Every finding on record at Edenbrook of Rochester

Based on interview and document review, the facility failed to monitor, assess, implement physician orders and notify the physician of worsening hypoxia for 1 of 3 residents (R1) reviewed for change in condition. This resulted in actual harm for R1 when as a result of the delay in care, R1 experienced respiratory distress without necessary and appropriate medical intervention for over two and a half hours before emergency medical staff arrived.Findings include:R1's admission note dated on 6/3/26 at 6:53 p.m. written by licensed practical nurse (LPN)-B included, [AGE] year-old male admitted to facility following a hospitalization for a fractured left femur which became infected. Resident came in a wheelchair and was accompanied by his daughter and granddaughter. Resident has history of COPD (chronic obstructive pulmonary disease)/Emphysema (chronic lung condition) and is on oxygen, 2L (liters) via NC (nasal cannula). Vitals completed. Resident states that his goal is to become stronger and return to the assisted living facility from which he came.R1's order summary dated 6/4/26, identified R1's primary diagnoses included pulmonary edema, COPD, heart disease, and chronic respiratory failure with hypoxia (condition characterized by the inability to effectively exchange oxygen and carbon dioxide).R1's admission Minimum Data Set (MDS) assessment, dated 6/5/26, indicated R1 had no cognitive impairment and required maximum assistance for toileting and transfers.R1's shortness of breath assessment dated [DATE] identified R1 with the following:-Shortness of breath or trouble breathing with exertion-Shortness of breath or trouble breathing when sitting at rest-Shortness of breath or trouble breathing when lying flatR1's physician orders dated 6/3/26 included:-Check oxygen saturation level every shift and as needed (PRN)-Monitor for signs and symptoms of pulmonary edema (PE), (is the abnormal accumulation of fluid in the lungs, particularly in the alveoli, which impairs gas exchange and can cause life-threatening breathing difficulties), including chest pain or shortness of breath (SOB), notify the provider immediately if or any of the above, and document in the progress note every shift.-Oxygen continuous oxygen via nasal canula (NC), 1L at rest/awake, 2L with exercise/activity every shift.-Vital signs every shift for 72 hours and documented in the progress note-Lasix (furosemide) 40 mg tablet one time a day related to heart failure- Ventolin HFA Inhalation Aerosol Solution 108 (90 base) mcg/act (albuterol sulfate) 2 puff inhale orally two times a day for SOB rinse mouth with water after use and spit.-Ventolin HFA Inhalation Aerosol Solution 108 (90 base) mcg/act (albuterol sulfate) 2 puff inhale orally every 4 hours as needed for SOB rinse mouth with water after use and spit.R1's standing orders for skilled nursing facilities dated 2/16/23 instructed:-To initiate and titrate supplemental oxygen (O2) from 1-4 L/minute (min) via NC PRN for dyspnea, hypoxia (O2 saturation lower than 90% or 88% for COPD) or acute angina to keep O2 saturations above 90%; immediately update provider with nursing assessment.-Heart failure management included: Daily weights for patients with heart failure, call for weight gain 3 pounds or greater in 24 hours or 5 pounds in one week weight, assess lung sounds, peripheral edema, and respiratory effort daily unless directed otherwise.Review of R1's vital sign record identified the following:6/4/26 at 10:59 p.m., blood pressure 95/56 on laying position on left arm. Temperature was 98.4 Fahrenheit (F) on the forehead, heart rate (HR) 74 beats per minute (bpm), respirations (RR) 18 breaths/min, and O2 sat 98% via nasal cannula (NC).6/5/26 at 11:42 a.m., blood pressure 94/55 on sitting position on left arm. Temperature was 98.3 F on the forehead, HR 76 bpm, RR 16 breaths/min and O2 sat 90% via NC.6/5/26 at 11:16 p.m., blood pressure 92/58 on sitting position on left arm. Temperature was 97.7 F on the forehead, HR 85 bpm regular, RR 14 breaths/min, and O2 sat 91% via NC.R1 medical record lacked evidence whether the provider was notified about R1's low blood pressure from 6/4/26 through 6/5/26.A review of R1's record from 6/3/26 through 6/6/26 lacked documentation staff completed daily or as-needed lung sound assessments. R1's progress note dated 6/6/26 at 5:53 p.m., written by LPN-B included nurse started their day at 6am. There was no indication in report there were concerns with R1. NA-A went into R1's room to give him a bed bath and found R1 had removed his oxygen tubing. NA-A alerted LPN-B. Oxygen was put on immediately and R1's oxygen level read 84%. During the bed bath, R1's granddaughter visited and said R1 had called her and said he could not breathe. R1 did not alert nurses or staff at any time to this concern. LPN-B was with another resident when overheard the granddaughter say to R1, I turned up your oxygen so you can breathe better. LPN-B went to R1's room and looked at the O2 meter which read 4 liters per minute. LPN-B said to the granddaughter, Please do not turn the dial up or down, we have orders from the physician as to where R1's oxygen levels need to be and how much we can administer. If his needs are outside the parameters of the order, we can proceed with contacting a provider. Continuous checks were done to watch R1's oxygen which declined to 74%. LPN-B increased oxygen to 3L then to 4L for 5 minutes and remained at 74%. LPN-B asked the resident if he wanted to be sent into the emergency room for evaluation and he said, No, there isn't anything that they can do there that you aren't already doing here. LPN-B called the on-call nurse to inform her of the situation and the interference of the granddaughter. LPN-B was instructed to ask R1 one more time if he wanted to be sent in. LPN-B asked the resident this and he looked at his granddaughter who was shaking her head yes, and then he said, Yeah, I guess so. LPN-B stated that she would print all the paperwork for the paramedics and then make the phone call for the transportation. LPN-B took a bed hold into the room for the resident to sign and explained to him what it was. The granddaughter said, That won't be necessary because he won't be coming back here. Two paramedics arrived and assessed the resident. During the assessment, the paramedic asked LPN-B if this resident's lips were blue like this since awakening and writer proceeded to state that this resident admitted here with blue/gray skin color and purple lips. The granddaughter said, Yes but they weren't that bad. LPN-B did this resident's admission, and he looked no different this morning than he did the day he admitted . Paramedics called for back up to assist. Firemen showed up and were directed to R1's room as well as an ambulance person who came at the tail end of the situation. After the resident had left, the ambulance employees who arrived in a separate car, came to the desk and asked who the nurse manager was that was on duty. LPN-B informed him of who it was and gave him the phone number to reach her. LPN-B asked if there was a concern and his response was, That is a very sick gentlemen right there and staff was not very helpful. Two hours had been spent working with R1. R1's progress note further noted, while at the hospital, R1 developed new onset of shortness of breath and lightheadedness. An ultrasound confirmed bilateral acute occlusive DVT (peroneal and posterior tibial veins) and CTA (computed tomography angiography) confirmed Pulmonary Embolism. Code status at facility was DNR/DNI (Do Not Resuscitate/Do Not Intubate). Resident was his own decision maker.R1's record lacked notification to a provider regarding the above situation.R1's record review lacked evidence of his vital signs earlier on the day of 6/6/26.R1's hospital admission summary dated [DATE], identified R1's primary admitting diagnoses included acute hypoxic respiratory failure, pulmonary edema/volume overload, and concern for septic shock.EMS arrived at approximately 9:39 a.m. on 6/6/26.R1's emergency medical services (EMS) report dated 6/6/26, included, ambulance unit number dispatched priority two to the facility listed for trouble breathing. Ambulance unit questioned dispatch priority and dispatch stated the facility nurse requested a downgrade due to minimal breathing issues. Unit remained priority two. Upon arrival the nurse spoke to EMS crew outside the resident's room and stated the resident is not having difficulty breathing and the resident has had the same type of breathing since his admission a few days ago. The nurse indicated the family requested medical. The nurse states that the family is a lot and is overreacting. Upon walking into the residents' room, the temperature was very warm. Resident breathing with retractions, pale, diaphoretic and has cyanosis (blue) around the lips. The nurse came into the room, she said she increased the oxygen to 3L/min and then walked out. EMS crew quickly provided a duoneb (a combination inhalation solution used to treat COPD) with increased oxygen flow. Vitals obtained and showed tachycardia (an elevated resting heart rate greater than 100 beats per minute), tachypnea (abnormally rapid, shallow breathing), and low O2. Resident O2 slowly improved with the duo neb treatment. The report further indicated R1 called a family member at approximately 7:00 a.m. reporting difficulty breathing and expressing fear of dying in the facility. When resident's breathing slightly improved attempts were made to move the resident. EMS crews were not able to move the residents and asked staff to bring in a mechanical lift, in which they did although had not brought in the needed sling to do so. EMS crew called for the fire crew to assist in lifting the resident on to the stretcher secured and transported via priority. During an interview on 6/15/26 at 11:54 a.m., LPN-A stated he provided care to R1 on 6/4/26 and 6/5/26 but did not recall reporting R1s low BP to the provider. LPN-A explained that on 6/5/26, occupational therapist (OT)-A reported R1's O2 sat levels were in 70s and 80s during therapy. LPN-A stated R1's O2 sat remained in the 80s while receiving O2 at 3L/min. LPN-A stated after rechecking R1's O2 sat using a different finger, he obtained a reading of 90% on 3L/min. LPN-A reported R1 denies experiencing any respiratory distress and remained in the dining room. LPN-A confirmed he did not document the episode of decreased O2 sat and did not notify the provider of the change in condition. Additionally, LPN-A stated he did not notify the provider regarding PT's request for reevaluation of R1's oxygen needs.During an interview on 6/11/26 at 4:45 p.m., registered nurse (RN)-A stated she provided care to R1 during the evening shift of 6/5/26, when R1's BP was recorded at 92/58 mmHg. RN-A stated she did recheck R1's BP which was within his baseline; however, she confirmed she did not document or notify the provider of the initial low BP reading and subsequent findings. RN-A stated nurses were expected to document assessments and report significant changes in a resident's condition to the provider.During an interview on 6/10/26 at 2:31 p.m., a nursing assistant (NA)-A stated at approximately 7:00 a.m. on 6/6/26, she responded to R1's call light. Upon entering the room, she observed R1 lying in bed without his NC in place with his phone resting on his chest. NA-A reported she informed LPN-B, R1 was not wearing his O2. NA-A stated R1 reported not feeling well and the information was reported to LPN-B, who came into the room to put back R1's NC and confirmed the O2 flow rate was 2L/min. NA-A stated R1 was weak and was unable to stand to get dressed. R1 requested to lie back down in bed which they did and left the room.During an interview on 6/11/26 at 11:21 a.m., a family member (FM)-A stated R1 called her at approximately 7:00 a.m., on 6/6/26 reporting difficulty breathing. FM-A stated when she arrived at the facility at approximately 8:30 a.m., R1 was crying and receiving O2 via NC. FM-A reported she increased R1's O2 flow rate to 2L/min because R1 had been on 2L/min the previous day when she left. FM-A stated LPN-B overheard the O2 adjustment, entered the room, decreased the O2 flow back and then left the room. FM-A reported when she noticed R1's lips and face turning blue and observed he was unable to speak; she went to the nursing station at approximately 8:45 a.m. and found LPN-B sitting there. FM-A stated she requested R1 be sent to the hospital. FM-B stated, approximately 5 min later, LPN-B entered the room, checked R1 O2 sat and found it to be in the 70's. FM-A reported LPN-B increased R1's O2 flow rate to 3L/min; however, R1 condition did not improve. FM-B stated she again requested R1 be sent to the hospital and LPN-B replied that there was nothing the hospital could do that they could have not done, and left the room without rechecking R1's O2 sat. FM-B stated, LPN-B returned to the room and asked R1 if he wanted to go to the hospital. FM-A reported R1 agreed, and LPN-B then left the room. During an interview on 6/15/26 at 4:30 p.m., LPN-B stated R1 experienced SOB during her shift on 6/6/26, with O2 sat of 84% on 2L/min during a bed bath. LPN-B stated she believed she could not titrate R1's O2 to 4L without a provider order, despite having standing order to utilize. LPN-B reported leaving the room to allow the nursing assistant to complete the bed bath and proceeded to administer medications to other residents in the dining room. LPN-B stated she later returned to R1's room after overhearing the family member (FM)-A increase R1's O2 flow rate in an attempt to help R1 breath more comfortably. LPN-B reported she did not check R1's O2 sat level before titrating O2 back to 2L/min per the order and educated FM-A not to interfere with R1's care. LPN-B stated when she rechecked R1's O2 sat, it was 74% on 2L/min. She increased O2 flow rate to 3L/min; however, the O2 sat remained at 74%. LPN-B stated R1 initially refused to go the hospital, but FM-A encouraged him to go. LPN-B stated she subsequently left the room to care for other residents. She later learned from FM-A that R1 had agreed to go to hospital. LPN-B further stated she did not reassess R1's O2 sat levels, did not obtain a full set of vital signs, and did not notify the provider. LPN-B stated she did not have time to write an SBAR (Situation, Background, Assessment, and Recommendation) communication. LPN-B confirmed she should have notified the provider regarding R1's condition.R1's medical record lacked documentation whether R1 was reassessed, or the provider was notified of the initial low BP or follow-up assessment findings.During an interview on 6/11/26 at 1:34 p.m., EMS-A stated when she entered R1's room on 6/6/26 at approximately 9:39 a.m., it was apparent R1 was experiencing severe SOB. EMS-A stated this was inconsistent with the information provided by LPN-B, who reported R1 was fine and had no change in condition. EMS-A stated LPN-B left the room saying I have other things to do. EMS-A stated FM-A reported R1 has been in respiratory distress since approximately 7:00 a.m. EMS-A stated upon assessment, R1's O2 sat was in 60s with 3L/min, respirations were 25, and heart rate was 125.During an interview on 6/15/26 at 10:35 a.m., a nurse practitioner (NP)-A reported she could not confirm whether the facility contacted the on-call provider on 6/6/26 regarding R1's change in condition. NP-A stated she reviewed the provider call logs from 6/4/26 through 6/6/26 and found no evidence the provider was notified regarding R1's respiratory distress. NP-A explained when a resident experienced respiratory distress, staff were expected to obtain complete vital signs, perform lungs and skin assessments, evaluate the need for a face mask and get the provider involved. NP-A further stated staff were expected to complete an SBAR and notify the provider immediately.During an interview on 6/15/26 at 6:24 p.m., the director of nursing (DON) stated staff were expected to immediately report any resident experiencing respiratory distress to the provider, including their assessment findings and interventions. The DON stated the assessment should include obtaining full vital signs, auscultating lung sounds, assessing for changes in skin color, administering nebulizer treatment or inhaler when clinically appropriate, and documenting the findings and interventions in the progress note. The DON stated R1 was readmitted to the hospital on [DATE] with hypoxia and respiratory failure. The DON confirmed education was initiated for nursing staff on 6/11/26 after the survey entrance conference regarding change in condition, oxygen therapy, standing orders and provider notification requirements.The Facility Oxygen Administration and storage Policy dated 8/1/15 revised on 6/15/23 directed staff to provide emergency administration of oxygen when it is necessary for the care of the residents. The nurse will then call the physician as soon as reasonable to obtain a physician's order. As a guideline, a beginning flow rate of 2L/minute and adjust according to oxygen saturation levels which should be kept above 90% unless otherwise ordered by a physician. The physician should be notified of any concerns identified with oxygen titration needs so the physician may determine a need to change the order to best meet the resident's oxygen needs.Facility Change in Condition Policy dated 8/1/15, revised on 11/13/24 identified the physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed. The Policy identified specific information that required prompt notification included:Significant change or instability of vital signs;A significant change in the resident's physical/psychosocial/mental condition;A need to transfer the resident to a hospital/treatment center

Based on interview and document review, the facility failed to provide necessary respiratory care consistent with professional standards of practice, physician orders, standing orders, the resident's care plan, goals and preferences for 1 of 3 residents (R1) reviewed for change in condition.Findings include:R1's hospital admission summary dated [DATE], identified R1's primary admitting diagnoses included acute hypoxic respiratory failure and concern for septic shock.R1's order summary dated 6/4/26, identified R1's primary diagnoses included pulmonary embolism, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and chronic respiratory failure with hypoxia. R1's admission Minimum Data Set (MDS) assessment, dated 6/5/26, indicated R1 had no cognitive impairment and required maximum assistance for toileting and transfers.R1's physician orders dated 6/3/26 included:-Check oxygen saturation level every shift and as needed (PRN)-Monitor for signs and symptoms of pulmonary edema (PE) including chest pain or shortness of breath (SOB), notify the provider immediately if or any of the above, and document in the progress note every shift.-Oxygen continuous oxygen via nasal canula (NC), 1L at rest/awake, 2L with exercise/activity every shift.-Vital signs every shift for 72 hours and documented in the progress note- Ventolin HFA Inhalation Aerosol Solution 108 (90 base) mcg/act (albuterol sulfate) 2 puff inhale orally two times a day for SOB rinse mouth with water after use and spit.-Ventolin HFA Inhalation Aerosol Solution 108 (90 base) mcg/act (albuterol sulfate) 2 puff inhale orally every 4 hours as needed for SOB rinse mouth with water after use and spit.R1's standing orders for skilled nursing facilities dated 2/16/23 instructed: -to initiate and titrate supplemental oxygen (O2) from 1-4 L/minute (min) via NC PRN for dyspnea, hypoxia (O2 saturation lower than 90% or 88% for COPD) or acute angina to keep O2 saturations above 90%; immediately update provider with nursing assessment.R1's progress note dated 6/6/26 at 5:53 p.m., indicated R1's O2 sat was 84% on 2L/min during a bed bath. The note further indicated R1's O2 sat decreased to 74% on 3L/min. R1 refused transfer to the hospital, and staff left the room to check on another resident.R1's medical record lacked provider notification.During an interview on 6/11/26 at 11:21 a.m., a family member (FM)-A stated R1 called her at approximately 7:00 a.m., on 6/6/26 reporting difficulty breathing. FM-A stated when she arrived at the facility at approximately 8:30 a.m., R1 was crying and receiving O2 via NC at 1L/min. FM-A reported she increased R1's O2 flow because R1 had been on 2L/min the previous day when she left. FM-A stated LPN-B overheard the O2 adjustment, entered the room, decreased the O2 flow back to 1L/min and then left the room. FM-A reported when she noticed R1's lips and face turning blue and observed he was unable to speak; she went to the nursing station at approximately 8:45 a.m. and found LPN-B sitting there. FM-A stated she requested R1 be sent to the hospital. FM-B stated, approximately 5 min later, LPN-B entered the room, checked R1 O2 sat and found it to be in the 70%. FM-A reported LPN-B increased R1's O2 flow rate to 3L/min; however, R1's condition did not improve. FM-B stated she again requested R1 be sent to the hospital and LPN-B replied, there was nothing the hospital would do that they could have not done, and left the room without rechecking R1's O2 sat. FM-B stated approximately 10 min later, LPN-B returned to the room and asked R1 if he wanted to go to the hospital. FM-A reported R1 agreed, and LPN-B then left the room.During an interview on 6/15/26 at 4:30 p.m., LPN-B stated R1 experienced SOB during her shift on 6/6/26, with O2 sat of 84% on 2L/min during a bed bath. LPN-B stated she believed she could not titrate R1's O2 to 4L without a provider order, despite having standing order to utilize. LPN-B reported leaving the room to allow the nursing assistant to complete the bed bath and proceeded to administer medications to other residents in the dining room. LPN-B stated she later returned to R1's room after overhearing the family member (FM)-A increase R1's O2 flow rate in an attempt to help R1 breath more comfortably. LPN-B reported she did not check R1's O2 sat level before titrating O2 back to 2L/min per the order and educated FM-A not to interfere with R1's care. LPN-B stated when she rechecked R1's O2 sat, it was 74% on 2L/min. She increased O2 flow rate to 3L/min; however, the O2 sat remained at 74%. LPN-B stated R1 initially refused to go the hospital, a decision that she stated was encouraged by FM-A. LPN-B stated she subsequently left the room to care for other residents. She later learned from FM-A that R1 had agreed to go to hospital. LPN-B reported she did not delegate any staff member to remain with R1 while she prepared the hospital transfer paperwork. LPN-A further stated she did not reassess R1's O2 sat levels, did not obtain a full set of vital signs, and did not notify the provider. LPN-B stated she did not have time to write an SBAR (Situation, Background, Assessment, and Recommendation) communication. LPN-B confirmed she should have notified the provider regarding R1's condition.During an interview on 6/15/26 at 10:35 a.m., a nurse practitioner (NP)-A stated she reviewed the provider call logs from 6/4/26 through 6/6/26 and found no evidence the provider was notified regarding R1's respiratory distress. NP-A explained when a resident experienced respiratory distress, staff were expected to obtain complete vital signs, perform lung and skin assessments, evaluate the need for a face mask and get the provider involved. NP-A further stated staff were expected to complete an SBAR and notify the provider immediately.During an interview on 6/15/26 at 6:24 p.m., the director of nursing (DON) stated staff were expected to immediately report any resident experiencing respiratory distress to the provider, including their assessment findings and interventions. The DON stated the assessment should include obtaining full vital signs, listening to lung sounds, assessing changes in skin color, administering nebulizer treatment or inhaler when clinically appropriate, and documenting the findings and interventions in the progress note. The DON stated R1 was readmitted to the hospital on [DATE] with hypoxia and respiratory failure. The DON confirmed reeducation was initiated for nursing staff on 6/11/26, after the survey started.The Facility Oxygen Administration and storage Policy dated on 6/15/23 directed staff to provide emergency administration of oxygen when it is necessary for the care of the residents. The nurse will then call the physician as soon as reasonable to obtain a physician's order. As a guideline, a beginning flow rate of 2L/minute and adjust according to oxygen saturation levels which should be kept above 90% unless otherwise ordered by a physician. The physician should be notified of any concerns identified with oxygen titration needs so the physician may determine a need to change the order to best meet the resident's oxygen needs.

Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition.Findings include:R1's order summary dated 6/4/26, identified R1's primary diagnoses included pulmonary embolism, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and chronic respiratory failure with hypoxia.R1's admission Minimum Data Set (MDS) assessment, dated 6/5/26, indicated R1 had no cognitive impairment and required maximum assistance for toileting and transfers.R1's physician orders dated 6/3/26 included:-Monitor for signs and symptoms of pulmonary edema (PE) including chest pain or shortness of breath (SOB), notify the provider immediately if or any of the above, and document in the progress note every shift.R1's standing orders for skilled nursing facilities dated 2/16/23 instructed:-To initiate and titrate supplemental oxygen (O2) from 1-4 L/minute via NC (nasal cannula) PRN (as needed) for dyspnea, hypoxia, (O2 saturation (sat) lower than 90% or 88% for COPD) or acute angina to keep O2 saturations above 90%; immediately update provider with nursing assessment.R1's occupational therapy treatment encounter note dated 6/5/26, indicated R1 was only able to complete four exercises with yellow (light) TheraBand for 1 set of 10-15 repetitions each due to significant SOB. Therapeutic rest break was utilized to increase oxygen saturation (O2 sat) level, educated in pursed lip breathing techniques and breathing through each respiration; however, R1's O2 sat continued to decrease to 70%. The note further indicated R1 was not recommended to continue with therapy due to poor O2 sats and inability to tolerate sessions.R1 medical record, lacked evidence the provider was notified of R1's O2 sat, poor activity tolerance, or recommendation to discontinue therapy.R1's physical therapy treatment encounter note dated 6/5/26, included, R1 was fatigued, and his O2 sat decreased to 80% on 2L/min when sitting at the edge of the bed. The note further indicated a physical therapist (PT)-A increased O2 flow to 3L/min; however, R1's O2 sat remained in the 80's. After R1 was wheeled out of his room to the therapy room, his O2 sat increased to 89% on 3L/min. Additionally, the note also indicated R1's respiratory status was reported to the nurse, with instructions to notify the provider for review of R1's O2 orders.R1 medical record, lacked notification of the provider.Review of R1's blood pressure report indicated the following:6/4/26 at 10:59 p.m., blood pressure 95/56 mm/Hg (millimeters of mercury) on laying position on left arm6/5/26 at 11:42 a.m., blood pressure 94/55 mm/Hg on sitting position on left arm6/5/26 at 11:16 p.m., blood pressure 92/58 mm/Hg on sitting position on left armR1 medical record, lacked evidence the provider was notified regarding R1's low blood pressure results from 6/4/26 through 6/5/26.During an interview on 6/11/26 at 3:29 p.m., an occupational therapy (OT)-A stated during a therapy section on 6/5/26, R1' s O2 sat was in the 80s and 70s with 2L/min while sitting. OT-A explained she reported to a licensed practical nurse (LPN)-A and did not know whether it was escalated to the provider.During an interview on 6/15/26 at 12:43 p.m., PT-A stated on 6/5/26, R1 was sitting at the edge of the bed with O2 sat of 80% while receiving O2 at 2L/min. PT-A reported notifying LPN-A, who entered the room and rechecked R1's O2 sat, obtaining a reading of 84% on 2L/min. PT-A stated R1 was experiencing significant SOB but could not recall whether LPN-A implemented any interventions to address R1's respiratory distress. PT-A explained LPN-A left the room and did not return. As a result, PT-A increased R1's O2 flow to 3L/min, after which R1's O2 sat increased to 89%. PT-A stated R1 declined participation in therapy activities due to SOB which was reported to LPN-A with request to reevaluate R1's O2 needs. PT-A further stated he did not know whether the change in condition was reported to the provider.During an interview on 6/15/26 at 11:54 a.m., LPN-A stated he provided care to R1 on 6/5/26. LPN-A explained OT-A reported R1's O2 sat levels were in 70s and 80s during therapy. LPN-A stated R1's O2 sat remained in the 80s while receiving O2 at 3L/min. LPN-A stated after rechecking R1's O2 sat using a different finger, he obtained a reading of 90% on 3L/min. LPN-A reported R1 denies experiencing any respiratory distress and remained in the dining room. LPN-A confirmed he did not document the episode of decreased O2 sat and did not notify the provider of the change in condition. Additionally, LPN-A stated he did not notify the provider regarding PT's request for reevaluation of R1's oxygen needs.During an interview on 6/15/26 at 10:35 a.m., a nurse practitioner (NP)-A stated she was present in the facility on 6/4/26 and 6/5/26 but was not notify of R1's respiratory distress or any request to reevaluate the resident O2 needs. NP-A reviewed the provider call logs from 6/4/26 through 6/6/26 and found no evidence indicating a provider had been notified regarding R1's respiratory distress. NP-A stated staff were expected to complete an SBAR and notify the provider immediately when such a change in condition occurred.During an interview on 6/15/26 at 6:24 p.m., the director of nursing (DON) stated staff were expected to immediately report any change in condition or resident concerns to the provider. The DON explained she was unaware of R1 respiratory distress that occurred during therapy sessions, including PT's staff request for provider notification to reevaluate R1's oxygen needs. The DON confirmed this information was not reported to the provider. The DON stated, while the surveyor was onsite, she initiated education for all nursing staff regarding the requirement for appropriate and timely notifications to the provider of changes in resident condition and concerns.Facility Change in Condition Policy dated 11/13/24 identified the physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed. The Policy identified specific information that required prompt notification included:Significant change or instability of vital signs;A significant change in the resident's physical/psychosocial/mental condition;A need to transfer the resident to a hospital/treatment center

Based on observation, interview and document review, the facility failed to ensure a cable cord face plate was fixed and secured for 1 of 1 resident (R1) reviewed for a safe and homelike environment. Further, the facility failed to remove discarded cigarette butts from the ground at the back entrance of the facility. This had the potential to affect all 56 residents, staff and visitors.Findings include:R1's comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had no cognitive impairment. R1 was dependent on facility staff for bathing and toileting, required substantial assistance for dressing, and dependent on staff for position changes.During an interview on 2/9/26 at 6:00 p.m., R1 pointed towards the wall and indicated she was upset about the hole with two cable cords coming out; it appeared to need a cable plate cover. R1 stated she asked the facility staff to cover the hole a month ago but, they haven't.During observation and interview on 2/11/26 at 9:53 a.m., the hole in the wall remained with cords still exposed, this still bothered the resident. R1 stated again she wishes they would cover the cords with an outlet cover. During an interview on 2/11/26 at 11:00 a.m., director of nursing (DON) stated she was not aware of the hole in R1's wall with cable protruding. The DON stated this could be a safety issue and should be fixed.During an interview on 2/11/26 at 2:33 p.m., maintenance (M)-A stated he was aware the cable in R1's room was protruding out of the wall. On 1/6/26 at 12:44 p.m. a maintenance request was submitted to fix the cable in R1's room. He stated after the cable ends were replaced, the faceplate was not reattached. The maintenance report had been marked as completed on 1/7/26 at 7:18 a.m. M-A stated the maintenance report should not have been marked completed until the face plate had been replaced. He understood why the hole in the wall might bother R1. M-A stated it is important to replace lost or missing items so that residents have a homey feel to their surroundings.During an interview on 2/11/26 at 2:39 p.m., administrator stated when residents let facility staff know about a building concern, this should be fixed as soon as possible. The administrator stated he was not aware of the hole in the wall, and this could be fixed as soon as possible. The administrator stated it is important for residents to feel like this is their home.Cigarette ButtsDuring interview on 2/10/26 at 09:16 a.m., family member (FM)-A stated she does not like to enter the facility through the back door. FM-A stated the back entrance area was littered with dirty, old cigarette butts. FM-A stated she was disgusted by the facility for not removing the cigarette butts.During observation on 2/10/26 at 9:48 a.m., the facility's back entrance was littered with dozens of cigarette butts.During observation and interview on 2/10/26 at 10:58 a.m., the administrator confirmed the cigarette butts lined the facility wall at the facility's back entrance. Further, cigarette butts lined the driveway extending towards the designated smoking area. Additionally, cigarette butts were found in the garden planter next to the designated smoking area. The administrator acknowledged the discarded cigarette butts were unpleasing to the eye. A facility policy titled Preventative Maintenance dated 4/6/23, routine facility inspections promote safety.A facility policy titled Preventative Maintenance dated 4/6/23, maintenance includes part replacements that is performed specifically to prevent faults from occurring.

Based on observation, interview, and record review the facility failed to ensure professional standards of practice were followed for accurate charting of dialysis assessments including vital signs and weights for 1 of 1 resident (R52) reviewed for dialysis assessment.Findings include:R52's comprehensive Minimum Data Set (MDS) assessment, dated 10/8/25, indicated R52 had moderate cognitive impairment and was dependent on facility staff for all dressing, hygiene, and mobility needs. R52's medical diagnosis included end stage renal (kidney) disease, requiring dialysis (process of filtering and removing excess waste and fluids from the body) three times per week. Side effects of dialysis include low blood pressure, mineral imbalances, and increased risk of infections.R52's care plan dated 9/30/25 indicated R52 required dialysis due to end stage renal disease. R52's interventions for dialysis included daily weight prior to going to dialysis and again upon return to facility. R52 had a dialysis routine to go to dialysis every Monday/Wednesday/Friday at 11:45 a.m. and return to the facility approximately 3.5 hours later, monitor vital signs as ordered, and notify provider of significant abnormalities.R52's active orders included weights and vitals signs before dialysis every Monday/Wednesday/Friday and weights and vital signs upon return from dialysis every Monday/Wednesday/Friday. R52's dialysis schedule included:11:30 a.m. - Transport to dialysis center11:45 a.m. - Start dialysis3:15 p.m. - Dialysis complete3:30 p.m. - 3:45 p.m. - Return to facilityDuring observation and interview on 2/11/26 at 11:26 a.m., R52 was being prepared to leave the facility for dialysis, nurse manager (NM)-A stated a set of vital signs (VS) and weight is completed before dialysis and again upon return to facility after dialysis. This process is done to ensure the resident is stable before leaving for dialysis and remains stable upon return from dialysis. Collecting vitals signs and weights after dialysis is especially important because dialysis can cause low blood pressure. Residents with low blood pressures can experience weakness, dizziness, and unsteadiness which can be dangerous if not identified quickly. NM-A stated each resident has a dialysis communication sheet to document all the information. The dialysis communication sheet for R52 dated 2/11/26 at 10:50 a.m. showed a blood pressure of 104/69 and no weight. This blood pressure was later documented in R52's chart at 3:17 p.m.; not reflecting the blood pressure was taken at 10:50 a.m.R52's Treatment Administration Record (TAR) reviewed from 12/12/25 through 2/9/26 for pre and post vital signs and weights indicated:16 pre-dialysis blood pressure were documented later in the day13 pre-dialysis weights were documented at a different time than when taken18 post-dialysis blood pressure were reported later than obtained.12 post-dialysis weights were documented later in the dayDuring observation on 2/11/26 at 3:34 p.m., R52 returned from the dialysis facility. R52 was placed in the main living room upon returning. No assessment had been completed upon return. During observation and interview on 2/11/26 at 4:08 p.m., registered nurse (RN)-A stated any resident returning from dialysis should be assessed immediately upon return to make sure they are stable after dialysis, since dialysis can cause them to have low blood pressure. RN-A confirmed she had not completed R52's vital signs and weights since she returned from dialysis. After asking RN-A to review the charted documentation for R52's vital signs, RN-A stated the blood pressure taken prior to dialysis was charted at 3:17 p.m. RN-A stated sometimes they will chart the vital signs at the end of the shift instead of at the time of completion. RN-A stated it is probably better to chart at time of completion though.During an interview on 2/11/26 at 4:17 p.m., director of nursing (DON) stated it is an expectation that dialysis residents have vital signs and weights completed upon return from dialysis. The DON stated she is aware staff are charting vital signs and weights at the end of the shift rather than charting at time of completion. The DON stated accurate charting is important so staff and providers have the correct information about when a task was completed.During an interview on 2/12/2026 at 9:24 a.m., nurse practitioner (NP) stated she expected vital signs and weights to be collected and entered as ordered. Further, she expected vital signs to be documented at the time they were collected, not documented at time of end of shift. NP stated she had difficulty at times with accurate charting, she has had to find out from the nurse if the time for vital signs was charted at time of completion or at the end of shift. It can be difficult to adjust cardiac medications when she is unsure if the blood pressure was taken before or after the medication was given. The NP expected that if nurses are charting later, they back chart to the correct time not just use the default time of entry when they chart at end of shift. Accurate daily weights are another charting issue she struggles with, staff may get resident weights in the morning before breakfast, however, they are documenting them as collected after their shift ends in the afternoon. Ultimately, the NP expected the charted time to be the time the task was completed, not the end of shift charting time.During an interview on 2/12/26 at 10:37 a.m., the administrator confirmed accurate charting was an issue the facility knows about. Administrator confirmed the charting should reflect the actual time of completion not the time of charting at the end of the shift.A facility policy titled Charting and Documentation dated 11/13/24, a treatment administration record shall be maintained which records the resident care procedures and/or treatments ordered by the physician that is performed and by whom the procedure/treatment was performed.

Based on observation, interviews and document review the facility failed to have an appropriately trained staff member assist a resident with meals. This affected 1 of 4 (R24) residents reviewed for dining services.Findings include:R24's annual Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. Diagnoses included dementia and Alzheimer's.R24's care plan revised on 8/11/25 indicated an activity of daily living (ADL) self-care performance deficit along with a cognitive deficit.During an observation on 2/09/26 at 12:28 p.m., cook (C)-A was assisting R24 to eat lunch. After C-A gave R24 four bites of food, C-A walked away to tend to something else. At that time a nurse assistant took over assisting R24 to eat.During an observation on 2/11/26 at 8:16 a.m., C-A was approaching R24 and stated to R24 they needed to eat. R24 was looking at her food and had not eaten. After several more minutes C-A was observed giving R24 two bites of food. C-A reminded R24 she needed to eat and then walked away. During an interview on 2/11/26 at 8:33 a.m., C-A confirmed she had assisted R24 with the meal on 2/9/26 and 2/11/26. C-A stated she was not a nurse assistant in the state of Minnesota.During an interview on 2/11/26 at 8:40 a.m., the culinary director (CD) confirmed C-A was a cook in the facility. The CD stated the facility did not use any paid feeding assistants and was sure the only people allowed to assist with feeding residents were nursing staff or people trained to feed the residents.During an interview on 2/12/26 at 9:18 a.m., the director of nursing (DON) stated the only staff that should feed residents are the clinical staff or somebody trained to assist with meals dietary staff should not assist residents with their meals.

Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to address clothing burns for 1 of 1 resident (R31) reviewed for smoking safety.Findings include:R31's quarterly Minimum Data Set (MDS) assessment, dated 12/10/25, indicated R31 was cognitively intact. R31's diagnoses included a contracture of the right hand (soft tissues such as muscles, tendons, ligaments, or skin undergo structural changes that make them stiff, tight, and shortened, resulting in a loss of full range of motion) and vascular dementia (decline in cognitive function, causing memory loss, cognitive decline, behavioral changes, and communication difficulties). R31's care plan dated 9/24/25 indicated contractures of the right hand, requiring assistance with dressing and undressing. R31's smoking care plan lacked interventions for clothing protectors. R31's smoking assessments dated 5/23/24 through 12/4/25 indicated R31 was safe to smoke without supervision. During observation on 2/10/26 at 9:48 a.m., R31's coat had two burn holes on the right forearm. R31 stated the burn holes happened right after she got her new coat a couple months ago. R31 stated she was right-handed and was having difficulty lighting her cigarette with her left hand because she didn't have much movement in her right hand due to the contracture. R31 stated she was upset about the burn holes because her jacket was brand new and it already had holes in it. R31 stated other than the two burns holes, she feels mostly safe smoking outside alone. During an interview on 2/10/26 at 10:39 a.m., nurse manager (NM)-B stated the process to complete a smoking assessment included reviewing the facility smoking process, staff assessed resident ability to go out to smoke independently and safely, provide smoking education, and provide safety equipment if needed (apron, blanket, etc.). NM-B stated R31 did not have any smoking safety equipment. NM-B stated if staff observed burn holes in the clothing; they would assess the resident for wounds and conduct another smoking assessment to ensure resident was safe to continue smoking independently. NM-B stated she was not aware of burn holes in R31's jacket. During an interview on 2/10/26 at 10:47 a.m., director of nursing (DON) stated the process to assess a resident for safety while smoking included review facility smoking policy, smoking education, and conduct a smoking assessment by observing the resident from start to finish of smoking independently. DON stated smoking assessments were completed quarterly and if/when the staff felt the resident was no longer safe to smoke independently. DON stated residents need to be free of burn holes in clothing, extinguish cigarettes appropriately, understand smoking policy and education, and be able to smoke outside independently. DON stated she was not aware R31 had burn holes in her jacket; staff don't routinely check clothing for clothing burns. DON stated a resident with burns in clothing should be reassessed immediately for safety to independently smoke. A facility policy titled Smoking and E-Cigarettes dated 3/1/21, the facility will complete a smoking assessment upon admission, quarterly, or with a change in condition.

