findings include: R44's annual Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition, was dependent on staff for personal hygiene and mobility, and required setup or clean-up assistance with eating. The MDS reported diagnoses of a stroke (when blood flow to a part of the brain is disrupted, causing a lack of oxygen and brain cell death), aphasia (a language disorder affecting a person's ability to communicate), dementia (loss of memory, language, problem-solving and other thinking abilities), and hemiplegia or hemiparesis (one-sided muscle weakness or paralysis). Additionally, the MDS identified he had a mechanically altered diet and did not exhibit signs or symptoms of a possible swallowing disorder. R44's order summary report dated 12/25/24, were reviewed on 2/24/25 and lacked documentation of an order for self-administration of medications. Additionally, his order summary report lacked an order for Tums, an antacid medication. R44's medication administration record (MAR) dated 2/2525, was reviewed on 2/24/25 and lacked documentation of an order for self-administration of medications as well as an order for Tums. R44's electronic health record (EHR) was reviewed on 2/24/25 at 9:19 a.m. and lacked documentation of an assessment to self-administer medications. During observation on 2/24/25 at 9:19 a.m., R44 was in bed with his bedside table over the bed, and on the bedside table was a bottle with the label Smoothies-flavored Tums. During observation on 2/25/25 at 10:05 a.m., the bottle of Tums remained unchanged on the bedside table. During observation on 2/27/25 at 10:02 a.m., the bottle of Tums remained unchanged on the bedside table. During interview on 2/27/25 at 10:08 a.m., registered nurse (RN)-C stated a resident wishing to administer their own medications should have an assessment for self-administration. RN-C stated the assessments were completed by nursing staff and then the provider would be updated. RN-C reviewed R44's EHR and confirmed he did not have a self-administration assessment or an order to self-administer medications. RN-C stated we did see it; we were asking our manager about the medications noted at his bedside table, and stated he has very high anxiety, he would get really upset about it if staff took the bottle away from him. RN-C walked into R44's room and confirmed there was a bottle of Tums on his bedside table and asked him where it came from. He responded, my family, and RN-C told him the bottle would not be removed right now but it would be discussed with the nurse manager. During interview on 2/27/25 at 10:16 a.m., licensed practical nurse (LPN)-B reviewed R44's physician orders and confirmed he did not have an order for Tums or a generic equivalent. LPN-B further verified he should have a self-administration assessment and order to have the Tums at his bedside and stated, I feel like he would be able to self-administer the Tums because of his pureed diet and the Tums being chewable or dissolvable. LPN-B stated, I will update the provider and the nurse manager. Per interview on 2/27/25 at 2:39 p.m., RN-D expected staff to complete a self-administration assessment first, then get an order from the provider with the okay to self-administer medications. RN-D also expected staff to remove medications from a resident's room the second someone noticed it. RN-D stated the risks could include possible medication contraindications or interactions, indications for use, safety implications and stated, we need to get the provider involved to make that decision. Per interview on 2/27/25 at 3:34 p.m., the director of nursing (DON) expected staff complete a self-administration assessment and obtain a provider order. The DON stated if a family member brought in a medication from home, staff should question why there was a need for that medication and get the provider involved. The DON indicated the risks included polypharmacy and interactions with other medications. Per facility policy titled Self Administration of Medications (SAM) revised 9/24, a self-administration of medications assessment would be completed for any resident requesting to administer any medication without the direct supervision of a nurse and the interdisciplinary team would review the recommendation to determine if the resident was safe to do so. The resident's physician would need to write an order for the resident to self-administer medications and only the medications permitted for self-administration would be left at the bedside. The resident's care plan should be updated to reflect self-administration of medications.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained during cares for 1 of 2 residents (R35) reviewed for dignity. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was dependent on staff for toileting and personal hygiene cares as well as mobility and transfers. The MDS identified R35's diagnoses of dementia and indicated she was unable to complete the mental status assessment interview. R35's care plan dated 2/5/25, identified impaired cognitive function or impaired thought processes related to dementia. Furthermore, the care plan indicated R35 had a communication problem related to finding the right words to say and directed staff to anticipate and meet R35's needs. Finally, the care plan identified activities of daily living (ADL) self-deficit related to dementia (a loss of memory, language, problem-solving and other thinking abilities) diagnosis and indicated R35 required staff assistance for dressing, personal hygiene, and toilet use. During continuous observation of evening cares on 2/26/25 between 5:56 p.m. and 6:26 p.m., nursing assistant (NA)-C and NA-D used a mechanical body lift to assist R35 into the bed at 5:58 p.m. and assisted to lay down. R35 began to call out, get out of here repetitively while NA-C pulled her pants down, removed her socks and unfastened the front tabs of her incontinence brief. NA-C told R35 they would be quick while they cleaned her up and NA-D held R35's hand and told her, It's okay. At 6:00 p.m., R35 was uncovered and exposed from the waist down and the NAs worked together to remove her top. NA-C turned her back towards NA-D and R35 and turned on the water at the sink and let the water run while R35 was completely nude and exposed on the bed. At 6:01 p.m., NA-C returned to the bedside. NA-D pulled R35's legs apart while she continued to call out, get out of here assholes. NA-C first washed her face, then they assisted R35 to turn onto her right side and began to wash her backside. NA-C stated, she's just going and she used cleansing wipes to clean feces from R35's buttocks. R35 continued to call out, get out of here. NA-C reported a new area to R35's buttock to the surveyor, calling the surveyor over to assess. NA-C changed soiled gloves and R35 remained nude, and her exposed backside faced the door. At 6:08 p.m., there was a knock at the door and registered nurse (RN)-C opened the door to R35's fully exposed buttocks. RN-C walked over to the bedside and draped the hospital gown over R35's neck, covering her front side and began to rub her back gently. RN-C stated this was done to promote her dignity and they wouldn't want their family members to be laying like that naked. RN-C expected staff to protect a resident's dignity during cares by covering them up with blankets or clothing when it would not impede cares. RN-C also stated it may help provide comfort since being naked might make the resident cold. During interview on 2/26/25 at 6:37 p.m., NA-C verified they had not provided for R35's dignity during cares. NA-C stated it was something they didn't think about and was grateful to be reminded especially for those residents who cannot speak for themselves. NA-C stated covering her also may have provided warmth, which could have promoted comfort during their cares. Per interview on 2/27/25 at 2:22 p.m., RN-D expected staff to only expose what needs to be exposed during cares. RN-D provided the example of covering the chest if perform peri-cares and keeping a resident's bottom covered if performing upper body cares. Per interview on 2/27/25 at 3:13 p.m., the director of nursing (DON) expected staff to try and maintain dignity to the highest level as possible during cares. The DON stated staff should shut the door, pull a privacy curtain if able, explain the task they are about to perform, and ask the resident how they could keep them comfortable. The DON stated staff should maintain privacy as much as they are able to in order to promote a resident's dignity. A policy pertaining to dignity was requested but not received.

