Every finding on record at Episcopal Church Home of Minnesota

Based on observation, interview, and document review the facility failed to provide supervision to necessary prevent elopement for 1 of 1 resident (R1) who required continuous care and supervision, resided on a semi-locked unit and left the facility without their knowledge. This resulted in an Immediate Jeopardy (IJ) for R1.The Immediate Jeopardy (IJ) began on 7/9/26, when R1 was visiting another resident outside the semi-locked unit on the first floor between 8:30 a.m. and 9:30 a.m. At approximately 9:30 a.m., assisted living campus administrator (ACA) noticed R1 was walking alone outside the facility in the parking lot heading towards a busy avenue. The Administrator and Director of Nursing (DON) were notified of the IJ on 7/21/26 at 5:15 p.m. The immediacy was removed on 7/22/26 at 1:00 p.m., but noncompliance remained at the lower scope and severity level D (isolated, scope and severity level) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R1's annual [NAME] Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, and had no episodes of wandering. There was no information for resident to be at significant risk of getting to a potentially dangerous place of stairs or outside of the facility. R1 had worsening behaviors of care rejection and wandering compared to prior assessment. R1's MDS further indicated she was independent with activities of daily living including dressing and mobility with a walker and had a wander/elopement alarm that was used daily.R1's Elopement Risk Evaluation (ERE) dated 6/01/26, indicated R1 had not made attempts to elope from current living situation although a recent attempt to elope was successful. The evaluation further indicated R1 was found sitting outside on one of the green benches nearest to Arby's fast-food restaurant with her walker in front of her. Resident was spotted by her family member (FM)-B while driving to come and see her. FM-B brought her back to the nursing facility. The director of nursing (DON) and social worker were updated. R1's care plan dated 6/12/26, indicated R1 had impaired cognitive function or impaired thought processes and was at risk for falls due to impaired memory, mobility balance and vision impairment. The care plan indicated a wander guard was placed on lower part of r1's four wheeled walker (4WW) related to an elopement.R1's Psychiatric Evaluation dated 6/30/26, indicated R1 had major depressive disorder and generalized anxiety disorder. The evaluation indicated R1 reported she was doing fine, there was nothing wrong with her and she had no issues but can be forgetful at times, outside of that she had no concerns. The evaluation further indicated R1 was cognitively below average; her insight and judgements were below average. The Evaluation indicated It is interesting that facility is concerned about her elopement status noting that she is allowed to leave the memory care unit and visit her [FM-A] on a daily basis on a different unit. If the facility feels concerns regarding her eloping, I recommend not allowing her to leave the memory care unit which would substantially decrease the chance of eloping. R1's (ERE) dated 7/09/26, indicated R1 had made elopement attempts from current living situation and had made 1-2 attempts previously and was successful. The Evaluation indicated R1 had short term and long-term memory loss and was found walking towards university avenue around the Garden assisted living facility. R1's care plan dated 7/9/26, included an elopement focus related to R1's desire to visit family member (FM)-A who was also a resident in the facility on the first floor. Interventions added included 1:1 staff as staffing allowed, hourly checks for three days, monitoring R1's location when she was not in common areas and documenting wandering. Attempt diversion, provider notification for medication changes as needed, and checking wander guard placement and functionality every shift. A Facility Reported Incident (FRI) dated 7/10/26, indicated on 7/09/26 at 9:35 a.m., R1 ate her breakfast on the semi-locked unit and requested to visit FM-A on the first floor which was not a locked unit in another area of the facility. At approximately 8:30 a.m., facility staff assisted R1 to FM-A and she remained with FM-A for an undetermined amount of time. Between approximately 8:30-9:35 a.m., R1 left FM-A, was unaccompanied and exited the building without the staff knowledge. R1 was found, unsupervised, in the assisted living parking lot by the ACA. The social services designee was notified and tried to redirect the resident who refused to re-enter the building. Staff remained with resident for three hours attempting to get her back into the building. R1 and staff ate at a nearby restaurant and finally returned to the facility campus. R1 was placed on 1:1 supervision for increased monitoring. In addition, the facility initiated further review of the resident's elopement risk, clinical condition, potential contributing medical factors, and the effectiveness of current interventions and an investigation was initiated. R1's Care Plan did indicate after the 7/19/26 incident it was revised on 7/21/26, and staff were now to assist FM-A to R1's room for visits and R1 was no longer to be taken off of her unit.R1 ERE dated 7/21/16, indicated R1 had made attempts to elope three times and was successful. The evaluation indicated she was able to walk to the ALF and did not go outside, another occasion she was found sitting on the green bench in front of the building and she was also seen in the parking lot by the ALF. The evaluation indicated she was at high risk for elopement and was on continuous 1:1 monitoring on all shifts by nursing staff.R1's Progress Notes (PN) indicated the following: 6/01/26, Resident was found sitting on green bench without supervision. Family member (FM)-B found resident while driving to facility and [NAME] resident back to the nurse's station. Care Plan revised on 6/12/26 to include a wander guard to lower part of walker. 6/09/26, Resident was found off the unit on 6/09/26 without supervision. Resident refused to return to unit. Chaplain was able to level with her and guided her back to the unit. Nurse Manager (NM)-A is working on getting a wander guard for her. Residents' family member (FM)-B is looking at touring a locked memory care unit on campus. 