Based on observation, interview and record review the facility failed to prevent the risk of infection for 2 of 3 (R30, R2) residents reviewed for infection control when it was identified the catheter bags were dragging on the floor. Additionally, the facility failed to implement enhanced barrier precautions (EBP) when caring for indwelling medical device for 1 of 1 (R52) resident reviewed for infection prevention.Findings include: R30's quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated a moderate cognitive impairment. Diagnoses included heart failure and renal insufficiency and R30 had an indwelling catheter. R30's care plan dated 9/29/25, indicated an actual/potential for alteration in elimination related to urinary retention. Interventions included suprapubic (a tube inserted through a small incision in the lower abdomen to drain urine directly from the bladder when normal urination is not possible) catheter changes at clinic per provider schedule. R30's care plan dated 12/2/25 indicated a urinary tract infection (UTI) due to positive urinalysis results. Interventions included take antibiotics as per provider orders. R30's progress notes dated 11/29/25 at 10:01 p.m., indicated R30 had an indwelling catheter and had been treated with antibiotics for a UTI. On 2/9/26 at 2:38 p.m., R30 was observed in his wheelchair in his room. The catheter tubing and bag were observed laying on the floor next to the resident and lacked a barrier between the catheter bag/tubing and the floor. R2's significant change MDS assessment dated [DATE] indicated a moderate cognitive impairment. Diagnoses included coronary artery disease and heart failure. R2 had an suprapubic catheter R2's care plan dated 11/28/25 indicated an actual/potential for alteration in elimination related to memory care deficit, heart failure, and reflux uropathy with a goal resident would have no complications related to the suprapubic catheter. On 2/10/26 at 9:24 a.m., R2 was observed rolling himself down the hallway to his room. His catheter bag and tubing was observed hanging on the bottom of the wheelchair. The tubing and catheter bag were noted to be dragging along the floor as he headed to his room. During an interview on 2/10/26 at 9:33 a.m., nurse assistant (NA)-C confirmed R2's catheter and tubing was dragging the ground as he rolled himself down the hallway. NA-C stated she had gotten R2 up this morning for breakfast and placed the foley bag and tubing under the wheelchair. NA-C stated catheter bags and tubing should not be able to come into contact with the floor. During an interview on 2/12/26 at 9:27 a.m., nurse manager (NM)-B confirmed R30 had a UTI in 12/25 and had an indwelling catheter when the UTI occurred. NM-B stated foley tubing and catheter bags should not come in direct contact with the ground due to the increased risk of infection. The tubing and bag could pick up bacteria from the floor. During an interview on 2/12/26 at 11:18 a.m., the director of nursing/infection preventionist (DON) stated catheter bags and tubing should not come in contact directly with the floor due to the increased risk of infection. Facility policy Foley Catheter Management last revised on 1/28/25, indicated correct positioning of the catheter would be maintained. R52 R52's comprehensive Minimum Data Set (MDS) assessment, dated 10/8/25, indicated R52 had moderate cognitive impairment and was dependent on facility staff for all dressing, hygiene, and mobility needs. R52's medical diagnosis included end stage renal (kidney) disease, requiring dialysis (process of filtering and removing excess waste and fluids from the body) three times per week. During observation on 2/10/26 at 1:21 p.m., licensed practical nurse (LPN)-A exited R52's room without proper personal protective equipment (PPE). LPN-A stated he didn't think R52 needed enhanced barrier precautions (EBP) because her room did not have an EBP sign and did not have the isolation equipment hanging on the door. He confirmed R52 had a dialysis line but didn't think her dialysis port needed EBP. During observation and interview on 2/11/26 at 11:13 a.m., director of nursing (DON) confirmed R52 had a dialysis catheter and should have an EBP sign with isolation equipment hanging on her door. Upon inspection, the DON confirmed R52 did not have an EBP sign or isolation equipment hanging on her door. The DON stated the importance of EBP was to protect the residents from infection. A facility policy titled Enhance Barrier Precautions dated 3/26/24, residents with indwelling medical devices required EBP to prevent infection or colonization from a multi-drug resistant organisms. Facility policy Foley Catheter Management last revised on 1/28/25, indicated correct positioning of the catheter would be maintained.

Based on interview and document review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) for 1 of 1 resident (R11) reviewed for accuracy of assessments. Findings include:R11's quarterly MDS dated [DATE], indicated R11 was cognitively intact. Diagnoses included hypertension and Parkinson's disease. R11 received Invasive Mechanical Ventilator (must have a tube or other item placed in the airway and connected to a ventilator machine to assist breathing).R11's care plan dated 2/28/25, indicated R11 used a continuous positive airway pressure (CPAP) machine at night. The CPAP machine has a mask that fits over the mouth to assist in keeping the airway open when sleeping.During an interview on 2/10/26 at 2:26 p.m., the MDS coordinator (MDSC) reviewed R11's MDS report from 11/19/25 and confirmed an invasive mechanical ventilator was marked in error and should be for a CPAP which was noninvasive mechanical ventilation.During an interview on 1/29/26 at 2:33 p.m., the director of nursing (DON) stated MDS accuracy was important as it is part of their payment.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 (R30, R2) residents who utilized a urinary catheter (tube from bladder to a bag outside the body) and 4 of 4 (R17, R25, R49, R52) residents who required assistance in the dining room.Findings include: R30's quarterly Minimum Date Set (MDS) assessment, dated 12/30/25, indicated a moderate cognitive impairment. Diagnoses included heart failure and renal insufficiency and had an indwelling catheter.R30's care plan dated 9/29/25, indicated an actual/potential for alteration in elimination related to urinary retention. R30's interventions included catheter changes per provider schedule.R30's progress notes dated 11/29/25 at 10:01 p.m., indicated R30 had an indwelling catheter.On 2/10/26 at 8:28 a.m. R30 was observed sitting in the commons area watching television. The foley catheter bag and tubing was noted hanging on the lower part of the wheelchair uncovered. There was a dark colored cloth bag noted on the opposite side of the wheelchair, not being utilized. On 2/10/26 at 8:41 a.m., R30 was observed in the dining hall eating breakfast. R30's foley catheter tubing and bag was on the right lower side of the wheelchair, uncovered. There were 8 residents present in the dining room. On 2/10/26 at 8: 46 a.m. nurse assistant (NA)-D confirmed R30's catheter tubing and bag were exposed and uncovered. The urine was observable draining down the tubing and into the bag. NA-D confirmed the tubing and bag should be covered in a dignity bag to prevent others from seeing residents who have a catheter. NA-D confirmed there was a dignity bag on the opposite side of the wheelchair not being utilized. R2's significant change MDS assessment, dated 2/5/26 indicated a moderate cognitive impairment. Diagnoses included coronary artery disease and heart failure. R2 had an indwelling catheter which included an suprapubic catheter (a catheter surgically placed through a hole in the lower abdomen to the bladder). R2's care plan dated 11/28/25 indicated an actual/potential for alteration in elimination related to memory care deficit, heart failure, and reflux uropathy with a goal resident would have no complications related to the suprapubic catheter.During an observation on 2/10/26 at 9:24 a.m., R2 rolled himself down the hallway to his room. His catheter bag and tubing was hanging on the bottom of the wheelchair, uncovered. There were several residents, staff members and visitors in the hallway, able to visualize R2's catheter tubing and bag, and the urine draining through the tube.During an interview on 2/10/26 at 9:33 a.m., NA-C confirmed R2's catheter bag and tubing were exposed. NA-C stated all catheter bags and tubing should be in a cloth dignity bag so nobody around the resident could see the catheter, tubing and urine draining. NA-C confirmed getting R2 and R30 ready and out to breakfast. NA-C stated they were not able to locate a dignity bag prior to transporting them to breakfast. During an observation on 2/11/26 at 8:16 a.m., NA-C was observed sitting with R17, R25, R49 at one table. NA-C was assisting R17 and R52 to eat. R25 had her food in front of her but did not eat. Staff brought R49 to the same table and brought his food out. R49 was observed not feeding self. At 8:19 a.m., NA-C stood up and gave R17 and R52 a bite to eat while standing. NA-C then went to R49 and gave him a bite to eat while standing. NA-C then moved to R25 and gave her a bite to eat, while standing. NA-C continued to go around the table to each one of the residents, gave them a bite to eat, all the time standing by each of the residents side and this continued the rest of the meal. There was no communication with the residents while NA-C assisted the residents to eat. During an interview on 2/10/26 at 1:11 p.m., NA-C stated there were four residents that sat in the dining room who needed assistance with eating. The residents sat together at the same table. NA-C stated normally staff would sit down next to the one or two residents they were assisting to eat so conversation could occur, the resident could look at you eye level and the resident could make choices related to what they ate. NA-C stated she was the only one in the dining room for lunch. The four residents at the table had gotten their food. NA-C indicated not wanting to let the food to get cold. NA-C said she stood up and started to feed each resident a bite of food before going to the next resident and then starting over. NA-C stated she felt it would be more of a dignity issue and a respect issue if NA-C would have just fed one resident at a time.During an interview on 2/12/26 at 9:27 a.m. nurse manager (NM)-B stated anytime a catheter bag or tubing was exposed, and urine could be seen draining. This would be a dignity and respect issue for the residents. NM-B stated, the staff should also be sitting when they are assisting with meals. It is ok to assist one or two residents, but they need to be at eye level and talk with the residents as they eat.During an interview on 2/12/26 at 11:18 a.m., the director of nursing stated residents with a catheter should either have a dignity bag to cover the catheter bag and tubing or a new catheter bag with a white out space that hides the urine in the bag. Staff should also sit at the dining table when they are assisting a resident with the meal and not stand up or go around the table feeding all the residents at the table at the same time.Facility policy Resident Rights: Dignity last revised 10/24/23, indicated the facility would treat each resident with respect and dignity and care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life.Facility policy Foley Catheter Management last revised 1/28/25, indicated all catheter bags would be covered at all times.Facility policy Dining and Food services last revised 2/12/25, indicated when staff fed a resident, staff should remember to sit down next to the resident and feed one resident at a time. Do not stand while a resident is fed.

Based on interview and document review, the facility failed to follow-up from resident council complaints and grievances after a determination was made by the facility. This had the potential to affect all residents in the facility. Findings include:During a resident council meeting on 2/10/26 at 12:59 p.m., five different residents vocalized concerns related to food. They indicated it has been mentioned at each of the meetings. The residents indicated they have not heard back from the facility staff or an rationale as to why no response.During an interview on 2/10/26 at 4:51 p.m., the life enrichment director ([NAME]) stated food was a big grievance mentioned at resident council meetings. There were a few other items brought up recently but could not remember what they were. After the meeting, the grievances would be taken to the appropriate department to handle from that point. [NAME] indicated they would follow up with the departments prior to the next resident council meetings and if there was anything to bring forward they would be brought to resident council at that time. [NAME] indicated they have notes about everything talked about in resident council but have not inputted the information in the new form yet.On 2/10/26 at 4:51 p.m., a copy of the [NAME]'s resident council notes was requested although not received.Facility Resident Council Meeting Minutes for 10/25 through 1/26 were reviewed, the following grievances were reported:- on 12/17/25, grievances related to can foods used to often and artificial sweeteners used was filed.No other grievances were filled out from resident council meetings.The minutes lacked documented responses and rationales of the concerns resident council brought forward.During an interview on 2/10/26 at 5:11 p.m., the administrator stated the resident council staff spokesperson, who was [NAME], would bring all grievances to the appropriate departments to handle. The facility would deal with grievances on a more personal level, instead of taking them back to the resident council.During a follow up interview on 2/10/26 at 5: 22 p.m., the administrator stated the [NAME]'s notes had been reviewed and lacked any proof follow-through with the resident council members had occurred related to grievances and complaints filed in resident council.

Based on observation, interview and document review, the facility failed to ensure medications were properly labeled with open dates, expired medications were removed and disposed of properly and discharged and/or expired residents' medications were removed from the cart in a timely manner to decrease the potential for drug diversion for 2 of 2 medication carts reviewed for medication storage. This deficient practice had the potential to affect all residents receiving medications from these medications' carts. Findings include: On 4/29/25 during continuous observation from 2:41 p.m. through 3:01 p.m., -2:41 p.m. an unidentified staff wearing dark blue scrub pants and top and was not wearing a name badge was working at the north medication cart and walked away from the cart and left it unlocked -2:42 p.m. an unidentified resident and guest walked past the unlocked medication cart - 2:44 p.m. the unidentified staff member walked back to the north medication cart, placed box of gloves on cart and walked away but did not lock cart - 2:45 p.m. to 2:53 p.m., the north medication cart remained unlocked and unattended - 2:53 p.m. an unidentified staff member wearing black scrub pants and printed floral scrub top walked by the unlocked medication cart and entered a resident room - 2:53 p.m. registered nurse manager (NM) walked down hallway, passed the unlocked medication cart but did not lock cart - 2:55 p.m. the unidentified staff returned to cart with paper in his right hand, placed paper on top of medication cart and walked away. Medication cart remained unlocked. - 3:01 p.m. the unidentified male staff returned to cart, opened top drawer, locked cart and walked away During an observation and interview on 4/30/25 at 7:10 a.m., licensed practical nurse (LPN)-C was administering medication from the north medication cart. LPN-C placed medications into med cup, did not lock the medication cart and walked into resident room. At 7:13 a.m., LPN-C returned to medication cart, locked the cart and walked away. Upon returning to the medication cart LPN-C acknowledged she had left the medication cart unattended when asked. LPN-C opened the north medication cart for a random review of medications and identified the following: R20's opened bottle of saline nasal gel lacked an opened-on date. An opened bottle of Vitamin C approximately one fourth full had an expiration date of 3/2025. LPN-C stated she did not use the expired bottle, and the bottle should have been removed and the medication destroyed. During an observation and interview on 4/30/25 at 10:08 a.m., NM was observed during a medication cart audit of the west medication cart. The following was revealed: R16's opened bottle of liquid Haloperidol lacked an open date. R5's opened bottle of Prednisolone eye drops lacked an opened-on date. R40's opened bottle of Lantoprost eye drops, an opened bottle of Dorzolamide eye drops, an opened bottle of Deep-Sea nasal spray and an opened bottle of Flonase nasal spray all lacked an opened-on date. Additionally, R16's-25 tabs lorazepam 1mg, 20 tabs lorazepam 0.5 mg, 51 tabs hydromorphone 2mg, 60mL hydromorphone 2mg/ml, and 12mL hydromorphone 1mg/ml was identified in the locked narcotic box of the medication cart. NM stated R16 had expired the previous day, and the medications should have been removed and destroyed at that time to prevent potential diversion. During interview on 5/1/25 at 1:58 p.m. director of nursing (DON) stated she expected multi dose medications like eye drops, nasal sprays and creams to be dated with the date it was opened for use. DON stated this practice is important because medications are good for a limited amount of time after opening and the open date ensures the resident is not getting expired medications. DON stated the NM audits carts to look for outdated/expired medications, undated medications and general cleanliness. She stated this was to be completed at least monthly and as needed. DON stated she expected medications for expired residents to be removed and destroyed the same shift as the resident expired on. She went on to state this was to avoid potential medications errors and drug diversion. Facility policy titled Policy and Procedure Medication Storage with revision date of 2/12/24, indicated the following: No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. Expired medications are to be removed from areas/medication carts prior to or at the time of expiration.

Based on observation and interview the facility failed to ensure a mechanical transfer lift was cleaned after resident use for 1 of 1 resident (R14), observed for infection control practices. Findings Include: R14's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R14 was cognitively intact, dependent on staff for toileting, required substantial/maximal assistance with transfers, personal hygiene, and dressing and used a wheelchair for mobility. R14's care plan dated 4/30/24, indicated R14 required the use of a standup lift (EZ stand) for transfers. During observation on 4/30/25 at 7:38 a.m., nursing assistant (NA)-A entered R14's room to answer his call light. NA-A went out of room and retrieved the EZ stand from the hall and brought into R14's room. The EZ stand had debris of a white flaky substance on it. NA-A and NA-B both assisted R14 from bed to the commode with the EZ stand. After completing task, NA-A removed EZ stand from R14's room and placed in hallway. The EZ stand was not cleaned after use. During observation on 4/30/25 at 9:09 a.m., NA-B removed the previously used EZ stand from the hallway and took into another resident room, the EZ stand was not cleaned prior to using it or after use on the other resident. During interview on 4/30/25 at 12:28 p.m., NA-B stated standard precautions are used to prevent the spread of infection from resident to resident. NA-B stated it is important to clean equipment in between use to prevent infection. NA-B stated it is an expectation to clean equipment such as an EZ stand after use. NA-B confirmed she did not wipe down the EZ stand after use with R14 or before use with second resident. NA-B confirmed staff receive infection control training at hire and annually thereafter. During interview on 4/30/25 at 8:40 a.m., licensed practical nurse (LPN)-A stated standard precautions are used to prevent infection, are used for every resident regardless of infection status, including hand washing, gloves, and cleaning commonly used equipment in between residents. LPN-A stated standard precautions are important because they protect residents from getting infections. LPN-A confirmed it is an expectation to clean commonly used equipment, like the EZ stand, after each use. LPN-A confirmed staff receive infection control training as a new employee and annually thereafter. During interview on 5/01/25 at 12:08 p.m., director of nursing (DON) stated standard precautions are a set of measures, they are the same for all residents, they are used to prevent infection. DON stated it is an expectation all commonly used equipment, such as an EZ stand, are cleaned after each use. Per facility policy titled Disinfection of Resident Care Equipment dated 5/8/24, reusable equipment will be cleaned and disinfected after each use of resident and before use with another resident.

Based on observation, interview and record review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 1 of 1 residents (R20) reviewed for medication administration. Findings include: R20's admission Minimum Data Set (MDS) assessment, dated 3/17/25 indicated R20 had intact cognition, with diagnoses of atrial fibrillation (an abnormal heartbeat), heart failure, respiratory failure, cataracts (clouding over the eyes lens), glaucoma or macular degeneration. R20's order summary indicated R20 had orders for the following medications: Brimonidine Tartrate Ophthalmic Solution 0.2% - instill 1 drop in both eyes two times a day related to glaucoma, and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8mg/mg - instill 1 drop in both eyes two times a day related to glaucoma. R20's record lacked evidence an assessment was completed or a provider order obtained for R20 to self-administration medications. During an observation on 4/29/25 at 9:05 a.m., a white bottle with a blue cap was noted to be sitting on the bedside table and within reach of R20. Licensed practical nurse (LPN)-C entered the room, picked up the bottle and placed it in her front right pocket. R20 stated to LPN-C I finished the blue one. LPN-C then left the room. R20 stated staff would bring her eye drops into the room and leave them for her to self-administer. During an interview on 4/29/25 at 2:08 p.m., LPN-C stated she took both of R20's prescribed eye drops into R20's room during the morning medication administration and had left one sitting on the bedside table and identified the medications was Dorzolamide-Timolol eye drops. LPN-C then reached into her front right pocket and removed the white bottle with a blue lid labeled with R20's name and identified the medication as Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8mg/mg. LPN-C stated R20 did not have an order to self-administer medications. During interview on 5/1/25 at 1:58 p.m., Director of Nursing (DON) stated any residents who wished to administer their own medications require a self-administration of medication assessment and a physician order to do so. DON confirmed R20 did not have an order to self-administer medications and expected staff to verify a SAM assessment was completed in order to determine is a resident was appropriate to safely self-administer medications. DON added a physician order was to be in place before leaving any medications at bedside. She went on to say this was important to ensure the resident knew how to safely administer their medications. Facility policy Medication Self Administration dated 2/12/24, indicated the resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medications. The ability to self-administer medications will indicate: A) able to self-administer medications independently, B) able to self-administer medications with supervision, cueing and/or set-up, C) not able to self-administer medications safely. Residents who have been deemed appropriate to self-administer medications independently or with supervision/cueing or after set-up shall have a physician order to do so. The self-administration of medications will be care planned with interventions specific to the individual resident.

Based on observation, interview and document review, the facility failed to ensure resident equipment was kept in a clean and in a sanitary manner to promote resident well-being for 1 of 1 resident (R31) observed for wheelchair cleanliness. In addition, the facility failed to provide comfortable sound levels for 1 of 1 resident (R44) observed for uncomfortable noise levels. Findings Include: R31 R31's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 is unable to speak and uses an iPad for communication needs. R31 has impaired vision requiring glasses, adequate hearing, and understands himself and others. R31's had intact cognition. R31 had functional impairment of both lower extremities requiring an electric wheelchair and functional limitations of both upper extremities requiring supervision and intermittently assistance for feeding task. R31 was admitted on [DATE] with a diagnosis of right-sided cerebrovascular disease (disease affecting blood flow to the brain), quadriplegia, dysphagia-oropharyngeal phase (difficulty swallowing, coughing, or choking when eating), muscle weakness, diffuse traumatic brain injury, and recurrent pneumonia. During observation and interview on 4/28/25 at 12:29 p.m., R31 was going to lunch in a personal electric wheelchair. R31's wheelchair foot plate, under seat platform, and right wheel and wheel cover had a thick layer of a dried substance of varying colors. R31 communicated on his iPad the substance was food and covered the bottom right side of the wheelchair for some time. R31 indicated he is unable to control his food when he eats and spills onto his wheelchair. R31 indicated he sometimes drops partially chewed food from his mouth because of his dysphagia. R31 indicated he is unable to clean his wheelchair due to his physical disabilities. R31 indicated he does not like the dried foods on his wheelchair. During observation and interview on 4/29/25 at 8:18 a.m., R31 was returning to his room from the dining room. R31's wheelchair continued to have chewed or spilled food dried on his wheelchair. Nursing assistant (NA)-A stated R31's wheelchair often had spilled or chewed food on it . NA-A stated she thought the night shift was responsible for cleaning the wheelchairs. NA-A stated she does not know how often residents' wheelchairs are cleaned. During interview on 5/01/25 at 12:08 p.m., director of nursing (DON) stated she knew R31 had old dried partially chewed food on his personal wheelchair and verified it was there for a while. DON stated the facility has a policy to clean facility and resident wheelchairs on the night shift. DON was unable to confirm the last time R31's wheelchair was cleaned and stated it would be in a progress note if it was completed. DON stated R31's wheelchair looks unsightly after every meal. DON stated R31's wheelchair should be cleaned after every meal as he does spill a lot. DON confirmed there is no interventions in R31's care plan to protect the wheelchair during meals. Per facility policy titled Cleaning and Disinfection of Resident Care Equipment dated 5/8/24, how often resident equipment was cleaned was not specified. R44 R44's Minimum Data Set (MDS) assessment dated [DATE] was incomplete, although included, R44 did not have any vision or hearing disabilities and was cognitively intact. R44 was observed using bilateral upper extremities, required assistance from staff for mobility and toileting. R44 was admitted on [DATE] with a diagnosis of muscle weakness, adult failure to thrive, severe obesity, chronic fatigue, rheumatoid arthritis, and need for assistance with person cares. During observation and interview on 4/28/25 at 4:20p.m., upon entering R44's room, the sound level in the room was loud and unpleasant. R44 stated her roommate's television (TV) was always very loud. R44 stated she had made multiple complaints about the noise of the roommate's television at all hours, but nothing has been done. R44 stated she told the social worker (SW) approximately one month ago about the unpleasant sound levels in her room. R44 stated she is unable to get up without assistance, or she would lower the volume herself. R44 stated her roommate leaves the room frequently throughout the day but she leaves the TV volume loud even when she's not in the room. R44 stated she will put her call light on during the day to have staff the lower the volume when the resident is not in the room; staff have told her they can't turn the volume down because it is the roommate's choice to have the TV volume up. During interview on 4/29/25 at 8:18 a.m., nursing assistant (NA)-A stated R44's roommate's TV is very loud; the roommate doesn't like to hear any of the other facility sounds. NA-A stated R44 will ask to have the volume turned down, informs R44 it is roommate's right to have her TV loud. NA-A stated if the staff notice the roommate is not in the room, they will try to turn the volume of the TV down, things are busy so they don't' always notice when the roommate leaves the room. NA-A confirms R44 is unable to turn the volume down due to her physical limitations. During observation and interview on 4/29/25 at 2:00 p.m., R44's roommate's TV is very loud, and can be heard halfway down the hall. Upon entering the room, R44 had facial wincing, when asked indicated because of the volume of the TV. R44 stated she had asked staff to turn it down, but resident just turns it back up when she returned to the room. During interview on 4/30/25 at 1:25 p.m., social services (SS)-A stated she was aware the roommate's TV volume could be loud at times. SS-A stated she had asked facility staff to keep an eye on the volume and turn it down when the resident was not in the room. SS-A confirmed no other interventions were in place to reduce the sound levels. SS-A confirmed R44 had told her approximately one month ago she was not sleeping well due to the volume of the roommates TV. SS-A stated this was when she asked facility staff to turn the TV volume down; no other interventions were initiated. During interview on 5/01/25 at 12:08 p.m., director of nursing (DON) confirmed she was not aware there was a potential roommate incompatibility with R44. DON confirmed R44's roommate leaves the room frequently as she can walk without assistance. DON stated social services would evaluate a situation; if the residents in the room aren't compatible, one resident can be moved to another room. DON confirmed there were no current plans to move either resident. The facility does not have a policy regarding roommate incompatibility or appropriate sound levels in each room.

Based on observation, interview and document review, the facility failed to implement specific resident-centered interventions for 2 of 2 residents (R35, R20) reviewed for care plans. Findings Include: R35's minimum data set (MDS) assessment dated [DATE] indicated moderately impaired cognition and moderately severe depression. R35 had a history of refusing cares and treatments. R35 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD, lung disease causing breathing problems), obstructive and reflex uropathy (blockage preventing urine from flowing normally), liver transplant, chronic kidney disease, major depressive disorder, and hydronephrosis with renal and ureteral calculous obstruction (urine buildup in the kidney due to blockage caused by kidney stones). R35's orders included, monitor for signs and symptoms of liver rejection including fever, pain in abdomen, yellowing skin, itching, increase in tiredness/weakness, swelling in abdomen or legs, and pale in color; notify provider and transplant coordinator immediately. Further, weigh every morning before breakfast; perform in the same manner (same scale, same method) every day and notify provider and transplant coordinator if weight increases by more than 5 pounds in one week. R35's daily weight record reviewed from 4/4/25 to 4/30/25 revealed R35 was not weighed daily and when completed was not according to provider orders (perform in same manner): -4/4/25 at 11:14 a.m. (166 pounds) -4/5/25 at 2:24 p.m. (166 pounds) -4/8/25 at 12:57 p.m. (165 pounds) -4/10/25 at 10:54 a.m. (164 pounds) -4/20/25 at 2:31 a.m. (166.5 pounds) -4/30/25 at 3:31 p.m. (165.8 pounds) R35's missed daily weights were documented as: -17 days were documented as refused R35's progress notes lacked a provider had been notified of R35's refusal of daily weights. During interview on 4/29/25 at 2:12 p.m., licensed practical nurse (LPN)-A stated R35 does refuse cares and medications sometimes. LPN-A stated due to R35's poor kidney function, the provider team ordered to have weights done daily. LPN-A stated accurate daily weights are important because if R35 was gaining weight rapidly it could indicate liver transplant rejection or if his kidney function gets worse, he could also have a rapidly increase in weight. LPN-A confirmed it is an expectation when a resident refuses cares or medication more than 2 days in a row, the provider would be notified. LPN-A confirmed provider notification would be a progress note and phone call. During interview on 4/29/25 at 2:52 p.m., registered nurse (RN)-A stated R35 will agree to medications and cares if staff explain the purpose of the medications and cares to him. RN-A stated R35's liver transplant anti-rejection medications and daily weights are important. RN-A stated R35 likes to remain in bed a lot, and needs a lot of encouragement to get up for eating, weights, daily cares. RN-A confirmed the expectation is to notify the provider if R35 refuses medications and cares; providers are notified by a progress note and phone call. During interview on 4/30/25 at 10:50 a.m. RN-B stated she works with R35's transplant team. RN-B stated daily weights are important because a rapid increase in weight could indicate liver transplant rejection. RN-B confirmed she had not been notified of R35 refusals of daily weights up to 10 days in a row. During interview on 4/30/25 at 2:18 p.m., nurse practitioner (NP)-A stated she works with R35's nephrology (kidney) team. NP-A stated daily weights for R35 are very important; daily weights allow the nephrology team to make specific medication changes based on weight increases or decreases. NP-A stated an acute increase in weight could indicate a decrease in kidney function and the sooner the team is aware of weight changes, the sooner they can begin to make medication changes to help kidney function. NP-A confirmed she had not been notified of R35 refusals. During interview on 5/01/25 at 12:08 p.m., director of nursing, (DON) stated it is an expectation ordered daily weights are completed per provider instructions. DON confirmed daily weights are ordered in the morning for R35 as this is the most accurate time of day to obtain weights. DON confirmed R35 had daily weights ordered so his provider teams can monitor liver transplant status and kidney function status. DON confirmed if R35 was refusing daily weights, it is the expectation to notify the provider as soon as possible. DON stated the provider would be notified by progress note or phone call. Per facility policy titled Resident Height and Weight policy dated 1/7/25, the stated purpose of this document is to provide guidelines for MD notification and documentation of weight changes. 49654 R20 R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 admitted on [DATE], was cognitively intact, had no behaviors, did not refuse cares and had the following pertinent diagnoses: A-fib (irregular heartbeat), congestive heart failure (the heart does not pump enough to adequately supply the body with blood or oxygen), and high blood pressure. R20's order summary indicated the following cardiac related orders: -Apply gradient compression garments to lower extremities-on during the day and off at night -CHF monitoring: monitor respiratory status (i.e. Orthopnea and dyspnea), edema, (i.e. leg or abdominal swelling), fatigue, change in mental status every shift and document findings in PCC (Point Click Care). Update provider with any signs/symptoms of worsening CHF. -Daily weights upon admission for residents with heart failure unless directed otherwise by provider. Notify [provider] if weight greater than 198.41 lbs one time a day. Process for weight: every morning before breakfast, perform in same manner (e.g. use same scale, same method) R 20's medical record indicated 22 of 29 weights recorded exceeded 198.4 lbs. for the month of April 2025 : 4/29/25 recorded weight 201.0 lbs. 4/28/25 recorded weight 200.4 lbs. 4/27/25 recorded weight 202.2 lbs. 4/25/25 recorded weight 209.0 lbs. 4/24/25 recorded weight 200.8 lbs. 4/23/25 recorded weight 199.2 lbs. 4/21/25 recorded weight 201.6 lbs. 4/20/25 recorded weight 199.3 lbs. 4/17/25 recorded weight 201.0 lbs. 4/16/25 recorded weight 201.4 lbs. 4/15/25 recorded weight 204.0 lbs. 4/14/25 recorded weight 201.8 lbs. 4/13/25 recorded weight 200.4 lbs. 4/12/25 recorded weight 199.8 lbs. 4/11/25 recorded weight 200.6 lbs. 4/10/25 recorded weight 202.6 lbs. 4/9/25 recorded weight 199.0 lbs. 4/8/25 recorded weight 199.6 lbs. 4/5/25 recorded weight 202.0 lbs. During observation and interview on 04/29/25 at 09:11 a.m., resident was in her room seated in wheelchair, feet in dependent position. Two ace wraps noted on counter above dresser. Resident stated her feet swell up and they should be wrapped up but staff don't always do it. Bilateral feet swollen and puffy. Resident stated she had too much fluid on her heart and sometimes had shortness of breath with talking. During observation on 04/29/25 at 12:45 p.m., resident noted in room seated in wheelchair, feet in dependent position. Ace wraps were not on. Feet swollen. During observation and interview on 04/30/25 at 10:33 a.m., resident in her room seated in wheelchair, feet in dependent position, watching TV. Ace wraps not on at the time; stated I think the pollen is up I've been short of breath today. Feet swollen and an indent from socks observed on both feet. During observation on 4/30/25 at 12:39 p.m., resident in her room seated in wheelchair, feet swollen and in dependent position. Ace wraps noted rolled up on counter area above dresser. During interview on 4/30/25 at 3:48 p.m., licensed practical nurse (LPN)-B stated he was familiar with R20 and her diagnoses. LPN-B stated residents with congestive heart failure should be closely monitored for edema, shortness of breath and weighed daily. He went on to say residents with ACE wraps or compression wraps should have them applied in the morning before they got up for the day and started to accumulate fluid in their legs. LPN-B stated nurses were responsible for applying ACE wraps and monitoring for any weight gain, and then follow their orders for increased weight such as updating a provider or giving an extra diuretic (medications to assist with fluid excretion). During interview on 4/30/25 at 4:03 p.m., LPN-C stated she was familiar with R20 and worked with her almost daily. LPN-C stated R20 had CHF, wore ACE wraps and took a 'water pill'. LPN-C stated resident weights should be completed at the same time each day using the same scale and ideally before the first meal of the day. She stated either nurses or aides could obtain the resident weights, but the nurses were responsible for monitoring for any increase in weight. LPN-C stated ACE wraps should be put on in the morning when residents get up, but sometimes she put them on late or after lunch due to time constraints. During interview on 4/30/25 at 4:15 p.m. Director of Nursing (DON) stated residents with CHF should be monitored for changes in mental status, increased weight, shortness of breath or difficulty breathing. DON stated a resident with daily weights should be weighed before the first meal of the day, and using the same scale, this would be the truest reflection of the residents' weight. DON stated if there was an increase in weight the nurse would be able to immediately identify this in the electronic medical record (EMR) because the weight would be highlighted in red to alert staff a change. In this instance she expected the nurses to assess the resident, notify the provider, document the assessment and put in a progress note in the resident's chart. She went on to state for residents wearing compression stockings they should be applied first thing in the morning before any fluid had accumulated and these were scheduled between 6:00 a.m. and 10:00 a.m . DON reviewed R20's weights for April 2025, acknowledged staff was to notify the provider for weights over 198 lbs, and confirmed there was no progress notes or provider notification of when weights were over 198 lbs in R20's record. DON stated it was important to follow an individual residents' orders to prevent an exacerbation of CHF and avoid potential hospitalization s.