Based on interview and document review, the facility failed to ensure an allegation of potential harm was reported to the State Agency (SA) in the required timeframe for 1 of 1 residents (R23) reviewed for anaphylactic reaction. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and required setup assistance for eating. R23's diagnoses included acute ischemia of small intestine (decrease in blood flow), type 2 diabetes, and [NAME]-[NAME] syndrome [a condition affecting appetite and causing one to always feel hungry). R23's diet order/dietary communication dated 11/29/24, indicated food allergies, ginger, bee pollen. R23's allergy list printed 2/25/25, indicated the following food allergens: ginger, bee pollen/royal jelly. R23's physician order history indicated the following: -Epinephrine injection solution auto-injector 0.3mg/0.3ml. Inject 0.3 mg intramuscularly as needed for anaphylaxis, allergy to ginger, daily - start date 11/29/24 at 5:00 p.m. -11/29/24 at 9:29 p.m. on hold, insurance does not cover. -12/18/24 at 3:19 p.m. resume, ordered per provider. -Date received-12/23/24, on hand. During interview on 2/24/25 at 11:51 a.m., R23 stated a few months ago she was provided a meal consisting of a piece of chicken and stir fry vegetables. R23 stated her meal ticket did not indicate chicken; therefore, did not know what type of chicken was provided. R23 asked several unidentified staff members if the food items contained ginger, and all said no. After a couple bites, R23 stated she thought she bit into a piece of ginger and within a few seconds her lips started tingling and she felt her throat beginning to tighten. R23 notified staff she was having anaphylactic reaction and requested epinephrine. R23 was told her epinephrine order was on hold due to insurance not covering it and staff did not have epinephrine in the emergency medication kit (e-kit). Review of facility week 2 menu for Saturday was Honey Ginger chicken thighs and Asian Stir fry vegetable mix. R23's progress note dated 12/14/24 at 10:56 p.m., indicated R23 reported to staff of having a food allergy after eating part of her dinner and on assessment discovered R23 having a stick [sic] throat, and does not feel well. R23 started having shortness of breath and was put on oxygen at 4 liters/min. Resident had an order for epinephrine but it was on hold and the medication was not available. Staff called 911 and resident was sent to the hospital. R23's progress noted dated 12/14/24 at 11:05 p.m., indicated, This writer re email [sic] resident diet order to kitchen because one of the dietary stated that they don't have the food allergy in their file. R23's emergency department after visit summary (AVS) dated 12/14/24, indicated, Reason for Visit ALLERGIC REACTION Diagnoses -Shortness of breath - Anaphylaxis, initial encounter. The AVS instructed, You were seen today for an allergic reaction. Your symptoms improved after an epi pen. Return to the emergency department with any new or worsening symptoms. Review of facility risk management lacked evidence facility completed an investigation or safety incident report for R23's anaphylactic reaction event. During interview on 2/27/25 at 2:29 p/m., director of nursing stated expectation for staff to initiate a safety event or risk management entry, both process include the required report of the event to the administrator and DON regardless of date, time or shift. DON stated either herself or the administrator would then file a report with the SA and initiate an investigation. DON confirmed that this did not happen following R23's anaphylactic reaction. During interview on 2/27/25 at 3:13 p.m., administrator stated expectation of any adverse event would be reported via a group text which included herself, the DON, unit managers and the manager on call. Administrator stated either herself or DON would submit a report to the SA and initiate an investigation. Administrator confirmed that the event involving R23's anaphylactic reaction that occurred on 12/14/24, was not reported to the SA until 2/26/25. Facility policy Incident/Accident Reports dated 1/24, indicated, When the incident/accident involves a resident, nursing is responsible for notation in the medical record Risk Management and progress note describing the incident /accident, as well as, prompt follow-up action, intervention and notification of family and physician. The policy further indicated, DON or designee would review and ensure documentation was complete and when appropriate ensure incidents were reported in accordance with state and federal law. Facility policy Vulnerable Adult-Abuse Prohibition Plan dated 10/24, indicated all incidents involving abuse, neglect, exploitation or mistreatment would be reported immediately to the SA. The policy defined neglect as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further indicated, All incidents requiring medical intervention or follow-up are documented in the resident record and DON, Administrator or other designee would immediately institute an internal investigation of the reported allegation or incident.