6/12/26, R1 cut off wander guard placed on her arm and brought it to the nursing station. States: I don't need this on my arm.7/09/26, R1 was observed outside the facility this afternoon after visiting FM-A who resides in the facility in an unlocked unit. Writer spent time with resident accompanied her on a walk. Upon initial contact resident was mildly agitated and stated she did not want to come inside with writer. During the walk resident engaged in casual conversation.7/19/26, R1 was downstairs visiting FM-A and took off to ALF, a Code Grey was called (meaning a resident had eloped) staff were able to get resident back to the unit resident was upset and agitated and difficult to redirect.During interview on 7/20/26 at 12:12 p.m., director of social services (DSS) stated they had a meeting last week to have R1 moved to a fully secured, locked unit and the plan was to talk to the family today and continue 1:1's until R1 moved to the locked unit. During interview on 7/20/26 at 12:26 p.m., NM-A stated R1 visited FM-A on the [NAME] Unit every day around 8:30 a.m. Staff assisted R1 to the unit. R1 eloped after she finished visiting since there really was no plan for R1's return to the semi-locked unit. On 7/09/26, was when R1 went through the ALF and exited through the doors. R1 was found in the ALF parking lot. NM-A stated after that occurred, R1 was placed on 1:1 staff supervision.During interview on 7/20/26 at 4:30 p.m., the administrator stated R1's confusion has increased lately they were not aware of why her confusion increased. R1 was placed on 1:1 staff since the incident occurred on 7/09/26, since she was found after not being seen for over five minutes of staff knowledge of her location. The administrator stated during camera review, they found out R1 went through the cafe door going into the assisted living, which was not wander guard secured, so the alarm did not sound alerting staff she had gone through the door. The administrator stated he was unaware the cafe door was not wander guard secured until after her elopement on 7/09/26. A company was coming out today (7/20/26) to look at the door to make sure it is secured. The Administrator further stated he was informed of R1's previous elopement. During interview on 7/20/26 at 7:33 p.m., R1's FM-B stated he was aware that in the past few months R1 had eloped at least two other times (before 7/9/26), and the last time he believed she traveled toward the ALF and got out through the front door. FM-B was aware R1 was outside for three hours and on that side of the building (ALF) her alarm will not set off the door alarm. FM-B further stated he was aware at one time she had her alarm (wander guard) on her wrist and she cut that off so it was then placed on her walker. FM-B stated he thought it was okay for R1 to go to the ALF to the movie theater and to the pub but was unaware the door was not wander guard secured. During interview on 7/21/26 at 10:10 a.m., the DON stated on 7/19/26, while R1 was on 1:1's, during change of shift in the afternoon, after R1 visited FM-A on first floor, the staff were unable to locate her. The DON stated R1 was found several minutes later in the ALF. During interview on 7/21/26 at 4:00 p.m., the administrator stated he provided staff with a Staff Alert: Constant 1:1 Supervision sheet to prevent further incidents from occurring, similar to the incident on 7/19/26. The Administrator stated they will be educating everyone that will be assigned to the 1:1 with R1. Facility document, Staff Alert: Constant 1:1 Supervision sheet, WHAT THIS MEANS:R1 is on constant one-to-one supervision. Someone must have eyes on her everyminute of every shift.The one-to-one does NOT stop at shift change. It must be handed off directly, person to person.Do not assume someone else is watching. If you are assigned, she is your responsibility until you hand off.AT SHIFT CHANGEDo a face-to-face handoff. Your relief must be standing with R1 before you leave.Say it out loud: You have eyes on R1 now. Get a clear yes back.Never walk away until the next staff member has visual contact.IF YOU NEED A BATHROOM OR BREAKFind another staff member to cover your one-to-one FIRST.Wait until they have eyes on R1 before you step away.When you return, take the one-to-one back with a clear verbal handoff.If you cannot find coverage, call the charge nurse immediately. Do not leave her alone even for a moment.WHY THIS MATTERSR1 has left the building unsupervised before and can move quickly. A gap of even aminute is enough for her to reach an exit. Constant eyes keep her safe.Questions? See the Charge Nurse or DON. Thank you for keeping R1 safe. Facility policy, Elopement/Missing Resident-Code Gray Policy reviewed 6/1725, indicated Elopement Risk assessment will be completed upon admission, quarterly, and as needed in case of a significant change. If a resident is determined to have a history of wandering or is assessed to have a high potential for wandering outside the facility, the plan of care will identify specific actions and se guards. The IJ that began on 6/30/26 and was removed on 7/22/26 at 1:00 p.m., when R1 was reassessed for elopement risk, and the care plan was reviewed and revised to include interventions consistent with her current level of risk, a new locked magnetic door was added to the unsecured door on the semi-secured unit, ALF door was magnetically locked, 1:1 supervision was applied with no gaps, R1 was no longer allowed to leave the secured unit, staff were re-educated and a discharge was planned for R1 to a more secured locked unit on 7/24/26.Elopement/Missing Resident-Code Gray Policy reviewed 6/1725, indicated Elopement Risk assessment will be completed upon admission, quarterly, and as needed in case of a significant change. If a resident is determined to have a history of wandering or is assessed to have a high potential for wandering outside the facility, the plan of care will identify specific actions and se guards. The IJ that began on 7/9/26. was removed on 7/22/26 at 1:00 p.m. when R1 was reassessed for elopement risk, and the care plan was reviewed and revised to include interventions consistent with her current level of risk, new locked magnetic door on secured unit, ALF door was magnetically locked, one to one supervision was applied with no gaps, R1 was no longer allowed to leave the secured unit, staff re-education and a discharge was planned for a more secured locked unit on 7/24/26.