Based on document review and interview, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to identify, investigate, analyze, and respond to medication errors by developing and implementing action plans for process improvement. This had the potential to affect all 50 residents who resided in the facility. Findings include: Review of the facility Quality Assessment Performance Improvement Committee Agenda Minutes in conjunction with Medication Error reports from December 2024 to February 2025. The QA minutes were not all dated nor identify which members of the committee were present. The Medication Error reports were identified in QA however, the reports did not consistently include a causal analysis/investigation, nor measures developed and implemented to prevent reoccurrence. The Quality Assessment Performance Improvement Committee Agenda/Minutes were reviewed and did not identify the date or time of the meeting, nor did it identify who the members were of the committee who attended. Further the QA minutes consistently did not address specific action plans to decrease the medication error rates. January minutes: The facility's Quality Assessment Performance Improvement Committee Agenda Minutes, form did not identify the date of the meeting nor quality members who were in attendance. The form identified Medication Errors as a topic to review and analyze. A goal for medication errors was not identified. In the section Current trends vs Historical Trends, Goals, included 1 medication error in December 2024, down from 6 medication errors in November 2024 due to tracking medication not available from house stock or pharmacy. Process followed to notify provider and placing medication on hold when not available or getting medication delivered stat. The data collected for analysis included: The undated Agenda minutes identified for December 2024 the facility had one medication error: R17's medication was not available from the pharmacy due to it being a special-order medication, family provided the medication and did not include measures to prevent reoccurrence. February minutes: The facility's Quality Assessment Performance Improvement Committee Agenda Minutes, form did not identify the date of the meeting nor quality members who were in attendance. The form identified Medication Errors as a topic to review and analyze. A goal for medication errors was not identified. In the section Current trends vs Historical Trends, Goals, included 5 medication errors in January 2025, up from one medication error in December 2024, due to tracking medication not available from house stock or pharmacy. Process followed to notify provider and placing medication on hold when not available or getting medication delivered stat. Two transcription errors, one entered as twice a day was ordered daily, one entered as self-administered instead of staff to administer, one medication not delivered from the pharmacy as new regulation state dialysis needs to supply, one over the counter eye drop not delivered due to a weather delay of ordered supplies, one resident was a readmit. one medication not delivered until night run and one medication were not sent at all. The section Historical Actions taken/New Action Plans/Steps, was left blank and did not identify who was responsible for the action step, did not specify what component of medication errors was being monitored daily at stand-up, nor specific activities associated with decreasing medication errors associated with types of medication errors that were identified in the report. The data collected for analysis included: Review of January 2025 Medication Error reports identified a total of five medication errors from 5 residents: 1. R4's Medication Error report dated 1/16/25 at 10:48 a.m., identified R4 received prophylactic Tamiflu 75 milligrams (mg) once daily for two weeks. Resident was receiving Tamiflu 75 MG BID (twice a day) for last eight days. Provider was updated and will discontinue Tamiflu as R4 has received adequate doses of prophylactic Tamiflu.R4 has not no adverse reactions from medication being given BID. Reviewed by IDT team. R4 had no adverse reaction. Medication was discontinued, provider stated he had sufficient medication for prophylaxis. The report did not include a causal analysis/investigation nor include measures to prevent reoccurrence. The reports did not identify who made the error nor any education for retraining. The report is unclear as to how many extra doses R4 received. 2. R16's Medication Error report dated 1/20/25 at 11:47 a.m., identified R16 missed Sevelamer Carbonate (medication to reduce phosphorus levels in dialysis patients) on 1/17/25 at 8:00 a.m., 1/18/25 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. doses. Omnicare contacted they stated that they do not supply this medication, stating that dialysis is responsible. Dialysis notified of missed medication by assigned nurse on 1/18/25. This resident did not receive his 8:00 a.m., or 11:00 a.m., dose of Sevelamer Carbonate today before dialysis. The facility has no more on cards and this medication is not kept in the Omnicell. Writer called Omnicare to ask them about this and they said that this medication is not covered under insurance for R16 and they also said that it must be ordered through Dialysis. Writer then called Dialysis who stated that this does not create a problem that R16 did not get it today as it only means that the phosphorus will excrete via his bowel movements versus urination. Fax sent to Mayo Clinic Nursing Home office as well. Reviewed by IDT. Omnicare pharmacy stated they no longer supply this medication due to it being a non-covered med and that dialysis is responsible for it. Dialysis team notified. Dialysis ordered medication for resident to pick up from Mayo pharmacy. R16 was able to pick up medication and facility has it in stock to be administered. The report did not include measures to prevent reoccurrence for other dialysis patients. The report did not identify who made the errors nor any education for retraining. This would be six missed doses which reflects six medication errors. 3. R15's Medication Error report dated 1/20/25 at 11:47 a.m., identified R15's over the counter (OTC) medication Muro eye drops (an eye drop used to treat corneal edema) TID (three times a day) administration missed from 1/14/25 - 1/20/25. Reviewed by IDT. Medication has been ordered. Supply has been delayed due to weather in the states that supply warehouses are located. Attempted to locate medication at a local pharmacy, none of them carry this medication. Awaiting supply. 1/23/2025 Medication placed on hold and supply ordered via Amazon. The report did not include a causal analysis/investigation nor include measures to prevent reoccurrence. The reports did not identify who made the error nor any education for retraining. This would be twenty-one missed doses which reflects twenty-one medication errors. 4. R14's Medication Error report dated 1/20/25 at 11:52 a.m., identified R14 missed Advair (inhaled medication to prevent flare-ups or worsening of chronic obstructive pulmonary disease) AM and PM on 1/17/25 to 1/19/25 indicating 6 missed doses. In addition, R14 missed Erythromycin Ophthalmic ointment (ointment used to treat eye infections) on 1/17/25. R14 was readmitted to the facility 1/17/2025. Erythromycin Ophthalmic ointment was a new medication and was delivered on the night run. Advair was not delivered. Reviewed by IDT. R14 readmitted to the facility on [DATE]. Erythromycin Ophthalmic ointment was a new medication and was delivered on the night run. Medication start date should have been the following day. Advair was not delivered. Pharmacy was contacted on 1/18/25 at 8:00 a.m., they stated Advair would be delivered on the run tonight. Pharmacy did not deliver Advair until 1/19/2025 at 9:33 pm. R14 had no adverse effects from missing doses. The report did not include a causal analysis/investigation nor include measures to prevent reoccurrence. The reports did not identify who made the errors nor any education for retraining. This would be seven missed doses which reflects seven medication errors. 5. R3's Medication Error report dated 1/27/25 at 8:00 a.m., identified R3's Heparin (blood thinner) order appears on MAR as completed as transcribed as self-med. No medication was administered by staff. Does not identify how many missed doses. Reviewed by IDT. R3 had no adverse reaction from missing doses. Order was corrected in the computer. Review of R3's MAR dated January 2025, identified R3 had nine omitted doses of heparin from 1/24/25 to 1/27/25 resulting in 9 medication errors. The report did not include a causal analysis/investigation nor include measures to prevent reoccurrence. The reports did not identify who made the error nor any education for retraining. The report did not identify who made the errors nor any education for retraining. This would be nine missed doses which reflects nine medication errors. After reviewing the facility's data analysis from the medication error reports for January 2025, the medication error rate would be 44 medication errors and not 5 medication errors with a difference of 39 medication errors that were not brought forward to quality assurance. Review of Medication errors dated February 2025, the facility identified 12 medication errors however review of medication error reports identified 42 medication errors, a difference of 30 medication errors that were not accounted for. During an interview on 3/11/25 at 2:42 p.m., director of nursing stated the facility department heads meet monthly for QAPI meetings. DON indicated at each monthly meeting they will discuss medication errors from the previous month. DON verified the QAPI notes from February 2025 identified six medication errors and the error rate was up 5 medication errors from the previous month. DON verified there was no new action plan in place to prevent future medication errors. DON further verified February 2025 medication errors increased to twelve, up seven from the previous month. DON stated they had not been tracking each omitted medication as one error rather identified if a resident who had several omitted doses as one error. DON indicated they had not completed an analysis of the February medication errors as they had not had their QAPI meeting for March yet, so no action plan was put in place to prevent future medication errors. During an interview on 3/11/25 at 3:49 p.m., nurse practitioner (NP)-A stated one omitted medication would be counted as one medication error and facility should be identifying this, should be analyzing for trends in medication errors to put prevention plans in place to prevent future medication errors. The facility policy, QAPI Policy and Procedure, updated 5/5/24, identified It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. The objective of this requirement is the completion and implementation of the QAPI plan to identify the high risk, problem prone and high volume areas to evaluate for improvement and identify, collect and use data relevant to the unique characteristic and needs of the residents . PROCEDURE: 1. The facility will develop, implement, and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life. 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: a. Tracking and measure performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 3. The facility maintains documentation and can demonstrate evidence that the program meets CMS requirements. 4. The facility presents evidence in the form of documentation to substantiate the ongoing implementation and QAPI program compliance with regulations to the State Survey Agency, Federal Surveyor or CMS if requested. 5. The Quality Assessment and Assurance Committee consists at a minimum of: a. The director of nursing services; b. The Medical Director or his/her designee; c. At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and d. The infection Preventionist - effective November 28, 2019 . 4. Our QAPI plan includes the policies and procedures used to i. Identify and use data to monitor our performance ii. Establish goals and thresholds for our performance measurement iii. Utilize resident, staff and family input iv. Identify and prioritize problems and opportunities for improvement v. Systematically analyze underlying causes of systemic problems and adverse events vi. Develop corrective action or performance improvement activities . Guidelines for Performance Improvement Projects (PIPs). Identified PIPs will be the center of the QAPI program. Identified areas of improvement will stay as focal issues until desired outcomes have been achieved. If the measures of interventions implemented are not delivering results, the details will need to be adjusted either at the quarterly, preferably monthly, meeting or sooner as appropriate. Once achieved they will be maintained and discussed routinely, however new focal points or PIPs will be introduced. Performance improvement activities must track medical errors and adverse resident events, analyze causes, and implement preventative actions and mechanisms that include feedback and learning throughout the facility. Responsibility and Accountability The administrator has responsibility and is accountable to the governing body and our corporation for ensuring that QAPI is implemented throughout our organization. QAPI activities and discussion will be a standing item on our regular governing body meeting agendas. The administrator will, report on and solicit input on all QAPI activities on a regular basis. The administrator is responsible for assuring that all QAPI activities and required documentation is provided to our corporation . Conducting Performance Improvement Projects (PIPs) Our organization will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. We will conduct PIPS that will lead to changes and guide corrective actions in our systems, which cross multiple departments, and have impact on the quality of life and quality of care for residents living in our community. We will conduct PIPs that will improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained. Method to Identify Potential Topics for PIPs The QAA committee will review data and input on a quarterly, preferably monthly, basis to look for potential topics for PIPs. We will monitor and analyze data, and review feedback and input from residents, staff, families, volunteers, providers, and stakeholders. We will look at issues, concerns, and areas that need improvement as well as areas that will improve the quality of life and quality of care and services for the residents living and staying in our community. Factors we will consider: high-risk, high-volume, or problem-prone areas that affect health outcomes, quality of care and services, and areas that affect staff. In addition, we will consider: o Existing standards or guidelines that are available to provide direction for the PIP o Measures that can be used to monitor progress o Quality Measures publically reported on Nursing Home Compare o Evidence based practices o Projects that require systemic changes o Projects that require environmental changes o Projects affecting staff Criteria for Prioritizing and Selecting PIPs Our QAA committee will prioritize topics for PIPS based on the current needs of the residents and our organization. Priority will be given to areas we define as high-risk to residents and staff, high-prevalence, or high-volume areas, and areas that are problem-prone. The QAA committee will use the CMS Prioritizing Worksheet for Performance Improvement Projects to prioritize PIPs. Consideration will be given to include staff most affected by the PIP. Anticipated training needs will be discussed as well as other resources to complete the PIP. The QAA committee will provide guidance on how to address issues that arise and need immediate corrective action. How and When PIP [NAME] Will be Developed A project charter will be developed for each Performance Improvement Project at the beginning of the project that clearly establishes the goals, scope, timing, milestones, team roles, and responsibilities. The PIP charter will be developed by the QAA committee and then will be given to the team that will carry out the PIP. Designating a PIP Team When designating a PIP team, the QAA committee will consider and give opportunity to all staff in the organization. The QAA committee will ensure that the team is interdisciplinary, there is representation from each job role that is affected by the project, and resident and/or family member representation is included, if appropriate. When chosen to participate on a PIP team, staff with direct care responsibilities will be replaced so that the needs of residents continue to be met. A team leader will be selected that has the ability to coordinate, organize, and direct the work. How the Team will Conduct the PIP: The PIP teams will consider each PIP a learning process. The team will follow steps and processes that are needed for any quality improvement project. The responsibilities for the PIP teams will be to determine what information is needed for the PIP and how to obtain the information. They will determine a timeline based on the PIP Charter. Requests for needed supplies, staff availability, and equipment will be made to the QAA committee. The QAA committee will respond in a timely manner to assure momentum is maintained. The team will develop an action plan using the organization's usual format. Interventions that will make change will be implemented by the team. The team will use root cause analysis to ensure that the root cause and contributing factors are identified. When determining and implementing interventions, PDSA cycles will be used. The team will select and/or create measurement tools to ensure that the changes they are implementing are having the desired effect team will be accountable to the QAA committee. Process for Documenting and Communicating Performance Improvement and Trends in Performance Measures: For ongoing monitoring of the PIP, we will use the CMS PIP Inventory to include milestones, PDSAs, outcomes, and other lessons learned from the PIP. Information about PIPs will be shared with staff, resident, and families. Systemic Approach to Quality Improvement: Our facility uses a systematic approach to determine when in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change. To get at the underlying cause(s) of issue, we bring teams together to identify the root cause and contributing factors using the Five Whys, Flowcharting, and the Fishbone Diagram. Preventing Future Events and Promoting Sustained Improvement To prevent future events and promote sustained improvement our organization develops actions to address the identified root cause and/or contributing factors of an issue/event that will affect change at the systems level. We use Plan-Do-Study-Act cycles to test actions and recognize and address unintended consequences of planned changes. Ensuring Planned Changes/Interventions are Implemented and Effective To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, our organization chooses indicators/measures that tie directly to the new action and conducts ongoing periodic measurement and review to ensure that the new action has been adopted and is performed consistently .

Based on observation interview and document review the facility failed to ensure their Facility Assessment (FA) included resident diagnoses of organ transplant recipients who currently resided in the facility. In addition, the facility assessment failed to identify education on specific care or practices necessary to meet identified care needs regarding organ transplant recipients which had the potential to affect 1 of 1 resident (R1) and all future organ transplant residents reviewed for quality of care. Findings include: The Edenbrook Rochester Requirements of Participation Facility Assessment, revision dated 9/18/24, was reviewed and lacked evidence identifying organ transplant recipients and specific care or practices related to organ rejection monitoring. In addition, the (FA) further lacked training/competencies and provision of care related to organ transplant recipient monitoring, and care services. Record review identified: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had a diagnosis of Liver transplant and end stage kidney disease. Attempted phone interview completed on 3/11/25 at 12:35 p.m., with the medical director office assistant (MDOA)-A who stated the medical director (MD)-A would be out of the office until 3/17/25. During an interview on 3/11/25 at 1:23 p.m., licensed practical nurse (LPN)-A identified he was the nurse responsible for R1's care. LPN-A stated he had never received any training related to organ transplant recipients and was unaware of the signs and symptoms for liver rejection monitoring. During an interview on 3/11/25 at 1:42 p.m., nurse manager (NM)-A identified she was the nurse manager for R1 and stated she did not remember receiving an education regarding organ transplant recipient care. NM-A stated they did not have any information on R1's liver transplant team and did not know how to get a hold of them. During an interview on 3/11/25 at 3:23 p.m., director of nursing DON) indicated their facility assessment did not identify organ transplant recipient provision of services care or monitoring. DON stated they did not have access to R1's liver transplant team for coordination of care as R1 came from another facility and that information was not in R1's medical records. During an interview on 3/11/25 at 3:28 p.m., regional nurse manager (RNM)-A stated the facility assessment does not identify organ transplant recipients or education regarding provision of care or services. During an interview on 3/11/25 at 3:49 p.m., nurse practitioner (NP)-A stated the facility does not have contact information regarding R1's liver transplant care coordinator. During an interview on 3/11/25, at 4:55 p.m. the Administrator confirmed the facility assessment had not identified organ transplant recipients, and did not indicate specific care or practices related to organ transplant recipient care. During an interview on 3/12/25 at 9:20 a.m., via phone registered nurse liver transplant care coordinator (RNLTCC)-A stated she had wondered what happened to R1 as she had not heard from him in quite some time. RNLTCC-A stated with liver transplant recipients it is very important to be monitoring for liver rejection signs and symptoms, ensure anti-rejection medications are given daily, and will need routine monitoring of labs and ultrasounds of the liver. A policy for facility assessment was requested, but not provided.

Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of an indwelling catheter to reduce the risk of infection to others for 1 of 1 resident (R1) reviewed for quality of care. Findings include: R1's face sheet identified diagnoses of obstructive and reflux uropathy and need of assistance with personal cares. R1's order summary dated 6/19/24, identified R1 had an order to provide catheter care every shift, ensure catheter is anchored via Velcro or tape. R1's care plan revised 8/2/24, identified a focus of actual/potential for alteration in elimination related to obstructive and reflux uropathy .goal identified will have no signs and symptoms of infection after completion of treatment through next review. Intervention dated 6/20/24 identified to change Foley catheter as ordered and monitor/document/report signs and symptoms of UTI: abdominal pain, weakness, functional decline, nausea, vomiting, dark cloudy urine, blood in urine and pus in urine. Did not identify EBP precautions. An additional focus revised 2/18/25 identified a focus related to renal failure due to end stage renal disease and had fistula created, waiting for fistula to mature, no start date for dialysis, does not want dialysis initiated. Intervention dated 7/2/24 identified to use enhanced barrier precautions. Care plan does not identify what cares identify the need for EBP nor does the foley catheter identify the need for EBP. During an observation and interview on 3/11/25 at 1:16 p.m., upon entrance to R1's room a paper sign was hung on the wall to the right side of R2's door. Two, STOP signs noted at the top on either side. Signage read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following activities. Dressing, Bathing/Showering, Transferring, changing linens, Providing Hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The sign also had color pictures of hand cleanser, gloves, and gown. During an interview on 3/11/25 at 1:23 p.m., licensed practical nurse (LPN)-A verified R1's catheter was lying on the floor and should not be related to infection control concerns. During an observation on 3/12/25 at 10:10 a.m., R1 was lying in bed and his catheter bag was hooked to the bed control cord and the bottom of the catheter bag was lying on the floor. At 2:17 p.m., NA-A verified the catheter bag was lying on the floor and should not be. NA-A stated he would have to find a catheter bag covering to put it in. At 10:19 a.m., LPN-A verified the catheter bag was lying on the floor, walked into R1's room with washing his hands and picked up the catheter bag without applying EBP per the room signage and hooked the catheter to the bed. LPN-A then picked up R1's breakfast tray and walked out of the room without washing his hands, walked down the hall, set the breakfast tray on the cart in between the east and west hallways, then proceeded to walk down the hall. LPN-A stated R1 should be on EBP precautions due to his Foley catheter and fistula and stated he should have used them in addition to washing his hands before and after entering/leaving the room. During an interview on 3/12/25 at 10:26 a.m., director of nursing DON stated staff should be using EBP's when touching R1's catheter bag. All residents with EBP have a sign clearly posted outside their room and staff should be looking for that and following our policy for EBP to help prevent the spread of infection. DON further stated staff should be washing hands prior to entrance of a room, after leaving a resident's room and between glove changes. DON stated not following EBP would be an infection control issue. Facility policy, enhance Barrier Precautions, dated 3/6/24, identified it is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with infection or colonization with an MDRO 1. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Enhanced Barrier Precautions will not only focus on residents with infection or colonization with MDRO's but will also address residents at risk for developing or becoming colonized. Enhanced Barrier Precautions are precautions that are between Standard Precautions and Contact Precautions. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact resident care activities. Novel or Targeted MDROs include: Pan-resistant organisms Carbapenem's-producing carbapenem-resistant Enterobacter [NAME], carbapenems-producing carbapenem-resistant Pseudomonas spp., carbapenems-producing carbapenem-resistant Acinetobacter baumannii, and Candida auris1Additional MDROs that are epidemiologically important include: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-producing Enterobacterales, Vancomycin-resistant Enterococci (VRE),Multidrug-resistant Pseudomonas aeruginosa, Drug-resistant Streptococcus pneumoniae. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High-Contact Resident Care Activities include1: Policy & Procedure: Enhanced Barrier Precautions: Dressing, Bathing/showering, Transferring, providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing1. Standard Precautions should be applied to all residents at all times. 2. Transmission-based precautions should be applied to all residents when standard precautions alone do not prevent pathogen transmission. 3. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. b. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. c. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. d. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. 4. Post clear signage on the door/wall outside resident room a. Type of precautions i. Contact Link: Contact Precaution sign ii. Droplet Link: Droplet Precaution sign iii. Airborne Link: Airborne Precaution sign iv. Enhanced Barrier Precautions Link: EBP Sign 5. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: 1. Dressing 2. Bathing/showering 3. Transferring 4. Providing hygiene 5. Changing linens 6. Changing briefs or assisting with toileting 7. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator 8. Wound care: any skin opening requiring a dressing 1 ii. In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. Outside the resident's room, EBP should be followed when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. iii. Residents are not restricted to their rooms or limited from participation in group activities. Because EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 6. Facility will ensure PPE and alcohol-based hand rub are readily accessible to staff. 7. Communication and education will be provided to all staff caring for or entering resident room for directions. 8. The Infection Preventionist may consult Public Health when needed for additional decisions regarding practices to prevent the spread of MDROs. Requested a handwashing policy and was not received.

Based on observation, interview and document review the facility failed to ensure a system to provide the correct physician ordered textured diet for 1 of 1 resident (R1) who was at risk for choking and history of aspiration pneumonia. This resulted in a immediate jeopardy for R1 and has the likelihood to effect current and future residents who required changes to textured diets to prevent choking/aspiration. The immediate Jeopardy (IJ) began on 1/3/25, when R1 returned from the hospital with new diet texture orders and received a regular textured diet through 1/9/25 related to facility system failure when dietary orders are changed. The administrator and director of nursing (DON) were notified of the IJ on 1/9/25 at 5:49 p.m. The IJ was removed on 1/10/25, but noncompliance remained at the lower scope and severity, level D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: International Dysphagia Diet Standard Initiative (IDDSI) Level 5 Minced and Moist Diet tool dated January 2019, identified foods that are soft and moist but with no liquid leaking/dripping from the food, biting is not required, minimal chewing is required, lumps of 4 millimeters (mm) in size, lumps can be mashed with tongue, foods can easily be mashed with just a little pressure from the fork, and should be able to scoop food onto the fork with no liquid dripping and no crumbles falling off the fork .may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced & Moist foods only need a small amount of chewing and for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. It's important that Minced & Moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or a fork .examples of foods to avoid .tough or fibrous foods-steak and pineapple .crumbly bits-dry cake crumble . International Dysphagia Diet Standard Initiative (IDDSI) Level 7 Regular: meant for individuals who do not have issues chewing or swallowing. R1's care plan dated 12/16/24, identified a focus, R1 had the potential for altered nutritional status related to pain, osteoarthritis, diabetes, increased body habitus, heart disease, generalized weakness, decreased mobility, antidepressants and on Ozempic (injectable diabetic) medication. Interventions dated 12/16/24, identified R1 was to receive a level 7 regular liberalized renal diet. On 12/18/24, identified R1 required set up assist with eating. R1's admission minimum data set (MDS) dated [DATE], identified R1's cognition was intact, diagnoses were diabetes, chronic obstructive pulmonary disease (COPD), and dyspnea (shortness of breath). R1 was independent with eating and required a therapeutic diet. R1's progress note dated 12/23/24 at 9:39 a.m., identified R1 was sent to the emergency department (ED) for altered mental status, abdominal breathing 30+ breaths per minute, possible aspiration as there was vomit beside her. R1 unable to speak clearly only mumbling. R1's emergency department (ED) note dated 12/23/24 at 10:21 p.m., identified R1 presented to the ED with shortness of breath from the nursing home, R1 had vomited and was noted to be aspirating on the vomit, was hypoxic and oxygen saturations were 80% (normal 90-100%) on 8 liters of oxygen. Antibiotics started because chest Xray shows right lower lobe pneumonia .will be admitted to the intensive care unit given her new BiPAP (a machine that helps remove carbon dioxide) status. R1's after visit summary (AVS) dated 12/23/24 to 1/3/25, identified R1 was hospitalized for acute hypoxemic(low level of oxygen in the blood)/hypercapnic (carbon dioxide buildup) respiratory failure presumed secondary too aspiration pneumonia (developed following presumed episode of emesis) and COPD exacerbation requiring BiPAP. She was also encephalopathic (a change in how your brain functions requiring medical intervention) on admission. R1 participated in a bedside dysphagia (difficulty in swallowing) evaluation on 12/26/24, to assess safety with oral intake/risks for aspiration. Factors contributing to aspiration risk include generalized weakness, respiratory status cognitive involvement and decreased activity intolerance. History of odynophagia (painful swallowing) secondary to Warthin's tumors (benign tumor occurring in the salivary glands) noted in the electronic medical record. Discharge orders included: Dysphagia clinical evaluation results: R1 participated in oral trials of thin liquids, puree and solid consistencies resulting in no observable signs of aspiration/penetration. However prolonged mastication with very small bite of cracker. No oral retention/pocketing. Current diet: solids IDDSI level 5 minced and moist, recommended form of medications crushed with puree. Recommendations: Dysphagia treatment. Aspiration precautions: Recommended Aspiration Precautions: Watch closely for signs of aspiration, Sit upright with all oral intake and when completing oral cares, Eat small bites, take small sips, eat slowly, Empty mouth before adding more food or liquid, Good oral care 3-5 times a day. Compensation Techniques/Adaptive Equipment: Requires supervision/assistance. Positioning: Positioning Recommendations: Upright as possible for all oral intakes take small sips, eat slowly, empty mouth before adding more food or liquid, minimize talking during meals, avoid lying down for 15 minutes after meals, good oral care 3-5 times a day every shift. Follow-up Information: Recommend dysphagia therapist evaluate and treat. Frequency and duration to be determined by the evaluating therapist. R1's physician order summary dated 1/3/25, included an order for liberalized renal diet Level 5 minced and moist texture with level 0 thin (regular) consistency. Aspiration precautions: Watch closely for signs of aspiration, Sit upright with all oral intake and when completing oral cares, Eat small bites, take small sips, eat slowly, empty mouth before adding more food or liquid, Good oral care 3-5 times a day. Review of R1's medical record identified R1's care plan and Kardex (abbreviated care plan for direct care staff) was not updated to include Level 5 minced and moist diet nor any interventions identified on the hospital discharge summary including but not limited to: R1 required supervision/assistance, minimize talking during meals, and avoid laying down for 15 minutes after meal. R1's progress note dated 1/5/25 at 10:36 p.m., identified R1 needed constant reminders to use call light. R1 stayed in her room the entire shift and had supper in bed and was able to feed self with appropriate set up. Oxygen saturations were 89% on room air with head of bed elevated, denied shortness of breath and pain. R1's physician visit dated 1/8/25 identified R1 followed a renal diet. Since admission to the facility average intake at meals ranging from 76-100%. Identified assessment plan for dysphagia to remain minced and moist renal diet and thin liquids. R1's Kardex dated 1/9/24 identified R1 required a level 7 regular renal diet. During an interview on 1/9/25 at 4:28 p.m., nursing assistant (NA)-A stated to ensure a resident received the right diet, staff would verify the food on the plate against the meal ticket and could also check the care plan as well. During an interview on 1/9/25 at 4:29 p.m. NA-B stated when staff have to serve food to a resident when they are eating in their room, we would verify the food ticket against what was served on the plate, if staff had questions they would ask the nurse. During an interview on 1/9/25 at 4:31 p.m. licensed practical nurse (LPN)-C stated when we deliver food to residents in their rooms, we would check the food ticket against what is plated. If there were any discrepancies we would ask the kitchen. During an interview on 1/9/25 at 4:33 p.m. registered nurse (RN)-A if there was a discrepancy with the food and the meal ticket, we could check the care plan and would notify my nurse manager. During an interview on 1/9/25 at 4:25 p.m., director of nursing (DON) verified R1's care plan was not updated with level 5 minced and moist diet and the care plan identified R1 was to receive a regular textured diet. DON explained NA's were trained to verify the food on resident's plates by the meal ticket and not the care plan. The facility had seven (7) days to update the care plan with diet changes. During an observation and interview on 1/9/25 at 12:53 p.m. R1 was seated in her wheelchair and had her tray table in front of her. R1 stated she would normally eat in the dining room but had gotten up late today so would be eating in her room. At 1:20 p.m., an unknown male nursing assistant delivered R1's meal tray and set it up on R1's tray table. Male aide then left the room. R1 attempted to use the side of her fork to cut off a bite of the roast beef and stated, this meat is tough. R1 took one bite at a time taking several minutes to chew and swallow each bite. After R1 swallowed a bite of her pineapple upside down cobbler, R1 coughed two times. R1 stated she was supposed to have moist and minced roast beef but they were not moist or minced nor were the carrots. R1's meal ticket dated 1/9/25 located on her tray included, Noon, regular level 7 diet. Entree roast beef, beef gravy, mashed potatoes, carrots, and pineapple upside down cobbler. R1 stated my meal ticket doesn't say moist and minced. At 2:03 p.m., licensed practical nurse (LPN)-A entered R1's room looked at R1's meal ticket that identified the regular diet, and reported R1 had received the wrong diet then removed the tray. LPN-A stated that R1 usually ate in the dining room and would be observed for aspiration as there is staff in the dining room during meal time. During an interview on 1/9/25 at 2:08 p.m., LPN-A stated she was unsure how R1's meal ticket did not match the current MD order and deferred the question to the dietary staff as they handle the meal tickets. LPN-A reported until she was prompted to refer to the record she was not aware R1 required her medications crushed in apple sauce and not whole; LPN-A gave R1 her medications whole this morning based on R1's response when she was asked how she took her pills. During an interview on 1/9/25 at 2:44 p.m., health unit coordinator (HUC)-A stated with a new admit she would be responsible to put new orders into the EHR physician orders which would include including diet orders and a nurse managers would doublecheck the entry to ensure accuracy. The clinical managers would be responsible to notify the kitchen staff with new diet orders. During an interview on 1/9/25 at 2:50 p.m. LPN-B stated he was one of the nurse managers. LPN-B stated the HUC would normally put the orders into the EHR and one of the nurse managers would be responsible to doublecheck the orders. LPN-B stated he was unsure who would be responsible for notifying the kitchen staff of new diet orders. The facility used to use a diet communication paper form but have not used one for quite some time. During an interview on 1/9/25 at 2:18 p.m., cook (C)-A stated residents who have new diet orders that would go through my manager (culinary director-CD). Level 5 diet is moist and minced, residents on this diet may not have teeth or have difficulty swallowing. For the noon meal today to meet the level 5 minced diet, the roast beef would have to be put through the food processor, similar to mashed-chunky texture, mashed potatoes would be fine, the carrots would have to go through the food processor too. During an interview on 1/9/25 at 2:23 p.m., culinary director (CD)-A stated when a new diet was ordered, nursing would enter it into the electronic health record (EHR), would typically email her that there was a diet change order, and/or verbally communicate the order. CD-A would then put the information on a dietary communication form, keep the form in a folder on her desk, then would enter the diet information into the [NAME] Brothers system that allows the meal ticket to print out which was used to inform dietary and nursing staff at meal times what was supposed to be plated. CD-A explained she was the only person who had access to to change diets in the system. CD-A did not get an email from nursing about R1's diet change when she returned from the hospital and had herself just returned from vacation. CD-A verified the ticketing system currently identified R1 was to receive a regular textured diet. CD-A verified R1's dismissal summary identified R1 was to receive a level 5 diet minced and moist starting on 1/3/25, and this was not done. R1 would have received the wrong textured diet from 1/3/25 to 1/9/25 due the meal ticket being wrong. During an interview on 1/9/25 at 2:52 p.m., DON stated the kitchen should have access to the resident discharge summary to see what the residents diet order was. DON indicated whoever was doing the admission should have notified the kitchen of a new diet order. The risk of R1 receiving the wrong textured diet would be aspiration and choking risk. Further R1 should have received her pills crushed in applesauce and not whole. During a phone interview on 1/9/25 at 3:13 p.m., speech therapist (ST)-A stated he had not been asked to evaluate R1 for swallowing. A person who received a regular diet who should have had a level 5 minced and moist diet would be at risk for aspiration and choking. For a level 5 minced and moist diet the food should be cut up small enough to fit through a fork tine, be well moistened with no excess fluid. Someone on a level 5 diet typically can not chew food particles or swallow well. During a interview on 1/9/25 at 4:34 p.m., nurse practitioner (NP)-A stated R1 had clear orders to receive a level 5 moist and minced textured diet. NP-A further stated if R1 had been receiving a regular diet since 1/3/25, the risk would be aspiration and pneumonia. NP-A indicated with this type of diet her pills should be crushed and not given whole. During a phone interview on 1/9/25 at 4:58 p.m., medical director (MD)-A stated R1's level 5 diet would require supervision with eating and the risk would be aspiration. MD-A stated signs and symptoms to watch for aspiration while eating would be a new cough, problems with breathing, choking, spitting up, fever and fatigue. Facility policy, Diet and Diet Orders, revised 12/11/23, identified Policy: All diets will be prescribed by the Attending Physician. The Dietitian will review diets for accuracy and therapeutic goals and recommend changes to the Physician as deemed appropriate. Purpose: The purpose of this policy is to provide consistency and accuracy in all diets provided to our residents and patients. Procedure: 1. All diets must be prescribed by the Attending physician and reviewed by the Dietitian. 2. Upon admission, the diet order is entered into the EMR, using the terminology on the attached Diet Conversion Chart. The diet ordered should match the terminology used by Dietary Services. 3. Diets are ordered or changed in writing and communicated to the Dietary department. 4. All diet orders should include diet type (e.g. regular or therapeutic), diet texture, and liquid consistency. 5. Specific requests such as high protein, low potassium, high fiber, etc. will be assessed by the Dietitian and adjusted on the resident tray card and listed in the care plan. 9. The facility will utilize a tray identification system to ensure diet accuracy in the service of the meals. 10. The Dietitian, Speech-Language Pathologist and Nursing department will document significant information relating to the resident's response to the diet offered in the resident's medical record, including the care plan. When diet orders are changed, the care plan and tray card will be updated to reflect the change in order. 11. Residents on therapeutic or mechanically altered diets will not receive foods or fluids outside the diet order unless approved by the Attending physician in conjunction with the Dietitian, nursing and/or therapy . Responsibilities: o Dietitian - Monitor compliance with policy by ensuring accuracy of diets and communicating changes or recommendations. Ensures that care plan is updated with diet changes. o Food Service Director/Dietary Manager - Ensures that food provided is consistent with diet order and that tray card accurately reflects resident/patient diet order and food preferences.- Nursing Department - Enters diet orders in EMR per Physicians order and in compliance with approved diet type and texture. In cooperation with the other departments, ensures appropriate diet and liquids are provided and reports any discrepancies The IJ was removed on 1/10/25, when it was verified through observation, interview and document review the facility completed the following: - Reviewed and revised policies and procedures related to serving resident meals and ensuring residents receive correct textured meals. - Educated to procedures as appropriate. -Educated all nursing staff to utilize diet communication form and give to kitchen staff and on updating the care plan for diet orders. - Educated dietary and all staff who serve resident food to recognize each specific diet type/textured meal. - Educated dietary staff related to the importance of ensuring the meal ticket is updated. - Educated all staff who serve resident food items on the importance of checking the diet slip, ensure the resident is getting the correct textured food, and then delivering the correct diet order to the resident. - Developed and implemented a plan to complete all training before each staff worked their next shift.

