Every finding on record at Edenbrook of Edina

Based on interview and document review, the facility failed to follow physician orders for 1 of 2 residents (R3) reviewed for nutrition.Findings include:R3's admission minimum data set (MDS) dated [DATE], included R3 was severely cognitively impaired. R3 had diagnoses of diabetes, hyponatremia (happens when excessive water accumulates relative to sodium), and hypertension (high blood pressure).R3's physician order summary report dated 1/22/26, included an order for daily weights due to heart failure with instruction to update the provider with a weight gain of 3 pounds (lbs) or greater in 24 hours or 5 pounds in one week unless otherwise directed by a provider. Order was started on 10/25/25.R3's weights outside of these parameters were as follows:10/28/25: 218.0 lbs10/29/25: 228.4 lbs11/18/25: 212.2 lbs11/19/25: 221.1 lbs11/28/25: 204.9 lbs11/30/25: 213.8 lbs12/7/25: 201.0 lbs12/8/25: 208.6 lbs12/10/25: 206.0 lbs12/12/25: 214.1 lbs12/24/25: 200.2 lbs12/26/25: 245.6 lbs1/20/26: 187.5 lbs1/21/26: 203.0 lbs Review of R3's medical records failed to include updates to the provider for weight changes as instructed in R3's orders.During interview on 1/21/26 at 11:19 a.m., licensed practical nurse (LPN)-A stated she would typically called a provider if someone had an order to monitor weights and they were outside of the parameters. LPN-A stated she would put a progress note in the resident's chart when she updated the provider.During interview on 1/21/26 at 11:21 a.m., assistant director of nursing (ADON)-A stated floor nurses were supposed to monitor the daily weights when an order is in place and update the provider when a resident is outside of the ordered parameters. ADON-A confirmed he was unable to find progress notes or provider notes when R3 had weight changes outside of the provider parameters. ADON-A stated the resident was at risk for fluid overload which could lead to hospitalization if a provider was not updated when a weight monitoring order was in place.During interview 1/21/26 at 1:37 p.m., director of nursing (DON) stated it was the nurse managers or ADON's responsibility to be monitoring weights and updating a provider as needed. The DON stated the floor nurse should enter the weight and update the nurse manager or ADON with any concerns they noticed. DON stated the provider could then adjust medication or parameters if the resident's condition indicated the need for changes.During interview on 1/22/26 at 9:46 a.m., physician assistant (PA)-A stated she would have wanted to be updated on any weight changes that were outside of ordered parameters. PA-A stated early adjustment to medications is important because it becomes harder to manage fluid changes with medication the longer it goes untreated. PA-A stated it was the goal to prevent hospitalization with early intervention. PA-A stated she would complete an visit note on all reviews of weight changes she completed.Facility policy for weight monitoring requested and not provided.

Based on observation, interview and document review, the facility failed to comprehensively assess for safe self-administration and storage of medications and failed to obtain a physician order for 2 of 3 residents (R24 and R50) reviewed for self-administration of medications.Findings include:R24's quarterly minimum data set (MDS) dated [DATE], included R24 was cognitively intact. R24's diagnoses included respiratory failure, chronic obstructive respiratory failure (a progressive lung disease that damages airways resulting to shortness of breath, mucus production, wheezing and chest tightness).R24's Order Summary Report dated 1/21/26, included an order for an albuterol sulfate inhaler (Ventolin HFA Inhalation Aerosol Solution) with instructions to take 2 puffs every 4 hours as needed.R24's self-administration assessment dated [DATE], included the selection of Not Applicable for the question regarding the resident's ability to store medications securely in his room. The results of the assessment included resident could self-administer medications after set up by a licensed nurse.During observation on 1/20/26 at 11:40 a.m., an inhaler was sitting on R24's bedside table. R24 stated it was his rescue inhaler, and he always had it with him.During interview on 1/21/26 at 9:14 a.m., licensed practical nurse (LPN)-A stated the there is an order in R24's chart that he can self-administer medications after a nurse sets them up. LPN-A stated R24 has always had his rescue inhaler at his bedside, but she was not aware of any other self-administration orders that stated he could store medications in his room.During interview 1/21/26 at 11:32 a.m., assistant director of nursing (ADON)-A stated a resident needed a self-administration assessment and an order from a provider if they wished to have medications in their room. ADON-A stated R24 had an order stating he could self-administer medications after set up by a nurse. ADON-A stated R24 could not keep his inhaler in his room.During interview in R24's room on 1/21/26 at 1:37 a.m., ADON-A confirmed R24 had an inhaler on his bedside table with a label of Ventolin. R24 stated it was his rescue inhaler, and he always had it with him.R50R50's admission MDS dated [DATE], included R50 was cognitively intact. R50's diagnoses included hypertension (high blood pressure), peripheral vascular disease (a narrowing or blockage of blood vessels commonly affecting the legs which could lead to leg pain, coldness, numbness and non-healing wounds), and diabetes.Provider progress note dated 12/10/25, included provider had a discussion with resident about nicotine gum and its effects on blood sugars. Per the note, the provider instructs the R50 she could continue to chew nicotine gum. Provider did not provide an order for nicotine gum during consultation.R50's physician order summary report dated 1/21/26, included an order for nicotine transdermal patch 24 hr with instructions to apply 21 mg transdermally (on the skin) one time a day for smoking cessation. No other nicotine orders were included on order summary. No order for self-administration of medication was identified on the order sheet.R50's care plan reviewed 1/20/26, lacked indication R50 could self-administer medications.R50's medical record lacked assessment of R50's ability to safely self-administer and store medications. During observation on 1/20/26 at 12:21 pm, R50 had a green box of cool mint nicotine gum on her bedside tray table. Staff placed a meal tray on R50's bedside table, which required her to move the box of nicotine gum off to the side.During interview on 1/21/26 at 8:14 a.m., R50 stated she always used nicotine gum and that her nephew brought the gum to her. Resident had a white box of Kirkland brand nicotine gum on her bed.During interview on 1/21/26 at 11:41 a.m., ADON-B stated a resident would need a self-administration assessment, a provider order, and a locked box for safe storage of medications prior to keeping medications in the room, including over the counter medications. ADON-B confirmed there was an order for a nicotine patch for R50, but not an order for nicotine gum. ADON-B stated she was unable to find a self-administration assessment for R50 or a provider order that she could store the nicotine gum in her room. ADON-B stated it was important for the assessment and order prior to self-administration to ensure the resident was able to take and store medications safely, and stated it was important for the provider to know all medications including over the counter medications a resident was taking to ensure they would not interfere with other medications ordered.During interview on 1/21/26 at 1:31 p.m., director of nursing (DON) stated an assessment was to be completed and an order obtained prior to a resident storing medication in their room to ensure they were able to take and store it properly. A lock box would have been provided for storage of the medication. DON stated this was also true for over-the-counter medications resident wished to take and keep in their rooms. The DON stated this was important to make sure there were no contraindications with other medications and to monitor the amount of medication being used.During interview on 1/22/26 at 9:46 a.m., physician assistant (PA)-A stated she was aware R50 was using nicotine gum, but was using it prior to her starting as a PA at the facility, so she was not aware she did not have an order. PA-A confirmed residents should have a provider order for over-the-counter medications.Facility policy for self-administration of medications dated 2/12/24, included a resident would be screened by a licensed nurse for safe administration of medication. A physician order would be needed for those who were self-administering medications.

Based on record review and interview, the facility failed to ensure ordered as needed (PRN) psychotropic medications were limited to a 14-day time period for 1 or 5 residents (R34) reviewed for unnecessary medications. Findings include:R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 was admitted on [DATE], was severely cognitively impaired and had the following diagnoses: hypertension, renal insufficiency, hyperlipidemia, dementia, anxiety, and depression. R34's order summary report dated 1/22/26, indicated R34 was currently prescribed Lorazepam 0.5mg (milligrams) orally every 1-hour PRN with a start date of 12/17/25. The order lacked an end date. R34's medical record lacked evidence of rationale to continue past the required 14-day timeframe for psychotropic medications.On 1/22/26 at 1:15 p.m. the director of nursing confirmed they were aware of the 14-day time frame for psychotropic medications and stated they missed it with R34 and were currently working on a new process to ensure it does not happen again. The DON stated the importance of addressing the medications rationale within the 14-day time period to ensure the medications were addressed appropriately and per regulations.The facility Psychotropic Medication Policy last revised 5/1/25, indicated PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN orders to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on record review and interviews, the facility failed to ensure the skilled nursing facility Advanced Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary notifications. Findings include:R59's Perspective payment system Part A Discharge Minimum Data Set (MDS) dated [DATE], indicated R59 was admitted on [DATE] and Medicare Part A discharge date of 8/13/25.R59's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), informed R59 services would end on 8/14/25. However, this notice was given outside of the 48 hours prior to services ending requirement and was provided on 9/22/25.On 1/22/26 at 1:14 p.m. the MDS Coordinator (MDSC) stated the facility had struggled to identify the correct payer source for the resident and once they did, they had R59 sign an SNFABN, however they were unable to locate the form and had R59 sign a new SNFABN on 9/22/25. The MDSC confirmed it was outside the required 48 hours prior to the end of services.On 1/22/25 at 10:18 a.m. the administrator stated their expectation was for the beneficiary notices to be provided to the residents 48 hours prior to the end of their services, and they were important to provide so the residents are aware of their payment changes, and they may be responsible for payment.The facility policy was requested and was provided an undated document titled Beneficiary Notice Guidelines which indicated R59 should have received an SNFABN.