Based on interview and document review, the facility failed to determine causal factors and develop new interventions to prevent falls for 1 of 1 residents (R1) reviewed for falls who had a history of falls and slid out of wheelchair while transporting to appointment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, schizophrenia and moderate cognitive impairment. R1's MDS further indicated she used a wheelchair for mobility and could not ambulate. R1's care plan dated 7/18/24, indicated R1 was at risk for falls related to deconditioning, balance problems, incontinence, psychoactive drug use and history of falls. R1's care plan directed staff to anticipate needs, give resident verbal reminders not to transfer without assistance and offer to lie down when observed restless in wheelchair. R1's Fall assessment dated [DATE], indicated R1 had intermittent confusion, chair bound, required assistive device and scored a fall risk of 13 (moderate risk for falls). A fall Interdisciplinary Note (IDT) note dated 5/28/24, indicated resident found lying on the floor, right side wheelchair nearby, shoes on. Resident stated she was trying to get back into bed. No injuries observed, impaired memory, confused, impaired safety judgement and misjudgment ability was noted. An Interdisciplinary Note (IDT) dated 8/28/24, indicated Driver called for res' called nursing station to say that res {R1} fell out of her wheelchair and that he could not get her to stay in the wheelchair. Writer told driver to call 911 to get assistance from EMT (emergency medical technician) but he refused to do that. The driver brought res back to facility as she sat on the floor of the van. When res arrived at facility, staff assessed her and returned her to her wheelchair. Resident {R1} unable to give description. The IDT note indicated using a gait belt and three staff members, res {R1} was returned to her wheelchair and then wheeled out of the van. Writer took her to dining room and sat with her while she ate dinner. When she was returned to her bed, nurse assessed her skin for any bruising and did a set of vitals. The IDT note indicated no injuries were observed, and she was wearing shoes, was confused and incontinent. A progress note dated 8/29/24 at 10:06 a.m., indicated reviewed R1's fall reported by transportation company on 8/28/24. Resident slid from her wheelchair while being transported back to facility following appointment. No injuries appears to be an isolated occurrence. Not reportable, abuse/neglect is not suspected. Care plan reviewed. Review of R1's electronic health record lacked documentation a post-fall assessment had been completed which identified the cause of the fall and updated interventions put in place to prevent additional falls from occurring while transporting R1 to appointments. During an interview on 9/26/24 at 9:04 a.m., family member (FM)-A stated R1 had her appointment on 8/28/24, she had surgery that day and the appointment was supposed to be canceled however there was a mix up. FM-A stated she was informed on R1's way back from her appointment she fell out of her wheelchair, the driver called for help, and refused to follow the facility's request to send R1 to the hospital. The facility informed FM-A they would follow up with the transportation company on what exactly happened and a week later FM-A stated she had called and the transportation company had no knowledge of the incident with R1. During an interview on 9/30/24 at 2:08 p.m., the health unit coordinator (HUC)-A for memory care/long term care stated on 8/28/24, when R1 returned from her appointment she remembered the driver informing her R1 slid out of her wheelchair and had raised her seat belt. The HUC-A further stated R1 had been refusing her medications, was confused as she was talking about Jesus, drinking margaritas and being pregnant by Jesus when she returned from her appointment. During an interview on 9/30/24 at 2:30 p.m., the facility administrator stated she was aware of the incident with R1 sliding to the floor of the transportation van. The administrator stated the transporting company called the facility stating R1 slid out of her wheelchair on her way back from her appointment and asked what was wrong with our resident because she kept wanting to sit on the floor. The driver said she was sitting on the floor for 10 minutes before arriving back to the facility after her appointment. The administrator did state after the incident, she had attempted to reach the transportation company with no return calls. During an interview on 10/01/24 at 9:45 a.m., nursing assistant (NA)-A stated R1 was at risk for falls and when she was in her wheelchair she always attempted to slide out of her chair. In addition, NA-A stated it never felt safe to have her in a wheelchair for transportation for appointments. During an interview on 10/01/24 at 10:00 a.m., NA-B stated whenever R1 was placed in her wheelchair, she attempted to get out and wanted to slide out. NA-B stated the nursing staff had been informed of it and the only way R1 would have been safe to be transported to appointments was in a reclining wheelchair, not a regular wheelchair. During an interview on 10/01/24 at 10:05 a.m., transportation company owner stated the incident occurred around on 8/28/24, at 4:20 p.m., during traffic time after the driver picked R1 up from her appointment. At first R1 was sliding a little and asked the driver to slid her back into her chair, and once the driver started to drive he had to stop and slid her back into her chair, and then she ended up on the floor shortly after he started to drive again. The owner stated she did not understand how they could have sent R1 alone in the van with just the driver since she would not sit in a wheelchair alone. The owner stated R1 would not be allowed to use their company again unless a staff member was with or in a stretcher. During an interview on 10/01/24, at 12:00 p.m., the facility director of nursing (DON) stated she was not informed R1 was at risk of sliding out of her wheelchair. The DON further stated the staff should have informed her prior to R1's fall. Ebenezer Policy Fall Risk, Post Fall investigation, Follow Up, and Care, revision 12/23 indicated, the purpose is to define nursing role in the management of patients at risk for falls and post fall investigation, follow up and care.