Based on interview and document review the facility failed to identify, comprehensively assess, monitor surgical wound changes for 1 of 1 resident (R5). This resulted in harm when the physician was not notified of R5's fall that caused R5's wound to dehisce which delayed healing because of required surgical intervention. Findings include R5's Minimum Data Set (MDS) assessment dated [DATE], indicated R5 admitted to the facility on [DATE] from a hospital with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, and type 2 diabetes mellitus. The MDS indicated R5 had a major surgical procedure during her prior inpatient hospital stay that required active care during her stay at the facility and had surgical wounds. R5's care plan included a focus dated 5/31/24, that included I have an alteration in skin integrity related to aftercare following surgical amputation of right lower extremity. Goals with revision date of 6/18/24 included I will be free of complication and minimized pain related to my skin alteration through the review date and My alteration in skin integrity will show signs of improvement in healing by the review date. Interventions dated 5/13/24 included administer my treatments as ordered, assess/monitor the alteration in my skin integrity and document status weekly, prevent trauma, and ensure I have proper fitting footwear. R5's physician note dated 7/3/24, indicated she had a right below the knee amputation (BKA) on 5/22/24 with placement of a wound VAC (negative pressure wound therapy via vacuum assisted closure dressing) placed for postoperative healing. On 6/21/24 R5 was evaluated by orthopedic surgery with the incision in excellent condition per reports and care with the wound VAC was continued. R5's physician order with start date of 7/2/24, instructed staff to complete a weekly skin check every Thursday on the day shift. R5's physician visit note from doctor of medicine (MD)-A dated 7/5/24, indicated R5 was seen in the cast room clinic for orthopedic surgery follow-up. It noted R5 had a right transtibial amputation (BKA) on 5/22/24. Her wound VAC was discontinued, 23 centimeter (cm) incision was noted to be healed, the remining sutures were removed, Steri-Strips were applied and to be removed in two weeks, she was fitted with a compression sock, she had a future appointment with the amputee clinic scheduled on 7/18/24, and further follow-up with orthopedic surgery was to be as needed. R5's Incident Note progress note by licensed practical nurse (LPN)-C dated 7/9/24 at 5:49 p.m., indicated therapy yelled for help and we discovered res[ident] lying face down on her floor and her wheel chair was lying beside her she was trying to reach for something in her drawer she said, we asked her where she hurt and if she hit her head, she said no to head and her stump was hurting and it was also bleeding the bp [blood pressure] machine was not working so we got her up with Hoyer [type of mechanical lift] and then we took her vs [vital signs] 174/70 [blood pressure] p [pulse/heart rate] 75. The corresponding Incident Report #1758, added the injury was located on front left lower leg and was described as a laceration. The report did not include further assessment of the laceration. R5's record did not include a comprehensive assessment of the injury to the residual limb that was identified in the Incident Note and Incident report dated 7/9/24. An SBAR [Situation, Background, Assessment, and Recommendation-physician communication form] progress note by LPN-C dated 7/9/24 at 5:55 p.m., included right hip abrasion and end of stump bleeding but did not include further assessment of the wound. R5's progress note dated 7/10/24, indicated R5 refused her shower that evening, she had one on Saturday. It did not include assessment of R5's skin or identify the wound on R5's right residual limb. R5's FOCUS progress note dated 7/10/24, indicated the reason for review was 7/9 17:10 [5:10 p.m.] unwitnessed fall in room and the skin and wounds section noted surgical incision with routine healing. It did not identify the recent alteration in R5's right residual limb wound or include assessment of the wound. R5's Post Fall assessment dated [DATE], noted the presence of leg pain but did not identify or include assessment of the wound on R5's right residual limb. R5'sWeekly Skin Check dated 7/11/24, noted an other type skin alteration on the front right knee 8 cm long with old blood stain, marked no new skin alterations identified, and the summary included no skin issues noted except old blood stain from recent fall per resident. It did not include further assessment of the wound on R5's right residual limb. R5's Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's provider note dated 7/12/24, indicated R5 was seen by the primary care provider team at the facility and did not indicate R5 had a recent fall or had experienced injury and bleeding at the incision site of her right residual limb. The physical exam noted skin is warm and dry and right lower leg: no edema. The physician note did not identify the appearance of the incision. R5's Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's second Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's Weekly Skin Check dated 7/18/24, noted R5 had a surgical incision on the front of her right lower leg and the summary indicated on the right leg, the removed one when she fell out of wheel chair she landed on her stump and broke it open, she still has an open area that we are now dreeing [sic], also coccyx area has small open area. The measurements section of the skin alteration charting for the wound on R5's residual limb was blank. No further assessment of the wound was included. R5's progress note dated 7/18/24, indicated she had a rbka [right BKA], right now it has an open spot due to fall that we are dressing, the cant fir [sic, they can't fit] the prosthetic until the wound has healed. It did not include further assessment of the wound on R5's right residual limb. Review of R5's Treatment Administration Record (TAR) for dates the month of July 2024, included a treatment ordered 6/26/24 and discontinued 7/23/24 directing staff to monitor for signs or symptoms of bleeding/bruising. Notify provider of any changes every shift. The order was scheduled to be completed on day shift, evening shift, and overnight shifts and charted with a check mark indicating completion on all shifts from 7/9/24 through 7/18/24. R5's physician visit note from MD-B dated 7/18/24, indicated R5 was seen in a clinic for physical medicine and rehabilitation follow-up. The note included unfortunately about a week ago she tells me she fell out of her wheelchair. She was not sure how she fell but she did land directly on her right residual limb and notice bleeding soon after . upon removal of her shrinker sock [compression sock over residual limb site] she had a gauze dressing and Steri-Strips still in place. The Steri-Strips had blood on them. Upon removal of the Steri-Strips there was a superficial dehiscence present with subcutaneous fat visible in the wound bed .unfortunately 1 week ago she slipped out of her wheelchair on her residual limb and has now suffered a superficial dehiscence of her residual limb . I called [MD-A's] service and discuss[ed] the case with them. They may want to see her back in the cast room for further evaluation given that her incision is now dehisced. I will follow the patient closely along with orthopedics and once she was [sic, is] healed have her seen back in the amputee clinic for prosthetic prescription. R5's progress note dated 7/19/24, indicated Resident out to cast room for appointment, cast room had called facility last night and stated resident would be a direct admit following appointment. R5's hospital records included an orthopedic surgery physician note dated 7/19/24, which noted Her [R5's] recovery from her right transtibial amputation was uneventful until this past week when she reportedly fell in her nursing home and developed an area of dehiscence distally over her tibia. She had a follow up appointment with the PM&R [physical medicine and rehabilitation] team yesterday, at which point we were contacted given concern for this dehiscence. Today in the cast room, she was examined and the decision was made to admit her directly to the hospital for right transtibial revision amputation on 07/21/2024. R5's hospital Discharge Planning assessment dated [DATE], included Patient has been residing at [facility] working on rehabilitation. Patient experienced a fall after a PT [physical therapy] session in which she stated she 'saw a lot of blood.' Patient stated she inquired about the status of her leg but was re-assured many times by staff at [facility] that it was 'fine' and 'not to worry about it.' Patient returned for a follow-up outpatient visit and was informed her wound had dehisced and required surgical intervention . The patient stated her current admission could have been prevented had she not had a fall. R5's hospital physician consult note by infectious disease dated 7/21/24, included Patient was initiate on empiric vancomycin and cefepime [intravenous antibiotics] prior to surgery. Patient was [is] currently status post revision and closure of dehisced wound following trauma to right BKA incision. Intraoperative cultures are currently in process. Given the superficial wound as well as source control with debridement, it is reasonable to continue empiric antibiotics for an additional 5 days. Would recommend p.o. [oral] Augmentin and doxycycline to complete course. R5's hospital physician progress note by the orthopedic surgery team dated 7/25/24, included [R5] underwent revision closure of the right leg wound on 7/21/24. The aftercare plan section included nonweightbearing right lower extremity until the wound has healed [and] the residual limb is ready for prosthetic fabrication (typically 6-7 weeks in this situation) . Wound care: incision VAC . Additionally, given the high risk of impaired wound healing, we will recommend extended negative pressure wound therapy to support the 9 cm x 7 mm [millimeter] x 5 mm wound during the first six postoperative weeks and perhaps longer depending on her clinical course . Orders have been placed for three cast room visits. Next vac change on Wednesday 7/31 . She will be seen again on Wednesday 8/7/24 to change the incisional VAC sponge (order placed). We anticipate retaining the sutures for a minimum of four weeks. R5's hospital physician consult note by MD-B dated 7/25/24, included We discussed the healing timeline after revision surgery. I will place an order for follow up in the amputee clinic in 6 weeks. The amputee service will continue to follow her in the hospital. In an interview on 7/25/24 at 3:20 p.m., hospital social worker (SW)-A stated R5 was still in the hospital and would discharge tomorrow, 7/26/24. In an interview on 7/29/24 at 9:12 a.m., MD-B stated he saw R5 at an appointment on 7/18/24 and the purpose of the appointment was to see her and prescribe a prosthesis for her residual limb. R5 had seen orthopedic surgery with MD-A on 7/5/24 and was cleared to get prosthetic fitting after her appointment with MD-B, and MD-B was expecting her residual limb to be healed on 7/18/24 and to begin the prosthetic fitting process. MD-B stated when he saw R5, he noted dried blood on her Steri-Strips and shrinker sock, removed them both and noted her wound was open and dehisced about two to three inches which hadn't been the case at the visit with MD-A on 7/5/24. MD-B stated R5 reported she fell about a week prior and landed on her residual limb and saw bleeding immediately that got on the floor but told him that her limb wasn't really looked at. MD-B stated based on the incision now being an open wound, he contacted orthopedic surgery and R1 was admitted the next day for revision surgery; since the wound was now open it needed to be surgically closed to avoid infection and to improve healing time of the wound. MD-A was not planning revision surgery when he saw her on July 5th as the incision had been completely closed. MD-B stated he was not aware prior to seeing R5 on 7/18/24 that she had fallen and injured her residual limb which had been bleeding and he did not see any evidence that MD-A was notified as he was the one who alerted MD-A. MD-B stated the medical recommendation would be if trauma occurs to a residual limb during the healing process and bleeding is seen the medical teams be alerted for further evaluation. Normally this far after surgery we would not expect bleeding from a residual limb, she was already six weeks past surgery. MD-B stated MD-A had to perform a revision surgery on R5's residual limb and it does delay the time healing, now we have to reset the clock to get her prosthesis and certainly there is going to be heightened emotional impact. MD-B thought R1 was understandably quite disappointed; R1 told him that. MD-B also noted that intraoperative cultures (soft tissue samples taken from the wound) returned positive for a bacterium and the orthopedic surgery team consulted with the infectious disease team who prescribed two antibiotics for treatment. In an interview on 7/30/24 at 12:24 p.m., R5 stated she had to have a second surgery after she fell and hit her residual limb. She stated staff did not seem too concerned about it the bleeding even though R5 told the nurse it's bleeding quite bit. The nurse responded oh, it's not that bad even though R5 told the nurse there was blood on the floor, to which the nurse responded we'll just clean it up later. R5 stated to her knowledge it wasn't ever checked again. R5 exclaimed thank god I had an appointment at the [physical medicine and rehabilitation clinic] already, I saw [MD-B]. R5 indicated MD-B contacted her surgeon, MD-A, who decided she needed to have another surgery and had her admitted to the hospital. R5 stated I could already be in my prosthetic if this hadn't happened and I'm angry. R5 explained it had already been a long healing process and has impacted her a lot. It has been really hard and very emotional. The wound delayed her from getting her prosthesis by maybe four weeks. It's not something I planned on at [AGE] years old, you know, and now I'm in another [rehabilitation] facility. R5 was noted to be tearful and emotional throughout the interview. In an interview on 7/29/24 at 11:00 a.m., LPN-C stated she was working when R5 fell and responded to the situation along with clinical manager (CM)-A. LPN-C stated she remembered seeing a small amount of blood coming from R5's stump, she removed the compression sock and there was blood coming from in-between the Steri-Strips over the incision site. LPN-C stated she cleaned the area with some gauze and put gauze over the Steri-Strips and the bleeding stopped. LPN-C noted that at the time of the fall she assessed the wound dressing, noted the Steri-Strips were intact and that there was blood and would document that in the risk management Incident Report in the injuries section. LPN-C stated she worked the next day and did not recall seeing any further bleeding from the site, the care for the site was just putting the compression sock on and off and we weren't doing anything else with it, just monitoring it and checking it. In an interview on 7/29/24 at 11:36 a.m., CM-A stated R5 had a fall on 7/9/24 and he responded because staff said there was bleeding. CM-A stated he assessed the site and there was bleeding obviously, but cleaning it up and applying pressure resolved the bleeding. There were no visible signs of opening or dehiscence, it sill looked intact, but obviously it was not because it was bleeding, but it wasn't a gaping wound. CM-A stated he did not see the wound after that but should have put an order in for nurses to monitor the wound and change the dressing and check up on it. CM-A had instructed LPN-C of what to include in the incident report. CM-A noted for a fall with injury there is a need for continued intervention from nurses including daily assessment of the site of the injury, should be looked at probably every shift. Nursing would monitor for new or worsening concerns and reporting those concerns to the provider groups if necessary. CM-A stated the findings should be documented in resident record. CM-A noted R5's EHR contained four Post Fall Assessments, dated 7/10/24, 7/12/24, and two on 7/14/24, and confirmed the first assessment should have been completed eight hours after the fall. CM-A stated he expected R5's surgical team to have been notified of the fall with injury to residual limb and the surgical team was not notified to his knowledge. He confirmed the Weekly Skin Check dated 7/18/24 did not include comprehensive assessment of the wound. Facility policy titled Post Fall Policy dated 10/13/23, included Monitoring and Re-evaluation: Document on resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status. o Staff will have increased awareness that the resident has recently fallen and report any changes in function, increased pain, and changes in cognition to the nurse for further evaluation . Update MD/NP with evidence of acute changes after a fall. Facility policy titled Pressure Injury Prevention and Wound Care Management dated 3/4/24, included Skin impairments, including pressure injuries, non-pressure injury wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, using the PCC Weekly Wound Assessment. Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining . Daily, the clinicians responsible for caring for the Resident will assess the status of the dressing if present, (intact, soiled, leaking), and evaluate for complications such as infection and/or uncontrolled pain .Nursing staff should update the attending physician immediately of wounds that have developed complications and/or not healing as anticipated.

Based on observation, interview and document review, the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented; and failed to comprehensively reassess and, if needed, develop interventions after a change (i.e., increase) in pressure ulcer risk for 1 of 2 residents (R11) reviewed for pressure ulcer care. This resulted in actual harm for R11 who developed an avoidable stage III (i.e., full-thickness tissue loss) pressure injury on their heel. Findings include: The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 2/2023, identified definitions for pressure ulcer care and treatment. This included, Avoidable, being outlined as, . the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. In addition, the guidance provided several stages of injury definition which included, Stage 3 Pressure Ulcer: Full-thickness skin loss . subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . depth of tissue damage varies by anatomical location . Undermining and tunneling may occur . On 3/26/24 at 8:31 a.m., R11 was observed lying in bed while in his room. R11 had a standard hospital-style bed with a non-air mattress in place. R11 had a light-green colored Prevalon boot (used to relieve pressure on the heel) on their left foot, however, under the right foot the linens were stained with visible, dark red-colored drainage. Shortly after, licensed practical nurse (LPN)-A entered the room and stated they had to complete a dressing change to R11's right heel. R11's foot was elevated from the mattress using a folded-over pillow and R11's heel was observed which contained a circular, dark-red area with a visible, black-colored center which appeared like a scab-type texture. LPN-A stated, I think it's pressure [related] when asked about the area and expressed the area, just on physical appearance, was approximately 2.5 centimeters (cm) by 1.5 cm in size when asked. R11 stated the area had developed over time to his recall but was unsure how long it had been present adding it had been a couple weeks or more he believed. LPN-A stated this was my first time seeing the wound so they could not comment on if it was healing or not. LPN-A then completed a dressing change to the area which involved cleansing the site with wound cleanser, patting it dry using gauze, applying a Santyl ointment (used to debride the area) to the site and covering it with a silicone-foam dressing. R11's admission Minimum Data Set (MDS), dated [DATE], identified R11 admitted to the care center from the community, had intact cognition, and demonstrated no behavioral symptoms (i.e., rejection of care, physical behaviors). The MDS outlined R11 had multiple medical conditions including anemia, heart failure, and thyroid disorder; and he consumed anticoagulant (i.e., blood thinners) and diuretic medications. The MDS identified R11 was at risk for pressure ulcer formation, however, had no current pressure ulcers present upon admission; and he used pressure-reducing devices for the chair and bed, however, the space to record a formal turning and/or repositioning program was left unchecked. The completed MDS' corresponding Pressure Ulcer/Injury Care Area Assessment (CAA), identified R11 was at risk for pressure ulcer development but had . no skin concerns at this time. The CAA outlined a care plan would be developed to minimize the risk of development and listed dictation reading, Risk for impaired skin integrity care plan was developed with the overall goal for skin to remain intact without breakdown and be free from pressure related injury . interventions were added for Braden scale score and according to Braden scale flow chart. Additional interventions will be added as needed to maintain skin integrity . will continue to complete Braden scale assessments as scheduled and [as needed]. Staff will monitor for changes in physical and medical conditions and report changes . Care plan will be reviewed and updated as needed. R11's Admission Screener - V5, dated 3/1/24, identified multiple sections to be reviewed upon admission to the care center including communication, vital signs, skin condition, oral status, sleep patterns, and elimination systems. The completed screener identified R11 admitted to the care center from the community (i.e., home) and had an admitting diagnosis listed, Neurocognitive disorder with Lewy Bodies. A section labeled, C. Skin Observation, identified R11's skin as normal coloration, warm to touch, and dry with a subsection labeled, Skin Integrity, listing no skin alterations were identified. A subsequent section labeled, Details/Comments, was left blank and no dictation was present. The section was signed as completed by licensed practical nurse unit manager (LPN)-B on 3/1/24. However, the completed screener lacked information on how much, if any, physical assistance R11 required with bed mobility, the medications used by R11 which could affect their skin condition and risk for ulcer development (i.e., steroids, anticoagulants), or if R11 had any previous history of pressure ulcer injuries. R11's corresponding Braden Scale For Predicting Pressure Sore Risk, dated 3/1/24, identified R11 had slightly limited sensory perception, had occasionally moist skin, walked occasionally (i.e., short distances), had slightly limited mobility (i.e., frequent though slight changes in body position), and a potential problem with friction or shearing. The scale scored R11 at a 17 which outlined, Mild Risk. R11's initial Baseline Care Plan/Evaluation - V13, signed 3/1/24, identified multiple sections had been evaluated including communication, allergies, functional status, and skin condition. The care plan outlined R11 had an activities of daily living (ADL) self-care deficit due to neurocognitive deficit and heart failure, and directed R11 needed assistance of one to complete personal hygiene, toileting, dressing, transfers and bed mobility. The care plan outlined R11 consumed diuretic and anticoagulant medications, and he was not diabetic. The care plan included a section labeled, 4. Skin Risk, which identified R11 had no current skin issues; however, a subsequent subsection labeled, 4d. Risk for skin breakdown, outlined R11 was determined to be at risk for an alteration in skin integrity and listed a goal which read, I will be free from skin breakdown through the review date. The care plan listed several interventions to help R11 meet this goal which included floating the heels while in bed, keeping the skin clean/dry, and, Turn and reposition me at least every 2 hours, per my particular tolerance and schedule. In addition, R11's corresponding comprehensive skin care plan, revised last 3/12/24, identified R11 was at risk for an alteration in skin integrity related to incontinence and listed a goal which read, . will be free from skin breakdown through the review date. The care plan listed several interventions to help R11 meet this goal including floating his heels while in bed, positioning his body to protect bony prominences, using a pressure-relieving cushion in his wheelchair, and, Turn and reposition me at least every 2 hours, per my particular tolerance and schedule. R11's subsequent Weekly Skin Check - V3, dated 3/10/24, identified R11 had bilateral edema present but added, No new skin issues. The form provided a human figure in anatomical position and corresponding spaced to record what, if any, skin wounds or irregularities were present. However, this was left blank and no skin issues were identified. However, R11's subsequent Braden Scale For Predicting Pressure Sore Risk, dated 3/15/24, identified R11 remained with slightly limited sensory perception, but he had declined in other areas and now had very moist skin, was chair-fast (i.e., ability to walk severely limited, cannot bear own weight and must be assisted into chair or wheelchair), and had very limited mobility (i.e., unable to make frequent or significant changes independently). The new completed scale scored R11 at 13 which outlined, Moderate Risk. R11's medical record was reviewed and lacked evidence R11 had been comprehensively reassessed for their skin risk, including with any tissue tolerance testing, to determine what, if any, new or modified interventions were needed to reduce the risk of pressure ulcer development despite this increased risk score (via the Braden). Further, the record lacked evidence what, if any, education had been completed with R11 pertaining to repositioning or the importance of such. R11's next completed Weekly Skin Check - V3, dated 3/17/24, identified R11 now had a skin impairment on their right heel which the check recorded as, Pressure Ulcer. The ulcer had recorded measurements of 4.5 (cm) by 3.5 cm with no depth and listed the wound as a stage I ulcer (i.e., non-blanchable redness over a localized area). This was recorded as a new skin alteration for R11 and included dictation, Measurement on RLE by the heel . cleaned with wound cleanser and foam border applied. No other skin concern noted. The completed form lacked any further information on what, if any, actions were immediately taken to re-evaluate R11's risk for ulcer development or what, if any, modifications to the care plan would be made to promote healing and prevent additional ulcers. R11's subsequent progress note, dated 3/19/24 (two days later), identified a Skin/Wound Note was completed which outlined, . has a newly noted pressure sore on right heel, it measures .2 cm deep, 4.3 cm long, and 3.4 cm wide, it is a stage 2 pressure sore, applied calcium alginate and a mepilex border and also will float heels while in. bed and when in recliner, also a mepi border on left heel for protectin [sic] it is soft. A corresponding Skin & Wound Evaluation V7.0, dated 3/19/24, identified the area on R11's heel as, 15. Pressure, and listed it as, 2. Stage 2: Partial-thickness skin loss with exposed dermis. The wound was recorded as in-house acquired, being newly onset, and measured at 4.3 cm X 3.4 cm X 0.2 cm with no tunneling or undermining evident. The wound bed was listed as having 20% granulation tissue (beefy, red-colored tissue) and 80% slough (dead tissue separating from living tissue) with moderate serous (clear to yellow fluid) drainage present. The wound was listed as, Healable, and a dressing option was selected with dictation present, Resident has new pressure ulcer to right heel . added to VOHRA wound rounds. The completed evaluation was signed by LPN-B on 3/19/24. R11's VOHRA Initial Wound Evaluation & Management Summary, dated 3/22/24, was completed via medical doctor (MD)-A and identified R11 as an [AGE] year old male with services being rendered (i.e., provided) at the care center. R11's past medical history and medication use was outlined, and the note directed to a completed Focused Wound Exam which was attached. The Focused Wound Exam (Site 1) identified a determination, STAGE 3 PRESSURE WOUND OF THE RIGHT HEEL FULL THICKNESS, and listed an etiology which read, Pressure, along with a duration listed, > [over] 7 days. The wound measurements were listed as 2.1 X 4 X 0.2 (cm) with moderate purulent drainage (thick, milky drainage which may indicate infection) and the wound bed having 80% slough tissue present. A treatment plan was outlined which included a review or R11's care plan and corresponding recommendations which read, Float heels in bed; Off-load wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours if able; Prevalon boots: On in am and remove at bedtime; Obtain consent from POA [power of attorney] for debridement. Further, the note outlined R11's dementia as a factor which could complicate wound healing but listed, The best medical estimate of the time required for this wound to heal with continued physician evaluation is 98 days . estimate is made with an 80% degree of certainty. When interviewed on 3/26/24 at 1:09 p.m., nursing assistant (NA)-A stated they had worked with R11 multiple times since they admitted to the care center and described (R11) as needing assistance of one to complete most ADLs. NA-A stated they were aware R11 had a wound on their right heel and explained they had noticed it when working with R11 adding just that morning (3/26/24) it had bled onto R11's linens so they alerted the nurse who dealt with it. NA-A stated they believed R11 had admitted to the care center with the wound as it was a really big wound and not just an overnight wound. NA-A stated the wound seemed to be from pressure on it [heel] for a long time and expressed, as a result, the staff were now using the Prevalon boots for off-loading and helping him reposition. NA-A explained staff were not helping R11 to reposition on a scheduled basis, nor were they floating their heels using the Prevalon boots or other devices prior to R11 having the wound to their recall as they had not been directed to do so. On 3/26/24 at 1:28 p.m., R11 was observed seated in their recliner chair with their family member (FM)-A present. FM-A was interviewed and explained R11 admitted to the care center due to themselves (FM-A) having a planned surgery soon and R11 needing respite care which may end-up being more long-term. FM-A verified R11 had no skin issues to their knowledge when he admitted to the care center and expressed the heel ulcer had developed onsite adding, Not to point fingers. FM-A stated now, since the wound developed, the staff were repositioning him and using Prevalon boots to off-load the heels but added, They weren't doing that before [the wound]. FM-A stated they were unable to recall the exact date R11 developed the wound but added they had been updated about it shortly after they discovered it. Further, FM-A stated R11 did wear shoes when he admitted to the care center but they were old shoes which R11 had for a long time prior without issue. When interviewed on 3/26/24 at 3:50 p.m., NA-B explained they had worked with R11 before and described him needing more physical help with mobility when he first admitted compared to now; however, NA-B explained R11 had trouble moving his legs and added doing so, Takes him a long time. NA-B stated R11 was able to somewhat move himself while in bed but added staff have to tell him as he would not do it on his own. NA-B stated R11 was not currently, or ever, on a repositioning program to their recall as he [R11] can do that himself. NA-B stated they were aware R11 had developed a wound on his right heel and expressed staff, including themselves, had not been floating his heels or repositioning him prior to it developing adding aloud, Not before the wound. NA-B stated they were unaware how R11 developed the wound. NA-B explained resident' repositioning was tracked using a paper sheet which was left at the nursing station but added, A lot of days we don't have that sheet. NA-B reviewed the nursing station and was unable to locate it but expressed, had one been there, the staff use it to track repositioning and the nurse then could review it. NA-B reiterated R11 was not on a repositioning program nor having his heels floated while in bed or the chair prior to the wound developing adding, Not that I'm aware of. R11's POC (Point of Care) Response History, printed 3/27/24, identified R11's bed mobility self-performance since 3/7/24, with spaces provided to record the level of assistance R11 needed from the care center staff. A total of 12 episodes were recorded in the five days prior (i.e., 3/13/24 to 3/17/24) to R11 being discovered with a pressure ulcer on his right heel and, of these episodes, seven of them were recorded as R11 needing, EXTENSIVE ASSISTANCE - Resident involved in activity, staff provide weight-bearing support. However, R11's entire medical record was reviewed and lacked any recorded or documented evidence (i.e., task or POC charting) to demonstrate R11 had been repositioned every two hours as directed by the care plan and despite R11 being recorded as needing extensive assistance with bed mobility on multiple occasions prior; nor was any documented evidence during the recertification survey to demonstrate such repositioning had occurred (i.e., tracking sheets). When interviewed on 3/27/24 at 9:37 a.m., registered nurse (RN)-B stated they had worked at the campus for a few months and worked all over on the various units. RN-B verified R11 had a developed pressure ulcer and explained when a resident admitted to the care center, the nurse will do your [their] intake and review them for skin risks in coordination with the therapy department who completed a slip which the aides used to know someone's transfer status and how much help with mobility they needed. These then were placed onto the care plan which was kept on a sheet the aides could keep with them but, upon looking for them at the nurses' station, RN-B stated they were unable to locate one adding they were not sure where such documents were kept. RN-B stated any assessment or comprehensive evaluation, outside of the completed Braden Scale(s), would be the nurse manager' responsibility to complete. RN-B stated some residents who needed more oversight to ensure repositioning was done had an intervention directing such placed on the Treatment Administration Record (TAR) so-as to prompt the nurse, but reiterated this was not done for all residents and rather only for those who needed closer supervision to ensure it was completed. If no such intervention was listed on the TAR, then RN-B explained the expectation was for the NA(s) to follow the care plan and complete repositioning, as needed, and added they should have a sheet to track such repositioning on, to their recall. Further, RN-B stated they had not worked with R11 prior so they were unable to comment on how the wound looked now versus a week (or more) prior, but expressed when staffing levels were short then some tasks, including repositioning, did suffer and not always got completed timely, if at all. R11's TAR, dated 3/2024, listed R11's treatments along with spaces for staff to record their initials if completed or if R11 refused. However, the TAR lacked any interventions or documentation for heel off-loading or repositioning prior to R11 developing the right heel pressure injury on 3/17/24. On 3/27/24 at 10:32 a.m., LPN-B was interviewed and verified they were the campus' wound nurse. LPN-B explained the process for a comprehensive skin assessment included, upon admission, reviewing hospital documentation and doing a skin observation using the admission screener along with a Braden Scale. If an active skin issue was present, then the floor staff were to notify the nurse manager who would ensure appropriate orders were in place. LPN-B explained the Braden Scale was then completed on a weekly basis for one month (i.e., four total) and then monthly moving forward in coordination with the MDS' schedule. When questioned on if any other skin assessments, including a tissue tolerance evaluation, had been completed for R11 upon admission or since, LPN-B responded, Not really. LPN-B explained if a skin issue, like a pressure ulcer, developed after admission, then a new Braden Scale would be completed which could be done by either the floor nurse or the nurse managers. LPN-B reviewed R11 and his medical record, and they verified R11 admitted to the care center with no active wounds present. LPN-B stated R11's mobility, including bed mobility, remained limited as had been for the entirety of his admission adding R11 was, at times, very weak with transfers. LPN-B stated, to their understanding, R11 was able to make repositioning movements himself while in bed with cues and reminders adding, He still is [today]. LPN-B explained R11's care plans, including the baseline and comprehensive, were developed using R11's completed Braden Scale' scores expressing R11's preventative skin care plan had been last revised on 3/12/24 which was before the pressure injury was noted. The interview continued, and LPN-B acknowledged the medical record lacked evidence R11 had received any education on repositioning and expressed aloud, I didn't go through that with him, adding further they were unaware if anyone else had or not. LPN-B stated completed education with repositioning was also most likely not officially documented even if completed. LPN-B explained repositioning was tracked, at times, using a 'task' within the EMR through the NA POC charting; however, upon review this had not been activated for R11 so there was no documentation to provide to demonstrate what, if any, repositioning had actually taken place prior to the pressure injury developing. LPN-B stated there was not a systematic reason when or when not to activate that task within the EMR but verified repositioning should be completed in accordance with the care plan adding, My expectation is they [residents] are repositioned. LPN-B explained R11 developed the wound, per the documentation, on 3/17/24 but they were not notified of the wound until 3/19/24 (two days later). LPN-B stated their expectation was for the staff to notify the on-call nurse immediately of such a wound but, after their investigation, they had determined that did not happen. LPN-B continued and explained the corporate regional nurse had identified the wound on 3/18/24 and, as a result, emailed the director of nursing (DON) and themselves (i.e., LPN-B) about it but neither of them had seen the e-mail adding, We get so many e-mails, they get lost. LPN-B stated they were unaware the aides had not been floating R11's heels or repositioning him, as care planned, prior to the pressure ulcer developing and expressed, I don't understand why they weren't doing it. LPN-B reviewed R11's medical record and verified R11 was not in a terminal condition and had adequate nutritional intake, and they also verified the Prevalon boots were implemented after R11 developed the wound. LPN-B stated they were unaware exactly how R11 developed the pressure injury and explained they had discussed it with MD-A and the nurse practitioner (NP)-A who observed the wound together on 3/22/24, who expressed it could have been a blister which progressed or due to R11's feet being pressed against his recliner chair. LPN-B stated the facility had completed a mock survey a few months prior and skin issues were identified as a potential issue, however, the resulted audits they implemented focused more on persons with active wounds, not preventative interventions, and LPN-B explained the facility' was still reviewing and trying to form a different program to help prevent ulcers. LPN-B stated a UDA [user defined assessment] was made which the interdisciplinary team (IDT) had not yet completed and, from that document and corresponding investigation, they would complete any needed education (i.e., following the care plan, documentation) with staff. Further, LPN-B stated, in hindsight, R11 likely needed more help with bed mobility than LPN-B originally believed (i.e., the documented extensive assist with bed mobility, worsening Braden Scale score) and expressed the developed pressure ulcer possibly could have been avoided had R11 had his heels floated and been repositioned according to the care plan. On 3/27/24 at 12:57 p.m., the director of nursing (DON), regional nurse consultant (RNC)-A and administrator were interviewed, and the DON verified they had reviewed R11's medical record. DON explained upon admission, a resident's skin was checked for any current issues and the staff review any referrals or hospital documentation to determine what, if any, treatments or supplies were needed. DON stated the admission screener was then completed, including with the skin review, and interventions were placed in the baseline care plan, if needed, such as repositioning or heel off-loading adding they felt the screener encompassed and covered all areas for skin risk, such as continence and nutrition, as outlined under the regulatory expectation just possibly not in one single section [i.e., skin]. DON stated the interventions marked in the care plans, including baseline and comprehensive, then pulled to the NA Kardex (a tool used to show what assistance a resident needed) with a symbol (i.e., small 'K') demonstrating such in the EMR. DON verified R11 developed the pressure ulcer after admission to the care center, and they explained a resident' mobility, including when considered for their respective skin risk, was evaluated between nursing and therapy and came from hospital notes, nurse-to-nurse report, and the screener completed upon admission adding those items gave staff a starting point and, if needed, a resident could be downgraded. DON verified R11 was listed as needing assist of one with transfers and bed mobility, and expressed the aides should be recording completed repositioning under the tasks in the POC charting. DON reviewed the completed POC charting and verified R11 was often recorded as needing extensive assistance with bed mobility, and there was no completed charting to demonstrate repositioning or heel off-loading had been completed. DON stated there were no sheets used, to their knowledge, to track repositioning, either. DON explained, since the wound developed, staff were using Prevalon boots and elevating his feet adding they believed those interventions had also been indicated on the baseline care plan. DON stated they would often see R11 in the recliner chair but, in hindsight, did not pay particular attention to the boots [if placed or not]. The interview continued, and DON explained resident' education, including with repositioning and the need thereof, was done as part of the initial screener adding, I don't know that we have a specific place [to document it]. DON stated they had early on talked to FM-A about making sure R11's feet were kept elevated but added, I did not put a note in [about it]. DON verified the medical record lacked evidence any education had been completed with R11 on the need to reposition himself while in bed or the chair. DON explained the skin evaluation process, including upon admission, did not routinely include tissue tolerance evaluation or pressure mapping. The administrator expressed there was an outside company whom, at times, would do it, if needed, for various residents at risk though. DON reviewed R11's completed Braden Scales and verified R11 increased in risk on the 3/15/24 evaluation, adding they felt the reason was due to different nurses' completing the evaluation. However, DON verified there was no other corresponding assessment or evaluation of R11's skin risk at the time to determine what, if any, additional interventions were needed to prevent skin injuries or pressure ulcers adding, I don't see anything in the notes. DON reiterated since the wound had developed, the staff were repositioning R11 and ensuring the heels were off-loaded adding, Now we're doing everything. The administrator explained the UDA process was still pending a full, documented review but reiterated R11's immediate needs and treatment once the wound developed had been completed. The administrator expressed they were aware of ongoing issues with staff not always getting cares or repositioning completed and were taking various steps to better ensure cares were getting completed including a planned education with the aides in the near-future. Further, DON explained they were aware MD-A and NP-A had observed R11's pressure injury and expressed they recalled NP-A thinking the wound was potentially unavoidable due to R11's inadvertent non-compliance (i.e., dementia and unable to full understand interventions) and himself being evaluated, but not started or approved, for hospice care prior to admission. However, DON verified R11 was not considered terminal or actively dying at the time of survey or since admission. On 3/27/24 at 2:00 p.m., NP-A was interviewed and verified they helped oversee R11's medical care while at the care center. NP-A stated, to their recall, R11 did not have any skin issues or pressure ulcers upon admission to the care center in early March 2024 adding, None that I know of. NP-A stated if a wound developed, they would then be notified by the nurse manager and added to a weekly wound rounding until it was resolved. NP-A explained they had been notified last week of R11 developing a wound on his right heel and, as a result, they observed the wound with MD-A and LPN-B on 3/22/24 (see VOHRA note). NP-A stated herself and MD-A felt the wound was likely pressure from not off loading, and they had a discussion with the care center to ensure an appropriate sized bed was in place due to R11's height. NP-A reviewed the EPIC (i.e., hospital) charting and stated R11's last albumin (lab value to help determine nutritional status) was in October 2023 and, at that time, was within normal range. NP-A stated they felt the pressure ulcer could have been preventable adding, I think it's healable. NP-A stated R11 had no personal history of wounds or pressure ulcers and expressed, I'm very optimistic that it will heal, adding further, It probably shouldn't have [happened]. A facility' provided Pressure Injury Prevention and Wound Care Management policy, dated 3/2024, identified a purpose which included, To identify factors that placed the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. The policy outlined a resident who admitted without a pressure injury would not develop such injury unless clinically unavoidable, and listed a procedure which included completion of a comprehensive assessment to identify risk factors and, based on such assessment, be addressed using the RAI process and care plan. The policy continued, Residents at risk for the development of a pressure injury will have their individualized care interventions and approaches documented in the resident care plan. However, the policy lacked information or direction on how repositioning would be documented, if at all, within the medical record.

Based on observation, interview, and document review, the facility failed to use a gait belt during transfer and ensure facility shower chairs were maintained for safety for 1 of 3 residents (R1) reviewed for falls. The facility's failures resulted in actual harm when R1 sustained a fall while being transferred incorrectly, and received a severe skin laceration after her fall when the shower chair seat fell on to her. R1 required transfer to the hospital and 16 stitches. Findings include: A facility Incident Report dated 12/21/22, at 7:53 a.m. indicated on 12/20/22, at 6:45 p.m. nursing assistant (NA)-A reported to licensed practical nurse (LPN)-C that R1 had fallen in shower room and needed assistance. R1 had completed her shower and was independently transferring from the shower chair to the wheelchair when R1's legs gave out, and NA-A assisted R1 to the floor. During the process of assisting R1 to the floor, the shower chair flipped over and landed on top of R1. When NA-B arrived to assist, he lifted the shower chair off of R1 and the seat cushion detached and fell on to R1's right lower extremity (RLE). A sharp metal piece created a serious skin tear and laceration that appeared quite deep. Due to the large laceration and profuse bleeding, it was deemed necessary to transfer R1 to the emergency department (ED). R1's Face Sheet dated 12/13/22 indicated R1 was admitted to the facility on [DATE], for short term rehabilitation. R1's diagnoses included abnormalities of gait and mobility, severe morbid obesity, and metabolic encephalopathy (delirium: confused thinking and disrupted attention). R1's admission Minimum Data Set (MDS) dated [DATE], lacked identification of R1's cognitive status. The MDS indicated R1 required extensive assistance of one staff member with transferring and toileting. R1's care plan dated 12/13/22, indicated R1 had limited physical mobility related to metabolic encephalopathy, obesity, and functional decline. The care plan identified R1 required extensive assist of one staff member for transfers, required a gait belt, and was at moderate risk for falls. Further identified R1 was at risk for skin/wound infection related to large laceration of right lower extremity (RLE) requiring suture repair and antibiotics. R1's late entry FOCUS Note (interdisciplinary meeting note) dated 12/20/2022, at 6:45 p.m. identified the reason for the Interdisciplinary FOCUS Review was R1 had a fall and subsequent skin tear to the right lower shin on 12/20/22, at 6:45 p.m. R1's skin tear required 16 stitches. The note identified R1 required extensive assistance from one staff. New interventions: all staff educated to not complete transfers in shower room. During an interview on 01/18/23, at 10:45 a.m. NA-A stated she was with R1 when she had the fall. NA-A explained she had finished R1's shower, wheeled her over to the dry area just past the half-wall. She dried R1 off, applied gripper socks, and wiped the floor with a blanket. NA-A assured the wheelchair brakes were locked, held the back of the shower chair and directed R1 to self-transfer to the wheelchair. NA-A stated she had previously directed R1 to independently walk to her bathroom in her room and did not place a gait belt for support. NA-A stated she had not looked in the care plan or medical record to see how R1 transferred, and she was not aware R1 required a gait belt. NA-A stated she was an agency nursing assistant and did not know the residents well. NA-A stated as R1 was standing, the chair started sliding backwards. This caused R1 to sit back down hard toward the front of chair. Because she was not all the way back, she started sliding off the front of the chair. NA-A reported R1 was a large lady, she could not keep R1 from falling off the shower chair, but she assisted R1 to the floor. The shower chair then tipped over and landed on top of R1. When the shower chair was picked up and moved by NA-B, the seat fell off, and a sharp metal piece cut R1's RLE. NA-A stated again she had not put a gait belt on R1 to assist with transfers because she did not know R1 needed a gait belt. NA-A had access to the care plan but did not review it before transferring R1. Attempts to contact NA-B on 01/18/23, at 1:06 p.m. and 01/24/23, at 9:22 a.m. were not successful and no return telephone call was received. On 01/22/23, at 7:56 a.m. the facility provided a picture of the broken shower chair and the bottom of the seat cushion. There was approximately eight jagged holes on the bottom of the seat cushion where the mounting brackets had been. The metal brackets that connected the seat to the PVC pipe frame were not pictured. During an observation on 1/18/23, at 12:00 p.m. bath chairs #47 and #101 observed on the floor in service (but not in use at the time), did not have weight stickers, and labels were not legible. During an interview on 1/18/23, at 12:38 p.m. the director of maintenance director (DM)-A stated the facility utilizes the TELS Building Management software system to schedule and track preventive maintenance tasks. DM-A stated the facility performed monthly visual inspections of the shower chairs. DM-A then logged into the TELS system, and stated monthly shower chair inspections were not included as a task. DM-A stated he would have to enter shower chair inspections as a monthly task, but does not have any documentation of these visual inspections. During an interview on 1/17/23, at 3:05 p.m. family member (FM)-A confirmed R1 was hospitalized and receiving antibiotics. FM-A stated R1 was very confused and did not remember she was in a nursing home when she fell . R1 stated she was at home when she fell . FM-A further stated with R1's confusion, cognitive communication deficit, and being a poor historian, an interview with R1 would not be credible. During an interview on 1/18/23, at 8:50 a.m. DM-A was re-interviewed and stated he had looked at the shower chair after the incident. DM-A stated it looked like there had been rust on the metal mounting brackets of the chair seat. DM-A further stated when R1 fell on to the shower chair, due to her excessive weight, she broke the mounting brackets. DM-A stated the facility did not have manufacturer's user manual due to the shower chair estimated to be greater than ten years old. DM-A stated due to the age of the shower chair and the inability to purchase replacement mounting brackets, the shower chair was thrown away. A new replacement shower chair was just purchased. DM-A identified after the accident, he looked at the other three facility shower chairs but two of the chairs in service did not identify weight restrictions. Due to the age of the two shower chairs, DM-A stated he was not able to identify the name brand or model number to identify what the maintenance schedule was per the manufacturer for these chairs. DM-A identified the facility uses the TELS Preventative Maintenance System for all equipment in the facility; no alerts for repair nor prevented maintenance had been recorded in the system for the shower chair involved in the incident. During an interview on 1/18/23, at 9:54 a.m. the administrator stated an awareness of the R1's fall. The administrator stated NA-A should have used a gait belt for R1's transfers. During an interview on 1/18/23, at 2:30 p.m. LPN-F stated there were no issues with the shower chair prior to R1's fall. LPN-F stated if there was a problem with the shower chair or any equipment concern, the equipment would be removed from service and taken to DM-A's office. LPN-F stated there were other shower chairs in the facility and the nursing assistants would move them around as they needed to so residents received their shower. During an interview on 1/18/23, at 11:10 a.m. the director of nursing (DON) stated it was reported to her that R1 stood up and fell back to the shower chair and began to fall to the floor. NA-A assisted R1 to the floor but R1 did not sustain an injury from the fall. When NA-B picked up the shower chair the cushion fell off and struck R1's RLE and tore her leg open. The DON stated NA-A did not have a gait belt placed and should have. The DON stated R1 was assessed to require extensive assistants to transfer which required a gait belt to be used. DON stated NA-A knew she should have used a gait but did not; NA-A also had access to care plan which directed the proper equipment for transfers. After the accident, the DON did not provide re-education to all staff on following care plans and gait belt usage, however, informed all staff the new policy of not transferring residents in the shower rooms due to small size and slip hazard. The facility policy Gait-Transfer Belt Policy & Procedure dated 8/1/15, directed staff to use a transfer/gait belt with transfers.