Based on observation, interview, and document review the facility failed to implement a fall management program which included development and implementation of care plans, comprehensive fall analysis for root causes, and implementation of appropriate fall interventions to prevent and/or reduce the likelihood of future falls for 5 of 5 residents (R1 had one unwitnessed fall with major injury, R6 who had four unwitnessed falls one with major injury, R2 had 8 unwitnessed falls, R3 had 4 unwitnessed falls, and R4 had 10 unwitnessed falls) who had an identified risk for falls. This resulted in actual harm for R6 who suffered a left tibial fracture and hospitalization and actual harm for R1 when she sustained a spinal fracture and hospitalization. Findings include R6 R6's face sheet dated 1/7/26, identified diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right side, epilepsy (brain disorder causing recurrent unprovoked seizures), Charot's joint (a severe, progressive condition where nerve damage causes bones and joints to weaken) of left ankle and foot, and dizziness. R6's physician orders dated 7/14/25, included an order for Meclizine HCl (Hydrochloric Acid) Oral Tablet 25 milligrams. Give one tablet by mouth two times a day for dizziness. R6's Significant Change Minimum Data Set (MDS) dated [DATE], indicated R6 was independent with transfers, did not have any falls within the last 6 months and did not have any falls with a fracture, however, R6 had four falls in the past 6 months and on 11/13/25 had a fall with fracture. R6 had severe cognitive impairment, had no behaviors, and was dependent in most activities of daily living. R6's fall focus care plan dated 11/14/20, identified R6 was high risk for falls related to immobility and traumatic brain injury. Goal to be free from major injury from falls. Interventions as follows: -11/14/20: review medication with medical doctor and/or pharmacist. Discontinue unnecessary medications. -11/20/20: evaluate for early acute changes in medical condition. Report findings to medical doctor and obtain requested lab or diagnostics. -11/20/20: low bed -2/5/25: therapy to screen for transfer status -2/21/25: mark floor to show where wheelchair positioning is best for transfer and auto lock/antiroll back for wheelchair. -4/14/25: R6 refuses to have help with transfers, refused therapy. Anti-skid tape to floor to assist with transfers. Risk verses benefit done on 4/14/25 regarding independent transfers to and from wheelchair. -5/13/25: call do not fall sign to bathroom wall. -6/10/25: Reacher to wheelchair. -6/9/25: physical therapy evaluation. -6/23/25: nursing encourage loose clothing as resident allows for easier removal in bathroom. -6/26/25: Offer help, but do not force and honor wishes and decisions. R6's mobility care plan last revised 1/8/25, identified R6 had limited physical mobility related to history of right foot osteomyelitis (serious bone infection), right sided hemiplegia and Charcot's foot. Goal to improve current level of function in bed mobility. Interventions as followed: -No ambulation per physical therapy. Revised on 6/10/25. -Transfers: IND, assist of 1 with gait belt as allows. Revised on 8/19/25 -Toileting: One-able to alert staff to needs, makes toileting needs known. Revised on 7/8/25. R6's Incident Report dated 7/21/25, identified R6 had an unwitnessed fall at 4:00 p.m., R6 was found on the floor in her room near the bed/bedside table, bleeding from the right side of her head with a laceration. R6 stated she had attempted a self-transfer when she felt dizzy. Immediate action taken: R6 sent to the emergency department (ED) for evaluation. R6's hospital ED After Visit Summary dated 7/21/25, identified R6 had a mild concussion and head laceration that required stitches. R6's Meclizine orders were adjusted to take 1 tablet 12.5 milligrams by mouth three times daily as needed. R6 was provided an as-needed nausea medication. R6's July treatment administration record (TAR) included an order on 7/22/25: Orthostatic blood pressure daily for 3 days, will need an assist of two to assist resident to stand. The treatment record was not signed off as completed on 7/23/25, 7/24/25 and 7/25/25. R6's IDT Post Fall Review form dated 7/29/25 indicated R4 had an unwitnessed fall on 7/21/25. The root cause of the fall was the resident stated she felt dizzy. The intervention put into place was orthostatic blood pressure monitoring. R6's meclizine dosage was increased at the emergency department visit. The question on the form, what is the effectiveness of those interventions put into place after the incident? was answered with No new falls. The resident had a head laceration that required staples at the hospital. Although Post Fall Review indicated potential causal factors of being dizzy and orthostatic blood pressures to be monitored, no blood pressures were obtained and no indication R6's care plan was revised for updated fall prevention interventions that prevented/reduced the risk of the self-transfers and addressed dizziness. R6's Incident Report dated 8/3/25, identified R6 had an unwitnessed fall at 5:50 p.m., in her room after self-transferring to bed. R6 reported she felt dizzy at the time of the fall. Immediate action taken of reassurance checks performed for safety (no frequency or duration was defined), offered assist bar on bed to help with transfers to bed as R6 uses bar in bathroom, however, R6 declined. Requested medication review from provider/pharmacist. R6 had been encouraged to drink, but only drinks Pepsi. R6's record did not identify any documentation of reassurance checks for safety and no indication R6's care plan was revised. Additionally, the report did not identify R6's purpose for self-transferring. R6's Pharmacist Consultation Report dated 8/6/25, identified R6's medications were reviewed due to falls and R6 feeling dizzy. Recommendation as followed: -adjust midodrine administration times to mealtimes (recommend not to administer medications after 6:00 p.m. or after the evening meal, or less than four hours before bedtime.) -perform orthostatic blood pressure assessments daily for one week (or as recommended by the provider) to assess for orthostasis which can cause dizziness. If orthostasis identified, provider may want to titrate (increase) midodrine dose while monitoring orthostatic blood pressures for effectiveness. Review of R6's August MAR and TAR did not identify orthostatic blood pressures had been obtained. The August MAR and TAR had the following order: Midodrine Hydrochloride Oral Tablet 2.5 Milligrams. Give 2.5 Milligrams three times a day for hypertension. Hold for blood pressure greater than 140. Administration times were adjusted to 0800, 1300, 1800 on 8/14/25. R6's Interdisciplinary Team (IDT) Post Fall Review/Summary dated 8/11/25, identified R6's 8/3/25 fall had been reviewed with a root cause of dizziness. Interventions in place to encourage to consume more fluids but prefers to only drink pop. Risk verses benefit completed, pharmacist reviewed R6's medications, offered therapy but R6 declined. There was no indication the care plan fall interventions were reviewed for effectiveness or identification orthostatic blood pressures were not obtained according to earlier physician orders. R6's Morse Fall Scale dated 10/16/25, identified R6 as high risk for falling due to history of falling in the past 3 month and overestimates or forgets her limits. R6's care plan was not revised to identify interventions that addressed the identified risk factor. R6's Incident Report dated 10/16/25, identified R6 had an unwitnessed fall in her room at 10:30 a.m., R6 was found lying on the floor on her right side. Immediate action taken was an assessment. The provider was updated about her dizziness. R6 frequently overestimated her physical limitations. Augment chair seating to help R6 stay upright during dizziness. R6's mental status was documented as baseline for individual, oriented to person, place, time and situation. The predisposing environmental factor section was left blank. The predisposing physiological factor section marked gait balance. The predisposing situation factors was marked as none. R6's fall focus care plan revised on 10/17/25 to included augmented seating by lowering back of chair. R6's IDT Fall Review/Summary dated 10/20/25, identified R6 had an unwitnessed fall on 10/16/25. Root cause of fall identified as R6 being dizzy and fell forward out of chair. Intervention put in place to seating augmented to assist resident with staying seated back in chair. R6's IDT fall review changed seating to assist resident with staying seated in back of chair. R6's therapy notes lacked documentation of augmented wheelchair seating had been evaluated. Although the IDT Fall Review indicated potential causal factors of dizziness there was no comprehensive assessment of the cause of the dizziness. R6's fall focus care plan was revised on 10/20/25 to include wheelchair seating modified to assist with sitting upright in chair. R6's Incident Report dated 11/13/25, identified R6 had an unwitnessed (self-reported) fall in her room at 2:00 p.m. R6 reported she fell in the bathroom after toileting during a self-transfer and fell on her left knee. R6 did not notify nursing staff, she fell on her left knee, got herself up on her own using a grab bar in the bathroom. The immediate action taken was to assess R6. The left knee was noted to be slightly swollen. R6 complained of significant pain. The pain provider was updated and saw R6 during the same shift. A different provider was also updated and saw R6 during the shift. A STAT X-ray was ordered to rule out a fracture. The toileting plan was updated (R1's care plan did not identify a historical toileting plan in place at the time of the fall). The rest of the sections on the form were left blank. Although the fall incident report indicated potential causal factors of toileting needs, and the care plan was revised on 11/14/25 included to offer toileting upon rising, before or after meals and at bedtime there was no corresponding comprehensive assessment completed prior to determining toileting schedule. R6's progress note dated 11/13/25 at 10:03 p.m., identified R6 had pain in her left knee from a fall she had in the morning and was administered pain medication. R6's physician progress note dated 11/14/25, identified R6 had pain, bruising, and swelling in left knee following a fall on 11/13/25 and x-ray of left knee ordered to rule out fracture. Physicians note additionally identified R6 had documented hypotension and required midodrine and had intermittent dizziness for which meclizine was used as needed. R6's progress note dated 11/15/25 at 6:03 a.m., identified R6 was in bed all night, not by choice but because she was unable to get out of bed as she usually does. R6 was having pain 5 out of 10 and unable to use the bathroom by herself hence, she was incontinent of bowel and bladder. R6's progress note dated 11/15/25 at 10:04 a.m., identified R6's x-ray results showed a comminuted (a severe break where the bone shatters into three or more places, usually from a high impact trauma like a fall) fracture in the left tibial plateau (on the top surface of the shin bone at the knee joint. R1 had pain 9 out of 10 and was sent to the ED for evaluation and/or treatment. R6's IDT Fall Review/Summary dated 11/17/25, identified R6 had an unwitnessed fall on 11/13/25 with injury of fracture or tibial plateau, had a root cause of self-transferred at risk-risk verses benefit in place. Intervention of toileting plan reviewed/updated, and effectiveness of interventions put into place after the incident stated effective, however, R6 was hospitalized [DATE] through 11/18/25. R6's hospital Discharge summary dated [DATE], identified R6 had been admitted [DATE] through 11/18/25 due to worsening leg/knee pain following a fall on 11/13/25. R6's x-rays were found to have a moderately displaced and impacted intra-articular fracture (a fracture that extend into the surface of the joint) of the lateral tibial plateau and probable non-displaced fracture of the medial tibial plateau. R6 underwent arthrocentesis (a procedure where a needle is used to withdraw fluid) in the ED for removal of grossly bloody fluid. R6's progress note dated 11/18/25, identified R6 returned to the facility via stretcher, had non-weight bearing status, transferred via total mechanical lift into wheelchair. R6 was impulsive and does not always recognize limitations. R6's fall focus care plan had not been revised upon return from hospitalization to include any further fall prevention interventions. In review of R6's record there is no indication orthostatic blood pressures had been obtained and evaluated. During an interview on 1/5/26 at 11:00 a.m., R6 reported she is currently independent with transfers, but had not fallen recently. Staff have not asked her about her preferences for her care plan pertaining to daily schedule and activities of daily living. She was not involved in the development of her care plan. During a follow up observation and interview on 1/6/26 at 10:20 a.m., R6's room was observed to have one strip of no-skid tape by her toilet but did not have any no-skid tape on the floor on either side of her bed and had a call, don't fall sign in her bathroom. R6 reported she felt dizzy all the time, and staff have not asked her about her dizziness at all. R6 was unable to articulate how, when, and if she communicated to staff about her dizziness and when she needed assistance. When asked what the call, don't fall sign in her bathroom means, she said ish, disgusting., R6 was unable to articulate what the sign meant that was in her bathroom. R6 was observed independently transferring from her bed to her wheelchair. The area where she placed her feet on the ground during the transfer did not have no-skid tape.During an interview on 1/5/26 at 10:10 a.m., nursing assistant (NA)-A stated he was responsible for caring for R6 on 1/5/26, however, he was unaware what R6's transfer status was and would need to refer to the Kardex (electronic health record). NA-A was also unsure if R6 had any falls. After referencing the computer, he stated R6's care plan had been updated on 11/19/25 to transfer her with a total mechanical lift with the assist of two staff. During an interview on 1/5/26 at 10:18 a.m., LPN-C stated she would need to check R6's care plan to know what her fall interventions were. The unit managers were responsible for updating care plans with fall interventions. During an interview on 1/6/26 at 9:39 a.m., physical therapist (PT)-A stated R6 briefly mentioned her dizziness one time towards the last few days she was on caseload following her tibia fracture. With her aphasia it was hard to know what kind of dizziness it was. R6 was given a quick screen, the dizziness did not seem vestibular in nature. The dizziness was not induced when she turned her head. PT-A indicated she would ask R6 throughout the sessions but wasn't weight bearing and was using the slide board and pivot transfers; R6 reported during the sessions she was not dizzy. PT-A indicated she thought R6 may have enough cognition to report dizziness to staff preemptively, she does convey a lot of information appropriately, but she can't get the words out. Patients are falling when they try to self-transfer it kind of comes down to making sure their needs are met. Why are they trying to get up? During an interview on 1/6/26 at 9:59 a.m., LPN-D was unable to articulate any fall prevention intervention in place for R6 and that R6 reports feeling dizzy every day she works, especially in the morning. During a follow up interview on 1/6/26 at 10:28 a.m., LPN-D stated R6 had no skid strips on the floor in her bathroom, however, did not have any no skid strips next to her bed and they should have been placed there since R6 is independent and could increase the risk of R6 slipping, falling, and getting hurt. R1 R1's face sheet dated 12/31/25, identified diagnoses of Parkinson's disease (a progressive nervous system disorder affecting movement that caused tremors, stiffness, slow movement, and balance issues) with dyskinesia (involuntary, erratic muscle movements), congestive heart failure (a condition where the heart does not pump blood as well as it should), atrial flutter (a fast heart rhythm), and diabetes mellitus (a condition that affects how the body uses sugar as fuel). R1's consultation notes from the hospital medical records, dated 11/29/25-12/5/25, indicated R1 had one fall prior to the hospitalization, on/off episodes of dizziness. history of episodes of frozen balance (a symptom where a person experiences sudden, temporary episodes of being unable to move their feet). R1 was on fall precautions during the hospitalization. R1 reported on and off episodes of dizziness. R1 reported episodes of dyskinetic movements of both upper and lower extremities that could happen at any time. R1's Morse Fall Scale (a tool used to determine risk for falling) dated 12/5/25, identified R1 was a moderate risk for falling due to overestimating her limits. R1's facility records did not identify a fall prevention care plan had been initiated after R1 had been identified as a moderate fall risk upon admission on [DATE]. R1's physical therapy (PT) evaluation dated 12/6/25, indicated R1 felt unsteady when walking and worried about falling. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 needed substantial assistance for transfers/toileting, and had one fall since admission with major injury, R1's MDS did not identify a cognitive assessment that had been completed. R1's Fall Incident report dated 12/7/25, identified R1 had an unwitnessed fall in her room at 4:00 a.m., was found lying on the floor, head to toe assessment completed and did not identify injury. R1 did not speak English and family member (FM)-A was called and translated for R1 who stated, she needed to use the bathroom and missed a step and fell. R1 was only oriented to person. The report had other marked under predisposing environmental, physiological, and situational factors, however, lacked any further description. The report lacked an immediate intervention to prevent further falls. R1's record did not include a comprehensive fall investigation/analysis that would address potential causal factors including the lack of care plan interventions that directed staff of R1's required level of care she needed to complete activities of daily living. R1's emergency department hospital medical records, dated 12/7/25, stated the patient presents to the emergency department after being found on the floor by nursing staff at 5:00 a.m. The patient presents from nursing home after falling while attempting to walk to the bathroom unassisted. Patient complains of bilateral knee pain, neck, and back pain post fall. CT scan shows acute superior endplate compression fracture with fracture lucency (a translucent area) visualized along the superior endplate of T12 with burst-type morphology and slight bony retropulsion of the superior endplate of T12 (spine fracture). R1 required pain management, a spinal brace and physical therapy for treatment. R1's progress note dated 12/8/25, indicated R1 discharged home against medical advice. However, there is no indication R1 returned to the facility after being transferred to the ED on 12/7/25. Additional record review identified R1's baseline care plan was not initiated/completed until 12/8/25 after R1 transferred/discharged to the hospital. During an interview on 12/31/25 at 8:36 a.m., FM-A stated he had called to the facility on [DATE] around 5:00 a.m., to check on R1 when he was told R1 had fallen but was okay. FM-A then drove the facility and stated R1 was in pain and reported to him she had been on the floor since 2:00 a.m. until 5:00 a.m., FM-A then called 911to have R1 transferred to the hospital. FM-A further stated at the hospital it was discovered R1 had a broken spine and needed to be hospitalized . Previously, FM-A had requested a fall mat on the floor next to R1's bed because she was at risk for falls, but the request was never completed. According to the facility call light log between 12/6/25 at 10:00 p.m. through 12/7/25 R1's call light had only been activated one time at 4:45 a.m., for 39 seconds. During an interview on 1/2/26 at 10:43 a.m., trained medication aid (TMA)-A stated on 12/6/25-12/7/25 around 11:00 p.m. to 12:00 a.m., TMA-A had helped R1 on the bedpan and did a brief change and had left the call light next to her. At around 4:00 a.m., the nurse found R1 on the ground and had asked TMA-A to assist because R1 said she had slid off the bed. When TMA-A entered R1's room, the call light was on, and her bed was in the low position. TMA-A and the nurse helped R1 back to bed, her brief was dry. After her fall, R1 called TMA-A for a few requests such as putting something on her head. TMA-A stated R1 was refusing some services but did not explain which services. During an interview on 12/31/25 at 2:24 p.m., licensed practical nurse (LPN)-A stated she had found R1 on the floor in her room at an unspecified time after hearing R1 screaming. LPN-A stated R1 had not used her call light, had gripper socks on and the last time R1 had been checked R1 was in bed, however, LPN-A was unable to articulate the exact time of when R1 had been last checked. LPN-A then called FM-A to inform him of R1's fall when FM-A translated for R1 who stated she had been attempting to use the bathroom and missed her step and fell. FM-A came to the facility that morning and wanted to take R1 to the hospital, LPN-A told FM-A it was okay to take R1 to the hospital. LPN-A was unable to articulate how R1 was supposed to transfer or any fall prevention interventions that were supposed to be utilized to prevent R1 from falling. During an interview on 1/5/26 at 3:57 p.m., assistant director of nursing (ADON)-A stated he thought R1's needs were met during her stay at the facility. ADON-A verified the baseline care plan was not completed since it was a new admission over the weekend. ADON-A could not verify when he became aware of R1's injury from the fall. The ADON's role after falls includes making sure there was a fall report completed with an immediate intervention, make sure all relevant parties were informed, and the care plan was updated. Later there is a root cause analysis completed. ADON-A stated not having a care plan for R1 increased her risk of falls. ADON-A did not think there was an investigation into R1's fall since she went to the hospital right away and did not return to the facility. ADON-A stated he didn't think the care plan being in place could have prevented the fall since R1 was impulsive and the nurses did not know the full extent of her ambulation. During an interview on 1/2/26 at 3:00 p.m., the director of nursing (DON) verified R1 had not had baseline care plan to include any fall prevention interventions even though R1 was identified as a moderate fall risk. The DON was unsure whether R1 had an injury from her fall on 12/7/25. Did she say anything about their admission process and why the careplan hadn't been initiated? R2 R2's face sheet dated 12/31/25, identified diagnoses of cerebral infarction (stroke), type II diabetes mellitus, diabetic retinopathy with macular edema (vision issue), epilepsy (seizures), hemiplegia and hemiparesis affecting the right dominant side (partial paralysis), gout (joint pain), and foot drop. R2's Medicare 5-day MDS assessment dated [DATE], indicated R2 needed substantial/maximal assistance for transfers, had a fall in the last month prior to admission, was mildly cognitively impaired and required substantial assistance with activities of daily living. R2's Morse fall scale assessment dated [DATE], indicated R2 was at high risk for falling. R2's fall focus care plan dated 12/31/25, identified R2 was a moderate fall risk related to dysarthria (motor speech disorder) following cerebral infarction, type II diabetes with retinopathy, syncope and collapse, need for assistance with personal care and cognitive communication deficit. Goal to be free from serious injury related to falls. Interventions were as followed: -Review medications with physician or pharmacist. Discontinue un-necessary medications, evaluate for uncontrolled pain, consider scheduled pain medication regimen. Provide/offer snacks in between meals or with signs of restlessness. Physical therapy and occupational therapy to evaluate and treat. Ensure environment is clear of clutter. Initiated 10/12/25. R2's Incident Report dated 10/12/25, indicated R2 had an un-witnessed fall at 4:15 p.m. R2 had been found sitting on the floor in front of her bed, had gripper socks on, and stated she was trying to transfer herself from bed to her wheelchair but slipped and fell. Immediate action taken as followed: place call light within reach, putting the bed in the lowest position, therapy evaluated R2 and changed transfer status from independent to assist of one. R2's mental status was documented as oriented to person, place, and time. The predisposing environmental factors was left blank. The predisposing physiological factors was left blank. The predisposing situation factors was documented as admitted within the last 72 hours. R2's mobility focus care plan revised on 10/12/25, that R2 required the assistance of one staff for transfers, used a wheelchair for ambulation. R2 could also ambulate with the assist of two staff, with the gait belt and wheelchair to follow. The fall care plan was updated on 10/13/25 to include patient educated to participate with plan of care, will work with therapy to regain maximum strength. R2's IDT Post Fall Review form dated 10/16/25 indicated R2 had an unwitnessed fall on 10/12/25. The root cause of the fall was documented as new admit from community, used to being independent, attempted to self-transfer and fell. The immediate intervention was to encourage and educate R2 to request assistance and participate in her plan of care. R2 will receive multiple therapies to maximize strength and independence. R2 agreed. The question on the form, what is the effectiveness of those interventions put into place after the incident? was answered with No new falls. There was no indication of a comprehensive analysis to identify causal factors was completed. R2's Incident Report dated 10/30/25, indicated R2 had an unwitnessed fall in her room. R2 was sitting on the floor with her back laying against her bed. R2 stated she was lying in bed when her call light fell and landed underneath the bed. R2 tried to get out of bed to get the call light and slipped and fell on the floor. Immediate action taken was to complete an assessment and encourage R2 to call for help at all times. A clip was placed on the call light. R2's IDT Post Fall Review form dated 11/4/25 indicated R2 had an unwitnessed fall on 10/30/25. The root cause of the fall was documented as R2 tried to get out of bed and slipped on the floor. R2 stated she was trying to get her call light. The immediate intervention was to replace the clip on the call light. The question on the form, what is the effectiveness of those interventions put into place after the incident? was answered with No new falls. There was no indication of a comprehensive analysis to identify causal factors was completed and no indication R2's care plan was revised. R2's Incident Report dated 11/8/25, indicated R2 had an un-witnessed fall in her room. A staff heard a loud thud, R2 was found in her room on the floor by the door. R2 stated she was trying to get up. R2 was assessed, no pain or injuries were noted. Immediate action taken was to encourage patient to ask for help when she needs to get up. Staff to put the wheelchair next to the bed to discourage patient from independent walking. R2's mental status was documented as baseline for individual. Predisposing environmental factors were documented as not applicable. Predisposing physiological factors was left blank. Predisposing situation factors was listed as ambulating without assistance. R2's care plan was not revised until 11/10/25 for the wheelchair placement intervention. During an interview on 1/5/26 at 10:20 a.m., nursing assistant (NA)-A was unaware that R2's wheelchair was supposed be left next to her bed and the only other fall prevention was to check on R2 frequently, however, was unable to specify how often R2 was supposed to be checked on while she is in her room. NA-A further stated R2 continues to self-transfer at times. R2's IDT Post Fall Review form dated 11/17/25 indicated R2 had an unwitnessed fall on 11/08/25 reviewed (9 days after fall). The root cause of the fall was documented as walking independently when R2 was care planned to have assistance. The immediate intervention put into place was to put her wheelchair next to the bed to discourage independent walking. The question on the form, what is the effectiveness of those interventions put into place after the incident? was answered with No new falls. R2's Incident Report dated 11/21/25, indicated R2 had an un-witnessed fall in her room. Staff told writer that R2 had a fall. The writer went to R2's room, R2 said she was trying to transfer herself to bed and fell on the floor. Resident was assessed with no injuries noted. She was encouraged to use the call light and call for help at all times. Immediate action taken was to administer Tylenol and put on gripper socks. R2's mental status was documented as oriented to person, place, time and situation. Predisposing environmental factors was documented as not applicable. Predisposing physiological factors was documented as none and impaired memory. Predisposing situation factors was documented as none. The physician and family member were notified. There was no indication of a comprehensive analysis to identify causal factors. R2's care plan was not revised to have grippers socks on when not wearing shoes until 12/2/25. R2's Incident Report dated 11/22/25, indicated R2 had an unwitnessed fall in her room. Staff heard a squeal in the hallway. R2 was found on the floor. R2 said she was trying to put her shoes on and she slid and fell. No injuries were noted. The immediate action taken was Pt encouraged to call for help to put on footwear. R2's mental status was documented as baseline for individual. Predisposing environmental factors was left blank. Predisposing physiological factors was documented as impaired memory. Predisposing situation factors was documented as reaching/bending. There was no indication of a comprehensive analysis to identify causal factors nor indication R2's care plan was revised. R2's Incident Report dated 12/2/25, indicated R2 had an un-witnessed fall in her room. R2 was found on the floor, sitting by the foot of her bed. R2 said she was trying to put her shoes on. R2 denied a head strike, her range of motion was within her baseline. R2 did not report pain, she was assisted up by two staff and seated in her chair. The immediate action taken was to remove her shoes and put in the closet when she is in bed, so the visual cue is not present. The predisposing environmental factors, predisposing physiological factors and predisposing physiological factors were all left blank. R2's IDT Post Fall Review form dated 12/6/25 indicated R2 had an unwitnessed fall on 12/2/25. The root cause of the fall was balance. The immediate intervention put into place was removal of visual cues. The question on the form, what is the effectiveness of those interventions put into place after the incident? was answered with Effective. Although the IDT Post Fall Review indicated potential causal factors balance, there was no care plan revision to include intervention regarding balance issues. The care plan was revised on 12/3/25 to include Remove shoes and put in closet when put in bed so visual cue is not present. R2's Incident Report dated 12/13/25, indicated R2 had an un-witnessed fall in her room. R2 stated she was trying to transfer herself from the wheelchair to her recliner. The immediate intervention put into place was a Call don't fall sign was placed in her room. The report indicated she was a

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to increase in resident falls by developing and implementing action plans for process improvement. This had the potential to affect all 60 residents that resident in the facility. Findings include:Based on review of facility records, Quality Review minutes, QAPI documentation, incident reports, and staff interviews, the facility failed to implement its QAPI program in accordance with its written plan, including failure to identify falls as a high-risk and problem-prone area, failure to initiate and sustain Performance Improvement Projects, failure to conduct comprehensive root cause analysis, and failure to develop, implement, and monitor effective corrective actions to prevent recurrence. Findings include The facility's QAPI Plan states that Edenbrook of Edina will conduct Performance Improvement Projects (PIPs) that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention and that these projects will lead to changes and guide corrective actions in our systems, which cross multiple departments. The Plan further states that the QAA committee will review data and input on a monthly basis to look for potential topics for PIPs and that factors considered include high-risk, high-volume, or problem-prone areas that affect health outcomes, quality of care and services. The Plan also requires that PIP teams use root cause analysis to ensure that the root cause and contributing factors are identified, and that to prevent future events and promote sustained improvement our campus develops actions to address the identified root cause and/or contributing factors of an issue/event that will affect change at the systems level. In addition, the Plan requires the facility to identify and use data to monitor our performance, establish goals and thresholds, systematically analyze underlying causes of systemic problems and adverse events, and develop corrective action or performance improvement activities. The facility provided documents labeled Quality Assurance Performance Improvement minutes and Quality Review minutes discussion. The documents identified the following: Review of the facility's corporate quality metrics identified that the facility's internal Quality Measure dashboard reflected triggers related to falls with major injury. Specifically, the Percentage of Residents Experiencing One or More Falls with Major Injury measure generated one trigger in Quarter 2 and one trigger in Quarter 3. According to the facility's QAPI Plan, performance data and thresholds are used by the Quality Assurance and Assessment Committee to identify high-risk, high-volume, and problem-prone areas and to determine potential topics for Performance Improvement Projects. Despite these triggers, the facility's Quality Assurance and Performance Improvement documentation did not reflect initiation of a sustained Performance Improvement Project, completion of comprehensive root cause analysis, or implementation and monitoring of system-wide corrective actions related to falls with major injury. Review of the facility's Quality Review documentation dated 6/6/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: March 2025 - Rate 4.2 (9 falls), April 2025 - Rate 15.1 (31 falls), and May 2025 - Rate 5.9 (12 falls), with April and May exceeding the facility's stated goal. The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 52 falls, including 46 unwitnessed falls. The location data identified that 37 falls occurred in resident rooms and 9 occurred in resident bathrooms. The Quality Review minutes and accompanying documentation did not reflect discussion of underlying causal factors, completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to the identified fall patterns. Review of the facility's Quality Review documentation dated 7/18/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: April 2025 - Rate 15.1 (31 falls), May 2025 - Rate 5.9 (12 falls), and June 2025 - Rate 9.0 (17 falls), with April and June exceeding the facility's stated goal. The Quality Review documentation further identified one fall with major injury (R6). The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 62 falls, of which 55 were unwitnessed. The location data identified that 43 of the 62 falls occurred in resident rooms and 9 occurred in resident bathrooms. Comparison of the June and July reporting periods identified an increase in cumulative documented falls from 52 to 62. Even though comparison of the June and July reporting periods identified an increase in cumulative documented falls from 52 to 62 and identified one fall with major injury (R6), the Quality Review minutes and accompanying documentation did not reflect discussion of contributing factors, completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to fall prevention. Review of the facility's Quality Review documentation dated 8/8/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: May 2025 - Rate 5.9 (12 falls), June 2025 - Rate 9.0 (17 falls), and July 2025 - Rate 3.1 (6 falls), with May and June exceeding the facility's stated goal. The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 35 falls, of which 30 were unwitnessed. The location data identified that 22 of the 35 falls occurred in resident rooms and 6 occurred in resident bathrooms. Although the cumulative fall data reflected a decrease during this reporting period, the Quality Review minutes and accompanying documentation did not reflect analysis of the factors, interventions, or changes in practice that may have contributed to the decrease, nor did they reflect efforts to evaluate, formalize, or sustain any practices associated with improved outcomes. The documentation also did not reflect completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to fall prevention. Review of the facility's Quality Review documentation dated 9/5/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: June 2025 - Rate 9.0 (17 falls), July 2025 - Rate 3.1 (6 falls), and August 2025 - Rate 8.5 (17 falls), with June and August exceeding the facility's stated goal. The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 40 falls, of which 34 were unwitnessed. The location data identified that 26 of the 40 falls occurred in resident rooms. Although the cumulative fall total increased compared to the previous reporting period and August reflected a return to elevated fall rates following the July decrease, the Quality Review minutes and accompanying documentation did not reflect discussion of underlying causal factors, completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to the identified fall patterns. Review of the facility's Quality Review documentation dated 10/10/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: July 2025 - Rate 3.1 (6 falls), August 2025 - Rate 8.5 (17 falls), and September 2025 - Rate 8.3 (16 falls), with August and September exceeding the facility's stated goal. The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 42 falls, of which 36 were unwitnessed. The location data identified that 31 of the 42 falls occurred in resident rooms. Comparison of the September and October reporting periods identified an increase in cumulative documented falls from 40 to 42. Even though comparison of the September and October reporting periods identified an increase in cumulative documented falls from 40 to 42 , the Quality Review minutes and accompanying documentation did not reflect discussion of contributing factors, completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to fall prevention. Review of the facility's Quality Review documentation dated 11/14/25 identified the facility tracked fall rates per 1,000 resident days with an established goal of 5. The minutes documented the following monthly fall rates and counts: August 2025 - Rate 8.5 (17 falls), September 2025 - Rate 8.3 (16 falls), October 2025 - Rate 6.1 (13 falls), and November 2025 - 12 falls month to date (Rate 5.7), with all reviewed months exceeding the facility's stated goal. The report identified R7 had a fall with major injury; the date of the fall and injury was not identified. A clarifying interview with DON on 1/26/26 at 10:30 a.m. verified R7's fall with major injury occurred on 8/18/25. At the time of the report was generated (11/14/25) R6's second major injury was not accounted for because the facility became aware on 11/15/25 after an X-ray was obtained. The facility had their quality meeting on 11/17/25, however R6's injury was not accounted for in the minutes. The Quality Review documentation included data tables and graphs that tracked cumulative fall totals and categorized falls by location, shift, and witness status. The graphs identified a total of 58 falls, of which 51 were unwitnessed. The location data identified that 47 of the 58 falls occurred in resident rooms. Comparison of the October and November reporting periods identified an increase in cumulative documented falls from 42 to 58. Even though comparison of the October and November reporting periods identified an increase in cumulative documented falls from 42 to 58 and minutes should have reflected one fall resulting in major injury, the Quality Review minutes and accompanying documentation did not reflect discussion of contributing factors, completion of a comprehensive root cause analysis, initiation of a Performance Improvement Project, or development and monitoring of system-wide corrective actions related to fall prevention Review of facility provided fall incident report log for the month of November 2025, identified the facility had a total 23 falls for the month of November, which demonstrated an accumulative increase of the number of falls from October. SEE F689:Based on observation, interview, and document review the facility failed to implement a fall management program which included development and implementation of care plans, comprehensive fall analysis for root causes, and implementation of appropriate fall interventions to prevent and/or reduce the likelihood of future falls for 5 of 5 residents (R1 had one unwitnessed fall with major injury, R6 who had four unwitnessed falls one with major injury, R2 had 8 unwitnessed falls, R3 had 4 unwitnessed falls, and R4 had 10 unwitnessed falls) who had an identified risk for falls. This resulted in actual harm for R6 who suffered a left tibial fracture and hospitalization and actual harm for R1 when she sustained a spinal fracture and hospitalization. During an interview on 1/7/26 at 1:51 p.m., director of nursing (DON) stated the quality committee meets monthly, however, did not meet in December because of the holidays. she began working at the facility first part of December 2025 and quickly identified the facility had a concern with falls. DON stated the fall rate to her was high for the month of November 2025, however, had not brought her concerns to the quality committee to begin an action plan to investigate the reason for the concern for falls. During an interview on 1/7/26 at 2:49 p.m., regional director of clinical services (RDCS) stated that the facility relies on their quality metrics to flag a concern. The metrics did not flag for the month of November for falls due to having a higher census that month, therefore the facility did need to create an action plan to correct this, however, RDCS identified the fall rate of 5.7 which exceeded the fall rate goal. During an interview on 1/6/26 at 3:04 p.m., medical director (MD) stated he is part of the QAPI committee and had not been informed of any concern with an increase in falls at the facility.