Based on observation, interview and document review the facility failed to comprehensively assess bruising for 1 of 1 resident (R1), and the facility was unable to ensure neurological checks (a critical assessment to identify any potential damage to the brain and nervous system) had been completed according per protocol. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. R1 was independent with activities of daily living including dressing and mobility with a walker and had a wander/elopement alarm that was used daily. The MDS indicated R1 had a fall since the prior assessment. R1's care plan dated 6/12/26, indicated R1 had impaired cognitive function, impaired thought processes and was at risk for falls due to impaired memory, mobility balance and vision impairment. The care plan directed staff to anticipate and meet needs, be sure R1's call light was within reach, encourage R1 to use it for assistance as needed and follow the facility protocol. A Facility Reported Incident (FRI) dated 7/21/26 at 3:17 p.m., indicated R1 was observed to have a bruise on the right eye socket that was not observed by the nurse at 10:00 p.m. on 7/20/26. It was first noted by the night nurse around 11:00 p.m. on 7/20/26, and at 7:00 a.m. on 7/21/26 by nursing assistant (NA)-A. There was increased swelling in size and further assessment showed a seven (7) centimeter (cm) by six (6) cm bruise and R1 reported pain on her right arm. The report indicated the nurse offered Tylenol and R1 declined and stated she was alright. The report further indicated on 7/20/26, in the evening, R1 had an agitation episode. R1 received scheduled evening medications and an as needed Lorazepam (antianxiety medication) 0.5 milligrams (mg) with stable vital signs at baseline. R1's family member (FM)-B visited and she calmed down. Licensed practical nurse (LPN)-D saw the resident at 10:00 p.m., with no bruises and at 11:00 p.m., LPN-B noted the bruise on R1's head and offered Tylenol which R1 declined. R1's Neurological Check list indicated the following:Vitals were taken on 7/22/26 at 9:35 a.m., (over 10 hours after the bruise was noted on R1's head) which indicated Temperature- 96.9, Pulse- 79, Respirations- 16 and Blood pressure- 153/95, neuros were with in normal limits and R1 reported pain on the right area of the eye when touched. Facility document, Facilities Falls Follow Up, indicated If a fall is witnessed and did not hit head VS [vital signs] X 24 hours. If fall is unwitnessed VS x72 hours. If hit head VS and Neuro checks X 72hours. If confused and unwitnessed VS and Neuro checks x 72 hours. The Follow up indicated VS and Neuros should have been taken every 15 minutes x 1 hour, every 30 minutes x 1 hour, every hour x 4 hours, every shift x three (3) days and return to Nurse Leader when completed. During interview on 7/21/26 at 11:45 a.m., R1's Nurse Practitioner (NP) stated she was notified R1 was sent to the emergency room at 9:45 a.m. on 7/21/26, with bruising on the right side of her face and was unable to open her right eye, neuros and vitals were within normal limits. NP was not sure what occurred and was unsure if R1 had a fall. NP stated R1 was very frail. NP was concerned since R1 was on aspirin and Eliquis which are both blood thinners, NP stated the staff should have sent R1 in as soon as they noticed the bruising due to her high risk for bleeding and risk for a brain bleed. A progress note dated 7/22/26, indicated R1 was seen at the emergency department and when questioned she reported she had a fall during the night and complained of pain in right arm. Tylenol was given and a cold pack was placed to the bruise on side of R1's face. No fractures were present and R1 had a BIMS (Brief Interview for Mental Status) (test to determine cognitive status. A score of zero to seven indicates severe cognitive impairment) score of 2, which means severely cognitively impaired. Orders in place to monitor bruising on right side of face until healed/resolved. Orthostatic blood pressures reviewed appear with in normal limits. Intervention: staff to encourage resident to allow bathroom light to be left on at night. During observation and interview on 7/22/26, at 12:20 p.m., R1 was in her room with family member (FM)-B sitting next to her. R1 had her food tray on her small table, and she was attempting to eat her food. A large bruise was noted on the entire right side of her face. When asked what happened R1 stated What do you think look at my face, she had word troubles stating what happened and when asked if she fell, she stated, no, and said she was sitting in a chair and her face went down and hit something. R1 was agitated and trying to give her food to FM-B. During interview on 7/22/26 at 3:55 p.m., the director of nursing (DON) stated nursing assistant (NA)-D worked the evening shift on 7/20/26, and she was the 1:1 with R1. The DON stated she was told by NA-D, R1 was having behaviors and had feces on the walls. NA-D noticed the bruise on R1's face at 11 p.m. LPN-A, the night nurse offered R1 Tylenol for pain and R1 refused. The DON stated they felt the bruising was from a fall, but they were not sure. Falls Policy for Episcopal Church Home effective June 2025, indicated All residents identified as being at risk for falls will receive individualized fall prevention interventions. The goal is to reduce fall incidence, prevent injury, and preserve resident dignity and independence.