Based on observation, interview and document review, the facility failed to complete a comprehensive pressure ulcer assessment, implement care plan interventions, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure resulted in harm to R6 who developed a stage 3 pressure ulcer after admission. Findings include: Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] (redness) of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [CONDITION(S)], intertriginous [CONDITION(S)] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI (pressure ulcer/pressure injury). Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Skin Tears: acute wounds that result from a mechanical force such as shearing or friction or a traumatic injury such as from a fall. R6's face sheet dated 11/8/22, identified R6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's significant change minimum data set (MDS) dated [DATE], indicated R6 was severely cognitively impaired, required extensive 1-2 person assist with most cares. MDS indicated R6 was total dependence on staff for hygiene and toileting, and was always incontinent of bowel and bladder. Further the MDS identified R6 was at risk for pressure ulcers, did not have pressure ulcers and/or any skin impairments. Skin treatments included pressure reducing cushions for chair and bed. No other interventions were identified. R6's progress note dated 10/14/22 indicated the physician was notified of the following: R6 had a new sacral injury that measured 1.3 cm x 1.0 cm., 100% epithelial tissue. Skin surrounding the wound was reddened, fragile with raised edges. Photo was obtained for monitoring. R6's MDS note dated 10/18/22, at 11:28 a.m., indicated R6 was completely incontinent of bowel and bladder, was currently checked and changed in bed. R2 had a stage 2 on his coccyx that had been noted on 10/14/22. R6's skin integrity care plan focus dated 10/27/22, identified R6 had alteration in skin integrity related to impaired mobility and bowel and bladder incontinence. Associated interventions dated 10/14/22 included: -Complete dressing changes as ordered -Position my body with pillows/support devices, and protect bony prominence's -Turn and reposition every two hours per particular tolerance and schedule. On 10/18/22, intervention identified R6 had a ulcer to coccyx (stage not identified) see treatment administration record. On 10/24/22 intervention was air mattress to be added. R6 skin/wound note dated 10/27/22, at 4:32 p.m., Identified R6 had a skin tear to left buttock caused from full body mechanical lift sling removal. New interventions included put an air mattress on R6's bed. The note did not include measurements and/or further assessment of the skin impairment. Corresponding photo dated 10/27/22 identified a pink area on sacral/coccyx area which was identified as resolved. Left buttock had an open wound approximately size of quarter. The wound bed was deep red in color with no skin flap visible in the photo. The skin surrounding the wound was excoriated or consistent with moisture associated skin damage. R6's record lacked a comprehensive wound assessment of the skin impairment identified as a skin tear. Additionally R6's care plan was not revised to reflect the resolution of the stage 2 pressure ulcer. An additional skin integrity focus was added to the care plan that identified the left buttock skin tear. R6's care plan included additional skin integrity care plan focus dated 10/27/22, identified R6 had a skin tear to left buttock. Associated interventions dated 10/27/22 included: -Air mattress -Toileting program initiated : check change approximately every two hours during wake hours and every 3 hours at night. -Turn and repositioning approximately every 2 hours when in bed, approximately every hour when in wheelchair. -Administer treatments as ordered. -Assess/monitor the alteration in skin integrity and document status weekly. -11/3/22 intervention; new dressing change orders received. R6's wound evaluation dated 11/3/22 identified R6 had a new skin tear to left buttock that measured 2.7 cm x 3.0 cm. with attached edges that appeared flush. Wound bed had slough (dead skin), 10% granulation tissue present (new connective tissue that forms on wound surfaces during healing process) and was pink or red. Surrounding wound was red, and fragile. Further identified wound as improving and healable. Interventions used included: mattress with pump, turning and repositioning program, and moisture barrier and control. R6's left buttock wound order dated 11/3/22, directed to clean wound with cleanser, pat dry, apply Medi honey (honey fiber) to wound bed. Then apply Duoderm to buttocks skin tear. The dressing was to be changed on the evening shift on Mondays and Fridays or sooner if it falls off or was soiled. During an observation on 11/8/22, at 8:27 a.m. R6 laid in his bed on his back. R6's mattress was not an air mattress in accordance with the care plan dated 10/27/22 or the skin evaluation dated 11/3/22. At 10:28 a.m. unknown staff members assisted R6 to his wheelchair. During a continuous observation on 11/8/22, that began at 2:02 p.m. and ended at 3:17 p.m. R6 sat in his wheelchair without offers/attempts to reposition/offload R6 in accordance with the care plan. -At 2:02 p.m. R6 sat in his wheelchair, self-propelling down the hallway. -At 2:33 p.m. R6 continued to sit in his wheelchair in the same position in the sunroom at a table with a puzzle. -At 2:55 p.m. administrator pushed R6 back to his room. -At 2:57 p.m. R6 self-propelled his wheelchair out of his room and an unidentified staff member pushed R6 back to the sunroom. -At 3:12 p.m. R6 sat at the puzzle table and unidentified staff member put his glasses on. -From 3:15 p.m. to 3:17 p.m. R6 observed self-propelling around tables in the sunroom. During an interview on 11/8/22, at 3:24 p.m. NA-A indicated after R6 was up in his chair at 10:30, she had repositioned R6 after lunch, it was about two hours ago around 1:30 p.m. (three hours after R6 was up in his chair). NA-A explained she completed the repositioning by moving R6 around a little bit by the mechanical lift sling that he was sitting on. NA-A demonstrated the action with her arms; action was that of moving back and forth or side to side. NA-A's demonstration would not alleviate pressure to R6's buttock area. On 11/8/22, at 3:29 p.m. NA-A and NA-E observed doing personal cares on R6 in bed. NA-A stated she needed to apply barrier cream and stated she would go to the nurse and get the cream and be right back. R6's right sacral area of redness approximately size of quarter. Coccyx was excoriated with superficial open slit. Right outer gluteal fold (buttock) was excoriated /peeling. Left buttock had an open wound between quarter and half dollar sized. Wound periphery was reddened with surrounding excoriation/peeling skin on the buttock/gluteal fold. R6 stated,OWW, OWW! as NA's cleaned the areas excoriation where the skin was peeling and red. When NA-A was done wiping, with same gloves on, she applied barrier cream to the wound. Then with the same gloves on she applied a bordered dressing to the wound. NA-E asked NA-A if she should be applying the dressing rather than the nurse. NA-A replied, yes, the nurse told me to go ahead and put it on, so I am. Staff removed gloves, did not perform hand hygiene, and left room. R6's progress note dated 11/8/22, indicated as of 10/10/22, R6 wounds have resolved except a new wound found to right buttock-will await update to recommend supplementation. Registered dietician (RD) recommends increased magic cup to 4 ounces twice per due to decreased appetite. Discontinue Prostat (sugar free liquid protein often used for wound healing) due to resolved skin tears, pressure injury as of 10/6/22. R6's record did not identify measurements of the wound after 11/3/22. During an interview on 11/8/22, at 4:00 p.m., nurse manager (NM) indicated R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/27/22 the new wound (skin tear) was identified however that measured 3.91 cm x 2.56 cm.; total surface area was 7.06 cm. On 11/3/22 measurements of wound were 2.73cm x 2.95cm; total surface area 6.18 cm. NM stated staff should follow R6's care plan; he should be offloaded every hour when in a wheelchair by using a pillow or such. NM stated it was definitely not appropriate to shift a sling under a resident because it would not remove the pressure from the wound. NM stated nursing assistance (NA) were not to complete dressing changes as they do not have the education on assessing and it was out of their scope. During an interview on 11/9/22, at 9:34 a.m. administrator and director of nursing indicated they had identified the nurse had indeed delegated the task of wound care to the NA and had given the wrong directions. Education to staff was provided. Additionally, facility also provided job description to staff and what to do if they were directed to complete tasks out of their scope of practice. During an interview on 11/10/22, at 1:34 p.m. wound doctor (WD) stated R6 spent a lot of time in his wheelchair and R6 was bony and susceptible to pressure ulcers. WD stated he had not seen R6's wound last week but had seen the wound today; he debrided the wound as much as R6 would tolerate. Wound measured 0.1 and 1.4 cm, width was 1.8 cm. There was 80% slough, 10% granulation tissue, and 10% other with a little drainage. WD stated the wound had gotten smaller in the surface area than what he had seen previously. The skin impairment was caused by skin tear and the bias from that was pressure related as well as he (R6) did have fragile skin (shearing wound caused by pressure). WD stated the wound was (currently) stage III pressure ulcer because it had some depth to it. WD indicated treatment was xeroform (medicated gauze dressing) and [MEDICATION(S)] with border (foam dressing). WD explained R6 should be repositioned in his wheelchair every one hour and every two hours while in bed, additionally should have an air mattress. R12 R12's Admission record indicated R12 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 to be cognitively intact and had no rejection of cares exhibited. R12 required extensive assistance of two or more staff for toileting, bed mobility, transfers, and required extensive assistance of one staff for hygiene. MDS also identified R12 was at risk for pressure ulcers and had one stage 1 pressure ulcer. Skin and ulcer treatments included: pressure reducing device for chair and bed, along with pressure ulcer care. R12's hospital After Visit Summary (AVS) dated 11/3/22, identified R12 was admitted to the hospital with a femur fracture after a fall that required surgical intervention. Details of hospital stay identified R12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Addition interventions were Prevalon boots (have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) when lying or sitting to help protect. R12's right heel was intact but at risk (for skin breakdown) just like her left. Assessment and plan for pressure ulcer of left heel stage 3 included, unable to assess today, nursing to evaluate upon admission. R12's medical record lacked a comprehensive skin assessment upon admission to the facility as directed by the hospital summary. Further even though the hospital summary directed to use Santyl, R12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's record did not identify an order to discontinue the Santyl and/or why there was a change to the treatment as identified by the hospital discharge summary. R12's Baseline care plan, signed 11/4/22, indicated R12 was at risk for alteration in skin integrity related to obesity, decreased mobility and dependence on staff. Interventions: float my heels or use heel suspension boots while I am in bed and keep my skin clean and dry. The baseline care plan indicated current skin integrity issues to include scratches/rash on right wrist, pressure injury left heel, surgical incision of left hip/thigh, and left shin scratches. R12's progress note, dated 11/4/22, at 8:44 p.m. indicated R12 complained of left heel pain. [MEDICATION(S)] applied. Skin dry and intact. R12's record did not include further assessment that identified source of pain, color, and texture (bogg/firm) of skin, and interventions used to relieve pain. During observation and interview on 11/8/22, at 8:55 a.m. R12 laid in her bed on her back with both of her heels directly on the bed. Both heels had a dressing around the bottom wrapped with gauze and secured with tape; the dressings were undated. R12 stated she used to have a pressure ulcer on her left heel that she got in the hospital a while back. R12 explained she thought her dressings were supposed to be changed daily, however, no one had changed her dressing in a few days. She was not aware if the treatment had changed. R12 stated staff did not come in and help her to reposition in the bed and was not aware she was supposed to call for assistance and/or reposition. R12 indicated no one ever offers and/or puts her leg up on a pillow like they did in the hospital. R12 explained she usually just laid in bed; she worked with therapy and sometimes therapy would get her up. R12's November treatment administration record (TAR) identified physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated R12's treatment to heel was completed from 11/5/22 to 11/10/22, however did not include description of R12's heel or wound. Additionally, TAR identified R12 had diabetic foot check completed on the night shift from 11/3/22 to 11/10/22, however, did not address R12's skin integrity to her heel. During an observation and interview on 11/8/22, at 2:13 p.m. R12 laid in bed on her back covered with a sheet. R12 stated she did not get the dressing on her left heel changed yet. R12 stated she had been in bed all day, and no one had offered to reposition her or offer to put a pillow under her leg. R12's heels were directly on the mattress and not floated. R12's pressure relieving boots were observed to be on the shelf at the end of her bed. During an observation and interview on 11/8/22, at 2:21 p.m. licensed practical nurse (LPN)-B stated because they were short staffed last night (11/7/22) she had not changed R12's heel dressing per physician orders. Instead, she reinforced the dressing with a gauze wrap. LPN-B walked to R12's room and verified R12's heels were not offloaded (floated) per the care plan. Further LPN-B did not offer and/or attempt to float R12's heels, place pressure relieving boots on her or offer to reposition. LPN-B indicated R12 refused to wear the pressure relieving boot because she thought it caused the pressure ulcer, no one has followed-up with therapy about the boot, and thought someone should do that. Although, R12's hospital discharge summary and base line care plan dated 11/4/22, directed to offload pressure from R12's heel and use pressure relieving boot, R12's TAR did not identify the directive or order until 11/10/22. The order included offload heel with Prevalon boots and wear Darco shoe outside. Float heel when sitting with pillows to keep heel pressure free every shift for pressure injury (ulcer) of left heel stage 3. A progress note dated 11/5/22 indicated R12 refused interventions, and on 11/9/22 identified R12's heels were offloaded, the facility did not consistently implement interverventions to prevent pressure ulcers. During an observation on 11/8/22, at 3:02 p.m. LPN-B removed R12's dressing to her left heel and verified the dressing was not dated. The back of R12's left heel (Achilles tendon area) was observed; heel had a rectangular butterfly shaped open wound that had small red dots on the wound bed, approximately 1.0 inch by 2.5 inch, no surrounding redness. Above the wound there was an area of dry skin, no areas scabbing were observed over or surrounding the wound. LPN-B looked at the [MEDICATION(S)] and stated, there was a small amount of serous drainage (watery discharge that is pale yellow and transparent) on it. While LPN-B removed the dressing there was a distinct pungent foul odor which LPN-B verified. LPN-B looked at the wound on the back of left heel and stated it was open. LPN-B explained she did not think it was open before, but since there was drainage on the dressing it must have been open. LPN-B measured area on left heel; announced measurements of 5.0 cm x 3.0 cm. Stated she was going to clean the area with soap and water and have the wound nurse look at it prior to applying the zinc and [MEDICATION(S)]. During an observation and interview on 11/8/22, at 3:22 p.m. Nurse manager (NM) verified he was the wound nurse for the facility. NM explained a wound specialist (WD) was at the facility every Thursday. On Thursdays, residents were brought to the treatment room where they used a computer application to take pictures of the wound. WD would complete assessments, obtain measurements, and ensure treatments were appropriate. NM entered R12's room and looked at R12's left heel- Achilles tendon area. NM stated the left heel was definitely open with multiple red pinpoint areas located across the wound base. NM stated the wound was most likely from pressure. NM measured the wound; he reported results of 3.6 cm x 4.0 cm which were inconsistent with LPN-B's measurements. NM explained there was nothing on her heel upon admission on 11/3/22. The area had some dry skin around it and was not open. As NM was touching R12's left heel he asked R12 if she could feel his hand. R12 closed her eyes and stated she could not feel it. NM stated for now he would cleanse the area with wound cleanser and apply a [MEDICATION(S)] and call the doctor to see what he wants to do with this. NM then put a pillow under R12's left leg so that the heel was off the bed. R12 allowed this without any rejection and/or refusals. R12's physician notification note, dated 11/8/22, at 4:46 p.m. included background of pressure ulcer to R12's left posterior (back) heel. Assessment included: posterior heel has a hard scab to previous pressure ulcer (documentation of a hard scab was inconsistent with observation at 3:22 p.m.). Upon evaluation on this day, the site measured 4.0 cm x 3.0 cm (Length x Width) to peri wound site appears with multiple pinpoint red areas. Old dressing had light serous drainage. Updated orders requested, currently using zinc barrier cream, site is dry. R12's progress note dated, 11/9/22, at 9:49 a.m. indicated a new order of [MEDICATION(S)] (Powder nutritional supplement drink mix that promotes the healing of pressure ulcers) two times a day to aid in wound healing related to pressure ulcer of the left heel. R12's progress note dated, 11/9/22, at 3:20 p.m. response from physician notification was, continue to follow wound MD. R12's progress note dated 11/9/22, at 7:34 p.m. included [MEDICATION(S)] to bilateral heels in place, left heel pressure injury present at this time. R12's admission MD visit dated 11/10/22, identified history of R12's left heel wound however, however did not identify current staging. The note included the following treatment orders and interventions: cleanse the wound with wound cleanser, pat dry, cover the wound bed with [MEDICATION(S)]. Change daily and as needed if soiled. [R12] to offload heel with Prevalon boots and wear Darco shoe outside. Float heel when sitting with pillows to keep heel pressure free. Nutritional consult with goal to improve nutritional status for wound healing. Any acute changes between visits should be documented and communicated ASAP (as soon as possible) to provider: a new wound or a change, if there is new or worsening drainage from a wound, redness, swollen or painful to the touch, if wound changes from pink or red to a tan or brown or black color, if development of fever or wound odor gets worse. Document and alert provider if patient declined repositioning or dressing change. During an observation and interview on 11/10/22, at 9:56 a.m. R12 laid on her back in her bed, heels were not offloaded/floated. R12's left heel had a [MEDICATION(S)] dressing placed underneath her heel but was not secured. R12 stated a doctor had just looked at her heel and no one has offered/attempted to offload her heel yet today. R12's weekly skin assessment dated [DATE], indicated left heel had blanchable redness measuring 6.5 cm x 4.0 cm. Further identified left heel pressure ulcer was a suspected deep tissue injury (SDTI) measuring 1.9 cm x 1.5 cm. Above blanchable redness surrounds the SDTI. The SDTI area is non-blanchable purple appearance, skin intact. During a phone interview on 11/10/22, at 12:27 p.m. WD stated he had not had a chance to review R12's medical records yet. WD explained R12 had told him she had the pressure ulcer on her left heel since August. WD indicated he had assessed R12's wound today; measured 1.4 cm x 1.9 cm. The new treatment orders will be to apply [MEDICATION(S)] (antiseptic liquid, put on minor wounds, cuts, abrasions or [CONDITION(S)] that helps reduce the risk of developing an infection) and a [MEDICATION(S)] dressing. WD further explained R12 would need to float her heels with a pillow or use the boots. Facility policy entitled, Pressure Injury Prevention and Wound care management, dated 8/26/2018, revised 4/27/21, stated that the policy was created for the facility to ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable, a resident who has pressure injury will receive care and services to promote healing and to prevent additional ulcers. Policy indicates to refer to dressing change policy and procedure for dressing changes. Education provided to nursing staff on 11/8/22 and 11/9/22, indicated wound care MUST be performed by a licensed nurse. A licensed nurse cannot delegate wound care to certified nursing assistant (CNA) staff. This is outside their scope of practice. Any CNA staff being asked by a licensed nurse to complete wound care on a resident is to notify the Nurse Manager/Charge Nurse/Director of Nursing immediately and not follow the direction of the licensed nurse related to the wound care.

Based on interview and document review the facility failed to identify, monitor, and comprehensively assess a change in respiratory status for 1 of 3 residents (R1) reviewed for respiratory change in condition. This resulted in an immediate jeopardy when R1 demonstrated symptoms of respiratory distress, the facility failed to immediately assess, failed to immediately provide respiratory interventions, and failed to notify the physician which resulted in delay in treatment, hospitalization , and death. The IJ was identified on [DATE], and Administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 12:05 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of D scope and severity level, which indicated no actual harm with more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had unclear speech and had severely impaired cognition. Further the MDS indicated that R1 had verbal and physical behaviors but did not reject cares. R1 was totally dependent on staff with most activities of daily living (ADL) R1's MDS did not identify any pulmonary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated [DATE], indicated R1 was on tube feedings, was vulnerable, was unable to communicate, and had anxiety. The care plan directed staff to be alert for changes in mood, behavior, pain, and signs and symptoms of aspiration including increased cough, congestion, fever, abnormal breathing and or lung sounds. Staff were directed to notify MD of abnormalities and as needed. R1's provider progress note, dated [DATE], at 3:02 p.m. indicated R1 had an elevated temperature with [CONDITION(S)] (heart rate over 100 beats a minute.) after receiving Tylenol. R1 was noted to having chills, minimally responsive, [CONDITION(S)] and R1 did not cooperate with the exam. R1 was sent to emergency department (ED) for evaluation. R1's ED visit note dated [DATE], identified R1's pulmonary status was normal, was diagnosed with urinary tract infection and possible [MEDICATION(S)] (inflammation of the bladder, usually caused by a bladder infection.) R1 was treated with antibiotic and discharged back to the facility. R1's progress note dated [DATE], at 1:15 p.m. included R1 was having convulsions, diaphoretic and at times unresponsive. R1's blood pressure was ,d+[DATE] (blood pressures under ,d+[DATE] are considered within normal range), pulse was 84, oxygen saturation was 95% on room air, respirations were 20 and temperature was 98.8. Progress note indicated R1 was asked if she wanted to go to ED and R1 indicated, no. The physician was notified of the change, gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Respiratory Standing orders (undated) directed the nurse to initiate and titrate supplemental oxygen (O2) from ,d+[DATE] L/min (liter/minute) via nasal cannula prn (as needed) for dyspnea (shortness of breath), [CONDITION(S)] (O2 saturation <90% or <88% for Chronic obstructive pulmonary disease ([CONDITION(S)]) or acute [CONDITION(S)] (severe pain in the chest) to keep O2 saturations >90%; immediately update provider with nursing assessment. R1's vitals sign report dated [DATE], at 1:02 p.m. identified R1's oxygen saturation was 83% on room air (normal oxygen saturations are ,d+[DATE]%); this value was documented by nursing assistant (NA)-A. R1's record did not include evidence of further assessment or interventions including administration of oxygen per standing orders. R1's vital record at 1:47 p.m. identified NA-B documented R1's oxygen saturation was again 83% on room air. R1's record continued to lack further assessment, monitoring, physician notification, or intervention for oxygen saturation below 90%. R1's record did not identify any further documentation and/or assessments pertaining to R1's condition was completed on [DATE]. R1's health status note dated [DATE], at 2:09 p.m. licensed practical nurse (LPN)-A documented R1 had been diaphoretic, and provider had been notified. R1 was to be seen on Monday by provider. R1's condition had changed drastically on the shift, nurse was unable to get accurate blood pressure reading, and oxygen saturation read 70% on room air. R1 was administered oxygen 4 liters per minute and physician was notified. Physician gave order to send R1 to the Ed. R1's ambulance report dated [DATE], indicated at 1:52 p.m. a call from the facility had been received. At 1:58 p.m. ambulance had arrived at the facility. Ambulance report indicated R1 was unresponsive and in respiratory distress with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's ED visit note, dated [DATE], at 2:50 p.m. indicated R1 had been sent to the ED after being found down, unresponsive with agonal (gasping for air because of not enough oxygen) respirations. Emergency medical service (EMS) reported to ED, R1 was last known to be well in the morning and she had received her medications. EMS reported facility stated R1 was checked on at 2:00 p.m.; R1 was found unresponsive. EMS reported to the ED they were unable to obtain intravenous (IV) access and obtained IO intraosseous (IO) (vascular access refers to the placement of a specialized hollow bore needle through the cortex of a bone) access. EMS bagged (Use of manual resuscitators to ventilate a patient) R1 until arrived at ED. R1 remained unresponsive to pain and had emesis in airway with no pulse. ED intubated R1 and placed her on a ventilator. CPR (cardiopulmonary resuscitation) was provided, and electrolytes were shown to be unstable. R1 did not respond to treatments and time of death was 2:36 p.m. Final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE], at 2:44 p.m. ambulance driver (AD) stated she was involved with R1's call on [DATE]. AD indicated initially facility staff were not able to tell them which room R1 resided in. Further stated, she was not able to obtain a medical history from the nurse that was working. Additionally, she was told by the nurse R1's provider had not been contacted about R1's change because R1 had an appointment next week. AD stated upon arrival to R1's room, R1 was in obvious respiratory distress. AD reviewed the ambulance report from [DATE] and verified the report as accurate. During an interview on [DATE], at 10:52 a.m. registered nurse (RN)-A stated she was familiar with R1; R1 was diaphoretic at her baseline with mild shakes. RN-A indicated she had completed R1's change of condition note (SBAR) and had notified the provider on [DATE], because of increased diaphoresis (excessive sweating) from her baseline and R1's upper body area was convulsing. RN-A stated she had talked to the provider because she felt the resident should be sent to the ED. RN-A stated that R1 had been declining over the last week, she had less behaviors and hollering out. RN-A reported that she had not received any orders from the provider before the end of her shift on Friday ([DATE]) but had passed on the SBAR change of condition in shift report. During an interview on [DATE], at 4:36 p.m. NA-A stated she had worked with R1 on Saturday ([DATE]). NA-A reported she was worried about R1 since Friday and kept an eye on her on Saturday because R1,just didn't look right. NA-A stated she had taken R1's vital signs on Saturday and R1 had a fever of over 100 and something. NA-A stated R1's oxygen level kept going up and down. She had been unable to get the machine to work properly so she got LPN-A and he was able to obtain the oxygen saturation with his personal finger thing (oximeter). NA-A stated she could not remember what the reading was on Saturday, but LPN-A had told her it was normal. NA-A indicted LPN-A did not apply oxygen or direct increased monitoring. NA-A stated she was unaware of what normal vital signs should be and stated oxygen saturations 70% to 80% was considered normal and was not able to articulate normal oxygen saturations were ,d+[DATE]%. NA-A stated R1 wasn't really responding much on Saturday, which was not her normal. During an interview on [DATE], at 4:23 p.m. LPN-A verified he was R1's nurse on [DATE]. LPN-A sated R1 was diaphoretic but was fine, she was at her baseline. LPN-A indicated he had administered R1's morning medications via her feeding tube and took her blood sugar which was 190 mg/dl (milligram per deciliter). LPN-A indicated he did not have any concerns with the medication administration. R1 was fine. LPN-A stated he did not take R1's vital signs and complete respiratory assessments during his shift. LPN-A indicated NAs were the ones who took the vital signs, and no one had reported concerning values to him. LPN-A stated he was not aware of the oxygen saturations of 83% that were documented in R1's record and had not been informed. LPN-A indicated had he been informed, he would have applied oxygen per standing order, completed a respiratory assessment, and notified the physician or call 911 if warranted. During an interview on [DATE], at 8:15 a.m. LPN-A stated he had taken care of R1 on Sunday ([DATE]). LPN-A explained Sunday morning a nursing assistant (NA) had reported R1's condition to him (did not elaborate on what the NA reported) but did not further assess R1 after the NA's report. LPN-A indicated the physician had already been notified of the condition change on Friday with a plan to follow-up on Monday. LPN-A stated he had administered R1's medications via her feeding tube, felt R1 had tolerated it well, and didn't have any concerns with R1's condition. LPN-A indicated later that afternoon NA reported to him that R1's oxygen saturation low. LPN-A indicated when he got to R1's room, she was turning blue and her oxygen saturations were in the 70's. LPN-A stated he had started the oxygen at 2 liters per minute (LPM) but had quickly bumped it up to 4 LPM because R1's oxygen saturations were not improving. LPN-A stated he then notified the provider right away when R1 was not improving, however could not articulate how much time had passed. LPN-A stated NAs would take the vital signs and enter them in the computer; NA's would notify the nurse if they were out of range. LPN-A stated no NA had informed him of vital sign concerns until Sunday afternoon related to R1. LPN-A articulated he would initiate standing orders for oxygen if a resident's oxygen saturations were below 90%. LPN-A stated that if a resident's oxygen saturations were in the low 80's and 70's, he would initiate oxygen just to be on the safe side. During an interview on [DATE], at 11:14 a.m. NA-C stated she worked on [DATE] and [DATE]. NA-C stated LPN-A was aware of R1's condition on both days. NA-C explained R1 was responsive on Saturday but not the same on Sunday. On Sunday R1 was more lethargic, less responsive to questions, and was not herself. NA-C reported that she had not completed R1's vital signs till after lunch on [DATE]. NA-C reported no extra monitoring was being done on R1 but was aware of R1's decline over the weekend. NA-C reported on Sunday the oxygen reading on the machine said low, she could not get the machine to function and hd to go get LPN-A. LPN-A used the little finger reader and took R1's vital signs together and oxygen saturations were unstable in 70's. NA-C reported the nurse went and got the oxygen machine at that time. During an interview on [DATE], at 2:22 p.m. director of nursing (DON) stated she was aware of the change of condition SBAR for R1 on Friday. DON stated she was not aware of the oxygen saturations of 83% that were taken on [DATE], and stated the nurse on that shift should have been informed. Further the standing order for oxygen should have been activated. DON stated an SBAR should have been completed and R1 should have been sent to ED on that day. DON stated she did not feel that R1 should have had increased monitoring after the SBAR on Friday because staff should have already been monitoring every 2 hours during R1's repositioning and checks. DON explained (LPN)-A should have been aware of the 83% oxygen saturations on Saturday because on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reported NAs take and document vital signs then nurses are responsible for checking them during their shift. DON stated NAs were supposed to be charting vital signs in real time, but this has been an issue at the facility. DON explained NA's were not trained on the evaluation of vital signs in the facility but it was an expectation that they would have learned that in NA certification training. During interview [DATE], 5:51 p.m. with administrator and DON reviewed R1's oxygen saturation entries for [DATE] and indicated LPN-A had acknowledged the oxygen saturations that were 83% which indicated LPN-A had been aware or should have been aware of the low saturations. During an interview [DATE], at 10:11 a.m. medical director (MD) stated he had not personally visited with R1. MD stated if a resident was to have low oxygen saturations below 90%, standing oxygen orders should be initiated and provider should be informed of the change of condition. MD stated if a resident was diaphoretic and shaking, the staff should be calling EMS immediately. If oxygen is 83% it's a change of condition and is an urgent situation, staff are instructed to communicate directly with emergency immediately. Facility Policy entitled, Policy & Procedure Change in Condition Issue date [DATE], updated [DATE], stated Specific information that requires prompt notification include, but is not limited to:Significant change or instability of vital signs. The IJ was removed on [DATE] at 4:25 p.m. when it could be verified the facility implemented the following: The facility completed a causal analysis of the incident. -Facility developed education for monitoring residents condition for acute changes, with emphasis on respiratory distress protocols and implementation of emergency interventions. -All clinical nursing staff were provided with education and found competent on change in condition, respiratory distress symptoms, emergency situations respective to job role. -On [DATE] interviews were conducted with licensed staff and nursing assistants between hours of 3:42 p.m. to 4:30 p.m. identified they were educated on the outlined correction respective to their job role.