Based on interview and document review, the facility failed to provide adequate supervision when staff allowed a family member to take a resident into the community where R4 subsequently fell and was hospitalized . R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 had impaired cognition with diagnoses including dementia. R4's care plan dated 7/24/24, indicated was an elopement risk due to cognitive ability, and history of wandering during the night and when out in the community. R4 was also a fall risk due to confusion and deconditioning. R4's hospital discharge summary dated 4/26/24, included a note by the hospital social worker which indicated there was an open vulnerable adult protection case as of 4/21/24. R4 had been placed in an assisted living and family member (FM)-B removed R4 against medical advice. FM-B also had lost R4 in their apartment building. She was unable to locate R4 and external parties were involved in locating R4. The note further indicated there would likely be concerns from the long-term care facilities about FM-B removing R4 against medical advice. Additionally, the note indicated part of the hospital discharge plan was for the receiving facility to not allow FM-B to bring R4 out of the facility. R4's Electronic Health Record (EHR) included special instructions: resident is not to go on outings or leave of absence with family, and call security for assistance as needed. On 7/24/24, a progress note indicated FM-B asked the nurse if she could take R4 out of the building. The nurse said she could not, and directed FM-B to talk to the nurse manager. At 3:50 p.m. R4 was discovered missing, and FM-B was called. FM-B told staff they were at the train station, and R4 had fainted. Staff went to the train station then called 911. Emergency medical services (EMS) transported R4 to the hospital for possible stroke. On 7/25/24 at 2:44 p.m., registered nurse (RN)-B stated there was information placed in R4's EHR on admission to not let him go out with FM-B because there were some problems with FM-B not keeping track of him in the community. On 7/25/24 at 3:48 p.m., RN-C stated she had told FM-B she could not take R4 out of the building. RN-D told FM-B she could take R4 out of the building because she was his primary contact. Later, when R4 was discovered missing, RN-B told RN-C FM-B was not allowed to take R4 out of the building. RN-C stated she did not see the information in the EHR about R4 not going out of the building with family. On 7/25/24 at 4:57 p.m., nursing assistant (NA)-A stated FM-B had requested a four wheeled walker so she could take R4 into the community. She relayed the request to RN-C and RN-D. The nurses requested NA-A to find out FM-B's name so they could confirm FM-B was allowed to take R4 into the community. Upon confirming FM-B's name, RN-D stated it was ok for FM-B to take R4 into the community. NA-A opened the locked memory care door for FM-B because RN-D confirmed it was ok. NA-A had gone to the train station three blocks away after FM-B informed the facility R4 had fainted. NA-A checked for a pulse and breathing then called 911. NA-A stated R4 was stiff and would not wake up. On 7/25/24 at 5:34 p.m., the director of nursing (DON) stated at the beginning of R4's stay, staff were nervous because of what they had been told about FM-B from hospital staff. R4 had a WanderGuard (alarm) placed on admission to prevent FM-B from removing R4 from the unit, but R4 was not exit seeking and FM-B had not visited, so it was removed. R4 continued to remain on the locked memory care unit where a staff badge was required for exit. The DON confirmed staff should not have allowed FM-B to remove R4 from the unit. R4 had been admitted to the hospital on 7/24/24 for suspected seizure. A policy on allowing visitors to take residents out of the building was requested but not provided.

Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 2 of 3 residents (R2, R3) reviewed for medication errors. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had severely impaired cognition, with diagnoses including dementia and depression. R2's hospital discharge orders dated 6/14/24 included vortioxetine (an antidepressant medication) 5 milligrams (mg) daily for adjustment disorder with mixed anxiety and depressed mood. R2's Medication Administration Records (MAR) for June 2024 and July 2024 lack indication vortioxetine was administered. R2 missed 16 doses in June 2024 and 17 doses in July 2024. R2's Consultant Pharmacist (CP) note dated 7/17/24 indicated the hospital discharge order for vortioxetine could not be located in R2's electronic health record (EHR) Physician Orders list. A facility report to the State Agency (SA) on 7/18/24 indicated R2 had not received vortioxetine since admission on 6/14/24. R3's quarterly MDS dated [DATE] indicated R3 had moderately impaired cognition, with diagnoses including depression, anxiety, and psychosis. R3's provider Telephone Order (TO) dated 6/7/24 instructed Abilify 5 (antidepressant) mg PO (by mouth) daily and 2mg PO Q2H (every 2 hours) PRN (as needed) x 14 days for delusion, paranoia, and hallucinations. R3's handwritten TO dated 7/22/24 instructed Abilify oral tablet give 5mg by mouth daily for paranoia. There are no initials in the column that indicated the order was transcribed into Point Click Care electronic medication administration record (eMAR) or that the order was second checked. R3's June MAR indicated Abilify 5 mg by mouth one time a day for delusions, paranoia, hallucinations for 14 days. It was administered daily from 6/8/24 through 6/21/24. There were no administrations of Abilify from 6/22/24 through 6/30/24 (8 doses). R3's July MAR lacked instruction to administer Abilify from 7/1/24 through 7/25/24 (25 doses). On 6/19/24 R3's psychiatrist note indicated Abilify seemed to have helped with targeting hallucinations as staff reported there have been no notes or concerns regarding psychosis or concerns of bugs crawling all over her. On 6/26/24 R3's behavior note indicated R3 told the trained medication assistant there were bugs crawling all over her body. On 7/10/24 R3's nurse practitioner (NP)-A note indicated R3 reported seeing bugs on her body and bed. R3 was anxious about this and