Based on observation, interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours, for 1 of 1 (R1) residents reviewed for resident safety.Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. R1's was independent with activities of daily living including dressing and mobility with a walker. The MDS indicated R1 had a fall since the prior assessment. R1's care plan dated 6/12/26, indicated R1 had impaired cognitive function and impaired thought processes. R1 was at risk for falls due to impaired memory, mobility balance and vision impairment. The care plan directed staff to anticipate and meet needs, be sure the R1's call light was within reach, encourage the R1 to use it for assistance as needed and to follow the facility protocol. A Facility Reported Incident (FRI) dated 7/21/26 at 3:17 p.m., indicated R1 was observed to have a bruise on the right eye socket that was not observed by the nurse at 10:00 p.m. on 7/20/26. It was first noted by the night nurse around 11:00 p.m. on 7/20/26, and at 7:00 a.m. on 7/21/26 by nursing assistant (NA)-A. There was increased swelling in size and further assessment showed a seven (7) centimeter (cm) by six (6) cm bruise and R1 reported pain on her right arm. The report indicated the nurse offered Tylenol and R1 declined and stated she was alright. The report further indicated on 7/20/26, in the evening, R1 had an agitation episode. R1 received scheduled evening medications and an as needed Lorazepam (antianxiety medication) 0.5 milligrams (mg) with stable vital signs at baseline. R1's family member (FM)-B visited and she calmed down. Licensed practical nurse (LPN)-D saw the resident at 10:00 p.m., with no bruises and at 11:00 p.m., LPN-B noted the bruise on R1's head and offered Tylenol which R1 declined. Even though the bruise on R1's was face was first noted on 7/20/26 at 11:00 p.m., it was not reported until the following day (7/21/26) at 3:17p.m. A progress note dated 7/22/26, indicated R1 was seen at the emergency department and when questioned she reported she had a fall during the night and complained of pain in right arm. Tylenol was given and a cold pack was placed to the bruise on side of R1's face. No fractures were present and R1 had a BIMS (Brief Interview for Mental Status) (test to determine cognitive status. A score of zero to seven indicates severe cognitive impairment) score of 2, which means severely cognitively impaired. Orders in place to monitor bruising on right side of face until healed/resolved. Orthostatic blood pressures reviewed appear with in normal limits. Intervention: staff to encourage resident to allow bathroom light to be left on at night. During interview on 7/22/26 at 3:55 p.m., the director of nursing (DON) stated nursing assistant (NA)-D worked the evening shift on 7/20/26, and she was the 1:1 with R1. The DON stated she was told by NA-D, R1 was having behaviors and had feces on the walls. NA-D noticed the bruise on R1's face at 11 p.m. LPN-A, the night nurse offered R1 Tylenol for pain and R1 refused. The DON stated they felt the bruising was from a fall, but they were not sure. The DON stated they did not immediately report the incident but after she thought about it, the DON felt they should have. Facility policy, Injuries of Unknown Origin: An injury should be classified as an injury of unknownsource when both of the following conditions are met:The source of the injury was not observed by any person; andThe source of the injury could not be explained by the resident; andThe injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is in an area not vulnerable to trauma) or thenumber of injuries observed at one particular point in time or the incidence of injuries over time. Reporting and Investigating/Responding:1. It is the policy of this organization that abuse allegations (abuse,neglect, exploitation or mistreatment, including injuries of unknownsource and misappropriation of resident property) are reported perFederal and State Law.2. The facility will ensure that all alleged violations involving abuse, neglect,exploitation or mistreatment, including injuries of unknown source andmisappropriation of resident property, are reported immediately, but notlater than 2 hours after the allegation is made, if the events that causedthe allegation involve a crime, abuse or resulted in serious bodily injury.3. The facility will ensure that alleged violations not involving serious injuryor a crime are reported no later than 24 hours if the events that causethe allegation do not involve abuse and do not result in serious bodily

Based on observation, interview, and document review, the facility failed to ensure medications were stored appropriately, securely, and not expired for 3 of 5 medication carts reviewed for medication storage. This had the potential to affect all the residents who received medications from those carts or resided in or visited the area of the facility in which those medication carts were located. In addition, the facility failed to ensure a medication for one resident (R8) was not left at the bedside of a different resident (R87), contributing to inappropriate medication storage practices for the facility.Findings include:Unsecured medications R4's provider order dated 4/2/26, indicated, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml [Insulin Aspart] (short acting insulin used to treat diabetes). R4's order dated 4/28/26, indicated, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml [Insulin Glargine] (long-acting insulin used to treat diabetes). R122's provider order dated 4/13/26, indicated, Insulin Lispro [1 unit dial] Subcutaneous Solution Pen-injector 100 unit/mil [Insulin Lispro]. R122's provider order dated 4/6/26, indicated, Acetaminophen Oral Tablet 500 mg. During continuous observation on 5/6/26 at 2:04 p.m., one medication cart located outside the transitional care unit (TCU) team room and adjacent to a common area with a television, sofa, table and several chairs, had a small med cup with two white pills sitting beside a large bottle of Tylenol. No staff were seen in the area. -At 2:09 p.m., registered nurse (RN)-I went to the med cart and gathered medications from the cart and walked away, leaving the two pills and bottle of Tylenol sitting unsecured on the med cart. -At 2:15 p.m., RN-I walked back to the cart, charted in the computer