Based on interview and document review, the facility failed to follow the facility's abuse prevention policy and procedures when the facility failed to timely report allegation of abuse, immediately initiate an investigation including the protection of residents for 1 of 1 (R1) resident reviewed for an allegation of staff to resident abuse. This resulted in an immediate jeopardy (IJ) for R1 and had the potenial to affect all residents residing in the facility. The IJ began on 6/16/21, when R1 alleged a nursing assistant (NA) pushed her into bed that evening. The IJ was identified on 6/22/21, and the executive director of operations, clinical nurse consultant, and the director of operations were informed of the IJ on 6/22/21, at 12:15 p.m. The IJ was removed on 6/23/21, at 3:40 p.m. but noncompliance remained at the lower scope and severity level of D, isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Facility Reported Incident (FRI) submitted to the State Agency on 6/17/21, at 9:05 a.m. indicated R1 reported allegations of physical abuse that had occurred on 6/16/21, at 10:00 p.m. The description of incident included, Resident told a therapist around 7:30 a.m. this morning [6/17/21] that a CNA [certified nursing assistant] pushed her last evening. Administrator & DON investigating. R1's face sheet, dated 6/23/21 identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 6/11/21 speech therapy note included, SLUMS [mental status examination] score of 12/26 indicating severe cognitive deficits primarily impacting short term recall. R1's care plan dated 6/11/21, included R1 had limited physical mobility related to right humerus fracture with shoulder replacement, right arm in immobilizer. Interventions directed staff to use one staff assist with bed mobility, for transfers use two staff assist with hemi-walker with right upper extremity immobilizer on, and for toilet use assist of two to ambulate to bathroom with hemi-walker. During an interview on 6/21/21 at 9:39 a.m. R1 sat in her wheelchair in her room, her right arm was in an immobilizer (sling). R1 indicated she was at the facility for short term rehab after a fall that resulted in a arm/shoulder fracture. R1 stated she just wanted to hurry up and get better so she could get out of here. R1 could not recall how long she had been at the facility and directed surveyor to look at the calendar on the wall. When asked if she had any concerns with how she was treated by staff at the facility, R1 said no. Physical therapy notes dated 6/17/21, included, [R1] reports that she was abused by CNA last night and talked to management. Reported to [name of therapy supervisor] DON, and administrator were meeting with her after our session. She reports that she did not sleep well last night but willing to participate. The note also indicated R1 reported fatigue from not sleeping last night. During an interview on 6/21/21, at 11:28 a.m. physical therapist (PT) stated on 6/16/21, he went to R1's room between 7:15 and 7:45 a.m. PT stated R1 looked a little sad and her eyes were different. PT stated R1 told him she had a tough night, she said an aide threw her down on the bed, and initially refused therapy, but then was agreeable after a few minutes. PT stated he took her down to the therapy room that morning to get her out of the environment, thinking that it would get R1's mind off of the incident that had occurred the night before. PT stated he immediately reported R1's allegation to the therapy manager who then reported to the director of nursing (DON). PT indicated the administrator was then notified. PT indicated he was interviewed by the administrator about the allegation and remembered the administrator stating she had heard about the allegation the evening before. On 6/21/21, at 9:15 a.m.during an interview with DON, administrator, and licensed social worker (LSW), administrator stated R1 had reported to the physical therapist (PT) that a female staff member threw her down on the bed last night. Administrator indicated PT then reported to the therapy manager, who then reported to the DON, who then reported the allegation to her. Administrator indicated herself and the DON interviewed R1, R1 could not recall any details. DON and LSW confirmed R1 could not contribute any descriptive factors about incident, including date, time, or staff member who pushed her. Administrator verified the facility used video cameras, however, footage was not reviewed because R1 could not identify what day and time the incident occurred. DON indicated she inquired with some staff members if they had concerns about other NA's, however, did not disclose that R1 had made allegations of physical abuse. Administrator indicated no other residents had been interviewed. DON stated a skin inspection was completed with no new injuries. Administrator stated LSW had again interviewed R1 on 6/18/21, in the presence of family member (FM)-A. LSW stated R1 again could not articulate date and time of incident, however, did identify that the female NA who pushed her had black skin tone. LSW stated we encouraged R1 to report if she recognized the NA who pushed her. The facility's investigative notes included two pages of paper. 1) line notebook paper had date of 6/17/21, at 8:00 a.m. indicated PT was interviewed and included abused by staff member thrown down to the bed she said she met with mgmt. [management]. The document also indicated the DON and administrator met with R1; indicated R1 reported, She [NA] was behind me and pushed me, I believe she is a good worker, can't remember time of day, I do not know what she was doing in my room, husky not fat, [sic] quiet, moves slow, has worked with her before. The note also indicated R1 stated she was sorry for not being able to remember, was not able to articulate color of the staff's hair or if it was long or short. 2) Statement signed by the LSW on 6/18/21, indicated LSW met with R1 to discuss alleged incident. Resident described incident as black female about 5'6 to 5'7 very slender being behind her and pushing her. The note also indicated R1 felt safe, could not tell LSW time of day incident occurred and why the accused staff were in her room, or name of staff. The facility lacked evidence of potential staff and resident interviews and associated investigative activities and protection modalities/interventions. R1's medical record lacked evidence of acknowledgement of R1's allegation and any corresponding follow-up assessments such as mood monitoring or behavioral changes. During an interview on 6/21/21, at 10:44 a.m. executive director of operations ([NAME]) stated the administrator had knowledge of R1's allegation on 6/16/21, at approximately 11:00 p.m. when a nurse had called her at home. [NAME] stated the administrator failed to report the allegation timely to the State Agency, failed to initiate an immediate investigation, and failed to ensure the alleged perpetrator(s) were not on the schedule. [NAME] stated the administrator was suspended pending further investigation. During a subsequent interview on 6/21/21, at 11:48 a.m. [NAME] indicated after investigating further, licensed practical nurse (LPN)-A had just informed the facility NA-A had been assigned to R1's unit the evening of 6/16/21; [NAME] stated NA-A was now immediately suspended pending further investigation. During an interview on 6/21/21, at 12:02 p.m. NA-A confirmed she had worked on R1's unit the evening of 6/16/21, NA-A stated that was the only unit she worked on. NA-A stated, I put her [R1] to bed, she [R1] transfers with one assist and a gait belt, everything was fine, [R1] never said anything, the nurse never asked me any questions [about the allegations], I have worked with [R1] since then [evening of 6/16/21], they [facility administration] didn't tell me anything [about the allegations against her]. During an interview on 6/21/21, at 2:33 p.m. LPN-A stated he was the nurse assigned to the north unit where R1 resided the evening of 6/16/21. LPN-A stated around 10:30 p.m. he and LPN-B were counting narcotics when NA-D reported to both that R1 had reported to her the NA who was helping her [R1] pushed her into bed. LPN-A stated he told NA-D to report to RN-A. LPN-A stated, We [LPN-A, LPN-B, and RN-A] all went into R1's room to interview her. LPN-A indicated R1 reported the accused NA was helping her from the bathroom to the bed and she pushed her into the bed. LPN-A stated R1 could not really describe what had happened. LPN-A stated R1 kept stating she was scared that NA could hurt a lot of people because she was double her [R1] size. LPN-A stated R1 said she feared the accused NA. LPN-A stated aside from NA-A, NA-B also fit R1's skin color description, however, NA-B was scheduled as a float and would not have put R1 in her bed. NA-B only covered NA-A when she went to break after dinner. LPN-A stated a skin examination of was not completed and confirmed he did not document in the medical record or record R1's interview. LPN-A stated he called the administrator sometime around 11:00 p.m. and reported R1's allegation that the evening aide pushed her into bed. LPN-A stated he did not give the administrator the name of the aide that was assigned to care for R1 and the administrator did not ask. LPN-A stated the administrator asked if the aide was still in the building; he responded no, and administrator asked if the resident was ok, he responded yes. LPN-A stated the administrator did not give any further instructions and informed LPN-A that she would do everything in the morning. LPN-A stated DON called him the next morning on 6/17/21, to clarify if the aide who was accused was NA-A or NA-D, LPN-A stated he told the DON it was NA-A. During an interview on 6/21/21, at 5:00 p.m. RN-A stated NA-D informed her R1 had made allegations of an evening NA pushing her into bed. RN-A stated she, LPN-A and LPN-B then interviewed R1. RN-A indicated R1 stated the incident happened right before bed when the NA was pushing her back when she was walking her. RN-A stated R1 reported feeling safe. RN-A indicated she did not document the interview or complete a skin assessment. During an interview on 6/22/21, at 10:15 a.m. LPN-B confirmed the NA-D overnight aide reported R1's allegations of abuse the evening of 6/16/21, between 10:15 and 10:20 p.m. LPN-B stated NA-D reported R1 told her the evening NA pushed her onto the bed after walking her from the bathroom. LPN-B indicated he, LPN-A and RN-A interviewed R1 following NA-D's report. LPN-B stated, R1 stated she was scared and R1 stated, I am literally scared of her attitude. LPN-B indicated R1 did not know the name of the NA who pushed her but was able to give enough of a description to rule out that it was not NA-D who pushed her. LPN-B indicated he did not document in the medical record, or document the interview. Nursing schedule was reviewed from 6/16/21 through 6/21/21 for staff who fit the desrciption given by R1. The schedule identified NA-A worked the following shifts where R1 resided without any changes and/or updates in NA-A's assigned unit following R1's allegations: 6/16/21- evening shift. 6/17/21- day and evening shift. 6/18/21- evening and night shift. 6/19/21- evening and night shift. 6/20/21- evening and night shift. 6/21/21- day and night shift. NA-B's schedule for the same dates was reviewed; the schedule identified NA-A worked the following shifts where R1 resided without any changes/or updates in NA-B's assigned unit following R1's allegations: 6/16/21- evening shift float 6/17/21- evening shift North Nurse [sic] 6/20/21- evening shift trained medication assistant (TMA) During an interview on 6/22/21, at 8:00 a.m. [NAME] stated he had suspended NA-B until further investigation. [NAME] stated he had interviewed NA-B; NA-B had one interaction with R1 around 7:00 p.m. when she assisted R1 to the bathroom. During an interview on 6/22/21, at 10:33 a.m. FM-A stated R1 did not care for one of the evening staff NA's, and that R1 and NA never really clicked. FM-A stated R1 did not know the NA's name because they don't wear their name tag. FM-A stated when he visited R1 on 6/17/21, R1 had told him what had happened the evening before; R1 told him NA pushed her bad shoulder. FM-A stated the facility had not notified him of the allegations until 6/18/21, when the social worker came into the room and attempted to ask R1 more questions, however, did not get anything out of her. FM-A stated he was not aware of who the NA was because he visited during the daytime. FM-A stated R1 used to be a nurse, was not the type to say anything nor would say anything that would cause trouble or conflict, she just wanted to rehab and go home. During a telephone interview on 6/22/21, at 8:20 a.m. administrator confirmed LPN-A had called her on 6/16/21 at 11:00 p.m. to report an NA had reported to him another NA had pushed R1. Administrator stated at that time she asked if the accused staff member was still in the building, the nurse said no, she asked about the resident, the nurse said that the resident was sleeping. Administrator stated since the accused staff member was not in the building and the resident was asleep and safe, I would start the investigation in the morning. The administrator stated she was not aware that the accused staff member was on the schedule the next morning for 6:00 a.m. and did not believe she asked the nurse to check the schedule to verify the accused NA was on the schedule. Administrator stated when she arrived at the facility the next morning, the DON was waiting for her, the DON reported that R1 had told PT that an NA had shoved her down into bed. Administrator was not aware the nurses had interviewed the resident prior to LPN-A calling her, and stated they should have documented the information. Administrator confirmed the accused NA(s) remained on the schedule. Administrator stated she should have reported the allegation immediately to the State Agency, should have went into the facility to start the investigation, and should have suspended the NA(s) who worked that evening pending further investigation. Facility policy and procedure Vulnerable Adult Abuse and Neglect Prevention dated 11/17/2020, included: Identification: a) In the event of suspected maltreatment, the needs of the resident will be immediately assessed and the safety of the resident will be ensured. The safety and health of the resident will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment, including medical interventions as needed. b) The resident will be assessed for physical appearance, skin injuries, trauma, and changes in resident affect, mood, and behavior. Investigation: a) Upon receiving a complaint of alleged maltreatment, the administrator must be notified immediately and they, the director of nursing, or assigned designee, will coordinate an investigation, which will include completion of witness statements. c) When a specific staff member is implicated in the alleged event, the person will be removed form the residents care area immediately interviewed by the supervisor assigned, asked to provide a written statement and suspended until the investigation is completed. MUST BE SUSPENDED IMMEDIATELY PENDING INVESTIGATION. e) Notify the resident's responsible party as well as the physician as soon as possible. g) Document resident behaviors and environment at the time of the incident, as well as observations made of residents behavior during the investigation. Protection of Residents During Investigation. a) Immediately upon receiving the report, the DON, social services director and delegated IDT members will coordinate delivery of appropriate medical and or psychological care and attention. Ensuring safety and well-being for the vulnerable adult is of utmost priority. Safety, security and support of the resident, their roommate, if applicable, and other residents with the potential to be affected will be provided. Reporting of Incidents a. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the administrator is not present, the report must be made to the administrators designee. b) The facility must report to the State Agency immediately, but no later than 2 hours after the allegation is made, if the events what cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. The immediate jeopardy that began on 6/16/21, was removed on 6/23/21, when the facility put in place protection of the vulnerable adult and residents by removing the accused NAs during the investigation. Educated administrative staff on abuse prohibition procedures that included timeliness of reporting, conduction for a thorough investigation and immediately protecting residents and found competent in all areas. Revised the abuse policy/procedures to include a systematic change that ensures accountability and ongoing compliance in the facility's procedures following reports of abuse allegations or suspicions of abuse.

Based on observation, interview and document review, the facility failed to implement CDC (Centers for Disease Control) and CMS (Centers for Medicaid and Medicare Services) guidance/recommendations for 4 of 4 residents (R1, R2, R5, R6) when the facility failed to separate and quarantine covid positive residents from negative resident roommates. The facility failed to ensure proper infection control procedures were followed to prevent and/or mitigate the risk of an outbreak of COVID-19. This deficient practice had the potential to affect all 41 residents residing in the facility and staff who were at risk for contracting COVID-19. The immediate jeopardy began on 11/22/20, when the facility failed to implement appropriate infection control practices to mitigate or reduce the spread of COVID-19 in the facility, the IJ was identified on 12/3/20. The administrator, regional nurse consultant (RNC) and the director of nursing (DON) were notified of the immediate jeopardy at 3:19 p.m. on 12/3/20. The immediate jeopardy was removed on 12/4/20, when the facility had developed and implemented an acceptable plan. However, noncompliance remained at the lower scope and severity level of G, isolated scope and severity, which indicated harm that is not immediate jeopardy. Findings Include: The facility did not ensure COVID positive residents were placed in quarantine separate from COVID negative residents. In addition, infection control concerns were observed during observations and the facility lacked evidence of comprehensive risk analysis of potential exposures and/or transmission to other residents, investigation of the illness, and identification of potential causal factors of disease transmission. According to the census reports, R1 and R2 resided in the same room on the COVID unit. R1 R1's Admission Record, indicated R1 was admitted to the facility 9/28/20. R1's [DIAGNOSES REDACTED]. R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had intact cognition. R1's progress note dated 11/17/20 included, COVID PCR (polymerase chain reaction) test completed as part of house wide testing due to COVID positive status in the building. Will await results. R1's progress note dated 11/22/2020, at 12:59 p.m. included, 11/16/2020 COVID-19 test result confirmed as positive. Droplet Precautions initiated. R1's progress note dated 11/24/2020, at 11:13 p.m. included, Resident doing well, no c/o (complaints of) pain, dyspnea, cough. VS (vital signs) remain WNL (within normal limits), LS (lung sounds) clear. Good appetite and output. Some diarrhea this evening. Encouraging fluids for replacement. R1's progress note dated 11/25/2020, at 4:31 a.m. included, ocass (occasional) loose non prod (nonproductive) cough. denies SOB (shortness of breath), denies pain. has been asleep most of the night. R2 R2's Admission Record, indicated R2 was admitted to the facility 1/20/20. R1's [DIAGNOSES REDACTED]. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had long and short-term memory problems and was independent with decision-making skills for daily living. R2's progress note dated 11/17/2020, at 7:31 p.m. included, COVID PCR (polymerase chain reaction) test completed as part of house wide testing due to COVID positive status of the building. Will await results. R2's progress note dated 11/22/2020, at 5:31p.m., included, (R2)'s roommate tested positive for COVID-19. Although her result came back undetected, (R2) will be treated as COVID-19 positive. Droplet precautions will be instituted . R2's progress note dated 11/23/2020, at 9:02 p.m. included, COVID POC (point of care) [MEDICATION NAME] test completed today with negative results. COVID PCR (polymerase chain reaction) test was also completed and sent to lab as part of house wide testing due to COVID positive status of the building. Will await results. R2's progress note dated 11/30/2020, at 2:47 p.m. included, Resident noted to have some COVID-like symptoms. Completed point of care [MEDICATION NAME] test which was negative. Also completed a confirmatory PCR (polymerase chain reaction) test. Will await results from the lab. R1 was tested for COVID during the facility wide testing on 11/17/20. The facility received R1's positive COVID lab results on 11/22/20. R1 was asymptomatic. R1 and roommate R2, were moved to the COVID unit on 11/22/20. R2's COVID tests results were negative however, R2 was moved to the COVID unit because the facility considered her to be presumptive positive from sharing a room with R1. R2 had been COVID positive in July 2020. On 11/30/20, R2 started to have symptoms of two medium emesis of undigested food, R2 complained of abdominal discomfort in umbilicus region and headache after emesis. Documentation indicated the facility was waiting for results of R2's PCR testing, and R2 was tested for COVID via the point of care [MEDICATION NAME] testing on 12/3/20 which was negative. At that time, R2 was moved to a room off the COVID unit and was placed on 14-day droplet precautions. During an interview on 12/2/20, at 1:40 p.m. the regional nurse consultant (RNC) stated R2 should have been kept in her room, placed on 14-day precautions and the roommate (R1) that was positive should have been moved to the COVID unit to separate them. RNC stated R2 had been previously positive and had recovered from COVID. According to the census reports, R5 and R6 had resided in the same room on the COVID unit. R5 R5's Admission Record, indicated R5 was admitted to the facility on [DATE]. R5's [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 had intact cognition. R5's progress note dated 11/23/2020, at 8:57 p.m., included, COVID POC (point of care) [MEDICATION NAME] test completed today with positive results. R5's progress note dated 11/24/2020, at 2:37 a.m., included, 2L (liters) supplemental O2 (oxygen) started due to sats (saturations) below 90% (88%). R5's progress note dated 11/25/2020, at 11:22 a.m. included, Change of condition .Nursing observations, evaluations and recommendations are: Baseline status but increased. Primary Care Provider Feedback A. Recommendations: Send for admission (Provider ordered R5 to sent to hospital for admission) . R6's Admission Record, indicated R6 was admitted to the facility 6/28/2017. R6's [DIAGNOSES REDACTED]. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had intact cognition. R6's progress note dated 11/17/2020, at 7:17 p.m. included, COVID PCR (polymerase chain reaction) test completed as part of house wide testing due to COVID positive status of the building. Will await results. R6's progress note dated 11/23/2020, at 9:03 p.m. included, COVID POC (point of care) [MEDICATION NAME] test completed today with negative results. COVID PCR (polymerase chain reaction) test was also completed and sent to lab as part of house wide testing due to COVID positive status of the building. Will await results. R6's test results were negative. R6's progress note dated 11/30/2020, at 2:56 p.m. included, COVID PCR (polymerase chain reaction) testing completed. Will await results. R6's progress note dated 12/2/2020, at 2:11 p.m. included, Resident tested positive for COVID this afternoon. C/O (complaints of) not feeling well, headache, and temp (temperature) of 102.2. Rapid test was done. R6's progress note dated 12/3/2020, at 6:07 a.m. included, Vital Signs: BP (blood pressure) 110/58, P (pulse) 77, T (temperature) 96.6, RR (respirations)19, O2 (oxygen saturations) 95% 2LNC (liters nasal cannula). Active COVID Symptoms (cough, malaise, fatigue, SOB, fever, headache, loss of taste/smell, GI sx (gastrointestinal symptoms)): non-productive cough, fatigue, increased sleepiness ADL( activities of daily living)/functional declines or recent falls noted: no changes- in bed all night. Emotional/Psychosocial Concerns: none. Appetite and Fluid intake: sleeping, water at bedside. Current interventions and effectiveness: rest, encourage fluids. R5's onset of symptoms was identified as occuring on 11/23/20, when documentation indicated R5 had loose stools. On 11/23/20, the facility completed POC testing and results were positive. R5 shared a room with R6. The room shared was on the COVID unit created 11/22/20. R5 and R6 shared a room on the COVID unit until R5 was hosptalized on [DATE]. R6 remained in the room they shared on the COVID unit until R6 requested to be moved off the unit on 11/28/20. On 12/2/2020, R6 displayed symptoms headache, temperature 102.2 and had complaints of not feeling well. A POC test was completed and results were positive. R6 was moved back to the COVID unit. During an observation on 12/2/2020, at 11:45 a.m. in the COVID unit, RN-B and resident (who had mask on) entered from the exit door of the building. RN-B had only N95 donned- no other PPE. RN-B walked up the length of hallway thru the plastic barrier into the nurse breakroom (in unit). RN-B came out of the breakroom with face shield on walked through barrier and then donned gown. RN-B stated she did not think the set up was appropriate. There should be a doffing/donning by the exit door. During an interview on 12/2/20, at 1:56 p.m. the RNC stated R6 had remained in the room with R5 until R5 was hospitalized as he initially had refused to move rooms. The RNC verified the facility did not have documentation of R6's refusal to move rooms. During an interview on 12/3/2020, at 10:21 a.m. RNC stated the facility had nothing documented for contact tracing at this time for residents, but had a plan to complete an analysis once the outbreak had concluded. RN-C stated going forward the facility planned to review residents that were newly positive to identify if there are any common denominators between staff and residents that could be a potential link to possible spread. She stated for positive staff, the facility was completing the staff risk assessments however, going forward the facility was going to be expanding the analysis to include any potential exposure to residents they had cared for and other staff they had worked with and any potential exposures out of work. During an interview on 12/4/2020, at 9:16 a.m. certified nurse practitioner (CNP)-A stated was not aware the facility had not been aware residents were being inappropriately cohorted. CNP-A stated the symptomatic and/or COVID positive residents should absolutely not be in the same rooms as residents that are negative and/or do not have symptoms. The facility's COVID-19 policy revised 10/19/20 included, Policy: The facility will conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of COVID-19. Due to the constantly changing and fluid nature of [MEDICAL CONDITION]; the facility will monitor, follow, and implement recommendations and guidance in accordance with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), CMS (Centers for Medicare & Medicaid), and the State Department of Health to include identification and isolation of any suspected cases. The immediate jeopardy that began on 11/22/2020, was removed on 12/4/2020, at 2:37 p.m., when it could be verified the facility had reviewed their policies, had appropriately implemented cohorting and transmission based precautions strategies, had initiated risk assessments for residents, and had provided staff education.

Based on interview and document review the facility failed to appropriately monitor, implement physician orders [REDACTED]. R1 sustained harm when his condition deteriorated resulting in re-hospitalization , with [DIAGNOSES REDACTED]. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderate cognitive impairment. R1 required one staff physical assistance and supervision for eating and drinking. The MDS also included R1 was administered antibiotics. R1's Facility Admission record included, [DIAGNOSES REDACTED]. R1's hospital Discharge Summary dated 9/24/2020, indicated R1 was discharged to the facility on [DATE] and included [DIAGNOSES REDACTED]. Identified in the section titled, Active Issues Requiring Follow-up included the following, lab tests-CBC/BMP (complete blood count/basic metabolic panel) every three days and CRP (The level of C-reactive protein (CRP), which can be measured in your blood, increases when there's inflammation in your body) every three days. R1's physician orders [REDACTED].>-Encourage resident to drink plenty of water every day and even evening shift (order start date 9/24/2020) -[MEDICATION NAME] (antibiotic) 750 milligrams (mg) every other day (start date 9/24/2020) -[MEDICATION NAME] (antibiotic) 500 mg three times a day (start date 9/24/2020) R1's Post Acute and Long Term Care Standing Orders last revised 6/8/18, included orders for change in condition that directed the following; If patient is ill, yet clinically stable: -clear liquids if indicated -Encourage fluids if not on diuretic/[MEDICATION NAME]/have fluid restriction. -Monitor vital signs and intake and outputs each shift until symptoms resolved. -If patient has acute dyspnea (shortness of breath) collect vitals and notify clinician if vitals abnormal indicated below, condition unrelieved after 1 hour or if condition declines. -If temperature is >/=100.5, respiratory rate >28, heart rate >110, systolic blood pressure <80 or >200, oxygen saturations <88% from baseline room air/oxygen, notify clinician. R1's record lacked documentation of any follow up laboratory testing completed after R1 was admitted to the facility until 10/7/20. R1's Registered Dietician-Nutrition assessment dated [DATE], identified R1 was not on a fluid restriction and estimated daily fluid requirements were 1891 milliliters (ml) per day. The assessment indicated R1's average fluid intake at meals was less than 1200 ml; the section Comments r/t (related to) fluid intake was left blank. R1's Medication Administration Record [REDACTED]. R1's MAR indicated [REDACTED]. Although, R1's fluid intake was recorded in Point of Care (health record system for documentation used by nursing assistants) and identified R1's 24 hour daily totals as: -On 10/1/2020 intake was 900 ml -On 10/2/2020, intake 320 ml -On 10/3/ 2020 intake 640 ml -On 10/4/2020 intake 640 ml -On 10/5/2020, intake 800 ml -On 10/6/2020, intake 680 ml according to R1's record, R1 was not meeting daily fluid recommendations. R1's October MAR indicated [REDACTED]. -On 10/1/2020, output 1675 ml -On 10/2/2020, output 1320 ml -On 10/3/2020, output 1250 ml -On 10/4/2020, output 300 ml (no output documented for evening and overnight shift) -On 10/5/2020, output 850 ml -On 10/6/2020, output 400 ml R1's blood pressure record on 10/1/2020, at 10:10 p.m. was 88/57 R1's blood pressure record on 10/2/2020, did not identify a blood pressure was taken. R1's progress note dated 10/3/2020, at 3:38 p.m. indicated R1's blood pressure was 98/48. R1's progress note dated 10/4/2020, at 3:38 p.m. indicated R1's blood pressure was 88/47. R1's progress note dated 10/5/2020, at 6:51 a.m. indicated R1's blood pressure was 87/54 and included, Loose stools this shift. Resident febrile 100.8 short duration with sustained 100.1 t/o (sic). R1 was shivering and extra blankets were effective. Resident worried about loose stools; [MEDICATION NAME] {antidiarrheal) was not administered d/t abx (do to antibiotics) The note indicated the physician was notified. A subsequent note at 10:26 a.m. indicated R1 had multiple loose stools and R1's blood pressure was 88/47. R1's blood pressure record on 10/6/2020, at 1:03 p.m. was 102/57 and at 11:33 p.m. was 70/50. Although R1 had a decrease in urinary output, had a decrease in fluid intake with low blood pressures from 10/1 through 10/5/2020, there was not evidence the physician was notified until 10/5/2020 when the Covid ( a mild to severe respiratory illness that is caused by a coronavirus) and [MEDICAL CONDITION] (Clostridioides difficile is a bacterium that causes diarrhea and [MEDICAL CONDITION] (an inflammation of the colon) testing was ordered. However the record did not include a response from the physician in relation to input/output and low blood pressures. In addition, the record lacked evidence of R1 being monitored and assessed to correct low blood pressures or loose stools. R1's physician note dated 10/7/2020, indicated on 9/25/20 R1's labs included creatinine (Cr) (A test reveals important information about your kidneys) was 1.1, BUN (bun urea nitrogen) 13, GFR >60 and sodium 137, but today (10/7/20) Cr 2.2, BUN 37, and GFR 29 and noted acute kidney injury with today's results. Resident is fatigued, hypotensive (low BP). The note also indicated the physician had given a verbal order for R1 to be sent to the emergency department. R1's progress note was dated 10/7/2020, at 2:38 p.m. included Resident today had a low BP of 55/39. A call from NP (nurse practitioner) to update nursing that residents labs showed signs of acute kidney injury disease and stated she had attempted to make contact with family but was unable. NP stated she had called (name of hospital) to update on resident status and to send resident to (hospital) ED (emergency department) During an interview on 10/15/2020, at 1:46 p.m. director of nursing (DON) stated nurses were supposed to be tracking and monitoring fluid intake as well as the nursing assistants. DON stated diarrhea could cause dehydration, and low blood pressures could be a symptom of dehydration. DON indicated the focus and concern was COVID symptoms and in hind sight should have completed dehydration assessment. DON indicated when the physician was notified of the loose stools on 10/5/2020, a COVID and [MEDICAL CONDITION] labs were ordered. DON further indicated that adequate fluid intake was important when residents had [MEDICAL CONDITION] and antibiotics were hard on kidneys. DON indicated the facility did not currently have a system in place to track fluid intake, however, it would be a standard of nursing practice and something a physician would not specifically order. During an interview on 10/15/2020, at 2:58 p.m. R1's family member (FM)-1 stated once R1 arrived at the emergency room physicians were concerned of septic shock and his kidneys were shutting down. R1 had very low blood pressure, and normally R1 had high blood pressure. FM-1 stated the emergency room had a difficult time starting a IV (intravenous catheter) because of low blood pressure, and R1 received 5 bags of fluids and an IV medication to increase his blood pressure. FM-1 stated R1 was then transferred to another hospital, admitted to the intensive care unit (ICU) where they gave him 2 more bags of fluids. During an interview on 10/15/2020, at 4:09 p.m. nurse practitioner (NP)-A confirmed R1's [DIAGNOSES REDACTED]. NP-A reviewed R1's lab records; stated labs were not completed per the hospital discharge summary, stated an unawareness of why they were not completed and they should have been. NP-A stated the facility should have been monitoring and evaluating R1's fluid balance, it was a standard of practice. NP-A stated the facility should have identified and reported the decrease in intake/output in conjunction with the presence of low blood pressures, and was not provided that information. R1's recorded fluid intake and outputs were reviewed with NP-A, NP-A stated fluid intake and output is very low. During an interview on 10/15/2020, at 4:38 p.m. registered nurse (RN)-A reviewed R1's fluid intakes and outputs; stated the physician should have been notified about the decrease and further assessment of dehydration should have been completed. RN-A indicated staff were supposed to encourage fluid intake with encounters, however the amount and/or refusals were not documented. During an interview on 10/15/2020, at 5:16 p.m. NA-C thought she remembered R1 having loose stools prior to going to the hospital. NA-C stated she would encourage R1 to take a drink when she took care of him, however she did not record the amount. During an interview on 10/15/2020, at 5:42 p.m. hospital-1 registered nurse (H1-RN) stated R1 arrived at the ED on 10/7/2020, at 2:40 p.m. H1-RN stated R1 had been diagnosed with [REDACTED]. H1-RN stated when R1 arrived at the hospital blood pressure was 77/41, a central line was attempted however, it didn't work. H1-RN stated R1 was administered a bolus of fluid, two IV antibiotics, and a [MEDICATION NAME] drip. H1-RN confirmed R1 received fluids continuously over the course of 5 hours he was at hospital-1. H1-RN indicated R1's labs were indicative [MEDICAL CONDITION] and dehydration; and renal function and sodium levels had slightly improved after fluid administration. H1-RN stated R1 was transferred to hospital-2 at 8:23 p.m. During an interview on 10/15/2020, at 7:04 p.m. hospital-2 registered nurse (H2-RN) confirmed R1 arrived at hospital-2 and was admitted to the ICU. H2-RN indicated R1 was administered fluids. H2-RN stated dehydration could cause acute [MEDICAL CONDITION]. Facility policy Change in Condition 12/19/2018, included: The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed: Specific information that requires prompt notification include, but is not limited to: Significant change or instability of vital signs; Prolonged/unresolved emesis/diarrhea A significant change in the resident's physical/psychosocial/mental condition A need to alter the resident's medical treatment significantly Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional and resident representative will be documented in medical record. Facility Hydration Policy that was undated included: It is critical that each resident at risk for hydration deficit or imbalance .be identified and assessed to determine appropriate interventions. The resident may experience a decline in appetite or have difficulty eating or swallowing. Upon admission, each resident will be assessed by the R.D. to determine estimated fluid needs and risk for dehydration. Fluid needs and risk for dehydration will be documented in the Registered Dietician Nutritional assessment. Upon admission, Nursing will also assess physical status, including, but not limited to skin turgor, mucous membranes, urinary status, and vitals to determine if resident has adequate hydration or risk factors are presents. Residents who already reside in the building will be assessed for risk or symptoms of dehydration on a quarterly basis, or as needed if risk increases or symptoms are present. Conditions that contribute to increased risk of dehydration include, but are not limited to the following: increased fluid losses; included diarrhea, acute illness or fever, poor fluid intake, presence of an infection. If resident is at elevated risk of dehydration or symptoms of fluid deficit/dehydration are present, resident will be immediately referred to the I-team and/or MD for further review and assessment Symptoms of dehydration include, but are not limited to: orthostatic [MEDICAL CONDITION], dry mucous membranes decreased urine output or concentrated urine, change in lab values If resident is at elevated risk of dehydration or symptoms of fluid deficit or dehydration are present, any or all of the following interventions will be implemented and the care plan will be updated. MD notification, PUSH fluids order, Daily weights, Basic metabolic panel or other labs, IV hydration, Alert staff of increased fluid needs, Monitor vitals per protocol, Start resident on Hydration Program, Daily Intake and Output monitoring.