Based on observation, interview, and document review the facility failed to revise the care plan for 2 of 5 residents (R4.R6) who were reviewed for accidents/falls.Findings include:R4's face sheet dated 12/31/25, indicated R4 was admitted on [DATE]. Diagnoses included encounter for orthopedic aftercare, acute respiratory failure with hypoxia, seizures, mechanical complications of indwelling urethral catheter, insomnia, bipolar disorder, obstructive and reflux uropathy, presence of right artificial knee joint, heart failure, bilateral primary osteoarthritis of knee, myalgia (muscle pain), psychoactive substance abuse and reduced mobility. R4 fall focus care plan dated 11/3/25, identified R4 was high-risk for falls related to acute respiratory failure with hypoxia, sepsis, seizures, post-traumatic stress disorder, bipolar disorder, history of pulmonary embolism, benign prostatic hyperplasia without lower urinary tract symptoms. R4's goal was for her injury related to falls will heal without complication by the review date. Interventions as followed: 11/03/25 Review medications with physician or pharmacist. Discontinue un-necessary medications. Evaluate for uncontrolled pain. Consider pain medication regimen. Evaluate for early acute changes in medical condition. Report findings to physician and obtain requested lab or diagnostics. Gripper socks on when up. Ensure the environment is free of clutter. R4's Incident Report dated 11/13/25, indicated R4 had a self-reported unwitnessed fall. A staff went to get R4's vitals when R4 reported she had a fall earlier that day. R4 stated she was trying to transfer from the bed to the wheelchair but did not realize one of the wheelchair brakes was not locked. R4 slid and fell. R4 called for help, an aide came and said he would come back to help but did not return. Later, another staff helped her back to bed. The immediate action taken was to place brightly colored tape on the wheelchair brakes as a reminder to lock the brakes. R4 was encouraged to wait for assistance with transfers. R4's mental status was documented as baseline for individual, oriented to person, place time and situation. R4's fall focus care plan was updated on 11/14/25, to include brightly colored tape to wheelchair brakes to remind R4 to lock them, risk verses benefit discussed and completed regarding self-transfers. During an observation and interview on 1/2/26 at 10:15 a.m., R4's wheelchair did not have colored tape on either of the brakes, however, had anti-roll bars on both wheels. R4 stated the tape has not been on her brakes of her wheelchair for a while since the bars were put on the wheels. During an interview on 1/2/26 at 3:02 p.m., director of nursing (DON) stated R4's wheelchair had anti-roll brakes placed on her wheelchair a while back due to her repeated self-transfers, however, R4's care plan had not been revised to remove the tape on the brakes of her wheelchair nor the antiroll bars and should have been done in a timely manner. R6's face sheet dated 1/7/26, identified diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right side, epilepsy (brain disorder causing recurrent unprovoked seizures), Charot's joint (a severe, progressive condition where nerve damage causes bones and joints to weaken) of left ankle and foot, and dizziness. R6's Significant Change MDS dated [DATE], indicated R6 was independent with transfers, did not have any falls within the last 6 months and did not have any falls with a fracture, however, R6 had a falls in the past 6 months and on 11/13/25 had a fall with fracture. R6 had severe cognitive impairment, had no behaviors, and was dependent in most activities of daily living. R6's mobility focus care plan dated 1/8/25, identified R6 had limited physical mobility related to right sided hemiplegia and Charot's foot. Goal to improve current level of function in bed mobility. Interventions as followed:-transfer: assist of two with total mechanical lift (initiated 11/19/25) During an interview on 1/5/26 at 10:20 a.m., nursing assistant (NA)-A stated R6 had been self-transferring to her wheelchair multiple times during the shift, however, when he reviewed R6's care plan he identified R6 needed a total mechanical lift and needed to find the nurse to clarify how R6 was supposed to transfer. During an interview on 1/5/26 at 10:32 a.m., therapy director (TD) stated she believes R6 had been made independent with transfers but would need to review the recommendations. During an interview on 1/5/26 at 10:54 a.m., occupational therapy (OT)-F stated R6's transfer status had been changed to independent on 12/23/25 from a total mechanical lift. OT-F further stated that the recommendations are given to the nursing department once made so nursing can change the transfers status in the care plan in a timely manner. During an interview on 1/5/26 at 2:36 p.m., assistant director of nursing (ADON)-B stated R6's care plan had not been revised to reflect a change in transfer status after receiving a therapy recommendation on 12/23/25 and should have been done in a timely manner so staff are aware of how R6 transfers. Review of the facility's Care Plan - Baseline and Comprehensive Policy dated 7/18/24, indicated the interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly.

Based on interview and document review, the facility failed to timely report to State Agency (SA) falls with serious injury for 2 of 2 residents (R1, R6) who had falls without implementation of appropriate fall interventions to prevent/mitigate risk of recurrent falls. Findings include: R1's face sheet dated 12/31/25, identified diagnoses of Parkinson's disease (a progressive nervous system disorder affecting movement that caused tremors, stiffness, slow movement, and balance issues) with dyskinesia (involuntary, erratic muscle movements), congestive heart failure (a condition where the heart does not pump blood as well as it should), atrial flutter (a fast heart rhythm), and diabetes mellitus (a condition that affects how the body uses sugar as fuel). R1's Morse fall scale (fall risk assessment) dated 12/5/25, indicated R1 had not fallen in the past 3 months, had more than one diagnosis, normal gait, and overestimated or forgets her limits. R1 was at moderate risk for falling. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 required substantial assistance for transfers, toileting, and some activities of daily living. The assessment lacked a cognitive assessment. R1's Fall Incident report dated 12/7/25, identified R1 had an unwitnessed fall at 4:00 a.m., resident was found lying on the floor with her head on the pillow. No injury was noted. According to FM-A, R1 stated she wanted to use the bathroom, missed a step and fell. R1 was only oriented to person. The incident report did not include a comprehensive fall investigation/analysis that would address potential causal factors including the lack of care plan interventions that directed staff of R1's required level of care she needed to complete activities of daily living. R1's progress note dated 12/7/25 at 7:34 a.m., indicated resident was found lying on the floor with her head on a pillow. No injury was noted. According to R1's family member (FM)-A, R1 was trying to use the bathroom, missed a step and fell. A head-to-toe assessment was done with neuro checks and vital signs. R1 denied pain and was assisted back to bed by a mechanical lift. FM-A and provider were updated. FM-A came to the facility and transferred R1 to the hospital due to the incident. R1's emergency department hospital medical records, dated 12/7/25, stated the patient presents to the emergency department after being found on the floor by nursing staff at 5:00 a.m. The patient presents from nursing home after falling while attempting to walk to the bathroom unassisted. Patient complains of bilateral knee pain, neck and back pain post fall. CT scan shows acute superior endplate compression fracture with fracture lucency visualized along the superior endplate of T12 with burst-type morphology and slight bony retropulsion of the superior endplate of T12 (spine fracture). R1 required pain management, a spinal brace and physical therapy for treatment. R1's progress note dated 12/8/25, indicated R1 discharged home against medical advice. However, there is no indication R1 returned to the facility after being transferred to the ED on 12/7/25. Additional record review identified R1's baseline care plan was not initiated/completed until 12/8/25 after R1 transferred/discharged to the hospital. During an interview on 12/31/25 at 8:36 a.m., FM-A stated he had called the facility on 12/7/25 around 5:00 a.m., he was told R1 had fallen but was okay. FM-A then drove the facility and stated R1 was in pain and reported she had been on the floor since 2:00 a.m. until 5:00 a.m., FM-A then called 911to have R1 transferred to the hospital. FM-A further stated at the hospital it was discovered R1 had a broken spine and needed to be hospitalized . During an interview on 12/31/25 at 2:24 p.m., licensed practical nurse (LPN)-A stated she had found R1 on the floor in her room at an unspecified time after hearing R1 screaming. LPN-A stated R1 had not used her call light, had gripper socks on and the last time R1 had been checked R1 was in bed, however, was unable to articulate the exact time of when R1 had been last checked. LPN-A then called FM-A to inform him of R1's fall when FM-A translated for R1 who stated she had been attempting to use the bathroom and missed her step and fell. FM-A came to the facility that morning and wanted to take R1 to the hospital, LPN-A told FM-A it was okay to take R1 to the hospital. LPN-A was unable to articulate how R1 was supposed to transfer or any fall prevention interventions that were supposed to be utilized to prevent R1 from falling. R6 R6's face sheet dated 1/7/26, identified diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right side, epilepsy (brain disorder causing recurrent unprovoked seizures), Charot's joint (a severe, progressive condition where nerve damage causes bones and joints to weaken) of left ankle and foot, and dizziness. R6's Significant Change MDS dated [DATE], indicated R6 was independent with transfers. R1 did not have any falls within the last 6 months and did not have any falls with a fracture. R6 had severe cognitive impairment, had no behaviors, and was dependent in most activities of daily living. Review of R6's fall incident reports between 7/1/25 and 11/12/25 identified R6 had 3 falls, 7/21/25, 8/3/25, and 10/16/25 where dizziness was repeatedly identified as a causal factor however, the records did not include monitoring of dizziness nor comprehensive assessments that identified individualized fall prevention strategies and/or services that could prevent or mitigate R6's risk for falls related to the identified causal factor of dizziness (SEE F689). R6's Incident Report dated 11/13/25, identified R6 had a self-reported unwitnessed fall in her room at 2:00 p.m. R6 reported she fell in the bathroom after toileting during a self-transfer and fell on her left knee. R6 did not notify nursing staff, she fell on her left knee. The immediate action taken was to assess R6. The left knee was noted to be slightly swollen. R6 complained of significant pain. The pain provider was updated and saw R6 during the same shift. A different provider was also updated and saw R6 during the shift. A STAT X-ray was ordered to rule out a fracture. The toileting plan was updated (R6's care plan did not have a toileting plan prior to the fall on 11/13/25). The rest of the sections on the form were left blank. R6's progress note dated 11/15/26 at 10:04 a.m., identified R6's x-ray results identified a comminuted (a severe break where the bone shatters into three or more places, usually from a high impact trauma like a fall) fracture in the left tibial plateau (on the top surface of the shin bone at the knee joint. R1 had pain 9 out of 10 and was sent to the ED for evaluation and/or treatment. R6's hospital Discharge summary dated [DATE], identified R6 had been admitted [DATE] through 11/18/25 due to worsening leg/knee pain following a fall on 11/13/25. R6's x-rays were found to have a moderately displaced and impacted intra-articular fracture of the lateral tibial plateau and probable non-displaced fracture of the medial tibial plateau. R6 underwent arthrocentesis (a procedure where a needle is used to withdraw fluid) in the ED with removal of grossly bloody fluid. During an interview on 1/6/26 at 12:01 p.m., the administrator stated R1 and R6's falls had not been reported to the state agency after knowledge of a serious injury due to the falls being explainable by the resident and did not have an allegation abuse. During a follow up interview on 1/6/26 at 3:33 p.m., the administrator stated she was not aware R1's fall that occurred on 12/7/25 that R1 had sustained a serious injury; administrator was unaware on R1's admission MDS dated [DATE] that R1's fall had been coded as a fall with major injury. MDS coordinator worked offsite, when she obtained information from the hospital records that identified a major injury, this should have been reported to the administrator immediately and should have been reported to the state agency within two hours. The facility policy Vulnerable Adult Abuse and Neglect Prevention last revised 3/25/25, directs the facility must report to the State Agency if the events that cause the allegation result in serious bodily injury.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment for 2 of 3 residents assessed (R1 and R3). R1's room was observed having the bed made over a urine-soiled facility bath blanket. R3's room was cluttered with facility supplies covering up furniture and clean supplies found on the floor. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 10 indicating R1 had moderate cognitive impairment. R1 required maximum assistance with toileting hygiene, dressing, personal hygiene and transferring. R1's pertinent diagnoses were left femur (hip) fracture, chronic respiratory failure, and unspecified intellectual disabilities. R1 was frequently incontinent of bowel and bladder. R1's care plan revision dated 11/13/24 indicated R1 had functional bladder incontinence. Her interventions were to clean peri-area with each incontinent episode. Monitor for signs and symptoms of a urinary tract infection. R1 had a voiding routine to be offered toileting, check, and change at rising, before and after meals at bedtime and as needed. Upon interview on 12/30/24 at 12:37 p.m. R1 stated she often has to pee in her incontinent brief in the night because staff does not answer her call light in time or staff will tell R1 to urinate in her incontinent brief and they will change her, but urine gets on her bedding. R1 stated on 12/29/24 she had to ask the staff three times to change her bedding because it was wet and smelled of urine. The bedding was change on 12/30/24 per R1. Upon interview on 12/30/24 at 1:34 p.m. R1's family member (FM)-A stated she had visited R1, and her room had a urine odor to it. She stated she was not certain where the odor was coming from. Upon interview on 12/30/24 at 1:50 p.m. R1's family member (FM)-B stated R1's bed and blankets smelled of urine when she had visited. She stated she has called the facility to make sure R1 was not put to bed in a bed that smelled of urine. Upon observation and interview on 12/31/24 at 9:05 a.m. R1 asked surveyor to look at her bed because staff had made the bed covering up urine. R1 stated the night staff told her to urinate in her incontinent pad again and that leaves her bed soiled. R1's bed was found to have wet light-yellow urine seeped area approximately 10 inches in circumference on a bath blanket that was folded across the center of R1's bed between her top and bottom sheet. A sheet and comforter were covering the soiled area. A slight odor was noted. Upon observation and interview on 12/31/24 at 9:31 a.m. R1 told nursing assistant (NA)-A that her bed was soiled. NA-A pulled back R1's comforter and top sheet noting the soiled area. Registered nurse (RN)-A was also observing in the room and stated she could see and smell the urine from approximately 12 feet away from the bed. NA-A took the soiled bath blanket off the bed and placed a clean bath blanket in the bed. NA-A did not change the top sheet which had been in contact with the soiled bath blanket. R3's significant change MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 had no cognitive impairment. R3's behavior status indicated he rejected cares 1-3 days out of 7. R3 was totally dependent upon staff for oral hygiene, toileting hygiene, showering, lower body dressing, personal hygiene and transferring. R3 was always incontinent of bowel and bladder. R3's pertinent diagnoses were chronic congestive heart failure, acute respiratory failure, acute pulmonary edema (fluid in the lungs), type II Diabetes, morbid obesity, absence of left foot, contracture (shortening of muscles, tendons or ligaments that limits movement) of the left hand, acquired absence of the right leg below the knee. Upon observation on 12/31/24 at 12:20 p.m. R3 had a large electric wheelchair in front of his bathroom with oxygen tubing laying on the floor. Along the wall on the side of the head of his bed was a chair, a commode (a portable toilet), and a bedside table. On the floor next to the chair was a basin with mail and an old medication box. On the chair was a sterile wound draping cloth, a bath blanket and a plastic basin filled with wound supplies. Underneath the chair were socks and a Chux pad (a disposable under pad for a bed or furniture). Next to the chair was R3's commode, which was covered with two sterile wound drapes, wound supplies, unfolded bed sheets, a facility bed spread, a hanger, a hospital gown and other clothing. Below the commode was an empty plastic gallon jug, a clean incontinence pad and oxygen tubing. Next to the commode was a bedside table piled with incontinence wipes, a razor, incontinence briefs, old medication boxes, rubber gloves and some bottled lotions. On the floor between the bedside table and the bed was a wound care sterile drape and a clean incontinence pad. The wall on that same side of the room was missing paint in area approximately 3 feet x 1 foot, it appeared the paint had been scraped off. On the adjacent side of R3's room was another bedside table with a small refrigerator on top, a plastic laundry bin and another chair. There were three plastic bags on the floor filled with unidentified items. The laundry bin was overflowing with clothing. The chair had dirty laundry on it, the sling used for R3's EZ stand (a machinal lift to stand people) and an empty plastic bin. The wall under the window beside R3's bed had what appeared to be multiple small areas of food stains. Upon interview on 12/31/24 at 12:30 p.m. R1 stated he was not certain if the bedding on the commode was clean or dirty. He stated did not believe the facility was using the oxygen tubing that was on the floor, if he noticed that it was being used, he would have stopped them. He stated he would like his room clean, so his family had a place to sit when they visit. He stated he asked staff about a week ago if his would care items could all be placed in a plastic bin, so they were not spread all over his room. Upon observation and interview on 12/31/24 at 12:46 p.m. the assistant director of nursing (ADON) stated R3 had been in and out of the hospital frequently and some of the bags on the floor were items from the hospital. The ADON stated she was not certain if the linens on his commode and chair were clean or dirty. She stated the supplies that were on the floor should not have been there. She told R3 that she and housekeeping would clean his room after lunch and any items in question would be laundered. The room was cleaned. Upon interview on 12/31/24 at 2:45 p.m. the Director of Nursing stated beds should not be made if they are soiled. In addition, she stated R3 had the right to have his room the way that he wanted it. She also stated that the facility ADON completed an audit every week and one of the questions to all the residents was if there were anything they would like done in their room and R3 had stated no. The DON stated she was just informed on 12/30/24 that R3 would like a bin for his wound care supplies and was in the process of getting him one. A policy regarding a homelike environment was requested however none was received.

Based on interview and document review the facility failed to ensure the comprehensive care plan was developed to implement cares and services for a leg prosthetic for 1 of 1 resident (R3) reviewed. R3's care plan did not have any person-centered details for R3's prosthetic placement or use. In addition, R3's comprehensive assessment did not indicate R3 had a leg prosthetic. Findings include: R3's significant change MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 had no cognitive impairment. R3's behavior status indicated he rejected cares 1-3 days out of 7. R3 was totally dependent upon staff for oral hygiene, toileting hygiene, showering, lower body dressing, personal hygiene and transferring. R3 was always incontinent of bowel and bladder. R3 was not on a bowel toileting program. R3's pertinent diagnoses were chronic congestive heart failure, acute respiratory failure, acute pulmonary edema (fluid in the lungs), type II Diabetes, morbid obesity, absence of left foot, contracture (shortening of muscles, tendons or ligaments that limits movement) of the left hand, acquired absence of the right leg below the knee. R3's MDS did not indicate R3 had a leg prosthesis. R3's care plan with a revision date of 5/14/24 indicated R3 had an activity of daily living performance deficit related to decreased mobility secondary to below the knee amputation of the right leg and trans metatarsal (procedure that removes part of the foot) amputation of the left foot. R3's interventions included: [NAME] (to place on) prosthesis daily as resident allows. R3's care plan with a revision date of 8/15/24 indicated R3 had a physical mobility related to decreased mobility secondary to below the knee amputation of the right leg and trans metatarsal (part of the foot) amputation of the left toes. R3's interventions included: Ambulation/locomotion - wheelchair - electric independent, no walking, transfer assistant of two staff members with an EZ-stand (a mechanical lift to assist residents from a sitting to standing position). R3's care plan did not indicate when the prosthesis was to be used, how to place the prosthetic and if the prosthesis was required with the use of the EZ-stand. R3's Kardex dated 12/31/24 indicated R3 was to ambulate using an electric wheelchair and was independent. He was to transfer with two staff members and the EZ-stand. The Kardex have any documentation regarding R3's prosthetic. Upon interview on 12/31/24 at 12:30 p.m. R3 stated he does refuse to wear his prosthesis when he is in bed and does not wear it when he goes out of the facility for dialysis. He stated he has swelling in his leg and the prosthesis became painful and irritated him. He stated when physical therapy (PT) put the prosthesis on, they do it quickly and it feels right. When the floor staff put it on it takes them a long-time and it does not feel right. R3 stated he had to tell staff how to put the prosthetic on as many do not know to use the prosthetic sock liner. Upon interview on 12/31/24 at 12:46 p.m. the assistant director or nursing (ADON) stated she stated she was not certain how staff were trained on R3's prosthesis or the details of the care plan. Upon interview on 12/31/24 at 1:08 p.m. nursing assistant, NA-B stated she had worked with R3. NA-B was not certain whether he was required to wear the prosthesis when he was being transferred or not. She stated the answer would be on R3's Kardex. NA-B denied any specific training with R3's prosthesis. She stated she recalled from her nursing assistant course to make sure to lock a prosthesis, but could not recall exactly how to lock R3's. Upon observation interview on 12/31/24 at 1:40 p.m. NA-C stated he knew how to put R3's prosthesis on. He had not been trained specifically through the facility but had been a nursing assistant for many years and had learned at other facilities throughout his career. He stated R3 would direct staff on how to put the prosthetic on by telling them to place his special sock on and how to place the metal parts together forming a clicking sound. NA-C reviewed R3's Kardex on his computer to show the surveyor how the Kardex read for R3's prosthesis and stated R3's prosthetic was not on the Kardex therefor nursing assistant staff would not know exactly what to do. Upon interview on 12/31/24 at 2:20 p.m. the director of physical therapy (PT)-A stated it is understandable that the nursing assistants may not be as quick as the therapies when donning the prosthetic. He stated most prosthetics use a pin system and are straight forward to use, however not all prosthetics are the same. He was not certain how the nursing assistants were trained. He stated a resident with a leg prosthetic would not always need to wear the prosthetic when using the EZ-stand however in R3's case due to balancing concerns with his left hand it is advised and should be on the care plan. Upon interview on 12/31/24 at 2:45 p.m. the Director of Nursing verified R3's prosthetic was not on the nursing assistants Kardex. She stated the reason nursing had not populated it when producing the care plan. In addition, she stated that the care plan identified R3 had a prosthesis and to [NAME] it as resident allows. She stated the nursing assistant staff is taught prosthetic cares in their nursing assistant training course therefor they were aware of how to use, not requiring anything more specific on the care plan. A facility policy titled Care Plan - Baseline and Comprehensive with a revision date of 6/20/23 indicated that each resident was to receive care individualized to him or herself and that that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative.