wanted medication adjustment as able. NP-A indicated Oxycodone would be restarted because that has been the first medication change which perhaps prompted the hallucinations of bugs. The medication list on NP-A's note did not list Abilify. On 7/22/24 R3's NP-A note indicated R3 reported worsening hallucinations of seeing bugs all over her body, into her hair and into her eyes. R3's left eye was visibly red suspected to scratching eye. Also, various scratch marks over face, chin and chest. R3 was moderately distressed given hallucination complaints. NP-A reached out to R3's psychiatrist with current medication orders. It was discovered R3's scheduled and PRN Abilify had been discontinued instead of just the PRN order. NP-A advised to monitor for worsening symptoms of hallucinations and delusions. NP-A ordered to restart Abilify 5mg daily per psychiatrist recommendations. On 7/25/24 at 10:52 a.m., family member (FM)-A stated R3 had hallucinations a while ago, but then they went away. The hallucinations were back again. R3 was feeling bugs crawl on her, so she was scratching at her skin. FM-A thought the hallucinations were disturbing to R3. On 7/24/24 at 3:22 p.m., licensed practical nurse (LPN)-A verified R3 did not have an active order for Abilify. On 7/25/24 at 12:02 p.m., registered nurse (RN)-A stated she transcribed the order for Abilify on 6/7/24. She thought both the scheduled and PRN dosing were for 14 days. She should have clarified with the provider. There was no procedure for nursing to follow up with a provider when a medication was ordered for a specific time frame. She would assume the provider would be reassessing automatically. The nurse would only follow up if the order specified to follow up with provider. On 7/25/24 at 4:42 p.m., psychiatrist (MD-A) stated R3 was prescribed Abilify for tactile hallucinations. She was contacted by NP-A regarding R3's increased hallucinations on 7/22/24. She reviewed R3's medication orders because she wanted to increase R3's Abilify dose. The Abilify was not on R3's current medication list. She communicated to NP-A to reorder Abilify. She confirmed she had not given an order to discontinue the Abilify, and the scheduled dose should not have been transcribed for 14 days. Missing doses of Abilify may have contributed to R3's increased hallucinations. She expected orders to start the day after she wrote the order to give the facility time to obtain the medication from the pharmacy. Abilify should have been administered starting 7/23/24. On 7/25/2024 at 5:34 p.m. director of nursing (DON) stated when a new admission arrived at the facility, provider orders were first entered by the health unit coordinator or by a nurse. All orders must be second checked by a nurse. All pages of a resident's discharge order summary should be checked for provider orders. R2's discharge order summary had been double checked, but the order for vortioxetine was on the top of the last page of orders and had been missed by both nurses. The missing order was discovered by the consulting pharmacist. A facility wide chart audit was not completed to assess if there were any other medications that had not been transcribed. R3's Abilify order should have been clarified by the provider before entering the 14-day time frame. R3's provider order dated 7/22/24 for Abilify was not transcribed according to facility policy. There should have been initials in the column that indicated the order was transcribed into Point Click Care electronic medication administration record (eMAR) or that the order was verified. Handwritten provider orders should be placed in appropriate bins for order to be entered, second checked then uploaded. It appeared the order was placed into the to be uploaded bin before the order was transcribed. Abilify had been ordered for R3 to treat hallucinations. The Transcription of Physician's Orders policy dated 8/23 directed to ensure accurate transcription of physician orders the order is documented by physician or nurse practitioner. The HUC or nurse transcribes the order into Point Click Care and signs off. The order is faxed to pharmacy. The order is double checked by a nurse and signed off as checked. HUC uploads any paper copies of orders into point Click Care.

Based on observation, interview, and document review the facility failed to ensure handwashing and appropriate glove usage was implemented for 1 of 1 resident (R9) observed for personal cares. Findings include: During observation of personal cares on 3/20/24 at 8:54 a.m., nursing assistant (NA)-A was changing R9's brief. NA-A applied gloves, used wipes to clean R9's peri area and bottom, put on a new brief and pulled up his pants. Then NA-A (without removing her gloves) removed R9's shirt, put on a new shirt, pulled the covers up to his chin, adjusted the pillow (under his head), put the bolster under the fitted sheet on his bed, and used the bed controller to put the bed in a low position. NA-A then walked out of the room (wearing the same gloves) and brought R9's shirt to the soiled utility room, removed her gloves, and used hand sanitizer. During interview on 3/20/24 at 9:05 a.m., NA-A verified she had not removed her gloves and washed her hands after changing R9's brief and should have. NA-A stated staff should always change their gloves and wash or sanitize their hands when going from a dirty area to a clean one (Ex: changing a brief to adjusting the residents pillow). During interview on 3/20/24 at 10:34 a.m., the Infection Preventionist (IP) stated staff should always remove their gloves and wash/use hand sanitizer after changing a residents depends or going from a dirty to clean area. The IP further stated if staff do not remove their gloves, they could be spreading bacteria to other residents and/or surfaces. During interview on 3/20/24 at 1:35 p.m., the director of nursing (DON) stated staff should be removing their gloves and washing their hands/using hand sanitizer after providing peri cares and then don a new pair of gloves before moving on to other areas. A facility policy on handwashing/appropriate glove usage was requested and received but it didn't address when staff should change their gloves or wash their hands when providing cares to residents.