Based on observation, interview, and document review the facility failed to implement transmission based precautions when R39 demonstrated flu like symptoms then tested positive for Influenza A, and failed to operationalize the facility's surveillance program in order to prevent the spread of influenza which had the potential to cause serious injury impairment or death for all residents, visitors, and staff. The facility's failures resulted in immediate jeopardy (IJ). In addition, the facility failed to ensure appropriate hand hygiene was maintained during personal cares for 2 of 2 residents (R16 and R28) observed for personal cares who had indwelling catheters; and failed to ensure appropriate disinfection of glucometers (used to check blood sugars) for 2 of 2 residents (R46 and R17). The IJ began on 12/31/19, when R39 was observed to have influenza like symptoms and the facility failed to obtain physician ordered influenza swab, failed to implement appropriate transmission based precautions to prevent spread of infection, and failed to implement infection control surveillance to identify trends or patterns of potential infectious outbreaks. The IJ was identified on 1/6/2020, and the administrator and interim director of nursing (IDON) were notified of the IJ at 3:36 p.m. on 1/6/2020. The IJ was removed on 1/8/2020 however, noncompliance remained at the lower scope and severity level of F- widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Influenza Precautions: During an observation on 1/6/2020, at 11:59 a.m. R39 was seated in a wheelchair in her room. No signage was observed on R39's room door, and there was no personal protective equipment (PPE) cart outside the resident's room. At 12:06 p.m. the surveyor heard licensed practical nurse (LPN)-E directing nursing assistant (NA)-M that R39 required a room tray for lunch and somebody needed to sit with her because she was on droplet precautions. At that time, the surveyor asked LPN-E why R39 was on droplet precautions and LPN-E stated R39 had been diagnosed with [REDACTED]. Further LPN-E stated all residents had been started on [MEDICATION NAME] (an [MEDICAL CONDITION] that lessons flu symptoms). On 1/6/2020, at 12:10 p.m. NA-M walked into R39's room, donned a facemask and sat next to R39 to provide verbal cues for R39 to eat her food. NA-M did not wear gloves. At 12:17 p.m., NA-M picked up R39's lunch tray, walked out of R39's room, removed her mask as she walked and disposed of the mask in a small waste receptacle on a wound treatment cart, then placed the food tray on a cart, used hand sanitizer located in the hallway, and walked into another resident's room. During interview with NA-M on 1/6/2020 at 12:19 p.m., NA-M stated R39 required supervision with meals and had to eat in her room because she was sick. NA-M stated she was unaware of what R39 was sick with. NA-M verified R39 did not have signage on her door or an isolation cart with PPE in or outside of R39's room to alert staff R39 was ill. NA-M stated she was not aware if R39 was considered to be on isolation related to illness. -At 12:21 p.m. LPN-E stated when someone was diagnosed with [REDACTED]. LPN-E stated on Friday there was supposed to be an isolation cart put in front of R39's room, and separate laundry and trash containers were supposed to be placed in her room. LPN-E stated she was uncertain why this had not happened but was currently working on it. LPN-E stated staff were supposed to put on a gown, mask, and gloves prior to entering R39's room. Further, LPN-E stated when a resident was placed on isolation, a message was posted to a message board in the electronic health record (EHR) program. During the interview, LPN-E accessed the message board in R39's EHR and verified there was no alert posted, and R39's care plan had not been revised. R39's Admission Record dated 1/10/19, included [DIAGNOSES REDACTED]. R39's SBAR (communication tool) progress note dated 12/31/19, at 4:00 a.m. included: Situation: Sx (symptoms) started 12/30/19 evening. T (temperature) 100.6. Non productive croup cough. runny nose, low grade fever. The note further indicated R39 had been administered cough syrup and a breathing treatment. Temperature at 4:00 a.m. was 99.6. R39's physician visit note dated 12/31/19, documented the reason for visit as: non-productive cough with fever. Per the physician note, R39 had a temperature of 100.6 during the overnight on 12/30/19 with a non-productive cough, and on 12/31/19 had a temperature of 99.6. Per family reports she was at her baseline on Sunday 12/29 when she attended a family Christmas gathering. There were no sick contacts present however, there were family members that were not present who do have flu. The note indicated family had reported to the physician that during the gathering, R39 had a new cough and had been coughing several times during the gathering. The physician's note further indicated R39's symptoms were consistent with [MEDICAL CONDITION] exacerbation and would start empiric treatment which included 5 day course of [MEDICATION NAME], and [MEDICATION NAME] (antibiotic). In addition, the note directed labs to be done for influenza A/B and Respiratory [MEDICAL CONDITION]. R39's record included the lab order for influenza A/B swab that was dated 12/31/19 at 2:00 p.m. however, R39's record lacked evidence the lab work had ever been completed. R39's treatment administration record (TAR) included an order to: Monitor symptoms while on antibiotic, document in PCC (Point Click Care, an electronic medical record) every shift for 5 days, notify provider of symptoms (start date 12/31/19). The order was revised on 1/2/2020 to monitor until 1/11/20. `In addition, the TAR had boxes checked and staff initials that indicated the directive was completed, and R39's vital signs were documented once daily on the TAR. R39's record and TAR, did not indicate what types of symptoms staff should be monitoring for. Review of R39's record indicated vital signs were taken once daily from 12/31/19- 1/2/2020. A physician's visit note dated 1/2/2020, indicated R39's physician was conducting follow-up from the 12/31/19 visit. The Impression/Report/Plan section included of the note included: #4 Cough and #5 Influenza like illness. Documentation of the physical examination indicated R39 had: Adventitious lung sounds; crackles in both lungs and expiratory wheezes. The note indicated the plan was to continue breathing treatments four times a day, obtain chest x-ray, implementation of close monitoring, start on additional antibiotic, and obtain influenza swab. R39's record indicated the influenza swab was completed at 6:20 p.m. on 1/2/2020, and on 1/3/2020 at 12:09 a.m. the completed lab results revealed R39 was positive for influenza. A facsimile (Fax) received at the facility from the physician at 10:27 a.m. on 1/3/2020, included: Patient is positive for influenza [NAME] Place on droplet precautions and isolate to room. Unfortunately, symptom duration is outside of treatment parameters, ill since 12/31/19. Will speak to medical director regarding possible [MEDICATION NAME] in the facility. According to R39's physician orders, the order for droplet precautions for 7 days had not been transcribed into the electronic health record until 3:34 p.m. (5 hours after the order was received). A physician visit note dated 1/3/2020, included: Resident (R39) has tested positive for Influenza [NAME] Director of Nursing at Edenbrook has been informed in person and asked to please start isolation precautions. The assistant DON (ADON), HUC (health unit coordinator), medical director, and provider informed via email. The note further indicated upon physical exam, R39 Continued to have adventitious breath sounds and had a cough. The plan included: Unfortunate 2nd to the fact that patient has had symptoms for greater than 72 hours, will not treat influenza. She should be isolated, on droplet precaution. When she is out of her room she should wear a mask. The note was electronically signed by the physician at 2:23 p.m. According to R39's physician orders, [MEDICATION NAME] 30 mg (milligrams) once per day for influenza A for 5 days was started on 1/4/2020. Review of the (MONTH) infection control log was blank and facility records lacked evidence of infection prevention measures (with the exception of empiric [MEDICATION NAME] for eligible residents) and documentation to indicate there would be surveillance activities implemented. During an interview on 1/6/2020, at 1:00 p.m. the facility's ADON stated licensed practical nurse (LPN)-B was the infection preventionist for the facility. When was asked to provide the facility's infection control logs for (MONTH) 2020, the ADON stated the logs were maintained electronically. The ADON accessed the electronic log for January, however it was blank. The ADON verified the log was blank, and stated LPN-B needed to update it. The ADON stated R39 had started demonstrating flu like symptoms on 12/30/19 however, also stated the resident had frequent respiratory symptoms due to her chronic obstructive [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). When the ADON opened the (MONTH) 2019 infection control log, R39 was not identified even though R36 was seen by the physician on 12/31 and treated with an antibiotic. The ADON verified a nurse practitioner (NP) had seen R39 on 1/2/2020, because R39 continued to have symptoms. She stated the NP had ordered an influenza swab, and had performed the test. During the interview, the IDON stated she was not aware of R39's symptoms until 1/2/2020 around 4:00 p.m. The ADON stated during the morning of 1/3/2020, the NP had communicated to the facility R39's swab was positive for influenza A, so the NP had prescribed droplet precautions, and had communicated to staff that if R39 came out of her room she was supposed to have a mask on. The IDON and ADON confirmed the precautions to prevent transmission had not been implemented as prescribed. R39 was not isolated to her room, and continued to wheel herself around the facility without a mask on between 12/31/19 and 1/3/2020 when the swab test had come back positive. Further, the IDON stated on 1/3/2020, when R39 came out of her room with a mask on because it was difficult to keep in her room because of R39's cognitive impairment. The ADON stated, After we got the positive results staff were made aware immediately, and it was added to the 24 hour report. The IDON stated droplet precautions consisted of gown, mask, gloves however, verified the precautions were not implemented according to facility policy, and surveillance was not operationalized as it should have been. During an interview on 1/8/2020, LPN-B confirmed she had been assigned to oversee the facility's infection control program in (MONTH) 2019. She stated a nurse consultant had been responsible prior to her appointment. LPN-B also stated since her appointment to this role, she had received some training and had started the Centers for Disease Control (CDC) education modules. LPN-B stated, Until this week I was not aware that tracking of illness started at the time of onset. During an interview on 1/9/2020, at 1:05 p.m. with LPN-B, IDON and registered nurse consultant (RNC), RNC indicated that prevention measures and surveillance were essential to prevent or minimize further spread or outbreak. RNC stated, More people will get it if appropriate measures are not put into place. The IDON stated staff had not provided R39 a mask prior to 1/3/2020, and confirmed R39 had the likelihood of coming into contact with others in the facility which could impact others, and could potentially lead to serious medical issues and/or death. Review of the facility's infection control logs from (MONTH) through present were also completed with LPN-B, RNC, ADON. ADON and LPN-B confirmed the surveillance log documents did not identify illnesses that were not treated with antibiotics, lacked identification and investigation of infectious trends, and also lacked evidence of infection control prevention activities. During an interview on 1/10/2020, at 4:00 p.m. interim director of nursing (IDON) confirmed the influenza lab was not completed on 12/31/19, per physician order [REDACTED]. Review of the (MONTH) infection control log was blank and facility records lacked evidence of infection prevention measures (with the exception of empiric [MEDICATION NAME] for eligible residents) and implementation of surveillance activities. During an interview on 1/6/2020, at 1:00 p.m. assistant director of nursing (ADON) stated licensed practical nurse (LPN)-B was the infection preventionist for the facility. When ADON was asked to provide the facility's infection control log for January, ADON indicated the logs were kept electronically, she opened the spreadsheet for January, the log was blank. ADON verified the log was blank and indicated LPN-B needed to update it. ADON indicated R39 had started demonstrating symptoms on 12/30/19, however, she frequently had respiratory symptoms on and off because of chronic obstructive [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). ADON opened the (MONTH) infection control log, R39 was not identified. ADON stated R36 was seen by the physician on 12/31 and treated with antibiotic. ADON indicated the nurse practitioner saw her on 1/2/2020, because R39 continued to have symptoms, ordered the influenza swab, and performed the test. IDON stated she was not aware of R39's symptoms until 1/2 around 4:00 p.m. ADON stated the next morning on 1/3 the NP communicated that R39's lab resulted in positive for influenza A, ordered droplet precautions, and if R39 came out of her room she was supposed to have a mask on. Interim director of nursing (IDON) and ADON stated transmission precautions had not been implemented, R39 was not isolated to her room, and R39 wheeled herself around the facility without a mask on between 12/31/19, and 1/3/19 when the test came back positive. IDON stated on 1/3, when R39 came out of her room she had a mask on, she was difficult to keep in her room because of cognitive impairment. ADON, stated after we got the positive results staff were made aware immediately, and it was added to the 24 hour report. IDON stated droplet precautions consisted of gown, mask, gloves. IDON verified transmission precautions were not implemented and the facility policy for surveillance was not operationalized and should have been. During an interview on 1/8/20, LPN-B indicated she had been assigned to oversee the infection control program in (MONTH) 2019, a nurse consultant had been responsible prior to her. LPN-B indicated since that time she has had some training and had started the Centers for Disease Control (CDC) education modules. LPN-B stated until this week was not aware that tracking of illness started at the time of onset. During an interview on 1/8/2020, at 12:46 p.m. (ADON) stated she did not have formal infection control training however, had started the CDC education modules. During an interview on 1/9/2020, at 1:05 p.m. with LPN-B, ADON, and registered nurse consultant (RNC), RNC indicated that prevention measures and surveillance were essential to prevent or minimize further spread or outbreak. More people would get it if appropriate measures were not put into place. IDON stated R39 did not have a mask on prior to 1/3, and potentially could have come into contact with everybody who was in the facility and impact to others could have potentially lead to serious medical issues and/or death. Review of the facility's infection control logs from (MONTH) through present were also completed with LPN-B, RNC, ADON. ADON and LPN-B confirmed the surveillance logs did not identify illnesses that were not treated with antibiotics and documentation lacked identification and investigations of infectious trends, and also lacked evidence of infection control prevention activities. During an interview on 1/10/2020, at 4:00 p.m. interim director of nursing (IDON) confirmed the influenza swab was not obtained for testing on 12/31/19, per physician order [REDACTED]. The facility's 9/18/18 Isolation Precautions policy included: To establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to other. Droplet Precautions: 1) implement droplet precautions for resident with suspected or confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing, talking, or during procedures. 2) Residents shall be placed in a private room if available. 3) Prior to entering the isolation room, the following steps are required: a) perform hand hygiene and apply gloves and mask prior to entering the room. b) while providing direct care, remove gloves and wash hands after coming in contact with infectious material: c) Remove gloves and perform hand-hygiene before leaving room. 4) adequately clean/disinfect an items with an approved solution prior to removing the item from room and before use on another resident. The facility's 12/3/18 Infection Control Program protocols included: The facility establishes a program which investigates, controls, and prevents infections in the facility. Decides what procedures such as isolation, should be applied to an individual resident and maintains a record of incidents and corrective actions related to infections. The policy also included: The intent of the policy is to assure, through the infection control program systems in place, to provide surveillance investigation and monitoring to prevent, to the extent possible, the onset and the spread of infection. Prevent and control outbreaks and cross-contamination using transmission based precautions in addition to standard precautions. Develop implement, maintain nursing home process using data records of incidents corrective action taken, and staff education to improve infections outcomes. The IJ that was identified on 1/6/2020, was removed on 1/8/2020, at 11:05 a.m. when appropriate transmission based precautions and notifications were implemented for R39, the facility's surveillance program was properly implemented, and education was provided to all staff. The removal plan was verified by review of documents, interviews with staff, and observation. R27's Resident Progress Notes identified the following: 1/3/20, at 14:06 (2:06 p.m.) Situation: Resident is presenting with wet cough and fatigue. Assessment (RN) Appearance (LPN): Vitals: 140/82, 98.2, 78, 18, 98% Recommendations/Requests: influenza swab. 1/6/20, at 20:06 (8:06 p.m.) Visited with resident tonight and asked her if she was having any symptoms of influenza. She denies coughing and stated, I only coughed one day last week and it was because of [MEDICAL TREATMENT]. No observations of coughing. Resident temperature was 99.3 Fahrenheit when checked tonight. When asked further about symptoms, she stated, I am just tired from [MEDICAL TREATMENT]. Res was started on [MEDICATION NAME] on 1/4/20 and the influenza swab was completed tonight and sent to the lab via courier at 6:30 p.m. tonight. Will await results. R27's Medication Administration Record [REDACTED]. During interview on 1/6/20, at 4:51 p.m., RN-A stated she obtained the swab (influenza) this evening, due to the order from the physician to obtain an influenza A and B swab. RN-A stated the SBAR (communication sheet to the physician) had been documented Friday, but the order just came up today. RN-A stated with possible flu, I could have done something sooner, like call the on call provider. RN-A further stated the SBAR note was documented at 2:00 p.m. on Friday (1/3/2020), but was left in a box for the provider to address during a visit at the facility. RN-A verified the note would have not been looked at by a provider until today (1/6/2020). During observations on 1/6/20 at 6:40 p.m., R27 was placed on isolation droplet precautions. During interview on 1/13/20 at 11:22 a.m., the IDON stated if R27's symptoms had continued, she would have expected staff to follow up with the on call physician over the weekend. HAND HYGIENE: During an observation on 1/6/19, at 2:29 p.m. R16 was laying in bed on her back, and an indwelling urinary catheter was observed secured on the bed frame. NA-J and LPN-C donned gloves, removed R16's incontinent garment, and assisted R16 to a side lying position. A small amount of stool was observed on R16's bottom. NA-J removed the stool with an incontinent wipe. While wearing the same gloves, NA-J applied barrier cream inside the gluteal folds and rectal areas prior to rolling R16 back onto her back. Then NA-J cleaned R16's groin area and peri-area with a new wipe, and then proceeded to apply barrier cream to R16's groin without having removed her gloves, or use of hand sanitizer. In addition, NA-J did not clean the catheter tubing. When care was completed, NA-J and LPN-C removed their gloves and sanitized their hands. During an observation on 1/8/19, at 3:00 p.m. NA-A and NA-L donned gloves and removed R28's incontinent brief while he laid in bed. The NA's assisted R28 to roll onto his side, a small amount of stool was observed at R28's rectum. NA-A used an incontinent wipe to remove the stool then rolled R28 back over onto his back. Without changing her gloves, or using hand sanitizer, NA-A used a new wipe to clean R28's groin, and to cleanse the exposed urinary catheter tubing (approximately 3-5 inches coming out of penis). NA-A then removed gloves and sanitized her hands. During an interview on 1/8/19, at 3:38 p.m. NA-A verified she had washed R28's bottom, followed by his groin, followed by wiping the catheter tubing. NA-A stated she should have either cleaned the catheter first, proceeding to the groin, then the bottom, or changed her gloves after cleansing R28's rectal area. During an interview on 1/9/19, at 1:05 p.m. the facility's assistant director of nursing (ADON) and consultant registered nurse (CRN) confirmed staff should have changed their gloves and conducted hand hygiene after cleaning the residents rectal areas. They also stated staff should have provided cares to the cleanest area first prior to cleansing feces from the rectum. GLUCOMETER CLEANING: During observation on 1/8/20 at 10:56 a.m., LPN-C, washed hands, applied gloves and checked R46's blood sugar using an individual resident glucometer. LPN-C removed gloves, carried the glucometer out to the medication cart with bare hands and cleansed the glucometer using a micro drop bleach wipe with bare hands. LPN-C then washed her hands. During interview on 1/8/20 at 11:06 a.m., LPN-C verified she had not applied gloves prior to cleansing the glucometer. During observation on 1/8/20 at 11:11 a.m., RN-B applied gloves, checked R17's blood sugar using an individual resident glucometer, removed gloves, carried the glucometer out of R17's room and laid the glucometer on top of the medication cart. RN-B then obtained supplies and prepared insulin for injection (cleansed rubber [MEDICATION NAME] with alcohol wipe and drew up insulin into a syringe) to administer to R17. RN-B entered R17's room, washed hands, applied gloves, administered the insulin to R17, removed gloves, washed hands, walked back out to the medication cart and documented the administration of the insulin. RN-B prepared an oral medication for R17, administered the medication and documented the medication. The glucometer used to check R17's blood sugar remained on top of the medication cart without having been disinfected. During interview on 1/8/20 at 11:29 a.m., RN-B confirmed she had not washed hands before or after checking R17's blood sugar and had not cleansed the glucometer. During interview on 1/10/20 at 11:55 a.m., the interim director of nursing (IDON) stated staff should use gloves when cleansing a glucometer, hands should be washed before checking a blood sugar and after checking a blood sugar, and staff should be cleansing the glucometer after checking a blood sugar with the appropriate wipes. The facility's 11/20/19 policy Cleaning and Disinfection of a Glucometer, indicated all glucometers were to be cleaned and disinfected using a 1:10 bleach (sodium hypochlorite) solution or commercially prepared EPA (Environmental Protection Agency) germicidal (bleach) wipe. The policy further indicated staff should perform hand hygiene and apply gloves before cleaning the glucometer, and after cleaning the glucometer, should remove gloves and perform hand hygiene.

Based on observation, interview, and document review the facility failed to adequately assess, monitor and implement interventions to treat [CONDITION(S)] and related concerns for 3 of 3 residents reviewed (R22, R9 and R52). R22 sustained harm when the skin in the lower extremities opened up due to the [CONDITION(S)], became infected, and required antibiotic treatment. Findings include R22's hospital discharge summary dated 9/26/18, indicated R22 presented to the emergency department because of weight gain and physical exam demonstrated significant peripheral [CONDITION(S)]. The Discharge documentation dated 9/26/18, indicated R22 had been admitted to the hospital on 9/24/18 and was discharged [DATE]. The documentation indicated R22 had [CONDITION(S)] with blisters that would come and go. R22's admission progress note dated 9/27/18, indicated R22 had open areas from the blisters caused by [CONDITION(S)]. Additional review of R22's record lacked evidence of ongoing skin and [CONDITION(S)] evaluations since the time of admission until the first Weekly Skin Check evident in the record dated 11/1/18. R22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Minimum Data Set (MDS) assessment dated [DATE], indicated R22 had no cognitive impairment and did not exhibit rejection of care behaviors. The MDS indicated R22 required extensive assistance from two plus staff for bed mobility, transfers, toileting and dressing. The MDS further indicated R22 had no rashes, [CONDITION(S)], moisture associated skin damage and/or required applications of ointments/creams. The MDS also indicated R22 took a diuretic medication. R22's activity of daily living Care Area Assessment (CAA) dated 10/9/18, included; resident recently hospitalized with congestive heart failure exacerbation and is on supplemental oxygen. R22's Nursing Home Standing Orders dated 9/27/18, included: Congestive Heart Failure: Daily weights unless otherwise ordered. Notify provider if weight increases above established dry/baseline weight over 2 pounds in 2 days or 5 pounds in 7 days. Additionally, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's [CONDITION(S)] care plan dated 10/10/18, indicated R22 had [CONDITION(S)] related to CHF. Interventions included; administer/monitor the effectiveness of medication, monitor edematous area(s) for skin changes, observe for signs/symptoms of [CONDITION(S)] or fluid overload (respiratory difficulty, increased swelling, change in vital signs). R22's diuretic therapy care plan dated 10/10/18, related to [CONDITION(S)] and hypertension included interventions of: monitor dose may require modification in order to achieve desired effects while minimizing adverse consequences. R22's congestive heart failure care plan dated 10/10/18, included interventions of check breath sounds and monitor/document labored breathing, monitor/document/report to MD as needed any signs of and symptoms of congestive heart failure: dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], shortness of breath on exertion, cool skin, dry cough, weakness, weight gain unrelated to intake, increased heart rate, lethargy, and disorientation. R22's skin integrity care plan dated 9/27/18, included interventions of: keep skin as clean and dry as able, monitor skin and report changes, treatments as ordered. R22's progress note dated 10/11/18, indicated R22 had bilateral lower extremity [CONDITION(S)] 2+ and lungs were clear to auscultation. R22's progress note dated 10/17/18, indicated lungs were auscultated and trace bilateral lower extremity [CONDITION(S)]. R22's progress note dated 10/20/18, indicated bilateral lower extremity [CONDITION(S)] 2+, would update MD (medical doctor) as needed. R22's progress note dated 10/23/18, indicated bilateral lower extremity [CONDITION(S)] 2-3+, weeping left lower extremity ABD pads (absorbent dressing) applied to contain moisture. Will continue to monitor and update MD as needed. R22's progress note dated 10/25/18, indicated R22 continued to have bilateral lower extremity [CONDITION(S)] 2-3+ with weeping to the left lower extremity, ABD was applied to contain moisture, and would continue to monitor and update MD as needed. R22's physician visit dated 11/1/18, indicated R22 had skin irritation in the groin folds and staff reported excoriation on the left inner upper thigh that was raw and rough appearing. The physical exam indicated the physician viewed the left inner thigh and described as: excoriated, erythemic area noted on the left inner leg, starting just below the popliteal fossa and extending up to the mid thigh, also had scaly yellow skin to the thigh area. The skin itself looked quite raw but there were no open areas. The physical exam also indicated R22 had 2+ lower extremity pitting [CONDITION(S)] and no ace wraps were on. The note included She will continue with [MEDICATION(S)] daily and daily weights, and going to have staff apply low stretch wraps on her lower extremities, on in the morning and off in the evening to assist with her lower extremity [CONDITION(S)]. She tells me staff is using some sort of cream to her lower extremities every day. I am unsure if this is that any cream or urea, although staff has not documented that they have been using urea. Aside from excoriation on her left inner leg, the rest of her left lower extremity is intact. I will have staff apply [MEDICATION(S)] to her left lower extremity excoriation. In any excoriation that is noted on the right lower extremity. I will have staff use this twice a day and I will reevaluate in 2 weeks on my return. Staff will continue to monitor for any [CONDITION(S)]. R22's Weekly Skin Check and Skin Wound Progress documentation included: 11/1/18, at 9:58 a.m.: skin turgor-poor elasticity, no skin alterations. (Physician had more detailed description of skin and irritation). 11/8/18: skin turgor-good elasticity, no skin alterations. 11/11/18: resident has peripheral [CONDITION(S)]. 11/13/18, indicated R22 had moisture associated skin damage on the left knee, skin was intact, no drainage, and no drainage. The note indicated the area as resolved. 11/15/18: indicated R22 had an open area on right lower extremity medial portion of leg. Hydrogel impregnated gauze and [MEDICATION(S)] applied over for protection per standing orders until wound nurse could assess. A separate Weekly Skin check dated 11/15/18, indicated both of R22's legs were weeping. 11/17/18: R22's left leg below the knee had an area of redness that was weeping clear fluid. The area was cleansed with normal saline and covered with ABD and secured with roll gauze. 11/22/18: indicated weeping to bilateral legs. 11/29/18: did not identify any skin concerns. The record further lacked comprehensive evaluation of the open and/or weeping areas. R22's weight records were also reviewed. Although daily weights were ordered, the record did not include daily weight monitoring: 11/2/18, weight was 293.8 11/4/18, weight was 293.8 11/5/18, weight was 295.6 11/6/18, weight was 295.0 11/7/18, weight was 299.8-weight reflected over a 2 pound weight gain in two days 11/15/18, weight was 299.8 11/16/18, weight was 299.2 No weights were documented between 11/16 and 11/28/18. 11/28/18, weight was 298.0 12/1/18, weight was 298.2 12/2/18, weight was 297.7 12/3/18, weight was 295.7 During an observation and interview on 12/3/18, at 4:19 p.m. R22 was observed to be sitting in her wheelchair with her legs dependent (down). Both legs were observed to be edematous, with no compression stockings or compression wraps on. R22's right inside pant leg from the knee down was wet. R22 stated the wetness was from her leg weeping, and stated she'd asked the nurse to cover the area however, stated the nurse wanted it to drain. R22 stated she was supposed to have ace-wraps on but they hadn't been put on today. R22 also stated her weight fluctuates because of fluid. During an observation on 12/4/18, at 8:32 a.m. R22 was sitting on a commode in her room; nursing assistant (NA)-E was providing morning cares. R22's legs were observed to be edematous, her right shin had multiple superficial ulcerations observed that were slightly red and did not have ace-wraps on. During an observation and interview on 12/4/18, at 3:39 p.m. R22 was observed seated in her wheelchair in her room with her legs dependent, she had fuzzy socks on but no ace-wraps had been applied. R22 stated her legs were again weeping. R22's legs were observed to be more edematous than when observed earlier that morning. The right leg had a small amount of weeping from the shin area, from just below the knee to lower shin the skin was observed to be scaly, peeling, and errythemous (red). The right shin area continued to show superficial abrasions. R22 confirmed her right leg seemed more edematous, abrasions, and the flaking skin, and stated sometimes that happened. R22 verified the abrasions were not being covered and staff had not wrapped her legs today. During an observation and interview on 12/5/18, at 10:00 a.m. R22 was again observed sitting in her wheelchair with her legs dependent. R22's legs were observed to be edamatous. R22's right leg continued to be red and had small open superficial abrasions on the shin. R22 stated she did not have her ace wraps on today and stated they'd not been put on yesterday either. R22 stated she was not sure why they hadn't been applied. R22 stated both legs were really weeping last night and that staff had to put a sheet down to catch all the drainage otherwise it got all over her pants. R22 stated for the last several nights she has had to put something down to catch the drainage, but last night there was more. R22 indicated her legs did not hurt. During an observation and interview on 12/5/18, at 10:34 a.m. R22 was in the therapy room with physical therapist assistant (PTA)-A. PTA-A asked permission to look at R22's legs. R22's right leg had very firm [CONDITION(S)] and her pant leg and socks were damp from weeping. The right leg had red scaly skin below the knee with superficial open abrasions and scabs. The left leg was also edematous with red scaly skin just below the knee to mid shin with scabbed superficial wounds around the outside of the ankle. PTA-A stated R22 has had [CONDITION(S)] since admission, stated her legs get wrapped but it was dependent on how busy staff were. During an interview on 12/5/18, at 11:37 a.m. registered nurse (RN)-C stated R22 was supposed to have ABD bandages (absorbent wound dressings) applied to her legs where there was weeping and the ace-wraps applied in the morning. RN-C stated the weeping started about 10 days ago. RN-C then stated nurses were supposed to document on the skin integrity and measure the amount and extent of [CONDITION(S)]. RN-C also stated R22 was on diuretic therapy. R22's Skin and Wound Evaluation dated 12/5/18, indicated moisture associated skin damage of the right shin that measured 6.1 cm (centimeters) by 2.9 cm with light serous drainage, [CONDITION(S)] non-pitting [CONDITION(S)] around the wound, no dressing, and indicated treatment as moisture barrier and moisture control. The note was later updated to include: Resident has redness and scaly skin on right lower extremity with non-pitting [CONDITION(S)] and weeping. There is some skin breakdown in medial side just below the knee. The section for notes was originally left blank however, later included: We are applying mycology cream to the redness in order to help the skin heal. Nurses should try to allow the skin to air out overnight in order to not have the skin being constantly wet and moist. The note further indicated the physician was not updated. During an interview on 12/5/18, at 12:25 p.m. registered nurse consultant (RNC) was asked to observe and assess R22's lower extremities and review the skin assessment that had been completed for accuracy and completion. During an interview on 12/5/18, at 1:57 p.m. licensed practical nurse (LPN)-C sated she had been trying to wrap R22's legs this morning, and once she had them wrapped RN-E had removed the ace wraps and tried to re-wrap them. LPN-C stated R22's legs had been weeping and need to be covered with an ABD dressing or something to catch the drainage before the ace-wraps were applied. LPN-C stated R22 did not like to lay down during the day, which would help with the [CONDITION(S)]. During an interview on 12/5/18, at 1:58 p.m. LPN-D stated, [R22's] legs weep, even if you wipe it away, it comes right back. LPN-D then stated he had wrapped the resident's legs at night to catch the drainage because R22 didn't want the drainage all over the place. LPN-D stated R22 had refused to wear her wraps, but stated any refusals should be documented. LPN-D further stated R22 was encouraged to put her feet up. During an interview on 12/5/18, at 2:18 p.m. RN-E confirmed he had completed the skin assessment. RN-E stated no [CONDITION(S)] was marked because the wounds were not edematous. RN-E indicated the note section was not completed because the checked boxes completed the wound assessment. RN-E stated the treatment was [MEDICATION(S)] cream (antifungal) to the area of scaly skin, redness, and abrasions. RN-E stated the abrasions were not being covered, ABD dressings were supponsed to be on the legs during the day to soak up moisture and keep from soaking the wraps. RN-E verified there was not a treatment order for the right lower extremity. RN-E stated the legs were left open to air at night, and monitored daily. RN-E further indicated the left leg had been much worse, pictures were taken, nurse practitioner had reviewed them, and the treatment prescribed was [MEDICATION(S)] cream, and the leg healed up. RN-E indicated when he saw the right leg, it appeared to be the same thing as what the left leg was, pictures were not taken of the right leg, instead a note was written to the physician who approved the use of [MEDICATION(S)] cream for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-E stated there was not a concern of [CONDITION(S)] because the skin was not rocky hard like you would see in [CONDITION(S)]. RN-E reviewed skin assessment documentation, and confirmed the assessment lacked a comprehensive evaluation. R22's progress note dated 12/5/18 at 2:35 p.m. included: writer notified by nursing staff that resident's legs were edematous and weeping. Writer went to resident's room to assess bilateral legs. Legs were red, edematous +3 pitting [CONDITION(S)] and visibly weeping. Resident's scab on lateral left shin measuring approximately 1 cm x 0.5 cm, additional red rash area below scab. Left lower extremity at wide part of calf measuring 61.4 cm circumference, ankle circumference 33.2 cm. Right lower extremity at widest part of calf 55.8 cm and ankle measures 33.0 cm. Right lower extremity upper medial shin with three open areas within vascular wounds. Writer called and talked with NP, regarding weeping legs and compression wraps. NP gave writer telephone orders to place ABD over wounds prior to placing wraps and the resident to be seen by the doctor tomorrow. A verbal order from the NP dated 12/5/18 at 2:35 p.m. included: place ABD pads on bilateral extremities over wounds before applying low stretch wraps. During an observation on 12/6/18, at 8:27 a.m. R22 was not in her room. The ace wraps were observed on the bedside stand. At 8:29 a.m. R22 was observed to be sitting in the dining room with legs in dependent position with gripper socks on her feet, and no ace wraps. During an observation on 12/6/18, at 8:53 a.m. R22 was observed being wheeled down the hallway by an unidentified staff. At that time, R22 did not have ace-wraps on and had a baseball size wet spot on the inside of her right pant leg. As the staff member wheeled her down the hallway, an ABD dressing was observed to drop out of the resident's right pant leg onto the floor. During an observation and interview on 12/6/18, at 10:03 a.m. R22 was wheeling herself down the hallway. R22 did not have ace-wraps on and her right leg was observed to be much redder than the prior day. The wet spot on the right pant leg had grown, and the wetness was observed to extend from just below the knee where it measured approximately 4 to 6 inches wide, to the bottom of the pant leg where it measured approximately 3 inches wide. At that time, R22 stated staff had not wrapped her legs today. R22 also stated she thought there was more redness than yesterday but it doesn't hurt. R22 stated the wetness was from the weeping of her leg. During an observation and interview on 12/6/18, at 2:36 p.m. R22 was seated in her wheelchair with her legs in the dependent position with gauze wrapped around her ankles. R22's right wounds were visibly weeping in a constant stream. RN-B confirmed the amount of drainage from R22's wounds, and indicated the legs had not been wrapped until 11:00-11:30 a.m. and RN-B would be re-wrapping them now. R22's physician visit note dated 12/6/18, included [CONDITION(S)]: lower extremity worsening. Current weight is 297 pounds. Exam revealed right lower extremity [CONDITION(S)] worsening, with drainage and area of increased [CONDITION(S)] and superficial ulcers x 2 venous with area of [CONDITION(S)] concern. Assessment included: [CONDITION(S)], venous stasis, chronic combined systolic and diastolic heart failure, dementia without behavioral disturbance, and [CONDITION(S)]. The plan included 1) [MEDICATION(S)] for 7 days, 2) will ask nursing to call radiology to see how we can order ABI, 3) consider high volume compression stockings, however will be cautious given history of CHF. The note further included instructions: 1) Start [MEDICATION(S)] 500 mg by mouth twice a day for 7 days for [CONDITION(S)] right lower extremity, elevation of legs twice daily for 15-20 minutes as tolerated, 3) wound care referral made. During an interview on 12/7/18, at 9:20 a.m. assistant director of nursing (ADON) reviewed R22's record and verified the record lacked consistent comprehensive skin and [CONDITION(S)] assessments since admission. ADON stated nurses should be aware of signs and symptoms of [CONDITION(S)], skin should be monitored daily, and physician should always be notified with any changes in skin conditions. ADON stated if R22 was refusing her wraps it should have been documented as refused. During an interview on 12/7/18, at 9:30 a.m. the director of nursing (DON) reviewed R22's record and verified the record lacked comprehensive skin and [CONDITION(S)] evaluations. DON further indicated nursing should be monitoring for signs and symptoms of infection with open areas and documenting. Review of R9's record indicated the facility failed to consistently document and evaluate the effectiveness of diuretic medications and treatments and failed to evaluate fluid balance in order to prevent fluid overload and/or dehydration. R9's Admission Record dated 12/7/18, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's quarterly Minimum Data Set assessment dated [DATE], indicated R9 had moderate cognitive impairment, required extensive assistance from one staff member for bed mobility, transfers, toileting, and dressing. The MDS also indicated R9 received diuretic medication. R9's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2 liter daily fluid restriction, start date 10/29/18 Daily weight and vital signs in the morning. If weight is over 140 pounds (lbs.) administer [MEDICATION(S)] (diuretic) 2.5 milligrams (mg) 30 minutes prior to morning [MEDICATION(S)] (diuretic) start date 10/25/18 (no end date) Low stretch wraps bilateral lower extremities on in the morning off at night for [CONDITION(S)], start date 9/28/18. Notify provider if weight gain of more than 3 lbs in one day, or 5 pounds in one week, for [CONDITION(S)] ischemic, start date 3/3/17. [MEDICATION(S)] 2.5 mg every Tuesday, Thursday for heart failure (give 30 minutes prior to [MEDICATION(S)]), start date 11/12/18. [MEDICATION(S)] 100 mg tablet by mouth two times a day for congestive heart failure, start date 7/21/18. However, review of the handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Order dated 10/25/18: if weight is over 140 lbs. administer [MEDICATION(S)] 2.5 mg 30 minutes prior to morning [MEDICATION(S)] dose and notify provider. (This order was transcribed as a treatment and not for medication administration.) Order dated 11/5/18, notify provider if weight gain of 2 lbs. in 24 hours or 5 lbs. in one week. Order dated 11/5/18, discontinue order to administer [MEDICATION(S)] for weight over 140 lbs. R9's nutritional care plan dated 9/27/18, indicated R9 was at risk for nutritional deficit related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nutritional care plan included interventions of: 2 Liter fluid restriction 100 milliliters (ml) for nursing every shift, and 1400 ml for dietary, staff to monitor intake, weights, hydration per policy/MD (medical doctor) order, notify certified dietary manager, registered dietician as needed. R9's diuretic care plan indicated R9 had lower extremity [CONDITION(S)]. The interventions included: administer medications as ordered, observe for possible side effects every shift, monitor dose; may require modification. The cardiovascular care plan directed staff to monitor/document/report to MD changes in lung sounds, [CONDITION(S)], and changes in weight. R9's record was reviewed from 11/1 through 12/3/18, the record lacked evidence of [CONDITION(S)] monitoring and evaluation. R9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Point of care documentation for the last two weeks of November, and review of the November and December treatment administration records (TARs), indicated although fluid intakes were recorded, the record lacked evaluation for fluid deficits and/or fluid overages. R9's dietary assessment dated [DATE], indicated R9 required more than 1500 ml of fluid intake per day. R9's last 14 day's of fluid intake indicated the following 12/6/18- 1420 ml fluids recorded 12/5/18- 2480 ml fluids recorded 12/4/18- 1650 ml fluids recorded 12/3/18- 984 ml fluids recorded 12/2/18- 1552 ml fluids recorded 12/1/18- 1444 ml fluids recorded 11/30/18- 1460 ml fluids recorded 11/29/18- 3240 ml fluids recorded 11/28/18- 1840 ml fluids recorded 11/27/18- 1242 ml fluids recorded 11/26/18- 2720 ml fluids recorded 11/25/18- 1127 ml fluids recorded 11/24/18- 2040 ml fluids recorded 11/23/18- 1960 ml fluids recorded R9's progress notes were reviewed from 9/25 through 12/3/18. Documentation indicated the last time a physician was notified of weight gain was on 9/25/18, at which time the progress note indicated R9 was up 3.0 lbs and the nurse practitioner was notified. R9's physician visit progress note dated 10/25/18, indicated R9 weighed 134 lbs on 10/22/18, and her previous dry weight was considered to be 156 lbs. The note indicated staff were to use [MEDICATION(S)] 2.5 mg one half hour prior to [MEDICATION(S)] in the morning when R9's weight was over 140 lbs. R9's weights records, and October and November MARS were reviewed. The October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Although R9's weights were identified as greater than 140 on 10/26/18 (141.2 lbs), 10/27/18 (144.8 lbs), 10/28/18 (143.8 lbs), 10/29/18 (143.8 lbs) 10/30/18 (146.2 lbs) and 10/31/18 (146 lbs), 11/2/18 (147.4 lbs), 11/3/18 (147.2 lbs), 11/4/18 (149.0 lbs), 11/5/18 (150.0 lbs). The [MEDICATION(S)] was only administered on 10/29, 10/30 and 10/31/18. Not weight was recorded 11/1/18. A physician's visit note dated 11/5/18, indicated R9 was up 6 pounds from the previous week. The note indicated R9 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further included an order to discontinue the as needed [MEDICATION(S)], and notify the provider if patient has a two pound weight gain in 24 hours or a 5 lb weight gain in one week. A physician visit note dated 11/8/18, indicated the physician was following up with R9's weight. The note indicated R9 had 2+ [CONDITION(S)] in both legs and her weight had increased by 8.2 lbs. in 8 days. The note indicated adjustments were made to her diuretic medications. R9's physician note dated 11/12/18, indicated a follow-up regarding R9's heart failure. The note indicated R9 was up 7.3 lbs in the last 7 days and was seen by another provider on 11/8/18, who had prescribed an extra dose of [MEDICATION(S)]. The note further indicated on 11/8/18, R9 received one unit of packed red blood cells and was ordered to have 20 mg of [MEDICATION(S)] intravenous after transfusion however, her systolic blood pressure was less than 100 so she was unable to receive the [MEDICATION(S)]. Physical exam indicated 2+ [CONDITION(S)] of lower extremities and bilateral lower extremities wrapped with ace wraps. The note indicated changes to [MEDICATION(S)] and instructed to continue to do daily weights; weighing the same way with every weight. R9's physician visit dated 11/20/18, indicated R9's weight was down from 154 lbs on 11/18/18, to 151.6 lbs on 11/19/18. The note further indicated her kidney function and electrolytes were stable and indicated R9 had 2+ [CONDITION(S)] in both legs, which R9 reported as improved since last week. R9's weights since the last physician visit were reviewed; the record indicated weights were obtained at different times of the day. The record also lacked evidence of physician notification pertaining to weight increases of over two pounds in 24 hours per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 11/21/18 at 3:21 p.m. 150.2 lb 11/22/18 at 12:41 p.m. 149.6 lb 11/23/18 at 10:48 a.m. 149.0 lb 11/24/18 at 10:15 a.m. 151.6 lb 11/25/18 at 1:21 p.m. 146.6 lb 11/26/18 at 11:20 a.m. 153.8 lb 11/27/18 at 10:35 a.m. 154.2 lb 11/28/18 at 11:05 a.m. 157.2 lb 11/29/18 at 2:36 p.m. 158.2 lb 11/30/18 at 12:49 p.m. 155.0 lb 12/1/18 at 9:33 a.m. 154.0 lb 12/2/18 at 10:52 a.m. 150.6 lb R9's Nutritional assessment dated [DATE], indicated R9 had a diabetic diet with 2L fluid restriction per day. Nursing and dietary were to provide fluids. [MEDICATION(S)] ordered. Due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Current weight of 150.4 lbs. and weight one month ago was 134 lbs. The note indicated this reflected a weight gain of 12% in one month. Weight gain/losses related to fluid. Staff to monitor intake, weights, hydration per policy/MD order. Notify registered dietician as needed. R9's physician's progress note dated 12/3/18, indicated R9's creatinine had increased recently due to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 12/3/18, at 3:12 p.m. R9 was sitting in her wheelchair in her room. R9 had ace wraps on both legs and was observed to have [CONDITION(S)] in both legs. R9 stated her legs hurt and were very swollen. R9 stated she was on a fluid restriction, took water pills, and didn't feel like she was getting enough to drink. R9 pointed to a water cup on the bedside table and stated she didn't think anybody ever filled it. During an observation on 12/4/18, R9 was sitting in the dining room with her legs in a dependent position (down). R9 had ace wraps on both legs, and both legs were observed to be edematous. During an interview on 12/7/18, the dietary manager (DM) stated dietary staff entered the amount of intake served at each meal, but was uncertain if nursing documented fluid intake outside of meal times. The DM stated dietary did not evaluate fluid balance for deficits or overages in fluid restrictions, and stated nursing should be evaluating fluid balance. During an interview on 12/7/18, at 9:07 a.m. the DON reviewed R9's fluid intake and verified the record did not identify 24 hour totals, and/or fluid evaluations for deficits or overages. The DON stated R9's record lacked [CONDITION(S)] monitoring/evaluation and failed to indicate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Change in Condition policy dated 8/1/15, included: Purpose: to ensure prompt notification of the resident, the attending physician, and durable power of attorney/responsible party of changes in the resident's physical, psychosocial and/or mental condition and/or status. 1) Physician will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and or signs/symptoms unrelieved by measures already prescribed. 2) Specific information that requires prompt notification include but not limited to: l) A significant change in the resident's physical condition. m) a need to alter the resident's medical treatment significantly. n) refusal in treatment or medications (i.e. two or more consecutive times). Undated facility policy Intake and Output Recording (Fluid Balance Monitoring) included, Purpose: To provide an accurate record of the residents fluid intake and output. Intake and output are measured and recorded when ordered by a physician; determine if there are fluid restrictions or need for increased quantities of fluids needed. 9) 24 hour total are recorded on the appropriate resident clinical forms by the licensed nurse; assess skin turgor, diaphoresis, or other symptoms related to fluid balance. 10) Record any other pertinent observations in the nursing notes, such as urine color, consistency and odor or consistent fluid consumption which is significantly lower than calculated needs; Significant results are reported to the attending physician and to the next shift and Significant fluid balance, excess or deficits, will be reported to the physician and to the next shift. R52's face sheet identified R52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Each of these diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's medication orders included the following medications to control issues of fluid imbalance: [MEDICATION(S)] 40 mg once daily and 60 mg once daily. [MEDICATION(S)] (also a diuretic) 100 mg daily. [MEDICATION(S)] extended release (a beta blocker to reduce blood pressure) 60 mg daily. Orders also included: 1.5 liter per 24 hour fluid restriction, daily weights to be done on the same scale each day, a no added salt diet, and compression wraps to bilateral lower extremities and right upper extremity (to be applied in the morning, and remove