Based on interview and record review the facility failed to meet a resident needs and choices to perform activities of daily living of toileting for 1 of 3 residents (R3) reviewed when R3 wore an incontinent brief for toileting. R3 had a below the knee leg prosthesis and was unable to use his preferred method of toileting due to staff not able to apply the prosthesis in a timely manner to transfer R3 to the toilet or commode chair (a portable toilet chair) as indicated on R3's care plan. Findings include: R3's significant change MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 had no cognitive impairment. R3's behavior status indicated he rejected cares 1-3 days out of 7. R3 was totally dependent upon staff for oral hygiene, toileting hygiene, showering, lower body dressing, personal hygiene and transferring. R3 was always incontinent of bowel and bladder. R3 was not on a bowel toileting program. R3's pertinent diagnoses were chronic congestive heart failure, acute respiratory failure, acute pulmonary edema (fluid in the lungs), type II Diabetes, morbid obesity, absence of left foot, contracture (shortening of muscles, tendons or ligaments that limits movement) of the left hand, acquired absence of the right leg below the knee. R3 was not receiving amputation/prostheses care from restorative nursing program in training and skill practice. R3's quarterly assessment dated [DATE] indicated R3 was always incontinent of bowel. There were factors/conditions impacting his bowel continence identified. The assessment did not indicate any medications that may affect bowel incontinence. The assessment did not indicate any other contributing factors such as requiring physical assistance to the toilet. R3's perception to defecate was absent. R3 did not have an elimination pattern. R3 was on a toileting program to manage his bowel incontinence and the program was effective. The assessment did not show any documentation of what the toileting plan was. There were not bowel concerns identified. Upon record review of R3's progress notes dated 9/29/24 - 12/30/24 there was no documentation about R3's toileting indicating there were no attempts at alternative measures for R3 to be free from wearing an incontinent brief. R3's care plan dated 1/19/23 indicated R3 had an actual/potential for alteration in elimination related to decreased mobility secondary to below the knee amputation of right leg. R3's interventions included: Incontinence care after each incontinent episode and monitor for signs and symptoms of a urinary tract infection (UTI). R3's care plan dated 4/28/23 indicated R3 had a risk for constipation related to narcotic use. R3's interventions were: -Encourage resident to sit on toilet to evacuate bowels if possible. -Ensure residents feet are flat on the floor or flat on an elevated support during evacuation. Knees should be at 90 degrees or above hip height to promote ease of evacuation where possible. -Follow facility bowel protocol for bowel movement. -Monitor medications for side effects of constipation. Keep physician informed of any problems. -Monitor/document/report as needed signs and symptoms of constipation. -Record bowel movement pattern each day. Describe the amount, color, and consistency. R3's care plan revision of 5/14/24 indicated R3 had an activity of daily living performance deficit related to decreased mobility secondary to below the knee amputation of the right leg and trans metatarsal (procedure that removes part of the foot) amputation of the left foot. R3's interventions included: Don (to place on) prosthesis daily as resident allows. R3's care plan with a revision date of 8/15/24 indicated R3 had a physical mobility related to decreased mobility secondary to below the knee amputation of the right leg and trans metatarsal (part of the foot) amputation of the left toes. R3's interventions included: Ambulation/locomotion - wheelchair - electric independent, no walking, transfer assistant of two staff members with an EZ-stand. R3's quarterly assessment dated [DATE] indicated R3 was always incontinent of bowels. The factors/conditions impacting bowel continence was obesity and lower extremity amputation. R3 was taking laxatives and narcotics. Other contributing factors included impaired decision-making skills, depression, and anxiety. R3's perception to defecate was diminished. R3 did not have an apparent usual elimination pattern. R3 was not on a toileting program. The question Is current toileting schedule effective in management the resident's bowel continence was answered not applicable N/A. The question if bowel program is not effective: new intervention to be up in place was left blank. There not bowel concerns indicated. The assessment failed to indicate R3's preferences. R3's Kardex dated 12/31/24 indicated R3 was to ambulate using an electric wheelchair and was independent. He was to transfer with two staff members and the EZ-stand. R3 was to have incontinence care after each incontinent episode. Upon interview on 12/31/24 at 12:30 p.m. R3 stated he felt like a baby because the facility puts a diaper on him. He stated he didn't have a choice because he knows when he has to have a bowel movement, but by the time two staff members come to his room and put his prosthesis (a custom-made replacement for an amputated leg) on and place him in the EZ-stand he had soiled himself at times. He does refuse to wear his prosthesis when he is in bed and does not wear it when he goes out of the facility for dialysis. He stated he has swelling in his leg and the prosthesis became painful and irritated him. He stated when physical therapy (PT) put the prosthesis on, they do it quickly and it feels right. When the floor staff put it on it takes them a long-time and it does not feel right. R3 stated he does not get asked if he wants to use the commode in his room or the toilet, I am expected to use the diaper. R3 denied being about a toileting plan or being asked if the toileting plan the facility documented having in place was working for him. R3 had not been offered or tried any other toileting alternatives. Upon interview on 12/31/24 at 12:46 p.m. the assistant director or nursing (ADON) stated R3 had been fitted for a specific type of brief and she believed he wanted to wear incontinent briefs. She stated she was certain he wanted to the wear the briefs to his dialysis appointments because toileting was very difficult there. The ADON stated R3 was aware when he needs to have a bowel movement, but she had witnessed him on a p.m. shift refuse to put the prosthesis on for his transfer to get to the toilet. The ADON denied trying any alternative methods to assist R3 to not having to wear an incontinent pad. Upon interview on 12/31/24 at 1:40 p.m. NA-C stated he knew how to put R3's prosthesis on. He had not been trained specifically through the facility but had been a nursing assistant for many years and had learned at other facilities throughout his career. He stated R3 would direct staff on how to put the prosthetic on by telling them to place his special sock on and how to place the metal parts together forming a clicking sound. He stated R3 wore a brief and would call for assistance when needed to be cleaned up after having a bowel movement. He stated he did not ask R3 if he wanted to use the commode or toilet as he did not think that was R3's wishes. Upon interview on 12/31/24 at 2:45 p.m. the Director of Nursing stated the facilities plan was to have R3 use the toilet or commode, but since R3 would refuse to wear the prosthetic R3 needed to wear an incontinence pad. The DON was not aware of R3's wishes to not wear an incontinence pad for toileting. An email correspondence from the DON dated 1/6/24 at 3:28 p.m. indicated R3's care plan had him listed as incontinent. He had quarterly assessments in September and December which addressed his bowel and bladder status. In September it was noted that his perception of need to defecate was absent. In December, the perception of need to defecate was diminished. Both assessments note he is incontinent. With his preference of not wearing his prosthetic leg during the day and a diminished ability or absent ability to note the need to defecate, staff were not utilizing the commode as it was no longer appropriate. No findings of other alternative methods were sent post survey. A facility policy regarding activities of daily living as requested however none provided.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment and a physician's order was completed to allow a resident to safely administer their own medication for 3 of 4 residents (R263, R15, R54) observed with unattended medication. Findings include: R263's Admission Record dated 10/31/24, identified admission on 10/26/24, with diagnoses including orthopedic aftercare following surgical amputation and type one diabetes mellitus. R263's undated assessments list lacked a SAM evaluation for insulin until 10/28/24. R653's baseline care plan and comprehensive care plan dated 10/26/24, identified he could communicate easily and understand staff, however, lacked an assessment for SAM of home insulin until 10/28/24. R263's progress notes lacked assessment of SAM for home insulin. The progress notes lacked determination of R263's clinical appropriateness to SAM insulin, or involvement of the interdisciplinary team (IDT), including the physician, on the decision for R263 to SAM insulin. R263's behavior tracking dated 10/26/24 through 10/31/24, lacked any refusal of care. R263's Order Summary Report dated 10/31/24, lacked an order to SAM until 10/28/24. R263's Medication Administration Record (MAR) dated 10/26/24 through 10/31/24, identified an admission order for insulin regular (Human) inject six units subcutaneously with meals for diabetes mellitus (DM) and insulin regular (Human) inject per sliding scale if 151 to 200, give 2 units; 201 to 250 give 4 units, 251 to 300 give 6 units, 301 to 350 give 8 units, 351 to 400 give 10 units and call provider. No insulin was documented as administered on 10/26/24. R263's blood sugar summary dated 10/31/24, identified no blood sugars recorded on 10/26/24, on the day of admission. The readings on 10/27/24, ranged from 113 to 324 and on 10/28/24, 186 to 383. During an interview and observation on 10/28/24 at 12:21 p.m., R263 was awake and in bed watching TV. A mostly full Humulin R insulin bottle was observed on the bedside table. The bottle was not labeled with a date when opened. There was also small, narrow syringe without markings on it for dosing on the bedside table. His left upper arm had a continuous blood glucose monitor (CBGM). R263 stated he could check his blood sugar readings at any time on the CBGM. R263 stated his goal blood sugar was 120 and he would take 4.5 units of insulin for every 100 that his blood sugar was over 120, which conflicted with the physician's orders on the MAR. R263 stated the insulin and syringe were brought from home, he administered it himself, and that the nurse was aware from his admission on the weekend. R263 stated he had been managing his own diabetes and insulin for [AGE] years. Nursing assistant (NA)-C entered the room, took the urinal which was on the same bedside table as the insulin and syringe, emptied the urinal in the bathroom, rinsed it, returned it to the bedside table right next to the insulin and syringe, bagged garbage and linen and exited the room. During a follow up interview on 10/28/24 1:53 p.m., NA-C was unable to answer the process if she observed medications in a resident's room. When asked if she should let the nurse know, she replied yes. During an interview on 10/28/24 at 1:54 p.m., registered nurse (RN)-B stated he completed R263's admission assessments on 10/26/24. RN-B stated R263 administered his own insulin over the past two days since admission. RN-B stated he would ask R263 what his blood sugar was and how much insulin he administered and would then document those amounts in the MAR. RN-B stated R263 said he knew how to SAM insulin; however, a SAM assessment for safety was not completed and should have been, along with notifying the physician for an order. During a follow up observation on 10/28/24 at 3:12 p.m., the home insulin was no longer on R263's bedside table and syringe was gone. During a follow up interview and observation on 10/28/24 at 5:54 p.m., the director of nursing (DON), obtained the current blood sugar results from R263 and drew up the prescribed dosage of insulin. The DON entered R263's room with his evening insulin and explained the process for SAM while in the facility. The DON completed a SAM assessment with R263 which verified he was able to SAM insulin after nursing set up. The DON stated a R263's SAM assessment should be done and documented prior to actual SAM to assess for safety and ability. 48299 R15's quarterly Minimum Data Set (MDS) 8/12/24, indicated R15 was cognitively intact and varied from set-up to dependent assistance with activities of daily living (ADLs). R15's medical record lacked assessment for self-administration of medications. R15's physician's orders did not indicate R15 was able to self-administer medications. R15's care plan printed 10/31/24, directed staff to administer medications as ordered and did not indicate R15 self-administered medication. During observation on 10/29/24 at 8:22 a.m., R15 sat in the dining room eating breakfast with multiple medications in a cup next to his plate. Two dining services staff plated food and served residents. Multiple dining services staff and NAs entered and exited the dining room and served other residents in dining room or obtained a tray for delivery to a resident room. When interviewed on 10/29/24 at 8:35 a.m., NA-A stated nurses brought residents medications and made sure they were taken. NA-A confirmed medications were next to R15 without licensed staff, and R15 started to take his medications independently. When interviewed on 10/29/24 at 1:59 p.m., R15 stated staff usually left him with his medications and water, and R15 took his medications after he finished breakfast. When interviewed on 10/29/24 at 2:02 p.m., licensed practical nurse (LPN)-A stated residents required an order and care plan to leave medications with them. LPN-A stated R15 preferred to take his medications in the dining area and had been his routine for months. LPN-A did not know if R15 had an order or care plan for self-administration of medications. LPN-A verified they left the medications with R15 at breakfast and stated R15 got anxious when staff watched him take medications. R15 stated self-administration assessments were important for resident safety. When interviewed on 10/31/24 at 2:27 p.m., assistant director of nursing (ADON)-C stated residents needed a self-administration assessment and order from the provider for medications to be left with a resident. ADON-C stated it was important to assess a resident before leaving them to take medication without licensed staff supervision to ensure resident was able to swallow their medication without choking or dropping on floor. ADON-C confirmed R15 did not have orders, care plan, or assessment for self-administration of medications. On 10/31/24 at 4:36 p.m., the DON, expected staff giving medication to stay with resident until medications taken unless resident had an assessment, orders, and care plan for self-administration of medications. DON stated R15 did not like nursing standing over him, and staff should have followed proper procedure. 49617 R54's admission MDS dated [DATE], indicated she had intact cognition and was not receiving any scheduled or as needed (PRN) pain medications. Additionally, the MDS indicated R54 rarely had pain that interfered with her daily activities or sleep. R54's medical diagnoses included heart failure, atrial fibrillation (an irregular heartbeat), high blood pressure, kidney failure, and chronic obstructive pulmonary disease (COPD, or a group of lung diseases that causes breathing difficulties by restricting airflow to the lungs). R54's functional abilities Care Area Assessment (CAA) dated 9/23/24, indicated she had physical limitations resulting in a need for assistance with self-care. R54's electronic health record was reviewed on 10/28/24 and lacked documentation of a self-administration of medication assessment. R54's order summary, printed 10/31/24, lacked documentation of orders for Icy Hot pain relief roll-on as well as an order for self-administration of medications. During observation on 10/28/24 at 5:05 p.m., R54 sat in her room next to her bed. There was a bottle of Icy Hot roll-on pain reliver in the bag attached to her walker. R54 stated the previous night or two ago, she had pain in her legs overnight and she requested nursing staff to help her apply the Icy Hot. She stated it was effective at relieving her pain. During observation of morning cares on 10/30/24 at 7:44 a.m., NA-B reported NAs could apply barrier creams and lotions to residents but could not apply prescription creams or other topical agents. NA-B stated for topical pain relief medications, even over-the-counter (OTC), needed to be applied by a nurse. NA-B said if NAs saw any medications, topical agents or otherwise, they should be taken out of a resident's room and given to the nurse. NA-B confirmed there was a bottle of Icy Hot pain relief roll-on on R54's bedside table and stated she could apply that herself but sometimes would ask for staff's assistance. NA-B stated belief that the Icy Hot was a PRN and was not worried about the bottle being left in R54's room, and said, that is okay here. During observation and interview on 10/30/24 at 8:44 a.m., licensed practical nurse (LPN)-B prepared medications for administration and knocked on R54's door, introduced self and the task. LPN-B verified R54 had the Icy Hot pain relief roll-on at her bedside. After exiting the room, LPN-B reviewed R54's medical record and verified there was no order for the Icy Hot. LPN-B knocked on R54's door again, entered and retrieved the bottle of Icy Hot and returned to the medication cart. LPN-B reviewed the medical record and verified R54 did not have a self-administration assessment, nor did she have a provider's order for self-administration of medications. LPN-A stated if R54 wanted to apply the Icy Hot herself, she would need to be assessed for self-administration of medications before the facility obtained a provider's order that she was okay to self-administer medications. During interview on 10/31/24 at 2:38 p.m., the DON stated staff were expected to complete a self-administration screening, obtain a provider's order for self-administration, then update the resident's care plan if a resident wanted to self-administer any medication, including OTC products like Icy Hot. The DON stated the struggle the facility faced was residents and guests bringing in outside medications and not notifying nursing staff. The DON expected staff to remove medications, including OTC products and topical agents, from a resident's room and bring them to the nurse. A facility policy titled Medication Self Administration last revised 2/12/24, directed licensed staff to complete a screen to determine factors that may impact safe administration of medications. If the resident was deemed appropriate to self-administer medications, staff were guided to obtain a physician order and care plan the self-administration of medications with interventions specific to the individual resident.

Based on observation and interview, the facility failed to provide a homelike environment for 1 of 1 resident (R27) reviewed who had an unclean tube feeding pole. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was severely cognitively impaired, dependent on staff for all activities of daily living, had diagnoses of traumatic brain injury and dementia, and indicated they had a feeding tube through which they received more than 50% of their nutrition. During observation on 10/28/24 at 2:14 p.m., R27 was in his room with tube feeding running. The tube feeding pump was attached to a pole, which had smudged areas down most of the pole. The legs of the base had multiple drops and streaks of tannish colored substance which were scattered and approximately covered a quarter of the surface area of two legs. One of the legs of the base had a thick area approximately three by two and a half inches of crusted tannish colored substance, and the floor had four tannish colored drops approximately three quarters of an inch When interviewed on 10/28/24 at 3:53 p.m., registered nurse (RN)-A stated staff cleaned the tube feeding pole when they noticed it was dirty and did not document. RN looked at R27's tube feeding pole, base, and floor and verified cleaning was needed. RN-A stated there were infection concerns and added the tube feeding pole was not a good picture. When interviewed on 10/31/24 at 12:36 p.m., licensed practical nurse (LPN)-B stated they did not clean tube feeding poles on day shift, did not know what the routine was, and different shifts completed different tasks. LPN-B stated they wiped down tube feeding poles if they saw it was needed. LPN-B stated tube feeding poles were cleaned for infection control and resident dignity. When interviewed on 10/31/24 at 4:36 p.m., director of nursing (DON) expected staff to clean tube feeding poles.

Based on observation, interview, and record review, the facility failed to utilize enhanced barrier precautions (EBP) for 2 of 5 residents (R3) observed for personal cares and wound care treatments. Findings include: Per the Centers for Disease Control (CDC) dated 6/28/24: EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted multi-drug resistant organisms (MDRO) (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device. High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. R3's Face Sheet indicated R5 had diagnoses of paraplegia (paralysis caused by spinal injury or disease), peripheral vascular disease (abnormal narrowing of arteries other than those that supply the heart or brain), and methicillin resistant staphylococcus aureus infection (MRSA, a type of bacteria that has developed resistance to antibiotics). R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 was cognitively intact, and required the assist of two staff for toileting, transfers, and bed mobility. R3's care plan dated 10/14/24, indicated R3 had a history of MRSA and required EBP. R3's Physician Orders dated 9/12/24, directed wound care on left lower leg: Cleanse with normal saline and pat dry. Apply a nickel thick Santyl (ointment that removes dead skin) to the wound bed over slough, and cover with foam dressing. Change daily on evening shift and as needed. On 10/14/24 at 10:16 a.m., licensed practical nurse (LPN)-A entered R3's room to administer a suppository and reposition him. LPN-A donned gloves, but did not donn a gown. R3's door had a sign indicating he required EBP and directed to wear personal protective equipment for high contact care activities. On 10/14/24 at 10:22 a.m., LPN-A stated she went into R3's room to administer a scheduled suppository and repositioned him. LPN-A verified she didn't wear a gown. When asked about the EBP sign on R3's door, LPN-A stated she doesn't wear a gown unless a resident has an active infection, and stated the director of nursing (DON) could answer questions about it. On 10/15/24 at 9:43 a.m., LPN-B was observed wearing a gown and gloves, and providing wound care for R3. LPN-B removed R3's soiled dressing. She cleansed the wound with normal saline, patted it with a sterile dressing, opened the tube of Santyl ointment and applied it to the wound. She touched the trash can and removed the first set of gloves, and was wearing another set of gloves underneath the top set. DON-B entered the room to take a picture of the wound. LPN-B removed the second set of gloves, and without performing hand hygiene, applied a clean dressing without gloves. Outside of R3's room, LPN-B used a hand wipe to cleanse her hands. On 10/15/24 at 10:48 a.m., LPN-B stated hand hygiene should only be completed before and after wound care. LPN-B stated she used double gloves occasionally because she didn't know what to expect, and it was nice to just take the top set of gloves off. On 10/15/24 at 11:14 a.m., DON-B stated hand hygiene should be completed before putting gloves on, when changing gloves, and after soiled items have been touched. Double gloving was not an acceptable practice. On 10/15/24 at 11:22 a.m., registered nurse (RN)-A stated hand hygiene should only be completed before and after wound care was completed. She used double gloves when providing wound care because it was easier than taking gloves on and off. On 10/15/24 at 11:32 a.m., the medical director (MD) stated hand hygiene should be completed when going from dirty to clean, and during every glove change. Double gloving was not an acceptable practice because the second set of gloves would be considered dirty. Staff should follow the EBP signs on the doors, and should be using EBP properly. On 10/15/24 at 1:04 p.m., DON-A stated double gloves were not acceptable and staff had been recently trained in infection control. Hand hygiene should be completed before going into the resident room, when putting new gloves on and removing soiled dressings. Staff had been trained on EBP and should be following policy for wearing gowns. The facility policy Enhanced Barrier Precautions dated 3/26/24 directed EBP will be implemented during high-contact resident care activities when caring for a resident with chronic open wound requiring a dressing or residents with an infection or colonization with and MDRO. The facility policy Pressure Injury Prevention and Wound Care Management last revised 3/4/24, directed to refer to the dressing change policy for detailed policy and procedure for dressing changes. Clean technique for wound and dressing changes are indicated. A policy pertaining to infection control during wound care was requested but not provided.