and at 2:19 p.m., walked away from the cart, again leaving the medication unsecured on top of the medication cart. -At 2:21 p.m., RN-I returned to the med cart, retrieved the cup with the two pills and disposed of them in the TCU team room. During interview on 5/6/26 at 2:22 p.m., RN-I stated she did leave the med cup with the two pills, which were Tylenol (acetaminophen), and the container of Tylenol out on the med cart unsecured. RN-I stated she prepared the medication and then discovered R122 was in therapy when she attempted to administer the medication. RN-I stated the medication was just Tylenol, but she still should not have left it sitting out since anyone walking by could have grabbed it. During observation and interview on 5/7/26 at 9:02 a.m., a tote sat next to the TCU medication cart and contained a clear plastic graduated cylinder with three insulin pens inside. The three insulin pens were not in individual plastic bags and were touching each other. There were no staff around and the tote was sitting between the med cart and the TV in the small common area. RN-I approached the cart and was asked about the insulin pens. RN-I stated insulin pens were normally stored in the top drawer of the med cart, she opened the top drawer and exposed several other insulin pens stored appropriately. RN-I stated the insulin pens should not be left out in the open and unsecured since anyone could have walked by and grabbed one. RN-I further stated the insulin pens were normally in individual plastic bags and confirmed the three that were out were not in bags and were touching each other. RN-I stated the pens should not have been stored like that. RN-I identified one of the pens were Lispro and was labeled for R122. RN-I identified the other two pens as Aspart and Lantus (Glargine) and stated they were labeled for R4. During interview on 5/7/26 at 9:11 a.m., registered nurse (RN)-A stated expectation for medications to be stored in the med carts and not left out unsecured which could allow residents, visitors or other staff to grab them. In addition, RN-A stated insulin pens should be stored in the top drawer of the med carts and not in the transport totes. Resident insulin pens should not be stored in direct contact with other resident's insulin pens to reduce the risk of cross contamination. R34's quarterly MDS dated [DATE], identified severely impaired cognition, diagnoses of diabetes mellitus and non-Alzheimer's dementia. R34 received insulin injections seven out of seven days in the lookback period. R34's nursing progress note dated 12/13/25 at 14:39 (2:39 p.m.), identified due to persistent increased blood sugars this day the nurse practitioner was updated and gave a one-time order for six units of insulin aspart (rapid-acting insulin). R34's corresponding Medication Administration Record (MAR) dated 12/13/25, identified the insulin aspart was given as ordered one time. R34's Physician's Orders form dated 3/26/26, identified to discontinue Lantus insulin (long-acting insulin also known as insulin glargine) R34's corresponding MAR dated 3/1/26 through 3/31/26, identified insulin glargine give four units subcutaneously (between the skin and muscle) one time daily related to type two diabetes. The order included a start date of 1/22/25 and discontinue date of 3/26/26. During an interview and observation on 5/7/26 at 10:50 a.m., registered nurse (RN)-E reviewed the insulin storage for the household. Included was an insulin aspart pen with a handwritten label including R34's name, which was not dated when opened. RN-E verified the insulin aspart was not a current order. Additionally, a Lantus insulin pen with a faded pharmacy label on it including R34's name was present. RN-E reviewed R34's orders and found the Lantus was discontinued on 3/26/26, neither pen should be in the insulin storage and usually, when a medication was discontinued, they would be removed from storage and given to the clinical manager to dispose. During observation on 5/7/26 at 10:28 a.m., an unattended medication cart was observed on the May unit. On top of the medication cart, there was a bottle of acetaminophen 500 milligrams tablets, and a teriparatide injection 560 micrograms over 2.24 milliliters. During continuous observation between 10:28 a.m. and 10:42 a.m., four staff members and a family member walked by the medication cart. During interview on 5/7/26 at 10:42 a.m., licensed practical nurse (LPN)-B stated she gave a shot to a resident before she went to check on another resident. LPN-B stated she needed to put the injectable medication in the refrigerator in the nurse's station and lock the bottle of Acetaminophen in the medication cart, but she forgot to do it. LPN-B added I just forgot to put away the medications, somebody could have grabbed the medications. Medication left in wrong resident's room R87's admission MDS dated [DATE], identified R87 had intact cognition and required substantial to maximal assistance for most activities of daily living (ADLs). R87's diagnosis included neovascular secondary angle closure glaucoma (severe glaucoma involving blood flow to the eye resulting in increased intraocular pressure and potential vision loss) affecting the left eye. R87's provider orders did not indicate Diclofenac (topical pain gel). R8's provider orders dated 11/29/25, indicated, Diclofenac Sodium External Gel 1% .Topical. During observation and interview on 5/4/26 at 5:41 p.m., R87 sitting in recliner with a bedside table in front of him. There was a bag with a tube of Diclofenac gel sitting on the table. R87 stated did not know what that medication was or what it was used for. With further inspection, the prescription label on the tube of medication indicated it was for a different resident (R8). R87 could not explain why it was left on his table. Licensed practical nurse (LPN)-D entered room and was asked about the medication. LPN-D picked up the bag, looked at the label and stated it belonged to a different resident and then set it back down on R87's table. LPN-D stated it must have been left there by the day shift and could not explain why it was in the wrong resident's room. During interview on 5/4/26 at 5:51 p.m., LPN-A entered R87's room and stated the medication must have been accidentally left on the table earlier in the day and could not otherwise explain why. During