Based on observation, interview, and document review, the facility failed to ensure a pressure relief air mattress was assessed for safe size in relation to the bed frame and grab bars for 1 of 1 residents (R51) reviewed for accidents. Findings include: The Guidance for Industry and Food and Drug Administration (FDA) Staff - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], indicated Zone 3, the space between the mattress and the bed rail, should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails, and recommended a dimensional limit of less than 4 ,d+[DATE] inches (in.) for the area between the inside surface of the rail and the compressed mattress. R51's admission Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, and had diagnoses of sepsis, muscle weakness, and encephalopathy. R51 required substantial/maximal assistance for rolling left and right in bed and was dependent on staff for transfers and toileting. R51 was at risk for pressure ulcers, had one stage II pressure ulcer, and used a pressure reducing device for their bed. The MDS indicated R51 did not use bed rails. R51's Fall Risk assessment dated [DATE], indicated they had intermittent confusion and took ,d+[DATE] medications which could impact fall risk. A Custom Medical Solutions delivery ticket dated [DATE] at 4:23 p.m., indicated a low-profile air mattress measuring 36 in. by 80 in. by 8 in. and one control unit were delivered for R51. R51's Order Summary Report dated [DATE], included an order for an air mattress to assist with wound healing starting [DATE]. R51's Fall Care Area Assessment (CAA) dated [DATE], included R51 was at risk for falls related to loss of arm or leg movement, incontinence, cognition, infection, and pain, with an objective to minimize risks. The Functional Abilities CAA indicated they required assistance with all activities of daily living (ADLs) and was dependent for all transfers. R51's care plan dated [DATE], included R51 had and ADL self-care performance deficit, required a full body lift and two staff to transfer, and assistance of two staff for repositioning and turning in bed. Their falls care plan dated [DATE], included modify environment as needed to meet current needs: Non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills and clutter, and provide adequate, glare-free light. The skin integrity focus revised [DATE], included R51 had an air mattress on their bed. R51's Device Assessment and Consent dated [DATE], indicated R51 used an air pressure mattress and bilateral grab bars to enable or enhance independence, position, or body alignment. The form identified potential risks as strangulation, suffocation, serious bodily injury, and death when residents or parts of their bodies are caught between rails/bars, in openings in the rails/bars, or between the rails/bars and the mattress. During observation and interview on [DATE] at 3:22 p.m., R51 was lying in bed with the head of the bed elevated about 40 degrees on an inflated pressure-relieving air mattress, and one grab bar was affixed to each side of the bed frame. The flat surface of the bad frame was visible one each side of the mattress, leaving an approximately four to five inches of space between the edges of the mattress and the grab bars. R51 stated they used the grab bars to assist in turning and repositioning, and staff often put pillows in the gaps. One standard bed pillow was on the chair in R51's room. The bed was identified as a Zenith 9200 Slide-W-I-D-E (adjustable up to 42 inches wide for bariatric use.) The air mattress was labeled as Matrix ALAL. During observation on [DATE] at 8:25 a.m., R51 was not present in their room. The air mattress slid side to side freely on the bed frame, allowing up to an eight-inch gap on one side and two-inch gap on the other. During observation on [DATE] at 10:28 a.m., R51 was observed asleep in bed with the gap between the air mattress and the grab bars visible on the left side. No pillows filled the gaps. During observation and interview on [DATE] at 2:40 p.m., R51 was lying on bed on the air mattress at a 35-degree angle with the air mattress pushed toward the right side of R51's bed frame. The space between the left side of the mattress and the left grab bar measured approximately eight inches, while the one on the right measure approximately two inches. During interview and observation on [DATE] at 2:42 p.m., registered nurse (RN)-B stated if a pressure-relief mattress was needed for a resident staff rented one from a vendor based upon the resident's weight and size. They stated standard sized mattresses were interchangeable with standard sized bed frames, however a bariatric frame required a bariatric mattress. They stated when the specialty mattress arrived the staff moved the resident off the original bed, the vendor placed it on the frame and demonstrated how to use it, and staff assisted the resident back to their bed. They stated air mattresses had belts to attach them to the frame, and they had never encountered a situation where a mattress did not fit. RN-B indicated side rails/grab bars could only be installed on a bed if they assisted a resident with being more independent, were assessed to be safe for the resident, and with a provider order. Upon review of R51's bed, RN-B confirmed R51's mattress was attached with straps to the bed frame; however, the mattress was free to move from side to side allowing large gaps next to the grab bars. RN-B stated the mattress configuration was a little off, was supposed to fit snugly within the rails, and could be remedied by placing a pillow tucked in the gap. They then placed a pillow in the eight-inch gap between the left side of R51's mattress and the left the grab bar. During observation and interview on [DATE] at 2:58 p.m., RN-A assessed R51's mattress and bed frame with the grab bars and confirmed the mattress and frame were not compatible. RN-A stated R51 previously used a bariatric bed and mattress, and when staff ordered the standard sized air mattress for pressure relief, they did not change out the frame. They were unsure why it was not identified sooner, and stated if R51 rolled over they could have been stuck between the mattress and the grab bar, obtained skin tears, or slid off the bed. During interview on [DATE] at 3:02 p.m., director of nursing (DON) stated nurses completed assessments for R51's grab bars to see if there was a need or benefit, maintenance installed the brackets, and nurses or maintenance attached the rails once determined safe. They were unaware R51's mattress did not fit the bed frame and expected mattresses to be appropriate for the frame to prevent entrapment. DON stated when gaps were identified, the mattress or the bed frame should have been replaced by staff or the medical device supplier. During interview on [DATE] at 2:02 p.m., administrator stated staff checked each room and reviewed the equipment at the time of admission prior to transferring a resident into the room, and all resident bed and rails/grab bars were checked by maintenance monthly. They stated the facility had some replacement air mattresses for use, but sometimes they were rented from a medical supply company, so they were unsure who placed R51's mattress on the bed frame. They indicated if a mattress needed to be changed, they expected staff to ensure the replacement was the appropriate size, and if not, follow through by obtaining a different one, or contacting the vendor or maintenance to correct the issue to prevent entrapment concerns. During a subsequent interview on [DATE] at 10:12 a.m., administrator stated the vendor who delivered the air mattress placed it on R51's bed and did not inform the staff at the time of delivery. The Matrix ALAL Operating Instructions (undated) included entrapment may occur. Patient entrapment with bed side rails and mattress may cause injury or death. Mattress MUST fit bed frame and side rails snugly to prevent patient entrapment. Follow the manufacturer ' s instructions and monitor patient frequently. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size, or density could increase the risk of entrapment. Visit the FDA website at http://www.fda.gov to learn about the risks of entrapment. Refer to the owner ' s manual for beds and rails for additional product and safety information. Mattress MUST fit bed frame and bed rails snugly to reduce the risk of entrapment. The Basic American Zenith 9200 operating manual dated 2023, indicated all Basic American beds are designed in full compliance with the FDA's Hospital Bed System Guidance to Reduce Entrapment. Further, Risk of entanglement or injury may occur if the mattress used with mattress retainers does not fill the entire width between stops or which compresses to less than 1.50 inches under user's weight. Mattress must be properly sized to fit the mattress support platform and must remain centered on the support platform relative to State and Federal guidelines. Length and width should match the mattress support platform. Use of an improperly fitted mattress could result in injury or death. IMPORTANT: Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. The document indicated patients at high risk for entrapment include those with confusion, lack of muscle control, and altered mental status due to medication. The facility Adaptive Equipment policy dated [DATE], indicated mattresses must fit snug against the bed frame, and the distance between the rail and the mattress was not to exceed 4.75 inches.

Based on interview and document review, the facility failed to ensure the necessary coordination of services between the facility and the hospice agency for 1 of 1 residents (R2) reviewed for hospice services. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. R2's Diagnoses List printed 3/6/24 included diagnoses of schizoaffective disorder (disorder with a combination of symptoms of schizophrenia and a mood disorder), bipolar type. On 3/5/24 at 4:00 p.m., R2's medical record lacked current contact information for hospice staff (the case manager was not updated), and lacked a current medication list with a list of resident-specific hospice-covered medications, a care plan, goals for care, hospice certification and recertifications of the terminal illness, the hospice election form, and hospice orders. Additionally, the medical record lacked a schedule for hospice visits for March 2024. The most recent visit note in the hospice chart by a nurse was dated 2/2/24. On 3/6/24 at 11:39 a.m., social worker (SW)-A stated the facility had some coordination issues with the hospice agency including unanswered emails, forms not completed correctly, and inaccurate contact information for hospice team members. SW-A stated the phone number on the business card for the designated contact for hospice provided by the hospice agency was incorrect. Further, SW-A stated she expected the hospice staff to communicate with facility staff weekly. SW-A also stated she would expect a hospice plan of care for R2 as R2 had been with hospice since July 2023. On 3/6/24 at 11:50 a.m., the director of nursing (DON) stated R2's chart should contain a hospice plan of care, team member names and contact numbers, the frequency of visits, a visit schedule, a current medication list with hospice-covered meds listed, and visit notes by hospice team members. On 3/6/24 at 12:03 p.m., the hospice director (HD)-A stated she expected hospice staff to respond to facility staff emails, and the documents in the resident's medical record were current and complete with the required information. HD-A acknowledged the new updated paperwork provided to the facility on [DATE] lacked a care plan, a current provider's name (the provider identified no longer worked for the hospice agency), and the paperwork had blank pages that should have been completed. HD-A further acknowledged the last nurse visit documented visit was 2/2/24. Additionally, HD-A stated a nursing assistant (NA) should see R2 once or twice weekly, but the hospice record did not indicate NA visits in February. HD-A stated, It's sad how we missed so many things. The facility Hospice contract dated 7/26/24, indicated coordination of care between the facility and Hospice included a plan of care for each hospice patient, where Hospice retained primary responsibility for determining each hospice patient's appropriate plan of care, the facility would provide the description of services furnished by the facility. The contract indicted the facility communicates with Hospice physician and other practitioners participating in care to the Hospice patient as needed to coordinate hospice care with the medical care team. Additionally, the contract indicated Hospice would provide the most recent plan of care, medication information, and physician orders specific to each patient, the Hospice Election Form, physician certification and recertifications of the terminal illness specific to each Hospice patient, and contact information for Hospice personnel involved in care of each Hospice patient. The facility Hospice Care and Referrals in SNF [Skilled Nurse Facility] policy updated 2/24 directed social service (or delegate) obtained information from hospice including the hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in the hospice care, hospice medication information specific to each patient, and the hospice physician and attending physician orders. The policy further directed the hospice provider assured notes were provided to the facility in a timely manner and communicated the schedule of upcoming visits with the resident to the facility for care coordination purposes.