Based on observation, interview and document review, the facility failed to provide treatment to a skin tear and documented it had been completed for 1 of 4 residents (R3) reviewed for wound care. In addition, the facility falsely documented wound care was being provided for 2 of 4 residents (R4, R5) reviewed for wound care whose wounds had been resolved. Findings include: R3 R3's Face Sheet indicated R5 had diagnoses of paraplegia (paralysis caused by spinal injury or disease), peripheral vascular disease (abnormal narrowing of arteries other than those that supply the heart or brain), and methicillin resistant staphylococcus aureus infection (MRSA, a type of bacteria that has developed resistance to antibiotics). R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 was cognitively intact and required the assist of two staff for toileting, transfers, and bed mobility. R3's progress note dated 7/20/24, indicated R3 was noted to have a skin tear on his right lower leg. R3 stated it may have been from accidentally hitting a doorway. R3's Physician Orders dated 9/12/24, directed wound care on left lower leg: Cleanse with normal saline and pat dry. Apply a nickel thick Santyl (ointment that removes dead skin) to the wound bed over slough, and cover with foam dressing. Change daily on evening shift and as needed. R3's Wound Evaluation Form dated 10/9/24 indicated his front right lateral lower leg wound was improving. It measured 2.04 centimeters (cm) length by 1.16 cm width. There was no evidence of infection, it had moderate serous exudate define. R3's Wound Evaluation Form dated 10/15/24 indicated his front right lateral lower leg wound was improving. It measured 1.67 cm length by 1.11cm width. There were no signs of infection. There were no other descriptive details documented about the wound. R3's October treatment administration record (TAR) had the following documentation: -Licensed practical nurse (LPN)-C documented she completed wound care on 10/10/24 and 10/11/24. -Registered nurse (RN)-A was scheduled the evening of 10/12/24. The 10/12/24 box was left blank. RN-A documented she completed wound care on 10/13/24 -RN-B documented he completed wound care on 10/14/24. On 10/14/24 at 10:30 a.m., R3 was observed. The date on R3's dressing was 10/10/24. R3 stated the skin tear was from being scraped a few times while being in the shower chair. He stated the last time the dressing was changed was on 10/10/24. On 10/15/24 at 8:43 a.m., R3 was interviewed again. R3 stated he did not receive wound care on the evening of 10/14/24. The bandage was observed to have a date of 10/10/24 on it. On 10/15/24 at 8:55 a.m., director of nursing (DON)-A and DON-B entered the room to provide R3 repositioning and an incontinent brief change. When asked if there were a date or time on the dressing, DON-A verified the dressing had a date of 10/10/24 which indicated it was last changed on 10/10/24. DON-A stated she would have to look at the TAR and ask the nurses what had happened with the wound care. On 10/15/24 at 11:22 a.m., RN-A stated R3 told her the wound care was only supposed to be done once every three days, because the order had recently changed. RN-A stated staff must follow what the resident says if the order was different from the order in the computer. She was not sure who was responsible for managing wound care orders. She left the administration record for the wound care blank on 10/12/24 because there was an issue with the computer, but she did provide the wound care. She was not sure who was responsible for managing wound care orders once the wound was resolved. On 10/15/24 at 11:32 a.m., the medical director (MD) was interviewed. The MD was also responsible for completing wound rounds for R3 and prescribing wound care orders. She stated she had just been to R3's room to assess his wound after the wound care had not been completed for 4 days. R3's wound had continued to improve, it had reduced in size and showed no signs of infection despite wound care treatments not being given. Not following orders was not acceptable. When asked if she had concerns about nurses documenting that wound care orders were completed for wounds that had been resolved, she stated she was honestly not sure what to say. On 10/15/24 at 11:56 a.m., RN-B stated when he charted R3's wound care as being completed when it wasn't, it was an oversight on his part, and he took the blame for it. When a resident had a resolved wound, the nurse should call the physician to discontinue the order, they should not document it as given. R4 R4's annual MDS dated [DATE], indicated R4 was moderately cognitively impaired, and was independent with activities of daily living. R4's Physician Orders dated 8/6/24 directed wound care - right lateral foot: Cleanse with wound cleanser, pat dry, apply antiseptic, cover with foam dressing, once daily. R4's Wound Evaluation Form dated 10/2/24 indicated the wound was surgical and had healed. R4's October TAR indicated wound care was provided from 10/2/24 through 10/14/24 with the exception on the box being blank on 10/12/24. On 10/14/24 at 1:25 p.m., R4 stated there was no bandage on her right foot. R4 took her sock off, and no dressing or open areas were visible. On 10/15/24 at 9:12 a.m., DON-A assessed R4's foot and verified the surgical incision was healed. R5 R5's quarterly MDS dated [DATE], indicated she was cognitively intact, and had no skin conditions. R5's Physician Orders dated 8/16/24 directed skin tear left arm: cleanse area with generic wound cleanser, pat dry, apply oil emulsion, cover with dry dressing. Complete one time a day every 3 days. R5's October TAR indicated the left arm skin tear wound care was completed on 10/1/24, 10/4/24, 10/7/24, 10/10/24, and 10/14/24. R5's Physician Orders dated 9/24/24 directed skin tear left lower leg: cleanse with wound cleanser, pat dry, apply oil emulsion dressing. Cover with dry dressing. One time a day every Monday, Wednesday and Friday. R5's October administration record indicated the left leg skin tear wound care was completed on 10/2/24, 10/4/24, 10/7/24, 10/11/24, and 10/14/24. R5's Physician Orders dated 9/17/24, directed skin tear to left forearm: cleanse area with generic wound cleanser, pat dry. Apply oil emulsion dressing and cover with dry dressing. Change 3 times per week one time a day. R5's October administration record indicated the left forearm skin tear wound care was completed On 10/2/24, 10/4/24, 10/7/24, 10/9/24, 10/11/24, and 10/14/24. On 10/14/24 at 1:34 p.m., R5 stated all of her skin tears have been healed for a long time, she was unable to remember for how long. On 10/15/24 at 9:16 a.m., DON-A verified all three of R5's skin tears were healed. She thought staff were not feeling empowered to discontinue the wound care orders if the wounds were resolved. Nurses could also reach out to her or DON-B to tell them wounds have been resolved, and they could discontinue orders. Nurses should not sign out wound care was completed when it was not. The facility policy Pressure Injury Prevention and Wound Care Management last revised 3/4/24, directed residents who have a pressure injury or wound will receive care and services to promote healing.

Based on observation, interview and document review, the facility failed to protect a resident while an allegation of abuse was being investigated for 1 of 3 (R1) residents reviewed for abuse. Findings include: R1's Medicare 5 day Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, and required the assistance of one staff for eating, transferring, toileting, and bed mobility. R1's Face Sheet undated indicated R1 had diagnoses of type II diabetes, depression, anxiety, cognitive communication deficit, weakness, and dementia. R1's Special Instructions dated 8/5/24, in the electronic health record directed staff to complete Cares in Pairs (two staff present when completing cares). On 8/5/24 at 9:41 a.m., R1 was interviewed. R1 stated staff were rough with him, Yeah they just got real rough. They grabbed me by my shirt and lifted me up. It did hurt. On 8/5/24 at 10:02 a.m., R1's power of attorney (POA) stated a staff member yanked R1 up by his left arm while he was asleep to change his incontinent brief on 7/31/24. R1 told the POA he would be able to identify the staff member. When leadership brought in photos of staff to identify, R1 was unable to identify anyone. On 8/5/24 at 11:01 a.m., R1 was observed in his room. R1 stated he needed to use the bathroom, but he had not put the call light on. Surveyor put the call light on for him. At 11:03 a.m., a nursing assistant (NA)-A came into help. NA-A assisted R1 to use the bathroom without providing Cares in Pairs. On 8/5/24 at 11:34 a.m., NA-A was interviewed. NA-A was not aware staff needed to complete Care in Pairs with R1. On 8/5/24 at 1:12 p.m., registered nurse (RN)-A stated R1 alleged a staff member came in and jerked him around. R1 stated the staff member was male. After R1 was shown photos of staff who worked on 7/31/24, R1 was not able to identify the person he believed hurt him. There was only one male working that evening, and R1 did not identify that person as the alleged perpetrator. Following the allegation, Cares in Pairs was implemented. RN-A was unsure when the Cares in Pairs intervention was added to the special instructions. On 8/5/24 at 1:39 p.m., the director of nursing (DON) stated the investigation into the allegation of abuse was still underway, she planned on looking at his recent cognitive scores and interviewing staff to see if R1 had been more confused. Since R1 couldn't identify an alleged perpetrator from staff photos, leadership didn't have to worry about suspending any staff members. The DON was unsure when the Cares in Pairs was implemented. Cares in Pairs wouldn't be a protection for R1, it would be to protect staff from false allegations. On 8/5/24 at 2:36 p.m., the administrator stated R1's safety precautions following the allegation included a skin check and Cares in Pairs. She probably entered in the Cares in Pairs into R1's profile sometime on 8/2/24 but was unsure. The facility policy Vulnerable Adult Abuse and Neglect Prevention revised 10/4/23, directed under the protection of residents during investigation section, ensuring safety and well-being for the vulnerable adult is of utmost priority. Safety, security and support of the resident will be provided.

Based on interview and document review, the facility failed to have a designated charge nurse for each shift. Findings include: On 6/20/24 at 12:43 licensed practical nurse (LPN)-A stated there was not a charge nurse assigned the night of 6/14/24. LPN-A stated, Every nurse is in charge. On 6/21/24 at 2:18 p.m., the administrator stated via email, The nurses in the building are in charge. She stated the director of nursing (DON) is on call 24/7 for any clinical concerns. On 6/21/24 at 2:45 p.m., DON stated there was not a designated charge nurse each shift. A policy was requested regarding having a designated charge nurse for each shift. This was not provided.

Based on interview and document review, the facility failed to awake staff on the overnight shift to provide adequate supervision and care of residents for 1 of 3 residents (R1) when R1 called 911 due to pain and the need to use the bathroom. Findings include: R1's Medical Diagnoses list undated, included surgical aftercare following surgery secondary to malignant neoplasm of the colon (colon cancer) and ileostomy (a surgical opening in the small intestine which drains into an external bag). R1's care plan dated 6/13/24 directed to anticipate resident's need for pain relief, respond immediately to any complaint of pain, and administer medication for pain management. R1's care plan directed two staff to assist to the toilet due to reduced mobility status. The care plan directed R1 used a disposable brief, and staff were to provide incontinence cares after each episode of bladder incontinence. On 6/20/24 at 10:48 a.m., the director of nursing (DON) stated the facility became aware of allegations of staff sleeping on the night shift, when the police were called to the facility on [DATE] around 4:00 a.m. The facility reviewed the police report and spoke with the hospital on 6/17/24. Sleeping on the job was not tolerated, and the staff suspected of sleeping were immediately suspended. She initiated immediate education regarding the requirement to remain awake and working while on duty. On 6/20/24 at 11:05 a.m., the administrator stated the facility video surveillance and police report supported termination of the nursing assistant (NA)-A and licensed practical nurse (LPN)-A who were found to be sleeping on 6/15/24. The administrator stated R1 had called 911 because she wanted to go home. The administrator stated all staff who are working must be awake throughout their shift. On 6/20/24 at 12:43 p.m., LPN-A stated he was working when R1 called 911 on 6/15/24 around 4:00 a.m. He stated he had emptied her ostomy bag around 2:00 a.m. He was in the dining room when the police arrived, I was about to take my break. He denied sleeping. He stated NA-A was sleeping and he told NA-A to get up. He said R1 was not in pain when the police arrived. On 6/20/24 at 2:10 p.m., NA-A stated he was worked the overnight shift from 6/14/24 to 6/15/24. He stated R1 was yelling all night long. He stated R1 wanted to leave the facility. He stated, She said she needed to go to the bathroom, but I told her she had a catheter for her urine and a colostomy bag. NA-A stated he did not check R1's brief. Observation of police bodycam footage 6/15/24 showed police officers entering the facility on the first floor. A police officer appeared to wake LPN-B. LPN-B was in a completely dark office with the door almost closed. Officers knocked on the door. LPN-B's head was down on the desk. She was covered in a blanket. LPN-B slowly lifted her head and told the officer R1 was on second floor. The officers took the elevator to second floor. They looked around to find two staff sleeping in the dining room. The officers had to shine their flashlights to wake LPN-A and NA-A in the dark dining room. Police explained they were responding to a 911 call from R1 stating she was in pain and needed her bedding changed. As they entered R1's room, she could be heard yelling from down the hall. As they opened the door, R1 stated, Thank God you are here. They don't take care of me. NA-A is observed on the police bodycam footage sitting in the dining room chair with blankets on chair directly in front of him. NA-A stated to the police officer, She has been yelling all night. She was saying she wanted to pee. She already had a catheter. I explain to her. There's nothing I can do. I have other patients. I told the nurse. Observation of facility video surveillance on second floor, 6/15/24 at 3:58 a.m., showed police officer in video on second floor, exiting elevator at 3:58 a.m. Police officer turned to his left, then turned to his right and shined flashlight into the dining room. LPN-A got up from the far left corner of dining room. The dining room was observed to be very dark. The facility Vulnerable Adult Abuse and Neglect Prevention policy dated 10/4/23, directed to provide residents a safe environment that is free from harm. It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. All residents are susceptible to maltreatment and exploitation due to their need for nursing home care. Due to physical, emotional, and mental inabilities, residents may be dependent upon us to meet their needs. It is the policy to enhance the life of all residents through strong programming and appropriate care and treatment. Additionally, residents and staff will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties. An owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or harmfully neglect a resident.

Based on interview and record review, the facility failed to investigate a report of abuse for one of one resident (R1) reviewed for response to allegations of abuse when a police officer visited the facility to investigate an allegation of abuse. Findings include: R1's Admission Record printed on 6/10/24 indicated R1 was admitted to the facility on [DATE]. R1's diagnoses include post-traumatic stress disorder, dependence on renal dialysis, need for assistance with personal care, reduced mobility, borderline personality disorder, and major depressive disorder with severe psychotic symptoms. R1's progress note dated 11/3/22 indicated R1 was admitted to the facility with a primary diagnosis of chronic failure renal end stage renal disease dialysis dependent. R1's brief interview for mental status (BIMS) dated 5/14/24 indicated R1 had a score of 14, which indicated R1 was cognitively intact. R1's police report dated 6/6/24 indicated law enforcement went to visit R1 due to reports the nursing staff was grabbing her and jerking her around. The police report indicated R1 stated she did not need emergency medical services (EMS). The police report stated law enforcement spoke with the DON who told the police officer it is typical for R1 to accuse staff of abuse and that she investigates every report of abuse for R1. R1's progress notes indicate no progress note was made on 6/6/24 about allegations of abuse, that the DON, or assistant director of nursing (ADON), or the administrator talked with R1 about the alleged abuse. During an interview with R1 on 6/10/24 at 8:58 a.m., R1 stated she remembers law enforcement visiting her, but she didn't know when they visited her or why they visited her. R1 stated men were in her room and they were rough with her during cares. She did not say anything to the men while this was happening because she was dumbfounded. R1 stated she is afraid of the men that come in her room and is afraid to report the abuse because she is afraid the men will increase the severity of the abuse. During an interview with the DON on 6/10/24 at 11:54 a.m., the DON stated law enforcement came to visit R1 last week. The DON stated law enforcement told her they were there because they received a report of abuse to R1. The DON stated she did not start an investigation into abuse because law enforcement stated, she was fine and that R1's family member (FM)-A calls all of the time and alleges things. The DON stated she didn't feel it was necessary to start an investigation. During an email correspondence from the DON on 6/10/24 at 3:12 p.m., the DON stated the ADON met with R1 immediately after law enforcement left R1's room and R1 stated she was fine and had no concerns. During an interview with the ADON on 6/10/24 at 3:20 p.m., the ADON stated when law enforcement came out of R1's room, he went into R1's room and asked if she was ok and R1 stated to him that she didn't have any concerns. The ADON stated he spoke with the DON and the DON had told him why law enforcement was visiting R1, but the ADON did not remember why law enforcement was visiting R1 at the time of this interview. The ADON stated he did not call R1's guardian. During an email correspondence from the DON on 6/10/24 at 3:21 p.m., the DON stated the administrator followed up with R1. The DON stated the administrator checked in the R1 after law enforcement left and stated R1 had no concerns. During an interview with the DON on 6/10/24 at 4:51 p.m., the DON stated her expectation is abuse, neglect, or abuse should be reported. The DON stated if the facility gets a report on abuse, neglect, or abuse, the facility would assess the resident, they would report the abuse, and then the facility would investigate. The DON stated if the resident is alert and orientated and they tell them no abuse took place, then the facility would not investigate. The DON stated if there is a report of abuse and the resident states abuse happened, then the facility would investigate. The DON stated the administrator and the ADON visited R1 when law enforcement was there. During an interview with the administrator on 6/10/24 at 5:02 p.m., the administrator stated if there is a threat of physical abuse, then the facility would report the allegation first and then investigate after. The administrator stated law enforcement came out to the facility on Friday, 6/7/24 and she found out that they came to speak with R1. The administrator stated she never found out from law enforcement as to why they were at the facility. After law enforcement left, she went to visit R1 and asked if she had any concerns. R1 stated she did not have any concerns. The administrator stated she did not ask R1 specifically about abuse, neglect, or abuse because R1 stated she did not have any concerns. The facility's Vulnerable Adult Abuse and Neglect Prevention policy and procedure revised on 10/4/23 indicated any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, or misappropriation shall intervene to safeguard the resident and then immediately report to the Nursing Home Administrator and then the Administrator would report abuse to the state agency per State and Federal requirements. The policy indicated upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the DON, or designee, will coordinate an investigation, which will include completion of witness statements. The policy indicated that upon reports of resident maltreatment, each alleged report will be individually investigated.

Based on interview and record review, the facility failed to report alleged violations of abuse was reported immediately, but no later than 2 hours after the allegation is made State Agency for one of one resident (R1) reviewed when a police officer visited the facility to investigate an allegation of abuse. for reporting of alleged violations of mistreatment, exploitation, neglect, or abuse. Law enforcement visited R1 due to allegations of maltreatment and stated to the Director of Nursing (DON) they were there for allegations of maltreatment and the facility did not report the allegations of maltreatment. Findings include: R1's Admission Record printed on 6/10/24 indicated R1 was admitted to the facility on [DATE]. R1's diagnoses include post-traumatic stress disorder, dependence on renal dialysis, need for assistance with personal care, reduced mobility, borderline personality disorder, and major depressive disorder with severe psychotic symptoms. R1's progress note dated 11/3/22 indicated R1 was admitted to the facility with a primary diagnosis of chronic failure renal end stage renal disease dialysis dependent. R1's brief interview for mental status (BIMS) dated 5/14/24 indicated R1 had a score of 14, which indicated R1 was cognitively intact. R1's police report dated 6/6/24 indicated law enforcement went to visit R1 due to reports the nursing staff was grabbing her and jerking her around. The police report indicated R1 stated she did not need emergency medical services (EMS). The police report stated law enforcement spoke with the DON who told the police officer it is typical for R1 to accuse staff of abuse and that she investigates every report of abuse for R1. R1's progress notes indicate no progress note was made on 6/6/24 about allegations of abuse, that the DON, or assistant director of nursing (ADON), or the administrator talked with R1 about the alleged abuse. During an interview with R1 on 6/10/24 at 8:58 a.m., R1 stated she remembers law enforcement visiting her, but she did not know when they visited her or why they visited her. R1 stated men were in her room and they were rough with her during cares. She did not say anything to the men while this was happening because she was dumbfounded. R1 stated she is afraid of the men that come in her room and is afraid to report the abuse because she is afraid the men will increase the severity of the abuse. During an interview with the DON on 6/10/24 at 11:54 a.m., the DON stated law enforcement came to visit R1 last week. The DON stated law enforcement told her they were there because they received a report of abuse to R1. The DON stated she did not start an investigation into abuse because law enforcement stated, she was fine and that R1's family member (FM)-A calls all of the time and alleges things. The DON stated she did not feel it was necessary to start an investigation. During an email correspondence from the DON on 6/10/24 at 3:12 p.m., the DON stated the ADON met with R1 immediately after law enforcement left R1's room and R1 stated she was fine and had no concerns. During an interview with the ADON on 6/10/24 at 3:20 p.m., the ADON stated when law enforcement came out of R1's room, he went into R1's room and asked if she was ok and R1 stated to him that she did not have any concerns. The ADON stated he spoke with the DON and the DON had told him why law enforcement was visiting R1, but the ADON did not remember why law enforcement was visiting R1 at the time of this interview. The ADON stated he did not call R1's guardian. During an email correspondence from the DON on 6/10/24 at 3:21 p.m., the DON stated the administrator followed up with R1. The DON stated the administrator checked in the R1 after law enforcement left and stated R1 had no concerns. During an interview with the DON on 6/10/24 at 4:51 p.m., the DON stated her expectation is abuse, neglect, or abuse should be reported. The DON stated if the facility gets a report on abuse, neglect, or abuse, the facility would assess the resident, they would report the abuse, and then the facility would investigate. The DON stated if the resident is alert and orientated and they tell them no abuse took place, then the facility would not investigate. The DON stated if there is a report of abuse and the resident states abuse happened, then the facility would investigate. The DON stated the administrator and the ADON visited R1 when law enforcement was there. During an interview with the administrator on 6/10/24 at 5:02 p.m., the administrator stated if there is a threat of physical abuse, then the facility would report the allegation first and then investigate after. The administrator stated law enforcement came out to the facility on Friday, 6/7/24 and she found out that they came to speak with R1. The administrator stated she never found out from law enforcement as to why they were at the facility. After law enforcement left, she went to visit R1 and asked if she had any concerns. R1 stated she did not have any concerns. The administrator stated she did not ask R1 specifically about abuse, neglect, or abuse because R1 stated she did not have any concerns. The facility's Vulnerable Adult Abuse and Neglect Prevention policy and procedure revised on 10/4/23 indicated any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, or misappropriation shall intervene to safeguard the resident and then immediately report to the Nursing Home Administrator and then the Administrator would report abuse to the state agency per State and Federal requirements. The policy indicated upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the DON, or designee, will coordinate an investigation, which will include completion of witness statements. The policy indicated the facility must report to the State agency immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four hours if the alleged violation involves, neglect, misappropriation of resident property, or exploitation and involves not serious bodily injury. The policy indicated that upon reports of resident maltreatment, each alleged report will be individually investigated.