follow up interview on 5/6/26 at 1:48 p.m., LPN-A stated would not expect a medication for one resident to be left in a different resident's room. LPN-A stated medication should be stored securely and only left at the bedside of the correct resident if the resident was assessed safe to self-administer medication and safely store the medication at the bedside. During interview on 5/7/26 at 9:54 a.m., director of nursing (DON) stated expectation for all medications to be securely stored in medication carts and not left out unsupervised and would not expect medications for one resident to be left in a different resident's room. DON further stated insulin pens should be stored in the top drawer of the locked medication cart and should not be stored in the tote that was used to transport the insulin pens to the resident room for administration. DON stated each insulin pen should be stored in a separate plastic bag designated for each individual resident and should never be stored together, unprotected from other resident's insulin pens which could cause cross contamination. In addition, DON stated that insulin pens should be discarded when expired. Facility policy Medication Storage Policy dated 1/1/2015, indicated lockable medicine carts, cabinets, and drawers were provided for proper storage of medications. The policy lacked reference to expired medications. Facility policy Bedside Medication Storage, undated, indicated medications were stored at the bedside only when the resident was assessed safe for self-administration and storage of medication. The policy further indicated, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage.

Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene for 1 of 1 resident (R21) during incontinence cares and for 1of 1 resident (R29) during meal service which had the potential to affect all 14 residents in that household. The facility further failed to ensure appropriate personal protective equipment (PPE) was being worn for 1 of 2 residents (R115) on enhanced barrier precautions (EBP). Findings include: Incontinence Care R21's admission Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, was always incontinent of bowel and bladder, and dependent on staff for toileting and lower body dressing. R21 had diagnoses of non-Alzheimer's dementia and acute cystitis with hematuria (bladder inflammation with blood in the urine). R21 was taking an antibiotic with an indication identified. R21's Urinary Incontinence Care Area Assessment (CAA) dated 3/10/26, identified an admission following hospitalization due to having a UTI (bladder infection) with no complications noted. R21 was always incontinent of B&B (bowel and bladder) during the reference period. Staff were directed to continue to provide assist with peri care after each incontinent episode. R21's ADL (activities of daily living) care plan dated 3/31/26, identified one staff was required for toileting. During an observation on 5/4/26 at 4:54 p.m., nursing assistant (NA)-D brought R21 who was in her wheelchair, to her bedroom. NA-C entered shortly thereafter. NA-D and NA-C assisted R21 into her bed using a full body mechanical lift. While R21 was laying on her back, NA-C put on gloves, opened R21's incontinence brief and using wet wipes, cleaned up bowel movement from R21's groin at the front of the brief, and tucked the soiled wet wipes into the brief. R21 was assisted to roll on her side and NA-C cleaned up the rest of the bowel movement from R21's buttocks and tucked the soiled wet wipes into the brief. NA-C removed the soiled brief containing the soiled wipes, rolled it all up and put in the garbage. With the soiled gloves still on, NA-C put a new brief under R21, opened a jar of emollient ointment, and using the same soiled gloves, scooped out the ointment and applied it to R21's backside. Then NA-C removed her soiled gloves and put them in the garbage can. R21 was assisted to roll on her back, and the new brief was fastened. NA-C exited the room to dispose of the garbage.NA-C had contaminated the outside of R21's brief and the emollient jar by handling the items with soiled gloves. During an interview on 5/4/26 at 5:02 p.m., NA-C stated her gloves should have been changed right after incontinence cares. NA-C also said it was a mistake to go into the emollient jar with soiled gloves as the emollient was used on R21's legs also. During an interview on 5/4/26 at 6:25 p.m., NA-D stated gloves should be changed right after incontinence cares, disposed of, and new ones put on before touching anything else. During an interview on 5/4/26 at 6:27 p.m., registered nurse (RN)-F stated he expected gloves to be changed, hand hygiene performed right after incontinence cares and before touching anything else. RN-F stated he would have to dispose of the emollient jar as it may be contaminated with feces which could contribute to UTI. R29 R29's annual MDS dated [DATE], indicated severely impaired cognition, diagnoses of dementia, and no rejection of care behaviors noted. It further indicated R29 required assistance from staff with personal hygiene. R29's care plan dated 4/22/26, indicated R29 demonstrated ADL self-care performance deficit related to decreased cognition/confusion, impaired mobility. Non-compliant in waiting for assistance with an intervention requiring moderate to maximal assist of 1. During observation on 5/5/26 at 1:05 p.m., R29 was sitting in a chair in the dining room. The fingernails on both hands were approximately two inches long and had brown matter caked underneath them. During observation on 5/6/26 at 11:25 a.m., R29 was sitting at the dining room table drinking juice and waiting for lunch. The fingernails on both hands were approximately 2 inches long and had brown matter caked underneath them. At 11:45 a.m., NA-A set her lunch plate in front of her but did not offer to wash R29's hands or use hand sanitizer before she started eating. R29 proceeded to pick up her roll and eat it with her hands. Then she would pick up pieces of food (salad) off of her plate with her fingers and eat it. At 12:11 p.m., NA-A gave R29 ice cream for dessert. She ate the ice cream with a spoon, but when the ice cream was gone, she stuck her fingers in the cup and then proceeded to lick them. She then used her hands to brush the crumbs from her lunch off the table onto the floor. At 