Based on observation, interview, and document review the facility failed to provide care and treatment including timely repositioning/offloading, in order to promote healing of a stage III pressure ulcer and prevent and/or reduce the risk of new pressure ulcer development of pressure ulcers for 1 of 3 residents (R14) reviewed for pressure ulcers. Findings include. Pressure ulcer definitions: Stage 1 pressure ulcer: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage 2 pressure ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact blister or open/ruptured serum filled blister. Stage 3 pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some pars of the wound bed. Often include undermining and tunneling. Unstageable pressure ulcer: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. R14's Admission Record dated 12/7/18, included [DIAGNOSES REDACTED]. R14's R14's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R14 did not have cognitive impairment and did not have rejection of care behaviors. The MDS further indicated R14 was not ambulatory, required extensive assistance from two staff for bed mobility, transfers, and personal hygiene. The MDS also indicated R14 had functional limitation in range of motion to both lower extremities. The MDS also indicated R14 was at risk for pressure ulcers, had two stage 4 pressure ulcers and a surgical wound, required pressure ulcer care, surgical wound care, dressings to feet. The MDS also indicated R14 required pressure reduction devices for bed and chair, and did not have a turning and repositioning program. R14's pressure ulcer Care Area assessment dated [DATE], indicated R14 had surgical closure of stage 4 pressure ulcer on right sacrum and had a stage 4 pressure ulcer on right ischial tuberosity, stage 2 pressure ulcer on right 5 toe, had a special instructions for seat mapping. The CAA indicated R14 was at risk for non-healing and further alterations in skin integrity. During an observation on 12/3/18, at 7:53 p.m. R14 laid in bed on her back with her feet directly on the mattress. R14 did not have pressure-relieving boots on her feet. R14 confirmed she did not have anything under her feet and boots were not on. R14 stated, they don't always put my boots on, and wasn't sure why. R14 stated staff did not lift her out of the chair during the day, and she was laid down in bed for naps when she requested. During an observation on 12/4/18, at 8:24 a.m. R14 sat at the dining room table eating breakfast independently. R14 was leaning to her right side. R14 was not observed to have pressure-relieving boots on her feet. During an observation on 12/4/18, at 9:45 a.m. R14 sat in her wheelchair and stated her legs were falling asleep because of the way she was tipped back. Nursing assistant (NA)-E boosted R14 up to sit up straight. NA-E offered R14 to lay down in bed. R14 declined, NA-E then tilted R14 chair into an upright position. R14 did not have pressure-relieving boots on her feet. During an observation and interview on 12/4/18, at 3:21 p.m. R14 laid in her bed. R14's heels were elevated off the bed, pressure relieving boots were not on her feet. NA-L told R14 they were going to get her up and put R14's heel boots on. NA-L stated they were supposed to be on when R14 was up in the chair. NA-L asked R14 if the nurse had changed the bandage to her right hip, R14 stated no. The bandage on her right hip dated 12/4/18, had a golf ball sized amount of drainage that could be seen on the outside of the pad. NA-M assisted NA-L in removing R14's brief. R14's sacral coccyx area was observed to have a large surgical repair, the area had pin point holes on the top and bottom of the repair area where the base could not be observed. The sacral coccyx wound area was not covered by a dressing. NA-L stated R14 used to have pressure areas on her feet also however, they had healed and no sores were present now. During an observation on 12/5/18, at 7:46 a.m. R14 was laying in bed. Licensed practical nurse (LPN)-C stated she was going to change R14's dressings. NA-N was also in R14's room to assist LPN-C. R14's dressing to right hip was peeling off and had moderate amount of drainage on the bandage. On the side of R14's foot, area that measured approximately 1.5 centimeters (cm) and covered with a yellowish scab and had a slight depth; this area did not have a dressing on it. LPN-C stated the area of the foot used to be cleaned and dressed however, that was not being done anymore since the area was stable and scabbed. LPN-C sanitized hands and donned gloves, removed the old dressing from the left hip area. With the same gloves on LPN-C cleaned the wound as ordered. The periphery of the wound was reddened and within the reddened area was a small open area. LPN-C stated the red area and open area was new and questioned if it was from the tape. After cleaning the wound, with the same gloves on grabbed a clean ABD pad (absorbent dressing) and set it aside. LPN-C with same gloves on, opened one package of collagen powder and poured normal saline into the powder and mixed together with a Q-tip, consistency was not paste and more putty. LPN-C then removed her gloves, sanitized hands and donned new gloves. LPN-C used fingertip to remove the formed mixed collagen and used finger to press into the ulcer. LPN-C stated she only needed to use one package to pack the wound. LPN-C then rummaged through the basket of dressing supplies and removed a dressing from an opened package, removed gloves and donned new gloves and cut a piece of silver alginate, then removed a Drymax blue foam dressing from package and then placed the silver alginate followed by the Drymax blue over the top of the collagen. LPN-C stated there was supposed to be a blue foam dressing and was not sure why the dressing she had removed had a white foam dressing. LPN-C then taped the foam dressing onto the wound and dated. LPN-C then removed gloves sanitized hands, donned new gloves and cut the Interdry, cleaned the sacral coccyx wound with normal saline, then placed the Interdry over the wounds between the gluteal folds and placed the ABD dressing. LPN-C then removed gloves, sanitized hands and taped the ABD dressing onto the area. LPN-C stated there was a new open wound on the left inner buttock that was very small and was about 0.25 cm long. R14's current physician orders [REDACTED]. Float heels on blue heel lifter at all times while resident in bed every shift started date 10/30/18. Maintain pressure relief to feet and ankle, start date 7/12/18. Right lateral foot wound: cleanse with normal saline, pat dry, moisten collagen slightly with ansept gel, and apply to the wound bed, cover with hydrogel sheet daily, start date 11/3/18. Sacral wound: cleanse daily with normal saline, pat dry, use barrier spray to abrasion (allow to dry), cover area with Intradry, cover with ABD pad, and secure with small amount of paper tape daily. Start date 8/31/18 Right ischial wound: cleanse daily with normal saline, pat dry, apply skin prep to peri-wound, moisten collagen slightly with normal saline to make a past and fill wound bed with 2 packets fill rest of wound bed with sliver alginate, cover with absorbent dressing and secure with tape. Change every day shift. Start date 11/2/18. Skin must be inspected after every sitting session, start date 7/16/18. R14's skin care plan dated 4/12/18, included: actual/potential for alteration in skin integrity related to stage 4 sacral ulcer and [MEDICAL CONDITION]. The skin care plan included interventions: turn and reposition every two hours and as needed (11/27/18), monitor skin with cares and report changes (11/27/18), treatments as ordered (11/27/18), wound care to sacral flap incision, ischial tuberosity ulcer and foot ulcers as ordered, observe and report concerns, new concerns on bilateral feet (7/12/18). R14's alteration in mobility care plan dated 12/5/17, interventions included: heels off cushion system, in bed in supine position, place long blue cushion under both knees with higher side under knees, adjust so heels are in the air and not touching the bed (9/21/18), not to sit on hard surfaces, must adhere to sitting schedule laid out by MD see chart (7/13/18), pressure reducing cushion to chair (10/31/18), don not leave full body sling under her (7/13/18). R14's written physical therapist recommendation dated 7/30/18, included patient should wear her offloading boots when in wheelchair. She should also wear them in bed. If she refuses, she must have pillows under lower leg to take weight off her heels. R14's physician visit dated 8/30/18, included: Nursing has reported new open area on sacrum. 4/25/18 the patient underwent surgical debridement and bilateral be-why advancement flap of the stage 4 sacral pressure ulcer. When admitted to facility she did have an open area of the sacrum/flap. The open area of the flap is improving. It was noticed this week there is a new open area just distal (down) to this area with a small amount of bloody drainage. R14's physician visit dated 10/19/18, indicated R14 had a new wound on her right lateral foot that was being treated by cleansing daily with normal saline, pat dry, and [MEDICATION NAME] foam border applied for protection. The note also indicated there was two open areas of the sacral flap. Note also indicated heels are to be floated at all times. R14's physician visit dated 11/2/18, indicated physical exam on sacrum: small callused opening, no drainage. Pressure ulcer of sacral region stage 4: status [REDACTED]. Right ischial spine: no measurements available today small amount of serosanguineous drainage present. There is good granulation tissue present, unable to identify amount of slough based on depth so wound, peri-wound clean dry and intact. Continues to require turning and repositioning. Indicated the right ischial was unspecified and the right foot wound was decubitus ulcer stage 2. Wound treatment orders in the visit note reflected current physician orders [REDACTED]. R14's weekly Skin and Wound Evaluations since 10/1/18, included the following: R14's Skin and Wound Evaluation for sacrum lacked ongoing evaluations 10/24/18, Skin and Wound evaluation indicated sacral wound was surgical with total area that measured 0.1 cm2 and measured 0.3 cm x 0.3 cm no depth, wound bed was 100% [MEDICATION NAME], cleaned with normal saline, primary dressing was other (was not specified) no secondary dressing. Additional interventions included nutritional supplementation, heel suspension, turning and repositioning program moisture barrier and control, incontinence management. The assessment indicated the wound was resolved and dressing was applied to prevent wound from coming back ABD pad was used as per previous order. The note indicated physician was notified. 11/6/18, Skin and Wound evaluation indicated sacral wound was surgical with total area that measured less than 0.1 cm. Measurements included 0.2 cm x 0.2 cm with depth of .5 cm, wound bed was 100% [MEDICATION NAME]. Surrounding tissue was red, wound was slow to heal, treatment included clean with normal saline no debridement, primary dressing other (was not specified) secondary dressing was other (not specified) additional interventions included: heel suspension, moisture barrier and control, nutritional supplement and turning and repositioning program. The progress of the wound was indicated as resolved. The note indicated a dressing was placed to prevent any deterioration of the healed wound and the physician was not contacted. R14's record lacked evidence of any further evaluations/assessments of the sacral wound after 11/6/18. R14's Skin and Wound evaluations for the right trochanter lacked weekly evaluations. Those documented included: 10/24/18, Weekly Skin Wound evaluation indicated stage 4 pressure ulcer; total wound area measured 1.1 cm2. Wound measured 1.4 cm x 1.0 cm with a depth of 3.7 cm and undermining 2.0 cm. The assessment indicated wound bed was 50% granulation tissue and wound bed 50% slough, had moderate serosanguineous drainage. The assessment also indicated edges were not attached, surrounding tissue was macerated, and the wound was slow to heal. Wound dressing treatments and interventions were not identified and left blank other than writer reinforced that the resident is only to be up in her chair at most 2 hours at a time and indicated the physician was notified. No assessment was documented for 11/6/18 11/13/18, Skin and Wound evaluation indicated type of wound was Stage 4 Pressure ulcer. Total area measured 0.8 cm, 1.5 cm x 0.8 cm depth was 1.3 cm with 1.3 cm of undermining, wound bed had 100% granulation tissue, moderate serosanguineous drainage with moderate odor, edge appeared as cliff, surrounding tissue was macerated, wound was slow to heal, and the dressing was saturated. Wound treatment included cleaned with normal saline, no debridement, primary dressing as calcium alginate, secondary dressing was foam, incontinence management (should be noted R14 had suprapubic catheter and [MEDICAL CONDITION]), moisture barrier and control, nutritional supplementation, and turning and repositioning program. Assessment indicated wound was improving. The evaluation did not address and/or indicate if the odor was a new finding, and did not address interventions for the maceration around the wound. 11/20/18, Skin and Wound evaluation indicated stage 4 pressure ulcer with total wound are of 0.4 cm2. Measurements included 0.8cm x 0.6cm x 2.2 cm depth and 1.5 cm undermining. Indicated 50% of wound bed filled with granulation tissue, 50% wound bed filled with slough, no drainage, edges appeared as a cliff, and surrounding tissues were macerated. The assessment indicated dressing was intact and treatment included: cleaned with normal saline, autolytic debridement, primary dressing calcium alginate, and other (other was not specified), and secondary dressing was other (other was not specified), Additional interventions were the same as the aforementioned assessment completed on 11/13/18. The evaluation indicated the wound was improving even though the depth had increased from 1.3 cm to 2.2 cm and undermining increased from 1.3 cm to 1.5 cm. Furthermore, according to the physician orders [REDACTED]. The assessment also did not indicate the peri-wound maceration was addressed. 12/4/, Skin and Wound Evaluation indicated stage 4 pressure ulcer with an total wound area of 0.2 cm. Measurements included 0.6 cm x 0.4 cm with depth of 3.0 cm and undermining of 3.0 cm. Wound bed 50% granulation tissue and 50% wound bed slough, had heavy serosanguineous drainage. Peri-wound edges appeared as a cliff and had rolled edges. Surrounding skin of the wound was red (extent indicated 0). The treatment now included: cleaned with normal saline, enzymatic debridement, primary dressing marked as other (was not specified), secondary dressing was foam. Other interventions were the same as aforementioned assessments. The evaluation indicated the wound was improving, even though there was again an increase in wound depth from 2.2 cm to 3.0 cm and an increase in undermining from 1.5 cm to 3.0 cm. Furthermore, the assessment indicated a different form of debridement even though the physician orders [REDACTED]. The assessment also did not address the newly developed redness around the wound since last assessment. R14's evaluations for the dorsum right foot lacked evidence of weekly progress evaluation, lacked identification of wound type, lacked identification of dressing treatments, and completed evaluations of response to interventions that were added/and or removed. No assessment completed on 10/24/18 No assessment completed on 11/6/18 11/13/18, Skin and Wound evaluation, lacked identification of wound type. The evaluation indicated the start of the wound was unknown, total area 0.5 cm2, 0.9 cm x 0.7 cm, depth indicated not applicable, 100% [MEDICATION NAME], surface intact. Indicated wound was slow to heel, dressing was dry and intact, cleaned with normal saline, mechanical debridement, primary dressing was hydrogel, secondary dressing was foam, additional care included: heel suspension, moisture barrier, moisture control, nutritional supplementation, turning and repositioning program. Indicated wound was improving. 11/20/18, Skin and Wound Evaluation, lacked identification of wound type. Wound measurements included total area 0.2 cm2, 0.6 cm x 0.3 cm, depth indicated as not applicable, wound bed 50% [MEDICATION NAME], 50% granulation tissue, slow to heal, cleansing solution indicated as sterile water, mechanical debridement, no primary dressing was hydrogel, secondary dressing was marked as other and not specified in the evaluation, interventions included; incontinence management, moisture barrier and control, nutritional supplementation, and turning and repositioning program, progress indicated healing. 12/4/18, Skin and Wound Evaluation, lacked identification of wound type. The assessment indicated the wound was now larger since the previous evaluation. The measurements included; total wound area 0.7 cm 2, 1.3 cm x 0.8 cm depth was not applicable. The note indicated the wound was 90% epithelized and 10% of wound was granulation tissue. Wound was slow to heal, dressing was missing, normal saline used to clean the wound, no debridement, dressing was hydrogel, secondary dressing foam. Interventions included: incontinence control, moisture barrier and control, nutritional supplementation, turning and repositioning program. Progress of wound indicated the wound was deteriorating. The evaluation indicated even though the wound was deteriorating the physician was not notified nor new interventions and/or treatments put into place. During an interview on 12/5/18, at 8:24 a.m. LPN-C stated she should have washed her hands between removing the old dressing and cleaning the wound and putting the new dressing on. LPN-C stated the wound dressings kept changing and didn't always look at the orders. LPN-C stated the wound on the coccyx has had the small holes since she returned to the hospital, and the one on the left hip had gotten a lot bigger. During an interview on 12/5/18, at 8:42 a.m. RN-E stated he was the acting wound nurse. RN-E stated R14 had a pressure ulcer to her right ischium, one on her right foot, and the two holes on her coccyx were pretty much healed so measurements were no longer being evaluated and are not charted on. RN-E stated the area to the coccyx was high risk for pressure ulcers; Interdry and ABD dressing were used because of the high risk site. RN-E stated he had done the dressings on 12/4/18; improvised with the white foam dressing after talking with the provider because the supply of the Drymax blue had run out. RN-E stated he had not dressed the coccyx area yesterday and the dressing was not always put on dependent upon if there was any breakdown and redness. RN-E stated the right foot dressing has changed a couple of times; thought the order was for padding and secure with stretch gauze and Kerlix. During an observation on 12/5/18, at 9:20 a.m. R14 sat in the lobby area, leaning slightly to the left, and had pressure-relieving boots on. R14 attempted to straighten herself to midline however, was not able to hold the midline position for more than seconds and returns to the left leaning position. During a continuous observation from 9:20 a.m. until 11:00 am. 12/5/18, R14 continued to lean to her left side, At 10:47 a.m. NA-F asked R14 if she wanted to lay down, R14 declined the offer, NA-F titled R14's chair back slightly, however, R14 continued to lean more to the left side. During an observation on 12/6/18, at 8:18 a.m. R14 laid in bed on her right side, feet were elevated. R14's pressure ulcer to the right foot remained uncovered. During a continuous observation on 12/6/18, from 8:45 a.m. through 11:03 a.m. R14 sat up in her chair leaning to the left side without being offered to reposition to midline. At 11:04 a.m. NA-O offered R14 to lay down in bed, R14 declined the offer, NA-O then tilted R14's chair back slightly. During an interview on 12/6/18 at 11:06 a.m. NA-O stated R14 was offered to lay down and only sometimes offered to lift her up to in the full body lift to get her off her bottom. NA-O stated offloading of pressure ulcers should be done for at least two minutes. At 11:10 a.m., NA-O took R14 to her room and lifted her out of the chair. During an interview on 12/7/18, the director of nursing (DON) verified R14's physician orders [REDACTED]. The DON stated each wound should be assessed weekly. At that time, the registered nurse consultant (RNC) stated the sacral/coccyx ulcer surgical repair should be assessed weekly and the open areas measured for depth and healing as the area was at risk for increased pressure ulcer development. The DON also stated the skin and wounds should be monitored with every dressing changes and document any change. The facility's Pressure Ulcer Prevention and Management policy dated 12/3/18, included: It is the policy that each resident receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and care plan. The facility will ensure that a resident who is admitted without a pressure ulcer does not develop a pressure ulcer, unless clinically unavoidable. A resident who has an ulcer will receive care and services to promote healing and to prevent additional ulcers. -If a pressure ulcer is present, at least weekly there should be documentation of an assessment or evaluation of the wound characteristics. Documentation should include: date wound was observed, location, staging (or description of appearance and wound extent) size, color, odor, approximate amount of exudate, pain if present, wound bed, description of wound edges and surrounding tissue. -Daily, the clinicians responsible for caring for the resident will assess the status of the dressing if present and evaluate for complications such as infections and/or uncontrolled pain. -Wound skin care interventions will be monitored and evaluated for effectiveness. Care plan will include specific and measurable goals and interventions. The care plan will be reviewed and revised at least quarterly and with significant change in condition.

Based on interview and record review, the facility failed to ensure staff provided emergency care for one of five residents (R1) reviewed who requested cardio [MEDICAL CONDITION] resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 was a full code status. Harm occurred when R1 passed away. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had a [DIAGNOSES REDACTED]. R1's admission progress note dated [DATE] at 3:54 p.m., indicated the resident was alert and oriented and required an assist of one staff member with activities of daily living. R1 was admitted for physical and occupational therapy. R1 had a Provider Order for Life-Sustaining Treatment (POLST) that indicated cardiopulmonary resuscitation (CPR) should be performed in the event of no pulse and not breathing. The form was undated and signed by R1's spouse and a staff nurse. On [DATE], the Director of Nursing (DON) sent out a communication documentation note that indicated the emergency cart had been updated with the location of the cart and what items were on the cart. It was the expectation for all staff to read the communication note. Per progress note dated [DATE] at 7:18 am, Registered Nurse (RN)-A was asked at 6:07 a.m., to assess R1. RN-A documented R1 was non-responsive and warm to the touch. R1 did not have a pulse or a blood pressure, had no sound from carotid pulses and no respirations. RN-A documented that RN-A sent an unknown person for the crash cart and at that same time, the ambulance crew was arriving on scene. RN-A assisted in the CPR process after the ambulance crew arrived. R1's progress note dated [DATE] at 8:10 am by RN-B, indicated that on [DATE], around 5:15 a.m., R1 had a change in condition with difficulty breathing. RN-B went to R1's room and attempted to arouse R1. R1 was cold to the touch and skin was clammy. A blood pressure, temperature and pulse are documented, but RN-B was unable to get an oxygen saturation or respiration count. RN-B gave the resident a nebulizer. (Neb order was for a cough). RN-B was unable to find documentation of R1's code status at that time. In a statement written on [DATE] at 4:30 p.m., Licensed Practical Nurse (LPN)-E, indicates that LPN-E punched in on the time clock for the shift, arrived on the unit, heard about R1, and at 6:03 a.m., went to R1's room. LPN-E did not feel a carotid or femoral pulse and there was no breathing. LPN-E then stated she came out of R1's room to retrieve the crash cart to start CPR when the ambulance crew were arriving on the unit. Time entry documentation show LPN-E punched in at 5:59 a.m. LPN-E stated that RN-A was in R1's room prior to LPN-E arriving on the unit. The Gold Cross Ambulance report dated [DATE], indicates that while they were enroute to the facility at 6:01 a.m., the nursing home had called back and reported that the patient had died . When the ambulance crew arrived at 6:05 a.m., RN-A met them in the hallway. Ambulance crew asked RN-A about R1's code status. On arrival to R1's room, R1 was not breathing and had no pulse. They initiated resuscitation protocol with RN-A assisting with ventilation. R1 had no return of signs of life. The physician advised to discontinue CPR at approximately 6:34 am. When interviewed on [DATE], at 10:47 am, RN-A stated she went into R1's room after Trained Medication Aide (TMA)-C asked her to assess R1. RN-A checked R1's vital signs; there were no pulse or respirations, appeared pale and was warm to the touch. RN-A stated she asked about the code status and no one could find this information, so RN-A verbalized that R1 was automatically a full code. RN-A told someone by the door to get the crash cart. RN-A stated she stayed with R1, lowered the head of the bed down and as she was preparing to start CPR when the ambulance arrived. Per time entry documentation, RN-A's electronic time entry was at 6:04 a.m. The time clock is located in the basement of the facility. Ambulance arrived at 6:05 a.m. An interview with RN-B on [DATE], at 2:35 pm stated that she had checked on the resident two or three times during the night and R1 showed no signs of distress and was resting comfortably. Toward the end of the shift, TMA-C reported to her that R1 was unresponsive with a blood sugar of 100 and was unable to give her medications. RN-B said she went to R1's room with a cup of orange juice. RN-B tried to arouse R1, but R1 showed no response. RN-B stated she checked on the code status more than once but could not find this in the paper or electronic chart. RN-B's treatment for [REDACTED]. TMA-C came to her and said that R1 had passed away. RN-B stated she then called 911 back to cancel services but they were on the way and could not cancel. She also stated that she did not know where the crash cart was located at the time R1 was unresponsive. During an interview with TMA-C on [DATE] at 4:39 pm, she stated that she was caring for R1 on the night of [DATE] and TMA-C checked on R1 as needed through the night. R1 was alert and could use the light for help if needed. Around 5:15 am, TMA-C went into R1's room to give the roommate medication. TMA-C noticed R1's breathing had changed. Blood sugar check was performed, which took three attempts and the result was 100 (mg/dL). R1's fingers were cold but her body was warm. TMA-C reported the changes to RN-B who went to the kitchen to get orange juice and the blood pressure machine. RN-B also prepared a nebulizer for R1 and told TMA-C to take it off when it was done and left the room. R1 was still unresponsive at that time. TMA-C removed the nebulizer mask and heard R1 having agonal breathing and felt a carotid pulse. TMA-C went to get RN-B for help but RN-B was on the phone. At that time, RN-A was arriving for her shift. TMA-C asked RN-A to help locate the code status which could not be found. RN-A then went to assess R1. When RN-A and TMA-C entered the room, R1 was not breathing and did not show life signs. RN-A felt no pulse. TMA-C said she went to lower the head of the bed to start CPR when RN-A instructed not to. RN-A listened to R1's lungs with the stethoscope. RN-A did not start CPR. They both left the room. During an interview with TMA-D on [DATE] at 12:55 pm, she stated that TMA-D arrived around 5:15 am and observed RN-B with the blood pressure machine and obtaining juice for R1. TMA-D went to R1's room and found R1 unresponsive, attempted a sternal rub with no response and describes what she calls a death rattle from R1. TMA-D stated she told the staff that it sounded like R1 was dying. Everyone but RN-B left the room. RN-B asked them to close the door behind them. During an interview with LPN-E on [DATE] at 1:39 p.m., LPN-E stated she arrived on the unit for her shift on [DATE], went down to the basement to punch in, came back up to nursing station and staff were looking for the code status for R1. LPN-E told them that she had completed R1's admission and could verify that R1 was a full code. LPN-E went to assess R1, R1 was lying flat in bed. LPN-E checked for a carotid and a femoral pulse and there was nothing. LPN-E left the room to retrieve the emergency cart when the ambulance crew arrived on the unit. LPN-E stated she did not witness any staff doing CPR on R1 nor did anyone else retrieve the code cart. During an interview with the Director of Nursing (DON)-F on [DATE] at 2:30 p.m., she stated the POLST form was placed in a box to be signed by the physician. It was signed by the resident's spouse, with a full code status, which made the form valid. When staff could not locate the POLST in the chart, it would have been expected for staff to start CPR in the event no code status was known or POLST not located. The DON verified that it is a requirement for licensed nursing staff to be CPR certified during employment and both RN-A and RN-B had current CPR certification. During interview with the Medical Director on [DATE] at 10:00 a.m., he stated that when the resident was found to have no pulse or respirations, staff should have started CPR in addition to calling 911. CPR would be done if a resident is full code or when the code status is unknown. During the week of [DATE], the facility conducted education and re-training that included multiple mock drills on all shifts and review in-services were conducted on initiating CPR. There was also documentation that POLST training was completed with staff. The facility policy titled Policy and Procedure for Cardio-Pulmonary Resuscitation with revisions dated [DATE] indicates that if a resident becomes unresponsive (either witnessed or unwitnessed) the resident's Advanced Directives/POLST will be followed. CPR is to be initiated unless clinical signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer.

Based on observation, interview, and document review, the facility failed to implement a system to reduce avoidable accidents, for 5 of 5 residents reviewed (R1, R2, R3, R4, and R5), who were transferred by mechanical lifts. As a result (R1) sustained a neck fracture when being transferred by a mechanical lift. Findings include: Observations on [DATE] at 9:00 a.m. indicated that the facility has three resident care units (East, West, and North) with a total census of 62 residents. Each care unit has an Invacare Reliant full body lift and an EZ Way stand lift, for a total of six mechanical lifts throughout the facility. Thirty-two of the facility's sixty-two residents are transferred by mechanical lifts.R1's care plan, dated [DATE], indicated that R1 had self-care deficits with all activities of daily living and was completely reliant on staff to meet all needs. R1 was non-ambulatory. R1 required staff assistance with bed mobility and transfers. R1 needed to be transferred by one to two staff with the standing lift. R1's Fall Risk Assessment, dated [DATE], continued to indicate that R1 was at high risk for falls and required the same care plan interventions for mobility that were previously designated on [DATE]. The care plan did not specify any criteria for determining when R1 needed only one staff to assist with mechanical lift transfers versus needing two staff for assistance with transfers. The interdisciplinary notes from [DATE] - [DATE] indicated that some staff transferred R1 with "one assist" and others transferred R1 with "two assist," but no reasons were given for this difference. An incident report, dated [DATE] at 3:20 p.m., indicated that R1 was being transferred from the bed to the wheelchair by Nursing Assistant (NA)/(M) . After NA/(M) raised R1 to a standing position, one side of the transfer sling slipped out of the safety catch. R1 fell sideways out of the transfer sling, striking her head on the floor. The physician progress notes [REDACTED]. The nurse practitioner evaluated R1 immediately. R1 had fallen from a height of 3 - 4 feet and lost consciousness for about a minute. R1 had a scalp laceration that required further evaluation. Due to cognitive impairment, R1 could only say her head hurt. R1 was emergently transferred to the hospital by ambulance.The physician progress notes [REDACTED]. While hospitalized , it was determined that R1 had sustained bilateral lamina fractures of C2 in connection with the fall from the mechanical lift. Orthopedic Spine and Neurosurgery were consulted regarding R1's injuries but it was determined that R1 was not a surgical candidate. R1 had sustained terminal injuries. Palliative care met with R1's family and hospice care was initiated. R1 died at the facility three days later on [DATE]. R1's death certificate has not yet been filed with the Death Records Department at the State agency. The facility's internal investigation, dated [DATE], indicated that the mechanical lift that was used to transfer R1 on the East unit was removed from service and inspected by Safety Director/(G). On the left side of the lift arm, the black rubber grommet which supports the sling and keeps it in place was missing. It was also noted that the plastic cover on the control box was cracked and the hand control was not functioning properly. Caregivers are required to check all of these areas as a safety precaution prior to using the lift. Nursing Assistant/(M), who had transferred R1 when R1 fell , stated she conducted the safety inspection before using the lift but she did not know that care givers were required to inspect the black rubber grommets on the lifts. Nursing Assistant/(M) did not know if the black rubber grommet was present on the lift arm before she transferred R1 or if the black grommet dislodged from the lift during R1's transfer. The black rubber grommet was not recovered when R1's room was searched. It could not be determined if the lift's plastic cover on the control box and/or hand controller were faulty prior to the transfer or if these mechanisms were damaged during R1's fall. Nursing Assistant/(M) operated the lift with the controls on the main arm of the lift and did not use the hand controller when she transferred R1. Safety Director /(G) contacted the manufacturer of the lift and learned that the new EZ lift models are designed with a metal clip to hold the lift slings in place instead of a rubber grommet. For older EZ lifts to incorporate the safety feature of metal clips, the entire lift arm must be replaced. The facility reported R1's fall to the manufacturer as an isolated incident of equipment failure. Safety Director/(G) was interviewed on [DATE] at 1:45 p.m. and [DATE] at 8:50 a.m. Safety Director/(G) stated that the facility's EZ lifts were originally purchased in 2003 and 2006. Six to nine months before R1's event, the facility had experienced ongoing problems with the black rubber grommets periodically popping off the lifts. Safety Director/(G) had contacted the manufacturer several times to order replacement rubber grommets but was never advised about the availability of the new metal safety clips. Safety Director/(G) superglued the rubber grommets in place when they dislodged, which was a problem with all three of the facility's EZ lifts. Safety Director/(G) had no written records regarding incidences when the black rubber grommets had dislodged, the model numbers of the specific mechanical lifts that had this problem, or whether any residents were previously affected by the malfunction with the lifts. Safety Director/(G) stated he has performed routine maintenance on all six of the facility's mechanical lifts every month for the past seven years. The monthly maintenance includes an inspection of 41 items on each lift. The rubber grommets/safety catches are 1 of 41 items checked. Safety Director/(G) had no written records of any of the lift inspections or any maintenance that was performed on any of the facility's six mechanical lifts, until [DATE] when he began documenting the lift inspections after R1's event occurred. On [DATE], Safety Director/(G) installed the new lift arms on all three of the EZ lifts, which have metal clips that hold the transfer sling in place, instead of rubber grommets. Safety Director/(G) stated that all care givers have always been trained on proper use of the mechanical lifts during their orientation period at the time of hire and every three months thereafter. After the event with R1, the facility conducted an additional mandatory re-training of all care givers on proper use of the EZ lift with a focus on safety. Caregivers have always been trained to perform a safety inspection of the lift, prior to each resident transfer. The safety inspection includes a visual check of bolts and screws on the lift's spreader bar, that the machine turns on and the battery is fully charged, the lift's controller arm goes up and down, and the sling is not torn or frayed. Prior to installation of the new EZ lift arms, the safety inspection on the EZ lift also included care givers visually checking the black rubber grommets for placement. The facility's purchase records indicated that Safety Director/(G) had purchased six replacement black rubber grommets/safety catches from the EZ Way manufacturer on [DATE], which was the last purchase made prior to R1's fall. The rubber grommets cost $5.00 apiece. The facility's policy on Proper Use of the Invacare Reliant Mechanical and EZ stands, dated [DATE], indicated that caregivers were to "Do a visual inspection and routine check before using a mechanical lift or stand. Make sure all bolts, screws, and the spreader bar are in good working condition. Make sure machine turns on and battery is full. Change out the battery pack when ,[DATE] full and/or at the end of your shift. Test the machine to be sure the controller arm will go up and down. Inspect sling. If frayed or torn, get another one and give (Ward Clerk/(H) the frayed one. If (Ward Clerk/(H) is not present, put a "Do not Use" sign on it an put it by (Safety Director/(G)'s) office." The policy did not address any information pertaining to a responsibility of care givers to check the black rubber grommets for placement prior to using the EZ lift. Ward Clerk/(H) was interviewed on [DATE] at 10:30 a.m. Ward Clerk/(H) stated she orders all the sling and harnesses used for mechanical lift transfers. When slings or harnesses are in disrepair, staff return these to her and most of them are thrown away because they cannot be repaired. Sometimes the facility can repair the buckles on harnesses if the prongs/teeth break off. No one has returned any damaged slings or harnesses to her in "a long time." She did not receive any faulty slings or harnesses prior to R1's fall.Safety Director/(G) was interviewed on [DATE] at 8:50 a.m. Safety Director/(G) stated that he did not have any defective or worn-out transfer slings or harnesses returned to him, prior to R1's fall. Family member/(O) was interviewed on [DATE] at 1:37 p.m. Family member/(O) stated that he visited R1 almost daily and assisted with R1's care, including transfers with the EZ lift. Family member/(O) assisted care givers with R1's transfers on [DATE] and [DATE], just before R1's fall occurred on [DATE]. On [DATE], the care giver assisting R1 with the EZ lift transfer was applying a harness on R1 that had two of four teeth missing in the safety buckle. It was necessary for Family member/(O) to point out that the harness was faulty and request that the care giver get a different one for the transfer, which the care giver did. Family member/(O) observed the care giver roll up the defective harness and place it in the canvas bag that hangs on the back of the lift, where it was still accessible for another care giver to later use. On [DATE], the care giver assisting R1 with the EZ lift transfer forgot to buckle the harness around R1's waist. It was necessary for Family member/(O) to remind the care giver to buckle the waist harness. Observations on [DATE] at 10:05 am. on the North unit established that NA/(J) and NA/(L) transferred R2 to the toilet with the EZ lift. When R2 was raised to a standing position with the lift, neither staff had secured the harness belt around R2's waist. Although the harness belt had been buckled, the extra slack in the belt was not tightened to fit R2's waist. The harness belt fell down past R2's hips as R2 stood up and NA/(L) had to quickly pull the belt up to R2's waist and secure it in place. R2's care plan, dated [DATE], indicated that R2 was dependent on staff for all mobility needs and used a wheelchair as her primary means of locomotion, due to weakness. R2 needed to be transferred by two staff with the standing lift. Observations on [DATE] at 10:40 a.m. on the West unit established that NA/(J) and NA/(K) transferred R5 with the Reliant full body lift. Neither staff conducted the required safety check of the lift, prior to using the lift for the transfer. R5's care plan, dated [DATE], indicated that R5 was at risk for falls due to intermittent confusion and right-sided hemiparesis. R5 required several positioning devices in his wheelchair because R5 leans to his weak side and cannot maintain upright posture. R5 needed to be transferred by two staff with the full body lift. Observations on [DATE] at 11:35 a.m. on the West unit established that NA/(J) and NA/(K) transferred R3 from the bed to the toilet with the EZ lift. Neither staff conducted the required safety check of the lift, prior to using the lift for the transfer. R3's care plan, dated [DATE], indicated that R3 was at high risk for falls due to weakness and a recent decline in function. R3 needed to be transferred by two staff with the full body lift, not the EZ lift. Observations on [DATE] at 12:55 p.m. on the East unit established that NA/(I) transferred R4 from the wheelchair to bed with the EZ lift. NA/(I) did not conduct the required safety check of the lift, prior to using the lift for the transfer. R4's care plan, dated [DATE], indicated that R4 was at risk for falls due to [DIAGNOSES REDACTED] and inability to use his left side. R4 needed to be transferred with the assistance of one staff and the standing lift. The facility's mandatory re-education plan for staff, in response to R1's fall, indicated that NA/(J), NA/(K), and NA/(L) had all completed the re-training on proper use of the facility's mechanical lifts, as recent as ,[DATE] - [DATE]. NA/(I) had not completed the required mandatory re-training. Observation on [DATE] at 1:35 p.m. established that Safety Director/(G) had NA/(I) in the East hallway, re-training NA/(I) on proper use of the facility's mechanical lifts, including the precautionary safety inspection prior to using the lift. The original EZ lift arm involved in R1's fall was observed in the Administrator's office on [DATE] at 11:00 a.m., at which time the Administrator was interviewed about R1's fall. The Administrator showed the investigator where the black rubber grommet/safety catch kept the harness loops in place during a transfer. The Administrator stated that the black rubber grommet popped off during R1's transfer, causing the harness to dislodge from one side of the main transfer arm. The Administrator stated that R1's fall was a result of equipment failure and he filed a MedWatch report on [DATE] with the manufacturer and the FDA.