Based on interview and document review, the facility failed to effectively monitor and report skin condition changes for 1 of 3 residents (R3) reviewed for pressure ulcers. R1 developed an avoidable stage 2 pressure ulcer (defined as skin breaking open, wears away, or forms an ulcer) and deep tendon injury (defined as purple or maroon localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Findings include: R3's undated face sheet identified current diagnoses as acute or chronic congestive heart failure, chronic kidney disease (stage 4), anemia, shortness of breath, weakness, spinal stenosis, acute pericarditis, pleural effusion, chronic embolism and thrombosis of unspecified vein, thrombocytopenia, prosthetic heart valve, and diverticulosis of the large intestine. R3's admission documentation dated 1/14/23 indicated R3 was incontinent of bowel and bladder, had no current skin integrity or history of skin issues. R3 was at risk for skin breakdown with interventions that included apply moisturizer to my skin as needed - do not massage over my bony prominences, keep skin clean and dry, and use a pressure relieving cushion for the wheelchair. R3's Braden Scale for Predicting Pressure Sore Risk dated 1/14/23 indicated a score of 21 identifying R3 did not have a risk for developing a pressure ulcer. R3's Task List report dated 1/14/23, indicated certified nursing assistance (CNA) or personal care attendant (PCA) was to monitor R3's skin every shift. R3's Point of Care Response History (Facilities CNA/PCA documentation system) dated 1/14/23, indicated R3's skin was monitored 1/14/23 at 8:40 p.m. no new alterations, 1/17/23 at 9:47 p.m. no new alterations, 1/18 11:47 a.m. and 9:59 p.m. no new alterations, 1/20/23 1:59 p.m. and 9:59 p.m. no new alterations. All other shifts skin monitoring during R3's stay at the facility from 1/14/23 through 1/21/23 were left blank. R3's daily skilled charting dated 1/16/23 and 1/19/23 under objective data indicated R3 had no skin alterations, no skin concerns. A physician progress note dated 1/17/23 to establish patient care indicated R3 discharged from the hospital on 1/14/23 after a diagnosis of congestive heart failure. R3 reported diarrhea since arriving to the facility with a history of constipation. The physician placed an order for an abdominal x-ray. R3's admission care plan dated 1/14/23, indicated on 1/19/23 the facility identified R3 was at risk for skin alterations and skin integrity related to incontinence. R3's goal was to remain free from skin breakdown. The interventions were 1. Apply moisture to skin as needed and do not massage bony prominences. 2. Keep skin clean and dry. 3. Manage R3's clinical conditions and contributing factors to decrease the risk of skin breakdown. 4. Use a pressure relieving cushion for the wheelchair. On 1/19/23 the facility identified R3 had limited physical mobility related to weakness requiring the transfer assistance of one staff, and two staff with a stand-up lift. On 1/19/23 the facility identified R3 was unable to perform activities of daily living requiring the assistance of one staff for bathing and/or showering, and dressing. On 1/19/23 the facility identified a potential for alteration in elimination related to incontinence and staff were to apply barrier cream to peri area after each incontinent episode, check and change R3's incontinent brief, provide urinal at bedside. On 1/18/23 the facility identified R3 had bowel incontinence with interventions to provide a bedpan/bedside commode and loose fitting easy to remove clothing. R3's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R3 required extensive assistance of one staff member for dressing, toilet use, transferring and personal hygiene. R3 was frequently incontinent of urine and bowel. R3 was determined to be at risk for a pressure ulcer or injury. R3 did not have pressure ulcers, wounds, or dermatitis. A photo dated 1/21/23 of R3's buttock wounds was reviewed. R3 was laying in his bed at the facility on his right side. His bed sheet was being changed and he was laying directly on the mattress. The facility room could be identified on the photo. R3's right side showed five areas, (unmeasurable due to photo) of maroon discoloration the length of his buttock fold, over a bony prominence and two maroon marks lateral to his buttock fold. His left side showed a large maroon area the entire length of the buttock fold and one more maroon marking posterior of his fold. In addition, an open circular area midline to his buttock fold was identified. The open area was light red color appearing moist on the photo. R3's Care Area Assessment (CAA) dated 1/24/23, indicated pressure ulcer/injury was triggered for potential pressure ulcer due to the need for extensive assistance with bed mobility. Complicated by incontinence and immobility. R3 did not have any skin issues at the time of the assessment but remained at risk. Upon interview on 1/25/23 at 10:28 a.m. licensed practical nurse (LPN)-A stated on 1/21/23, the day R3 was transferred to the hospital was the first day she had worked with him. She stated R3's wife and two other people were present in his room and R3 was complaining of stomach pain. His vital signs were taken and they were low. R3 was sent to the emergency department. She stated that prior to be to R3's transfer to the emergency department, she was to administer a suppository to R3 and it was at that point LPN-A found the pressure ulcer it was a stage II, with patches of open areas and both buttocks covered with maroon discoloration. Upon interview on 1/25/23 11:09 a.m. nursing assistant (NA)-A stated she first worked with R3 on 1/21/23. She stated that he was incontinent of stool following a suppository. NA-A stated R3 had two small open areas inside the folds of his buttocks and the surrounding skin had multiple large deep red areas. She stated she did not report the skin condition findings to the nurse because R3 was sent to the emergency department within the hour after discovery due to shortness of breath and stomach pain with a low blood pressure reading. Upon interview on 1/25/23 at 3:12 p.m. a hospital social worker read the hospital wound notes dated 1/22/23 which indicated R3 had a community acquired wound. He had a scattered deep maroon boggy area covering his buttocks described as a deep tissue injury. R3 was receiving treatment every other day by cleansing the wound, covering with a Mepilex dressing and turning him every two hours. In addition, R3 had a heel ulcer being treated with betadine and covered with a 4x4 dressing. Upon interview on 1/25/23 at 4:35 p.m. family member (FM)-A stated she was visiting R3 on 1/21/23 and R3 was complaining of stomach pain, he had been having diarrhea and underwent an x-ray prior in the week which showed constipation. Upon request, LPN-A came in the room to give R3 a suppository. FA-A noticed at that time his skin, had some bleeding with broken down skin with his entire buttock region a deep red color. FM-A stated she took a picture of the wounds. Upon interview on 1/26/23 at 10:25 a.m. NA-B stated she worked with R3 the day shift on 1/18/23. She stated she did not change R3's incontinent brief, toilet him or clean him and therefore did not observe R3's buttock. She stated his brief was not soiled because he was using a urinal, therefore was not changed. At the end of her shift, she assisted him to a seated position on the toilet with an EZ-stand. She stated she did not observe R3's buttock. She did not assist him with getting off the toilet as her shift had ended and the evening shift assisted him then. Upon interview on 1/26/23 at 10:43 a.m. a hospital registered nurse (RN) stated R3 was admitted on [DATE] to the Intensive Care Unit (ICU) and has remained there. His admitting diagnosis was a gastrointestinal bleed, sepsis, syncope with hypotension and a low hemoglobin level of 7.4, deep tissue injury of the sacral area and pressure ulcer. The RN stated the sacral wound was closed. Staff is watching closing and it is covered with Mepilex dressing. For the deep tissue injury, the staff was focused on offloading at all times by turning from left turn right every 1-2 hours. The area remained the dark maroon color and no sloughing. The wound care team was following him. Upon interview on 1/26/23 at 11:00 a.m. the facility wound care physician observed the photo of R3's wounds and stated she had not seen him for a wound evaluation. She identified the wound as a deep tissue injury, which can come upon quickly within 24-48 hours, stating the staff should have noticed it. The deep tissue was likely caused by moisture and pressure. The circular area observed in the photo was a Stage II pressure ulcer. Upon interview on 1/26/23 at 12:18 p.m. NA-C stated she worked with R3 on his admission day 1/14/23, and the evening prior to his transfer to the hospital 1/21/23. On 1/14/23, R3 had a bowel movement and his skin showed no signs of discoloration or breakdown. On 1/20/23, NA-C did not observe his skin under his incontinent brief. She stated she transferred him from his wheelchair to his bed. She denied doing any peri-care or clothing change. She stated My understanding is that if I am doing cares, I observe the skin I am seeing and report to the nurse, I have never been told that I do a total skin check on my shift. Upon interview on 1/26/23 at 1:26 p.m. registered nurse (RN)-A stated all NA's should notify the nurse of any concerns with skin as they are performing their activities of daily living (ADL's). She stated she was not familiar with the NA's daily routines or what education they received from the facility on ADL specifics, and the exact reporting measures. RN-A stated in the Point Click Care (PCC), the facilities software system, there is a trigger response for documenting and was uncertain what triggers the nurse's attention, if missed and what NA documentation triggers it or not. In addition, she was not certain who is responsible for monitoring the NA documentation. Upon interview on 1/26/23 at 1:59 p.m. the assistant director of nursing (ADON) stated her expectation of NA's was to follow the care plan and that each resident has clean clothing and provided assistance with any other assessed ADL needs. She stated that a resident who is incontinent and receives extensive assistance with ADL's would have their full skin observed by an NA at least during morning and evening cares. Upon interview on 1/26/23 at 3:02 p.m. the director of nursing (DON) stated her expectation of staff is to complete all tasks on the care plan and report to nursing as appropriate. She stated the documentation for the nursing assistance compliance is scattered at this point in time and the facility is putting together an action plan for the missed charting. Upon observation of the photo of R3's wound, the DON stated her expectation was that staff would have noticed that significant of a skin condition and reported. A facility policy titled Pressure Injury Prevention and Wound Care Management dated 4/27/21, indicated the facility will ensure residents who are admitted without a pressure injury do not develop a pressure injury, unless clinically avoidable. Resident's skin will be monitored daily during cares by nursing assistant and skin check will be weekly by licensed nurse.

Based on interview and document review, the facility failed to ensure physician ordered laboratory monitoring was completed to prevent complications and ensure therapeutic dosing for 1 of 1 residents (R4) reviewed who consumed [MEDICATION NAME] (an anti-convulsant medication) for [MEDICAL CONDITION]. This resulted in actual harm for R4 when they developed symptoms of [MEDICATION NAME] toxicity (a condition were the levels of medication in the body are too high) and were subsequently hospitalized . Findings include: R4's hospital Discharge Summary, dated 11/18/19, identified R4 had been brought to the hospital after being found obtunded (a state similar to lethargy) at her home. R4 was brought to the hospital were she was found, . in [DIAGNOSES REDACTED] (a single [MEDICAL CONDITION] more than five minutes or two or more [MEDICAL CONDITION] within a five-minute period without the person returning to normal between them) with elevated ([MEDICATION NAME] kinase; a lab value) and multiple fractures. R4 was admitted and subsequently discharged after seeing neurology with several new orders, including an order for [REDACTED].>R4's corresponding After Visit Summary, dated 11/21/19, identified R4 was being discharged to the nursing home. A medication listing was included which outlined R4's active physician orders; these included: [MEDICATION NAME] ER (extended release) 300 milligrams (mg) daily; and several other medications which can interact with [MEDICATION NAME] and cause elevated blood-serum levels including [MEDICATION NAME] (an antacid), [MEDICATION NAME] (an anti-anxiety medication), and [MEDICATION NAME] (a sedative). R4's 5-Day Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and was independent with transfers and locomotion on and off the unit. Further, R4's [DIAGNOSES REDACTED]. On 3/24/20, at 9:33 a.m. R4 was interviewed. R4 explained she admitted to the nursing home in November 2019, from the hospital where she had been admitted due to developing new [MEDICAL CONDITION]. R4 stated when she discharged the hospital, and came to the nursing home, she was started on several medications including some which helped control her [MEDICAL CONDITION], including [MEDICATION NAME]. R4 expressed concern as she didn't think the [MEDICAL CONDITION] medication was being monitored correctly, and explained an incident had occurred about a month prior where she woke up feeling like I had bricks tied to my legs and could barely move or bear weight when she tried to stand up. R4 went to the Emergency Department (ED), and subsequently was hospitalized the following day, where they did some lab work and found the [MEDICATION NAME] level in her blood was way too high and she had, [MEDICATION NAME] toxicity. R4 stated she thought there had been some communication troubles between the nursing home and hospital which may have caused the incident, as the hospital told her they had tried getting ahold of the nursing home, however, couldn't get through to anybody. Further, R4 expressed since her hospitalization , her [MEDICATION NAME] monitoring had been going better as she was making sure it gets done. R4's Call Documentation note, dated 1/30/20, identified three separate, recorded entries which included: On 1/30/20, at 3:44 p.m., Message from (nurse practitioner (NP)-A) . Can you please call (nursing home) and let them know [MEDICATION NAME] level is low. Lets increase [MEDICATION NAME] ER from 300 mg at (bedtime) to 200 mg (twice a day) and rechecke (sic) [MEDICATION NAME] free and total levels (laboratory tests to monitoring the [MEDICATION NAME] level in a patient) in 2 weeks. On 1/30/20, at 5:19 p.m., Spoke with (nursing home) reception and call was (transferred) to Nursing. No answer and phone continued to ring with no VM (voicemail). Telephone encounter order, lab orders, and medications order printed and faxed to (fax number). On 2/5/20, at 11:46 a.m., Spoke with Nurse at (nursing home) and orders faxed on 1/30/20 were not rec'd (received). Wrong fax# was provided. Correct fax is (number listed). Orders re-faxed per request. The note identified a section labeled, Approved, which provided instructions for [MEDICATION NAME] 200 mg by mouth twice a day to be started on 1/30/20. The order was listed as authorized by NP-A, and had a visible handwritten star shape next to it along with a handwritten, nursing home staff signature (registered nurse, RN-B). Further, the note contained a section labeled, Orders Placed This Encounter, which directed a [MEDICATION NAME] Free and [MEDICATION NAME] Total (two separate lab tests) be completed. The labs had two associated columns present which included, Expected By, and, Expires, with dates listed as 2/13/20, and 3/14/20, respectively. There was no additional, handwritten documentation or dictation next to the lab test(s) which identified they had been acted upon or placed for draw. R4's Medication Administration Record [REDACTED]. An order was listed which read, ([MEDICATION NAME] ER) . 300 mg orally at beditme related to EPILEPTIC [MEDICAL CONDITION] . with a listed start date of 11/21/19. This order was recorded as administered until 2/4/20. A subsequent order for [MEDICATION NAME] was listed which read, ([MEDICATION NAME] ER) . 200 mg by mouth two times a day ., and listed a start date of 2/5/20. The order was recorded as being administered to R4 from 2/5/20 to 2/20/20 at 8:00 p.m. when the medication was then recorded as, H (held). The medication was then recorded as being held for several doses. R4's medical record was reviewed and lacked evidence the ordered laboratory monitoring from NP-A on 1/30/20, had been acted upon, drawn or clarified to ensure accuracy and/or the therapeutic dosing of R4's [MEDICATION NAME]. Further, there was no evidence the facility had increased or implemented any additional monitoring of R4's [MEDICATION NAME] use despite having a dose increase on 2/5/20, nor was there evidence R4 had been offered and declined the requested laboratory test(s) on 1/30/20. R4's medical record identified the following notes and other entries: On 1/31/20, a progress note recorded R4 as having no cognitive impairment and being, Full weight bearing. On 2/9/20, a progress note recorded R4 as having no cognition impairments, however, now listed R4 as having a, Decline in functional status. The note lacked any specifics pertaining to what abilities had declined, nor any subsequent assessment or intervention of this decline. On 2/19/20, a progress note identified R4 complained of being more shaky than usual and having trouble walking or standing up. Family member (FM)-A came to pick R4 up for an orthopedic appointment and reported R4 seemed to be more confused in the past week with extra shakiness. FM-A expressed concern R4 could have had another [MEDICAL CONDITION]. FM-A told the nursing home they were going to attempt to see R4's neurologist after her orthopedic appointment. There were no further notes or dictation which identified if R4 had been seen by neurology or not, nor any subsequent assessment or action to address the newly identified symptoms. On 2/20/20, a progress note identified R4 was taken to the ED by FM-A to address the weakness, shaking [MEDICAL CONDITION] concerns. The note identified no new orders were given from the ED and FM-A reported the ED was unable to determine the cause of R4's symptoms. R4's corresponding Emergency Department Provider Notes, dated 2/19/20, identified R4 presented to the ED with, generalized weakness. R4 had been scheduled to discharge the nursing home that day (2/19/19), however, developed weakness and heaviness in her legs three hours ago. FM-A was present and reported R4 had shaking chills, so bad that she should (sic) not fully talk, prompting presentation to the emergency center. The note identified FM-A had reported R4 seemed to have an increase in confusion in the past few days, however, there had been no witnessed [MEDICAL CONDITION] today. A, Review of Systems, identified R4 as presenting with chills and diaphoresis along with being short of breath. An ECG (electrocardiogram) was completed which showed no significant changes from a previous reading. A series of laboratory tests were completed which identified a [MEDICATION NAME] level of 25.8, and listed the result as, H (high). A reference range was not identified. An additional [MEDICATION NAME], Free level was collected, however, the results were listed as, Pending. The note listed an, Impression and Plan, which included dictation reading, Her ([MEDICATION NAME]) level is slightly supra therapeutic however, did discuss with pharmacy and added on a free ([MEDICATION NAME]) level, as with her CKD, this is likely to be affecting this level and free level would be more accurate. The dictation concluded that no acute reason for R4's symptoms could be found and she was returned to the nursing home. Further, the note listed a section labeled, Lab - All Results, which identified R4's [MEDICATION NAME], Free laboratory result as 2.7 mcg/ml (micrograms per milliliter) and listed a reference range of 1.0 - 2.0 mcg/ml. This result was identified as, H /\ ( high), and R4's [MEDICATION NAME] level was within the established reference range. A subsequent Conversation: Other note, dated 2/20/20, identified dictation completed by NP-A and outlined a discussion was held with FM-A regarding R4's increased bilateral leg weakness and shaking. The note identified, (NP-A) discussed with her that [MEDICATION NAME] level is elevated and her symptoms are likely [MEDICATION NAME] toxicity. The note listed several new orders for R4 which included a holding her scheduled [MEDICATION NAME] for several doses, obtaining new [MEDICATION NAME] levels and contacting the on-call neurologist with the results, and giving R4 as-needed [MEDICATION NAME] to help control the shakiness. On 2/20/20, a subsequent progress note identified R4 went to an appointment with FM-A, who then proceeded to take R4 back to the ED for a second time due to continued shakiness, weakness and confusion. The note identified R4 was subsequently admitted to the hospital for monitoring. R4's corresponding Abbott Northwestern Hospital Discharge Summary, dated 2/23/20, identified a principal [DIAGNOSES REDACTED]. The summary identified R4 presented to the Methodist ED on 2/19/20, for evaluation of leg weakness and chills. The Methodist ED completed laboratory test(s) which were remarkable for hemoglobin of 10.1 (normal range 12-15.5), creatinine of 1.23 (normal range 0.84 to 1.21) and [MEDICATION NAME] level of 25.8, and the note identified since no acute findings were present, R4 was discharged back to the nursing home and R4's neurologist was contacted who recommended lowering R4's [MEDICATION NAME] dosing given (the) elevated level. R4 was listed as presenting to the Abbott ED with ongoing bilateral leg heaviness and difficulty ambulating. An MRI was completed which was negative for stroke, and R4's [MEDICATION NAME] level remained elevated at 3.8 so her [MEDICATION NAME] was held. R4's [MEDICATION NAME] levels were listed as 2.1 (Free) on 15.1 (Total) on 2/23/20 and neurology felt that her symptoms were resolving. R4 was discharged from the hospital on [DATE], back to the nursing home. When interviewed on 3/24/20, at 10:45 a.m. registered nurse (RN)-A explained the nurse working when they receive orders or faxes from provider's were responsible to ensure any ordered laboratory test(s) were entered into the system to be completed. RN-A expressed she was unaware R4 had been hospitalized with [MEDICATION NAME] toxicity in the last month, and expressed she did not think [MEDICATION NAME] levels were drawn for residents residing at the nursing home. Further, when asked if she had received any education or training on [MEDICATION NAME] level monitoring since R4's hospitalization , RN-A responded, I don't want to answer. On 3/24/20, at 10:57 a.m. RN-B was interviewed and verified it was her signature on the Call Documentation note, dated 1/30/20, which directed to increase R4's dose of [MEDICATION NAME]. RN-B stated she could not recall if she acted on or ordered the laboratory testing which was requested on the form, however, expressed if she had ordered them then she would have done so using the electronic EMDEON system. RN-B reviewed this system, along with R4's medical record, and verified they lacked evidence the ordered laboratory testing and monitoring had been completed. RN-B stated R4 had been having complaints of chills well before her hospitalization in February 2020, however, acknowledged the sudden weakness and leg shakiness, which developed the day prior to her hospitalization with [MEDICATION NAME] toxicity, were new symptoms for R4 which she had not displayed before. RN-B stated the laboratory monitoring which had been ordered on [DATE], should have been completed timely so her dosing could have been adjusted and helped to prevent some of that (ED visits and hospitalization ). RN-B stated the facility had issues getting laboratory testing done consistently, so they were implementing steps to change the process including having all incoming faxes come to just a single fax-machine and appointing one health unit coordinator (HUC) to oversee them. However, RN-B stated she had not personally had any re-education since R4's hospitalization regarding this process. On 3/24/20, at 11:23 a.m. a telephone call was attempted with FM-A. A return call was provided on 3/24/20, at 4:05 p.m. and FM-A stated R4 had been hospitalized because the facility wasn't monitoring her [MEDICAL CONDITION] medications and doing the needed blood draws. R4 went to the Methodist ED on 2/19/20, however, they couldn't find anything wrong with R4 despite her symptoms, however, the ED never really got back to us with their lab findings or told them her [MEDICATION NAME] level was elevated. R4's symptoms continued which caused FM-A to worry and bring her back to the hospital the following day on 2/20/20, where the physician told her R4's [MEDICATION NAME] level(s) were way too high, and R4's developed symptoms were likely due to [MEDICATION NAME] toxicity. On 3/24/20, at 1:13 p.m. NP-A was interviewed and reviewed R4's hospital medical record. FM-A had contacted the clinic on 2/17/20, and reported R4 was confused, shaky and sleepy. The hospital records identified the ordered laboratory monitoring from 1/30/20, had never been completed which they verified. R4 then went to the ED on 2/19/20, where the laboratory tests were completed. R4 then presented to the hospital on [DATE], and was found to have likely [MEDICATION NAME] toxicity. NP-A explained R4 was hard to diagnose as they were trying to reduce her pain medications and she has displayed withdrawal symptoms which could mimic [MEDICATION NAME] toxicity, which is why the laboratory tests were ordered on [DATE]. NP-A stated if the ordered laboratory monitoring had been completed on 2/13/20, when it was ordered to be done, the levels would have been known sooner and NP-A would have done what Abbott (hospital) did and immediately reduce R4's dose so it didn't continue to go higher. NP-A explained she (couldn't) really say if R4's hospitalization could have been avoided had R4's laboratory tests been completed, however, added, Luckily (FM-A) took her to the ER. Further, NP-A stated she had issues before with getting ordered laboratory testing completed for patients while they reside at the nursing home adding the facility had been not super reliable in getting things done in the past. On 3/24/20, at 2:30 p.m. the director of nursing (DON) and licensed practical nurse manager (LPN)-A were interviewed and reviewed R4's medical record. DON expressed the written 'expected by' and 'expires' dates allowed the facility to obtain the laboratory tests between those dates. DON stated she did not consider the communication an actual order, either, as it was not physically or electronically signed by NP-A; however, DON added the nurse who received it should have clarified the intent of the note with the provider. DON stated if R4's [MEDICATION NAME] levels had been monitored more closely, the staff would have known she was getting too high sooner and it could have been addressed quicker. The DON expressed she did not know if R4's hospitalization could have been completely avoided, however, acknowledged R4's [MEDICATION NAME] levels could have been monitored closer as it was a critical medication, and they wanted to avoid negative outcomes. Further, DON acknowledged the facility had issues with getting ordered laboratory tests completed, however, they had been working on different systems to correct the issues including revising the orientation process for new nurses. However, they had not yet been able to educate all the current nurses with the progress and procedure changes. A provided Therapeutic Drug Monitoring policy, dated 2/21/19, identified a purpose which read, To provide guidance on laboratory monitoring in accordance with specific medication administration in accordance with recognized standards of practice and manufacturer recommendations. A procedure was listed which directed to obtain physician orders [REDACTED]. The laboratory tests will be monitored and communicated to the prescribing physician who will review them for any needed adjustments. Further, the policy included a table which outlined several medications with recommended laboratory testing. [MEDICATION NAME] was listed which listed a reference value range for 10-20 mcg/dl.