12:33 p.m., R29 left the table in her wheelchair and headed down the hallway towards her room. NA-A did not offer to wash R29's hands or use hand sanitizer when she was finished eating. During observation on 5/7/26 at 7:36 a.m., R29 was sitting in the dining room eating oatmeal and was using a spoon. The fingernails on both hands were approximately 2 inches long and had brown matter caked underneath them. When she had finished eating her oatmeal, she stuck her fingers in the bowl and then licked her fingers. NA-A asked R29 if she was done with her oatmeal and then took the bowl away. R29 picked up her spoon and started eating her yogurt with a spoon. At 8:23 a.m. R29 was sitting at the table eating orange slices. When she was finished, she started to fall asleep. NA-A asked her if she wanted to go back to her room to take a nap. NA-A assisted R29 to stand up and grab her walker and she headed back down the hallway towards her room. NA-A did not offer to wash her hands or use hand sanitizer. During observation and interview on 5/7/26 at 8:50 a.m., NA-B stated NAs were responsible for ensuring the residents hands and fingernails were clean and they were expected to wash the resident's hands (or use hand sanitizer) before and after meal service. NA-B verified R29's fingernails were long and had brown matter underneath them that appeared to have been there for a while, stating R29 often eats with her hands. During interview on 5/7/26 at 8:57 a.m.NA-A stated nursing assistants were responsible for ensuring resident's hands and fingernails were clean stating they have manicure sticks they can use on the resident's shower day, or they can wash them and clean underneath the nails if needed. NA-A further stated the NAs were also responsible for offering to wash the resident's hands or use hand sanitizer after meal service. During interview on 5/7/26 at 9:10 a.m., RN-B stated nursing staff (NAs and nurses) should be offering to clean the resident's nails at least once a week on their bath day and as needed, or they can soak their hands and clean underneath their nails. This is important to prevent germs from spreading. EBP R115's census identified he was admitted on [DATE]. R115's in-house nurse practitioner (NP) initial intake document dated 5/1/26, identified diagnoses of cellulitis, abscess of right lower extremity (RLE) and history of sepsis. R115 had a right lower extremity wound which was really weepy and required a towel underneath the leg to absorb drainage. A wound consult was ordered. R115's wound care orders dated 4/30/26, identified clean leg with antimicrobial cleansing solution, dry well, apply skin prep to peri-wound, xeroform (protective wound dressing) to wound bed, cover with non-adherent gauze, add ABD pad (consists of a soft outer nonwoven layer and fluff filler to absorb and disperse fluid) as needed if drainage, secure with kerlix (gauze). R115's care plan dated 4/30/26, identified actual impairment to skin integrity of bilateral lower extremity wound with interventions to follow facility protocols for treatment of injury. The care plan lacked EBP interventions. During an observation on 5/4/26 at 11:36 a.m., R115 was seated in his wheelchair. His RLE was wrapped in gauze up to the knee, covered with a grip sock and elevated on a folding chair. R115 stated he had an infection while in the hospital. He had a lower leg wound that had a once weekly dressing change, however it was recently changed to daily dressings as the weekly one would get too saturated and leak. During an observation and interview on 5/4/26 at 11:50 a.m., nursing assistant (NA)-E entered R115's room with a mechanical standing lift to complete a transfer. NA-E did not put on any PPE for the transfer. After NA-E exited the room, she was asked if R115 required EBP and she R115 was not on precautions, because there was no bin outside the room of PPE and no signage near the door. NA-E stated that was the reason she did not put a gown on to help R115 with his transfer. During an interview on 5/4/26 at 11:58 a.m., NA-F stated if a resident was on EBP a gown should be on for all high contact cares. Additionally, a sign and bin would be outside each room. NA-F looked at R115's room and said there was no PPE bin or signage for EBP and was unsure if EBP was in place. During an interview on 5/4/26 at 12:20 p.m., RN-G who was working with R115 today, stated if a resident was on EBP they needed a gown and gloves on for all direct care, including transfers. Though RN-G had been working with R115 today, she was unsure if he was on EBP and wanted to check with the nurse manager. During an interview and observation on 5/4/26 at 12:25 p.m., RN-G returned with a printed EBP instructions sign for R115's doorway and said he should be on EBP due to the wound. RN-G stated the wound was weeping fluid today when the nurse practitioner changed the dressing. During an interview on 5/4/26 12:26 p.m., RN-A stated R115 should have EBP in place as he was admitted with a wound. Each room on EBP should have their own bin and signage directing staff to follow EBP PPE precautions. During an observation on 5/4/26 at 12:30 p.m., NA-F placed a full PPE bin outside of R115's room. During an interview on 5/6/26 at 12:45 p.m., the director of nursing (DON) stated gloves should be changed immediately after incontinence cares, hand hygiene should be completed and new gloves put on if needed, and a resident with a weeping wound should be placed on enhanced barrier precautions for infection control purposes. During interview on 5/7/26 at 10:08 a.m., DON stated if a resident's fingernails are dirty the nursing staff are expected to clean them. They are also expected to be offering to wash the residents' hands or use hand sanitizer if they are visibly soiled after meal service. A facility policy regarding hand hygiene dated 10/2/24, indicated hands must be washed with soap and water if they are visibly soiled. Alcohol based hand sanitizer may be used for hand hygiene unless hands are visibly soiled. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, andcontaminated items, whether gloves are worn; immediately before and after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other elders, personnel, equipment and/or the environment. Hand hygiene is essential in order to prevent the transmission of infectious agents.