Based on interview and document review, the facility failed to provide an environment free of accident hazards for 1 of 4 residents reviewed when R1, who was at risk for elopement, opened a second story window, removed the screen and exited the building, falling to the ground outside and fracturing her hip. Findings include: R1's medical record was reviewed. R1 was recently admitted to the facility. R1's [DIAGNOSES REDACTED]. A Nurse Practitioner note, dated 11/24/2017 revealed staff reported that R1 made statements indicating to harm herself; however she denied having a plan to accomplish this. The care plan included to increase staff monitoring to every hour, and refer to psychiatry. A psychiatry note, dated 11/30/2017 revealed R1 presented with marked distress and agitation related to fears about safety and wellbeing. She presented with high anxiety and depressed mood, and impulsivity that contributed to her behaviors which included exit seeking, which is potentially unsafe. The recommendations included: Wander guard use, consider placement on secured unit due to wandering and attempts to leave the building, consider [MEDICAL CONDITION] medication, monitor resident from afar if she is showing signs of distress or over stimulation, Consider a higher level of care if her anxiety and paranoia interfere with functioning and/or pose a safety risk. A nurse's note, dated 11/30/2017 revealed the resident was confused, and trying to exit the building, other resident's verbalized their fear of the resident, the resident made comments she wanted to kill herself and others, and staff sent the resident to the emergency department for evaluation and treatment. A physician's orders [REDACTED]. A document titled an application by peace or health officer for emergency admission, dated 12/1/2017 revealed the resident was taken into the custody of law enforcement due to being a vulnerable adult/nursing home resident, who was impulsive and an elopement risk who needs safe transport back to nursing home from the hospital. During an interview on 12/6/2017 at 11:45 a.m. Licensed Social Worker (LSW)-H, stated R1 was admitted to the facility on [DATE]. At the time of admission, she was not expressing thoughts of self-harm. On 11/24/2017 R1 began expressing thoughts of self-harm with suicidal ideation, but no plan to accomplish that. Staff initiated every 30-minute checks of the resident for her safety, and requested a psychiatry consult. On 11/29/2017 R1 was expressing thoughts of paranoid and delusional nature, but R1 denied being suicidal. On 11/30/2017, a psychologist saw R1 and found her paranoid and delusional, with thoughts of self-harm, but no current plan. The psychologist approached R1's medical provider and requested [MEDICAL CONDITION] medication for the delusions and thought disorder. The provider declined to order the medications. LSW-H stated she began calling facilities to see if R1 be admitted to an in-patient unit for treatment for [REDACTED]. When R1 returned to the unit, staff moved her to the secure unit; staff placed her on 30-minute checks, she was pacing in the hall, but did not verbalize elopement or suicidal ideation. During an interview on 12/6/2017 at 6:40 a.m., Nursing Assistant (NA)-E stated he worked the night shift on 12/1/2017 into 12/2/2017. NA-E stated he was responsible for caring for R1 on the secured unit of the building. R1 was on 30-minute checks that night, which were completed as required. NA-E stated he understood from report at the beginning of his shift that R1 was suicidal. During the night shift, R1 was pacing on the unit and her room, and exhibited behaviors such as slamming doors. NA-E stated he last saw R1 at about 6:15 a.m. and at that time; she was pacing in her room. During an interview on 12/6/2017 at 7:15 a.m., Registered Nurse (RN)-F stated she worked the day shift on the secured 2 South on 12/2/2017. At about 6:30 to 6:40 a.m. she went to R1's room to check on her. RN-F stated she did not see R1 in her room, so she started to check the unit for R1. When she could not find R1, she called other staff on other units to ask them to check for R1. When she finished those calls, she went back to R1's room to see if the resident came back to her room. When RN-F came back to the room, she observed the window screen on the floor of the room and the window open. When RN-F looked out the window it was dark, but she something white on the ground under the second story window. RN-F realized that R1 must have gone out the window. RN-F ran outside to check for R1 and found her lying on her back under the window. RN-F stated she asked R1 if she was all right, and then had staff call 911. R1 told RN-F that her leg hurt. R1 stated she jumped out the window because she did not want to be at the facility anymore. Shortly after that, paramedics arrived and took R1 away to the hospital. During an interview on 12/6/2017 at 1:20 p.m., RN-B stated she became aware of the incident when staff on-duty contacted her on 12/2/2017. Communication with the hospital revealed R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. After the incident facility staff initiated a plan to double check all windows in the facility to ensure the [MEDICATION NAME] were in place on all windows. During an interview on 12/11/2017 at 10:55 a.m., Environmental Services Director (ESD)-J stated the facility is old and does not have central air conditioning (AC). Every summer, facility staff contract with a local contractor to put in the window AC units. In the fall they use the same contractor to remove the AC units and replace the window [MEDICATION NAME], so that the windows can only be opened 6 inches for resident safety. The contractor removed R1's AC unit, but did not replace the window [MEDICATION NAME] on her window, so this allowed R 1 to open her window all the way. ESD-J stated the facility had no plan to ensure all the [MEDICATION NAME] were put back in place after the AC units were removed, nor was there a policy related to how far the windows should open. ESD-J stated there was no written contract with the contractor related to what his responsibility for replacing the window [MEDICATION NAME] included. Policies related to the removal of window air conditioning units and placement of [MEDICATION NAME] on window frames were requested, but none was provided.