Based on observation, interview and document review, the facility to complete a thorough investigation and provide adequate supervision for 1 of 3 residents (R40) who experienced multiple falls as a result of self transfers. This resulted in actual harm when R40 sustained a left wrist and hand fracture resulting from a fall on 6/10/19. Findings include: R40's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified [DIAGNOSES REDACTED]. In addition, the MDS indicated R40 required extensive physical assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS also indicated R40 was not steady and was only able to stabilize with human assistance when moving from surface to surface, when moving from seated to standing position, and when walking, turning around and facing the opposite direction while ambulating. The MDS further indicated R40 had experienced a fall since the prior assessment without injury, had intact cognition and exhibited no behaviors. R40's care plan revised 7/15/19, indicated R40 was Resistive to care related to (r/t) impulsivity. Resident gets up and transfers on his own unsafely from bed to wheelchair when he gets impatient waiting for staff. This causes resident to fall and potentially sustain injury. The care plan indicated R40 had received Reminder and encouragement to call and wait for staff assistance before self transferring. The resident's behavior is de-escalated by explaining when you will return to assist him, or assisting him as soon as possible . The care plan further indicated R40 had an alteration related to multiple health issues including (but not limited to) weakness, right upper lobe mass, [MEDICAL CONDITION], severe malnutrition and being a smoker. The care plan identified R40 had fallen 11 times between 7/31/18, through 7/7/19, and of the falls 10 were noted as Unsafe self transfers. The care plan directed staff to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R40's activities of daily living (ADL) care plan revised 7/1/19, identified an alteration in self care and indicated R40 required extensive assist of one staff with ADL's including bed mobility, transfers and toilet use. On 7/22/19, at 12:02 p.m. when asked how long it took staff to come when he used the call light for assistance, R40 stated That is another thing I have a problem with, there is just not enough help here. When you call they do not come and you wait for a long time before they come to assist you. R40 stated he had to wait for over half an hour before help came and at times the staff came and would say they would be back and never came back for a long time. When asked about falls, R40 reported having fallen a couple times this month, one was outside when I was reaching for something and the other was in my room. Last month I fell in my room when I was attempting to transfer myself into the wheelchair and I got this fracture on my left hand and wrist. R40 stated prior to the fall and many other times he would put his call light on and staff would not come to answer the call light and then he would just transfer himself. R40 also stated, They tell me to use the call light but when I use it no one comes. R40 stated when he fell in (MONTH) 2019, one of the aides had came in as the call light was on and helped him off the floor because he was not able to do it and the aide had told him they would report to the nurse but he never saw a nurse come to see him when he came back to his room from smoking. When asked if he knew who it was he stated he could not remember and the nurse never came to check him out until the night shift when he told another staff about it as he was experiencing pain. When asked what the facility was doing to prevent the falls R40 stated staff would tell him to use the call light but stated they did not answer it when he did and if they did they acted as if he was bothering them. On 7/23/19, at at 3:27 p.m. R40's call light was observed on. When surveyor and the director of maintenance went into the room to follow up on environmental concerns, R40 was observed seated on the edge of the bed at the foot of the bed. R40 had socks on his feet without shoes and the wheelchair was parked across from the bed and was not within reach. R40 appeared agitated and stated his call light had been on for over ten minutes without staff having come to answer it. R40 started to yell and asked the surveyor to help transfer him into the wheelchair. The director of maintenance told R40 he would get him staff assistance. Review of the interdisciplinary Progress Notes from 6/5/19 to 6/12/19, revealed the following: A nursing note (NN) dated 6/5/19, at 6:26 a.m. indicated R40 kept self transferring from the bed to the wheelchair to go smoke. The NN further indicated, He does not wait for NA (nursing assistant) when he puts his call light on. A NN dated 6/9/19, at 6:40 a.m. included, R40 continues with the attitude that he will want to go bed, and he will not be patient for the aids (sic) to come and put him to bed. When they finally do, he will transfer himself back into the chair and go outside to smoke. A NN dated 6/10/19, at 8:45 p.m. included, The resident is still demanding to go to bed, and 5 minutes later he is out of the bed, sometimes by himself, or helped by a nurse or a N[NAME] When he does not have help immediately he complains of his light being on too long. In a single shift, he can go in and out of the bed 5 times, makes it too difficult for the staff and the NA on the floor. A NN dated 6/11/19, at 6:58 a.m. indicated R40 had complained of pain last night in his left hand. The night nurse, licensed practical nurse (LPN)-D, documented R40 had reported he'd fallen on 6/10/19 during the evening shift. LPN-D's note included, He (R40) said he told the aide to go tell the nurse but he never saw the nurse. The note further indicated LPN-D had applied as needed (PRN) BioFreeze and had administered Tylenol to R40. The note lacked any documented assessment describing R40's range of motion to the left hand and wrist, or description of whether the area had any swelling or deformity. An Incident Report dated 6/12/19, indicated an NA had reported to the nurse at around 1:30 a.m., that R40 wanted to see the nurse. The Incident Report indicated the nurse went to see R40 and the resident had shown the nurse his swollen left hand. The report indicated when the nurse went to touch the area, R40 yelled and told the nurse he was in so much pain that he could not sleep. A NN dated 6/11/19, at 12:15 p.m. indicated R40 had a fall on the evening shift on 6/10/19, during a self transfer. The NN indicated R40 had approached the nurse and stated, I fell yesterday and now my wrist hurts. The NN indicated, Upon inspection resident noted to have some swelling to the left wrist. Resident was holding his wrist still. Per resident his wrist is painful with movement and without. Resident Provided BioFreeze as ordered. When asked about the incident resident stated that he fell in his room in the evening time. The notes indicated when R40 had been asked whether he'd reported the incident he'd stated, Someone was there when I fell . The NN further indicated the medical provider was made aware of the fall, and an X-ray was requested. Review of a hospital After Visit Summary report dated 6/11/19, identified R40 had been seen due to wrist pain and had been diagnosed with [REDACTED]. LPN-D was interviewed on 7/24/19, at 7:09 a.m. regarding R40's 6/10/19 incident. LPN-D stated, When I went into his room he told me he fell . When I asked him why he hadn't reported his fall to me earlier, he stated he had told the aide and the aide had said she'd tell the nurse. LPN-D stated he had worked a double shift the evening shift of 6/10/19, to a night shift. LPN-D stated on the evening shift a trained medication aide (TMA) had worked R40's side and he had not come in contact with R40 at all that evening. When asked about whether the NA's who had worked the evening shift on 6/10/19, had been interviewed about the fall, LPN-D stated, From looking at the schedule it would be easy as there were two aides on the floor. However LPN-D said he did not do the investigation at that time because the NAs had gone home. LPN-D was uncertain whether the director of nursing (DON) had followed up with the two aides. LPN-D further stated he didn't know about R40's fall until after the evening shift staff had left on 6/10/19. LPN-D stated when he asked R40 for details about the fall, R40 had stated an aide had assisted him off the floor. LPN-D stated R40 had reported he had left wrist pain, and it was swollen at the time he'd been notified which LPN-D documented. LPN-D reviewed the NN and incident report then verified he had not documented the resident's range of motion ability. LPN-D stated the following morning, he had reported the incident to the DON and the day shift nurse who obtained an order for [REDACTED].>On 7/24/19, at 12:14 p.m. the DON reviewed the 6/10/19 incident with the surveyor. The DON verified the resident's ROM hadn't been assessed when LPN-D was made aware of R40's wrist pain. The DON stated LPN-D was supposed to do an assessment by asking R40 to tell him if he hurt when he moved the wrist this way or that way. The DON also stated the house supervisor, usually was a registered nurse, would also have been available to do the assessment. The DON reviewed the fall incident Verification Of Investigation and acknowledged although multiple staff had confirmed R40 had stated he'd reported the fall to one of the aides, and had reported an aide had assisted him off the floor, the facility had not thoroughly investigated the fall or interviewed the staff that had worked on the unit during the evening on 6/10/19. The DON also verified following the fall no interventions had been put in place in an effort to prevent further falls. When asked if R40 was able to get himself off the floor the DON stated, I do not think he would be able to. He has left sided weakness so it would be hard for him to do that. The DON stated simply reminding and encouraging R40 to use the call light and wait for staff assistance was no longer an appropriate intervention, and stated even after the fall, R40 continued to self transfer and had experienced another fall 7/7/19. The facility's 12/4/18 Fall Reduction policy and procedure, indicated if a fall was not witnessed, or the resident hit his/her head, the staff was to initiate neurological checks, staff was to evaluate/assess the resident for injury, and if injury was known or suspected, necessary first aid treatment was to be provided and the physician and responsible party were to be notified. The policy also indicated a summary of the fall was to be documented to include assessment, intervention and resident response. Further, the policy indicated a summary of the the incident was to be completed by the interdisciplinary team (IDT) and was to include care plan review, effectiveness of interventions and the root cause of fall.

Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (R9, R16) reviewed for pain, received pain medications in a timely manner. This resulted in actual harm for R9 who experienced severe pain when the facility did not administer his narcotic pain medication in a timely fashion resulting in R9 calling 911 and requiring hospitalization for pain control. The findings include: R9 was admitted to the facility at 3:00 p.m. on 12/8/18, with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. narcotic drug for moderate to severe pain control) 5-10 mg every 4 hours PRN pain (last given in hospital on [DATE], at 2:01 p.m.) During interview on 5/6/19, at 2:47 p.m. R9 stated he started having pain in his back shortly after he arrived at facility, and requested medication to which staff told him it was too soon and he would have to wait. R9 then asked for some ice to be applied to his back. R9 indicated staff brought him a pillowcase of ice cubes without the ice contained in a plastic bag, and it started to melt right away getting his bed wet, but stated it was better than nothing. R9 indicated he continued to complain of pain that afternoon and evening without any medication intervention. R9 stated the nurse told him there had been a mix up and his medications were not there yet. Around 11:00 p.m. R9 stated he finally received some medications but his pain was out of control at that point. R9 stated he did not receive any relief from the pain medications he had received and around 2:00 a.m. on 12/9/18, he called 911 for lack of pain control. R9 further stated he was hospitalized for [REDACTED]. Review of (MONTH) (YEAR), Medication Administration Record [REDACTED]. The nurse on duty no longer works for facility and was unable to be interviewed. During interview on 5/9/19, at 10:45 a.m. the director of nursing (DON) indicated [MEDICATION NAME] and [MEDICATION NAME] are medications available within the facility Omnicell (an automated medication dispensing system) and copy of scripts had been obtained prior to admission. DON verified there was no reason R9 should have had to wait for his pain medications. R16 was admitted to facility on 5/1/19, around 4:30 p.m. with [DIAGNOSES REDACTED]. R16's physician orders [REDACTED]. Scripts were sent to the facility with R16's orders at the time of the admission to facility. R16's admission/readmit screener-V4 form dated 5/1/19, at 4:27 p.m. identified R16 had pain rated at 5 on a 1-10 pain scale from knee replacement. Review of R16's (MONTH) 2019, MAR indicated [REDACTED]. During interview on 5/9/19, at 8:45 a.m. DON stated [MEDICATION NAME] sulfate is available in the Omnicell and should have been administered evening of 5/1/19, as it was ordered every 12 hours starting on 5/1/19. During interview on 5/10/19, at 12:00 p.m. registered nurse (RN)-A stated she had completed R16's admission paperwork on 5/1/19. RN-A stated upon review of MAR indicated [REDACTED]. RN-A further stated there is no system in place to double check orders entered by a nurse. RN-A further indicated she did not remember R16 having pain but was likely he had discomfort since he was post operative from knee surgery. The facility's policy titled, Automated Medication Dispensing System (AMDS) revised 10/31/16, included: facilities may use to access emergency medications, first dose, medically necessary medications and interim orders or routine medications. Medications removed from the AMDS must have a corresponding physician order.

Based on interview and document review, the facility failed to identify and consistently implement interventions to prevent falls and/or injury when intoxicated for 1 of 3 (R1) residents reviewed for accidents. R1 sustained harm when she fell and required emergency services for a laceration when intoxicated. Findings Include: R1's admission record dated 5/22/2018, identified [DIAGNOSES REDACTED].Fall on same level from slipping, tripping, and stumbling without subsequent striking against an object, major [MEDICAL CONDITION], recurrent . R1's Care Plan printed 2/11/19, revealed, I HAVE AN ALTERATION IN SAFETY RELATED TO MY CO MORBIDITIES AS EVIDENCED BY HISTORY OF FALLS. MY CO MORBIDITIES ARE CLOSED COLLES FRACTURE RIGHT RADIUS FALL, ACUTE [MEDICATION NAME] WITHOUT HEMATURIA, UTI, [MEDICAL CONDITION] DUE TO STRESS, [MEDICAL CONDITION] .The resident is resistive to care r/t (related to) drinking. Resident is at a high fall risk when drinking. Care Plan Interventions listed as: -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/04/2018 -Encourage and educate resident on waiting for clear paths are made prior to proceeding Date Initiated: 09/05/2018, Revision on: 09/10/2018 - ER Visit Date Initiated: 01/11/2019 - Follow facility fall protocol. Date Initiated: 06/04/2018 -Gripper socks. Date Initiated: 12/31/2018 -Check resident for alcohol/medication each time she returns from outings, See MAR (medication administration record). Date Initiated: 01/13/2019 - PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Date Initiated: 06/04/2018 - Re-educate of risks of falls while using alcohol while on medications, PRN (as needed) Date Initiated: 10/18/2018 - The resident needs a safe environment with: even floors free from spills and/or clutter. Date Initiated: 10/02/2018, Revision on: 10/03/2018. R1's Care Plan lacked evidence for interventions to implement to reduce falls when found to be intoxicated and at high risk of falling. Facility Fall Reduction Policy addresses, .4. If the fall is not witnessed or the resident hit his/her head, initiate neurological checks based on the Neurological Status Evaluation. 5. Evaluate/assess resident for injury 7. Document in the clinical record summary of the fall including, but not limited to, assessment, intervention and resident response. 8. Immediate intervention will be added to the plan of care and communicated to caregivers. In the same policy under the heading SYSTEMS FOR QUALITY ASSURANCE, indicated .2. Resident with falls will be reviewed at Risk Management Committee meetings to identify root cause, effectiveness of interventions, and to make care plan revisions as appropriate . R1's Kardex Report printed 2/22/19, identified R1 as primarily independent with activities of daily living with a notation under DRESSING/GROOMING/HYGIENE indicating, Resident needs limited extensive assistance with transfers, bed mobility, dressing, grooming, toileting while under the influence of alcohol. Progress note dated 1/28/19, at 8:11 p.m. revealed, Resident intoxicated, meds held, BP (blood pressure) 105/59. Did not go to store on this shift, but did have alcohol in the bed. Progress notes lacked evidence interventions were implemented to reduce potential fall. Progress note dated 1/28/19, at 9:45 p.m. revealed, resident sustained [REDACTED]. Per primary nurse resident was intoxicated at time of fall, one empty bottle of vodka was found in resident's room. Writer suggested ice application to resident's head injury, writer asked resident if she had drank alcohol and resident responded 'Yes, I had four bottles of vodka .', writer asked resident if she went out on the evening of 1/28/2019 to buy alcohol and resident responded 'Yes', asked resident if she informed nursing staff that she was going outside of the facility and she responded No, per resident she was checked at the front desk and on the unit when she returned, but primary nurse and NAR denied checking resident because they were not aware that resident went outside of the facility. Writer called resident's daughter and her son-in-law tried talking her into going to the hospital but resident refused stating 'I just want to go to sleep, I'm not going to the hospital'. Primary nurse updated to provide frequent monitoring, update TCP, and oncoming shift to continue frequent monitoring. Fall assessment to be completed. Progress notes lacked evidence frequent monitoring was implemented. Progress Note dated 1/28/19, at 23:32 (11:32 p.m.) revealed, Resident fell 2nd time. Unwitnessed. Laceration to back of head. Vitals and neuros taken. 911 called. Progress note dated 1/29/2019, at 2:50 a.m. revealed, Resident came back from ER at 0240 (2:40 a.m.) on a wheel chair. She had 2 stitches at the back of the head. Will continue to monitor. No changes were identified in the Care Plan following falls on 1/28/19. Progress notes dated 2/9/19, at 11:33 p.m. Resident suspected by her primary nurse to be intoxicated, so primary nurse notified writer. Before writer responded to resident's room primary nurse saw resident getting out of bed attempting to walk but was very unsteady, so primary nurse assisted resident with walking to the bathroom. Writer suggested that resident be monitored at the nurses station to prevent her from attempting to self transfer d/t (do to) her unsteady gait. Resident was compliant with writer's suggestion temporarily but soon started insisting on going back to her room to lay down. Resident was assisted back to her room but not left alone as writer and primary nurse suspected that she would attempt self transfer and fall AEB previous hx. Writer briefly monitored resident while she laid in bed, later assigned an aid to continue monitoring resident and to assist her with transfer as needed. Writer also instructed NARs to rotate monitoring resident until resident is sober and safe to self transfer. Intervention was effective as resident did not self transfer and fall. Oncoming shift updated to continue intervention. During an interview on 2/22/19, at 8:54 a.m. nursing assistant (NA)-A indicated R1 would require 15 minute checks if found to be intoxicated. NA-A also stated the facility fall protocol is to inform the charge nurse and they would communicate a plan. On 2/22/19, at 9:04 a.m. registered nurse (RN)-A indicated a protocol to check R1's person for alcohol when returning from an independent community outing, adding if R1 was found to be intoxicated RN-A would report up the chain, update the doctor, hold medications, check level of consciousness and implement safety checks every 15 minutes. Additionally, if a fall was unwitnessed, RN-A stated he would start neurological checks. The director of nursing (DON) was interviewed on 2/22/19, at 11:17 a.m. She stated when R1 was intoxicated they would provide safety, make sure her environment is clear, and try to make sure she is seated, because she likes to walk around. We would try to figure out where she got it (alcohol), and where it is. Also would notify her physician of her current state. We had a couple different supervisions for (R1), one was hourly, but during the cold snap, we did 15 minute checks to make sure she wasn't getting out. DON went on to indicate the facility completed hourly checks when R1 was intoxicated and the documentation for those checks would be in the Medication Administration Record [REDACTED]. She continued by revealing the MAR indicated [REDACTED]. DON stated R1's normal routine was to come along in her walker, tell the nurse she was leaving and ordered a cab. R1 would typically go to target, drug store, etc. They asked when she would return. She would sign out and they knew she left with a cab. Then (upon R1's return) she would come and sign in, say she was back and then go to her room. When asked directly about (MONTH) 28th intoxication, DON stated they should have started hourly checks when they first identified she was intoxicated and documented those is the MAR. When asked about frequent monitoring and what level of supervision is this considered, and is that supervision documented anywhere? DON said, she would expect 1:1 monitoring, and that she believed that was the normal practice based on how the nurses talk to each other. DON added she would go back and look for more documentation and will ask the nurses what was going on (MONTH) 28th. On 2/22/19, at 1:00 p.m. the DON followed up to communicate she could not find charting for (MONTH) 28th. RN-B was introduced as the charge nurse on shift during the time of R1's falls. RN-B was interviewed and she stated that she did not get a call about the alcohol being found, she was not contacted after the first fall on 1/28/19, at 8:45 p.m It was reported that R1 fell and RN-B stated she was working on another floor and went down to see what was going on. R1 had a little bit of bleeding on the tip back of her head. RN-B instructed them to put ice on it to prevent swelling. R1 told her she went out and drank. RN-B stated she was still pretty new to the facility at that time and did not know the history of R1 but knew that she drank and then typically slept it off. She stated that she told nursing to hold meds, and called the primary. She further instructed for R1 to be watched closely with frequent monitoring which meant that staff should stay close to the door to be able to peek in and monitor R1. However, frequent monitoring did not occur. RN-B went on to reveal, after going back to her floor to pass medications, she got another call about R1 having another fall. At that point, RN stated, They called the daughter and son in law, and then tried again to get her to go to hospital (she refused the 1st time), and said you (R1) really need to go in because you (R1) hit your head. She still said no, but I said I would call 911 and not accept no, then at least someone could come look at her, and then she could decide to go or not. Regarding an incident where R1 was intoxicated on 2/9/19, and R1 was provided 1:1 monitoring to prevent a fall, RN-B stated that she was the charge nurse and did not have to be on a specific floor so she was able to supervise explaining that when she was got the call (R1) had attempted to transfer and and was intoxicated, I went and sat with her for a bit. At that time I knew if (R1) is left alone, she gets up, tries to go to bathroom, etc. So that prompted me to ask her to go to the desk with me while I charted, and asked her about her past to distract her. She finally wanted to get back to her room, and so I went with her and stayed with her a while in her room. We don't have 1:1 so I had to think how to keep an eye on her. I called the other floors, and asked if an aide could come down and stay with her since that floor was a little bit lighter. I told the aide to stay in her room. The aide stayed with (R1) and assisted her if she tried to get out of bed. RN-B was asked about protocols the facility has, she stated she was trained on all protocols, including fall protocol at orientation. RN-B stated she believed she also was in contact with the assistant director of nursing (ADON) on (MONTH) 28th and ended by stating, she was not aware how bad (R1) could get from drinking, and said that when she fell the second time on 1/28, she felt awful and knew that they could not let it happen again.

Based on observation, interview and document review, the facility failed to ensure assessment, monitoring and interventions were implemented in a timely manner for 1 of 1 resident (R35) reviewed with pressure ulcers. R35 suffered actual harm, deterioration of pressure ulcers and development of new pressure related breakdown. Findings include: R35 was observed continuously on 4/10/17, from 1:58 p.m. to 4:15 p.m. At 1:58 p.m. R35 was seated in a wheelchair near the nurses' station with her head lowered in a chin to chest position with her eyes closed. The resident was wearing a Prevalon (soft blue boot used to aid in pressure relief) on her right foot. The resident remained in the same position throughout the observation. At 3:15 p.m., nursing assistant (NA)-A walked by the resident. At 3:50 p.m., the director of nursing (DON) walked by the resident. No staff were observed to offer repositioning or any other assistance throughout the 2 hour and 17 minute continuous observation. On 4/11/17, continuous observations were conducted in the dining room from 12:30 p.m. to 3:19 p.m. R35 was seated in a wheelchair without being offered or assisted to reposition or toilet. At 12:30 p.m. approximately half of R35's meal remained, her eyes were closed and she leaned to the right side. R35 was wearing a Prevalon boot on the right foot, had a gripper sock on the left foot, and both feet were resting on the floor. R35 remained in the same position with no repositioning until 2:08 p.m. when R35 called out, Is anyone around? I'm ready to go to bed. No staff were present in the dining room. R35 then yelled, Can I have some water? Nurse consultant (NC)-F entered the dining room and provided R35 a glass of water and left the room. At 2:22 p.m. NA-A asked R35 if she wanted to go sit by the nursing station, and R35 declined. NA-A also offered R35 a drink of water which the resident also declined. NA-A locked R35's right wheelchair brake and walked away. R35 yelled out What time is it? NA-A replied from the nursing station, It's 2:25 in the afternoon. R35 again asked the time, and NA-A went to the resident to inform the resident of the time and asked her if she wanted to sit by the nurses' station. However no cares were offered. At 2:57 p.m. residents began gathering in the dining room for an activity. R35 remained at the table in the dining room with her head to her chin, eyes closed, and she was leaning to her right side. The facility's life enrichment coordinator (LEC)-A moved R35's wheelchair forward slightly to accommodate another resident. At 3:01 p.m. licensed social worker (LSW)- B entered the room and left without offering assistance to R35. Housekeeper (HK)-A then asked R35, You done eating? R35 responded, Yes. HK-A walked away to another table and left R35's food in front of her. At 3:06 p.m. R35's tray was removed, but no other care was offered. At 3:19 p.m., 2 hours and 49 minutes after the continuous observation had started, NA-F assisted R35 out of the dining room and informed her she would help change her incontinence brief. On 4/11/17 at 3:20 p.m., NA-F, the DON and NA-E, entered R35's room to help with her care. NA-F and NA-E assisted R35 to transfer to bed. When seated on the edge of the bed R35 stated, God almighty! Help me! I'm leaning way over. NA-F lifted R35's legs into bed and R35 stated, Ow. NA-F and NA-E removed the Prevalon boot, changed the incontinent brief and provided peri-care. NA-F described R35's brief as moderately wet. However, when NA-F and NA-E changed R35's incontinent brief, they also changed her slacks because the slacks she'd been wearing were wet with urine. In addition, R35's wheelchair cushion was saturated with a circular area of urine and smelled strongly of urine. NA-F confirmed the cushion was wet with urine, and attempted to clean it with a Sani Wipe. The DON then assessed the resident's skin condition. The DON described R35's skin: right upper buttock- open and excoriated from moisture; left ischial tuberosity- boggy and non-blanchable; left lower buttock- reddened but blanches; right ischial tuberosity- blanchable; right lower extremity-sores and scabs which have [MEDICATION NAME] dressings on them; right medial ankle- pressure ulcer with treatment scheduled for bedtime. R35's Prevalon boot was observed on the bed which the DON verified was soiled with blood and wound drainage. R35's wheelchair cushion was noted to be only about one half inch in thick and the DON stated, it does not feel adequate. During the observation, NA-F reported she did not know the last time R35 had been changed or repositioned. After the care, R35 requested to get up again, and was assisted back into her wheelchair. After the NAs and DON left the room, licensed practical nurse (LPN)-C and LPN-B entered at 3:45 p.m. to complete a right ankle dressing change. LPN-C and LPN-B performed hand hygiene and applied gloves. LPN-C removed R35's right sock and reported there was a sore on her great right toe, not previously observed. LPN-C stated the ankle dressing to be removed was dated 4/9/17 (two days prior). The soiled dressing was Kerlix and gauze that was saturated with foul smelling yellow/blood-tinged drainage. LPN-C reported no Allevyn was present on the ankle. R35 complained of pain when the dressing was removed. LPN-C described the wound as having slough (yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and proteinaceous material) and said she could not visualize the wound bed. LPN-C stated the ulcer was acquired because her ankles touch when she is in bed. LPN-C described the wound as reddened with discoloration on the edges and stated the wound measured 5 centimeters (cm) x 4 cm x 1.5 cm. LPN-B placed a barrier on the floor and placed supplies on the barrier. As she cleansed the wound with normal saline R35 screamed out, That hurts! LPN-B applied Santyl to the entire wound bed and edges, covered the wound with an Allevyn dressing, wrapped the entire area with Kerlix, and dated the dressing. On 4/12/17, continuous observations were conducted while R35 was lying in bed from 7:03 a.m. to 10:19 a.m. Throughout the observation, R35 was not offered any assistance with repositioning or toileting. At 7:03 a.m. R35 was resting in bed with her eyes closed, slightly tilted to her right side. The room had a strong urine odor. At 9:53 a.m. NA-F stopped at R35's door, looked in and continued to walk past the room. R35 remained in the same position until at 10:02 a.m. at which time the surveyor attempted to locate an available staff person to intervene. At 10:10 a.m. the surveyor informed the DON of the continuous observation of R35 without care. The DON stated she was unaware why care had not been provided for R35 but stated R35 sometimes resisted care. The DON stated she felt staffing challenges contribute to timely care for R35. The surveyor informed the DON of serious concerns regarding R35 and she responded, Me too. The DON entered R35's room at 10:19 a.m. (3 hours, 16 minutes) and completed an assessment of the resident's skin condition. The DON changed R35's incontinence brief and provided peri-care. The DON described R35's brief as saturated with dark colored pungent smelling urine. The DON acknowledged she was unaware of the last time R35 had been changed or repositioned. The DON then assessed the resident's skin condition and reported R35's left heel was lying directly on the bed. R35 moaned in pain and stated she hurt everywhere when assisted to turn to her right side. The DON stated the left ischial tuberosity had superficial skin loss over the previously identified Stage I from 4/11/17. R35 moaned, tightened her jaw and had furrowed brows when assisted to turn to her left side. The DON then observed the left heel, and stated there was a suspected deep tissue injury measuring 1 cm x 1 cm x 1 cm. R35 reported the area was painful to touch. The DON put the gripper sock back onto the resident's left foot, which was directly on the mattress without a pressure relieving device in place. The DON confirmed she was aware of the status of R35's left heel last week, but did not know the severity of the wound and had not reassessed it. The DON confirmed a comprehensive assessment had not been completed or documented related to R35's excoriation on her buttocks, Stage I on left ischial tuberosity, and left heel deep tissue injury. The DON stated she would have expected these skin issues to have been assessed immediately upon discovery. In addition, the DON stated she expected staff to follow the resident's care plan and change and reposition R35 at least every two hours. R35's record indicated the resident had multiple co-morbidities including: [MEDICAL CONDITION], signs/symptoms of [MEDICAL CONDITION], dementia with behavioral disturbances, depression, and anxiety per her [DIAGNOSES REDACTED]. Progress notes and medication/treatment administration records dated 1/6/17 through 4/13/17, indicated R35 had a history of [REDACTED]. A nutritional progress note dated 2/5/17, identified R35 had a low hemoglobin (8.7), low normal body mass index (19.3), and low normal body weight at 119 pounds. The nutritional progress note from 2/5/17, further noted R35's intake to be inconsistent, ranging from 26-100%. Nutritional goals were identified as: maintain stable weight, maintain hydration, and no skin breakdown. There was no further nutritional update. R35's annual Minimum Data Set ((MDS) dated [DATE], identified R35 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS further indicated R35 required extensive assistance with activities of daily living (ADLs), had no pressure ulcers but was at risk. The MDS indicated a formal assessment tool and a clinical assessment were completed to determine R35's pressure ulcer risk. R35's corresponding Care Area Assessment (CAA) dated 2/7/17, identified R35 needed physical assistance for ADLs and had limitations due to: weakness, limited range of motion, poor coordination, poor balance, visual impairment, and pain. The CAA dated 2/15/17, identified R35 to be at risk for skin breakdown. There was no comprehensive assessment of R35's risk factors contributing to the potential for breakdown. The CAA for cognition dated 2/7/17, indicated problems with short and long term memory, resident had daily behavior of calling out for assistance and can disrupt others, but is not danger or disrupt cares. Although the care plan printed 4/12/17, and provided by the facility as current identified a refusal of cares, there were no interventions identified to assist staff on what to do in the event R35 refused cares/treatments. Additionally, there were no specific interventions to minimize the risk for skin breakdown based on identified risk factors. R35's care plan dated 3/21/17, indicated R35 had an actual alteration of skin integrity due to being cognitively impaired, assistance with ADLs, [MEDICAL CONDITION], and had scratches/wounds on both lower extremities, left buttock, shoulder, and chest. R35's care plan directed facility staff to assist with repositioning frequently in bed in order to help R35 avoid laying on the open areas. The care plan directed staff to ensure that proper pressure reducing devices were in the wheelchair, and that R35 was positioned correctly when transferring to wheelchair. Further, the care plan directed staff to assist with repositioning in bed to avoid laying on open areas frequently. The care plan did not address R35's suspected deep tissue to left heel, unstageable ulcer to right heel, right inner ankle press ulcer, or right great toe wound. The care plan did not include interventions defining how often R35 needed to be turned/repositioned, nor did the care plan include other pressure reducing/relieving interventions. During an interview with NA-F on 4/11/17, at 3:20 p.m. she explained R35 did not like to lie down however, NA-F stated R35 did not decline offers to have her incontinence brief changed or offers to assist her reposition. NA-F verified R35 was unable to move herself. NA-F also stated that although R35 requested to use the toilet at times, she was unable to bear weight therefore, she required assistance to change her incontinence brief. NA-F stated if she observed a new skin alteration, she would inform the nurse at that time. NA-F denied being aware of open areas on R35's buttocks, but stated she had noticed red/yellow drainage from her right ankle on the bed sheet. NA-F stated R35 frequently complained of pain during the night. On 4/12/17, at 9:14 a.m. trained medication aide (TMA)-D said R35 yelled when staff did not respond to her requests for help. TMA-D also stated R35 received Tylenol for pain when she got up for the day, but not usually until 10:00 a.m. or 11:00 a.m. On 4/12/17, at 1:44 p.m. nurse practitioner (NP)-A stated she was new to the facility and unfamiliar with R35. NP-A stated it was an expectation the staff would contact the NP regarding any new skin alterations, but verified she had not been informed of any problems with R35's skin since she'd begun seeing the resident on 4/3/17. NP-A said if skin alterations were observed, NP-A would institute orders to off load pressure and would implement pressure relieving interventions. If a new wound had developed, she would potentially order a [MEDICATION NAME] dressing. A telephone interview was attempted with the medical director and a voicemail message was left on 4/12/17, at 2:19 p.m. On 4/12/17, at 6:15 p.m. a telephone interview was conducted with the wound physician (MD)-A. He reported he saw R35 for the first time on 4/7/17 and was following the right medial ankle and right heel pressure ulcers. MD-A was unaware of the left suspected deep tissue injury and skin break down on R35's buttocks. MD-A expected to be notified of significant decline in wounds. It was also expected daily dressing changes would be performed on R35's right ankle. MD-A reported R35 had a Stage IV ankle ulcer, and would have increased in size/severity without appropriate dressing changes. It was MD-A's impression the staff were elevating R35's heels, and at a minimum would have expected the heels to be off the bed, and the resident would be repositioned out of her wheelchair at least every two hours. It was also expected staff would implement pressure relieving interventions for R35's heels, ankle, and buttocks. NA-A stated on 4/13/17, at 8:17 a.m. R35 always says she is in pain and was cussing when getting dressed and putting her in the wheelchair. R35 complained of pain in her feet and legs. NA-A stated they are supposed to check on R35 every 15-20 minutes. Staff was supposed to ensure R35's feet were off the bed and she had a boot on, but NA-A was unsure which foot or when this intervention began. NA-A was unaware if there had been changes to R35's care plan. On 4/13/17, at 8:28 a.m. LPN-D reported she was aware R35 had sores on her legs and hip. R35 slept from 10:00 a.m. to 1:00 p.m. but it was still expected the NAs would check on the resident because of her skin issues. LPN-D believed the right hip area was due to pressure, and the other wounds were from scratching and picking at herself. LPN-D was unfamiliar with other wounds, as they had not been passed on during shift to shift reporting. On 4/13/17, at 10:56 a.m. NA-G stated she had repositioned and changed R35's wet incontinence brief at 7:00 a.m. NA-G stated the night shift had changed R35 at 5:00 a.m. NA-G reported R35 screamed in pain when assisted to reposition. R35 stayed in bed after incontinence care, and was reapproached at 10:00 a.m. and 10:35 a.m. to offer repositioning, but said R35 had refused. NA-G was unsure if R35 had wounds on her feet, or whether any changes had been made to her care plan in the last week. However, on 4/13/17, at 11:05 a.m. NA-H reported she had changed R35's incontinence brief at 7:30 a.m. and the resident had been incontinent of both bowel and bladder. NA-H was unsure when R35 had been changed prior to that time. NA-H was aware R35 had wounds on her thighs, toe, ankle, and heel. R35 had a lot of pain and would not let NA-H touch her right leg due to the pain. NA-H stated R35 was on a repositioning program of every two hours in bed, but did not have a wheelchair repositioning program. NA-H stated when R35 was in bed, she needed a pillow between her legs so her ankles did not touch. NA-H did not place a pillow under the resident's heels or feet. An interview was conducted with LPN-A via telephone on 4/13/17, at 11:12 a.m. LPN-A stated he worked on 4/10/17, but did not recall completing a dressing change that day. LPN-A stated when dressing changes were performed he usually dated and initialed the dressing, but at times was busy and rushed so may not have done so. LPN-A explained he had been the only nurse on the floor on 4/10/17, and it was busy and difficult to get things done. LPN-A stated R35 was in pain and every part of her body is sore. LPN-A was unaware of any other skin issues other than a pressure sore on the right ankle. On 4/13/17, at 12:30 p.m. the DON identified the following pressure related skin issues at the time of the survey: suspected deep tissue to left and right heel, right inner ankle, and right great toe wound. The DON stated R35's right ankle wound was first observed on 3/2/17 and though it had been monitored weekly the record lacked evidence of monitoring. The DON was aware of R35's left heel ulcer on 4/12/17, but it was not reflected in the documentation. The DON stated that the care plan is a mess and is not good and the DON was in the process of updating it. The DON confirmed there were no pressure relieving interventions noted on the care plan. Prior to the survey entrance the DON said she had not thought of putting a different mattress on R35's bed. The DON expected staff to reposition, check and change R35 at least every two hours. The DON expected nurses to monitor R35's skin every shift and assess once weekly on bath day, and to document findings. In addition, it was expected a comprehensive skin assessment would be completed when a new area was found. This included a head to toe assessment of skin, documentation of the location of wounds, wound measurements, with completion of a risk management form. The DON stated the current order for R35's right ankle was to apply Santyl, calcium alginate, cover with Allevyn and wrap with Kerlix. The expectation was for nurses to read the orders prior to completing the dressing change. The DON stated the right and left heel were to have skin prep applied, but verified this intervention was not identified on the Treatment Administration Record (TAR) or Medication Administration Record [REDACTED]. The DON expected the nurse to immediately notify the NP when the skin alteration was observed, and the NP ultimately oversaw care for R35. The DON stated R35 experienced pain with dressing changes. She was unsure whether pre-medication for pain was provided for R35 prior to care and dressing changes, but the DON stated she felt it should have been. Review of R35's progress notes from 3/6/17, to 4/11/17, identified on 3/6/17, R35's right inner malleolus was painful to touch and tender and there was no notation regarding an update to physician. On 4/1/17, a skin check was completed with documentation of: Other right heel-pressure stage unstagable, right ankle (inner) pressure- stage II and identified no new skin areas. The following day on 4/2/17, documentation identified that the dressing charge to right ankle was completed and had a large amount of yellowish drainage from the wound site. Documentation lacked evidence that the provider had been notified. On 4/6/17, the progress note identified the right ankle dressing change was completed and the wound looked bigger, had a white substance in the wound site and was odorous, however, the record lacked documentation that the physician had been updated. Review of R35's weekly wound documentation from 3/2/17, to 3/31/17. 3/2/17, right inner ankle was identified on this date by nurse manager with measurements of 2.0 x 2.5 cm and classified as an unstagable. Documentation identified that area was debrided on this date, depth is superficial, has 100% slough, a moderate amount of serous drainage, and pain associated with wound. Weekly wound documentation on 3/9/17, 3/16/17, 3/23/17, and 3/31/17, all indicated right inner ankle measurements of 2.0 x 2.0 x cm and classified as a stage IV. Documentation identified the depth was superficial with 100% slough and moderate serous drainage, and pain associated with wound. Documentation had a radio button marked that indicated MD/Physician/NP/Medical Professional and family were notified. However, nursing weekly wound documentation and R35's record did not reflect the right medial heel. Review of R35's weekly wound care specialist evaluation documentation from 3/2/17 to 4/7/17 revealed:: 1) 3/2/17: unstageable (due to necrosis or dead tissue) of the right, medial ankle of at least 5 days duration with measurements of 2 cm x 2.5 cm x not measurable depth cm with light serous exudate and 100% thick adherent devitalized necrotic tissue. The wound was cleansed and using surgical technique was devitalized tissue and necrotic SQ (subcutaneous) fat was removed at a depth of 0.1 cm . There is no indication of pain associated with this condition. 3) 3/9/17: unstageable right medial ankle with measurements of 2 cm x 2 cm x not measurable depth with moderate serous exudate and 90% thick adherent devitalized necrotic tissue with 10% granulation tissue. Documentation identified no change in wound progress. The wound was cleansed and with surgical technique devitalized tissue and necrotic muscle and surround fascial fibers were removed. There is no indication of pain associated with condition. 4) 3/16/17: unstagable right, medial ankle pressure wound which had light serous exudate. Documentation identified that R35 appeared to have associated pain evidenced by agitation. Measurements were 3 cm x 3 cm x not measurable with 100% granulation tissue and wound progress deteriorated. R35 appeared to have associated pain evidenced by agitation. 5) 3/31/17: unstageable (due to necrosis) of the right, medial heel, of at least 1 day in duration. There is no exudate with measurements of 1.5 cm x 1.3 cm x not measurable. Documentation identified 100% thick adherent black necrotic tissue. Skin prep was ordered daily. Right medial ankle was documented of measurements of 4.0 cm x 3.5 cm x 0.2 cm with light sero-sanguinous exudate, 85% granulation tissue, 15% other tissue, and tendon visible. No indication of pain associated with condition. 6) 4/7/17: right medial heel with measurements of 2.0 cm x 2.0 cm x not measurable with 100% thick adherent black necrotic tissue and no change in wound progress. R35's right medial ankle was measured at 4.0 cm x 4.0 cm x .02 cm with maceration at periwound radius, moderate sero-sanguinous exudate, 15% other tissue, 85% granulation tissue and tendon observed. Documentation identified there was no change in wound progress, nor was there an indication of pain associated with condition. The facility's undated Repositioning and Turning policy and procedure indicated: Residents are turned/positioned in accordance with the plan of care to prevent skin breakdown. Residents who are unable to reposition themselves will be turned and repositioned every one to two hours in accordance with their needs, using a written care plan as determined by licensed staff. The Charge Nurse is responsible for incorporating the plan, approaches, and goal on the care plan. A 4/21/14, facility specific Wound Care Program document indicated a Braden Scale was to be completed upon resident's admission and weekly for the first 4 weeks of admission to determine the score and the level of risk for skin breakdown. Then, the risk factor(s), potential cause(s) and interventions should be reviewed and addressed on the care plan. The document further indicated that when a resident is in bed or wheelchair they should be turned/reposition at least every two hours or as indicated on the resident's care plan. The care plan shall be evaluated and revised based on the resident's response to treatment, goals, and outcomes.