Based on observation, interview and document review, the facility failed to ensure the primary care provider (PCP) was notified of a change in condition for 1 of 2 residents (R21) reviewed for a change of condition. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified she had severely impaired cognition, no behaviors or rejection of care and was dependent on staff for toileting, bed mobility, transfers and lower body dressing. Diagnoses included diabetes mellitus and non-Alzheimer's dementia. R21 was admitted with an unstageable pressure ulcer/injury, was at risk for developing pressure ulcers/injuries and did not have foot problems. Skin interventions included pressure reducing devices for bed and pressure ulcer/injury care.R21's pressure ulcer Care Area Assessment (CAA) dated 3/10/26, identified she was admitted with left heel unstageable PI (pressure injury), dressing applied, to be seen by the wound nurse.R21's care plan dated 3/31/26, identified she had a pressure ulcer related to immobility with interventions to administer treatments, monitor for effectiveness, provide education, monitor nutrition and pressure relieving mattress on bed. The care plan lacked notation of any toe concerns.R21's weekly Skin and Body Audit form dated 4/4/26, identified the tip of right first toe (the big toe) had ischemic (dark or dusky color indicative of insufficient blood flow) tissue measuring 1.2 centimeters (cm) long by 0.9 cm wide. R21's nursing progress note dated 4/4/26 at 14:43 (2:43 p.m.), identified an on-call senior care nurse practitioner was notified of the ischemic tissue on the tip of the right first toe with instructions to continue monitoring with an update to the PCP wound nurse on Monday (4/6/26).R21's consultant wound care nurse practitioner (NP)-B visit note dated 4/16/26, identified the unstageable pressure ulcer to the left heel was healed, no new skin issues were reported to NP-B and to reconsult with any new concerns. NP-B was not updated on the new skin alteration to the right first toe observed on 4/4/26.R21's consultant wound care NP-A visit note dated 5/5/26, identified a non-pressure wound of the right first toe and full thickness of unknown duration, at least greater than 14 days. The estimated time to heal was one to two months. Care goals included to decrease wound area, improve new tissue growth, prevent infection, close monitoring, debridement, education and off-loading. Wound measurements were 1.2 cm long by 1.8 cm wide. The wound measurements had increased in width by 0.9 cm since it was last measured on 4/4/26. New orders were issued to apply Betadine (an antiseptic) once daily and as needed.During an observation and interview on 5/4/26 at 4:54 p.m., nursing assistant (NA)-D brought R21 into her room. The top of R21's right first toe was exposed and black on the top slightly larger than a dime in size. NA-D stated R21 had a bruise on the top of her right first toe and was unsure how long the skin alteration was present and estimated a week or more. During an interview on 5/6/26 at 7:51 a.m., licensed practical nurse (LPN)-A stated yesterday, on 5/5/26, the wound provider NP-A debrided (medical removal of dead, damaged, or infected tissue from a wound to promote healing) R21's right first toe wound, and they were waiting for the wound provider's transcription of the visit.During an interview on 5/6/26 at 8:22 a.m., the assistant director of nursing (ADON) reviewed R21's paper chart, electronic chart and 24-hour nursing report sheets and stated the order for 4/6/26 to update the PCP wound care provider should have been completed and was not. Because of the lack of notification, consistent monitoring was not completed of the necrotic right first toe.During an interview on 5/6/26 at 1:07 p.m., consultant wound care NP-A, stated as soon as a facility noticed a new skin alteration, they should contact the wound care team so they can examine during their next wound rounds and update their records. NP-A expected any directions for wound care should be followed. NP-B stated it was not a significant change in the past month to R21's right first toe wound and expected it to be treatable. NP-A was not concerned that the wound had increased in size since first noticed on 4/4/26, and stated sometimes wounds increase in size before they begin to improve and his assessment showed R21's wound was stable. NP-A stated if R21's skin alteration had been addressed on 4/6/26, as ordered, it could have decreased in size by this time. During an interview on 5/6/26 at 12:03 p.m., senior care NP-C stated their on-call service was notified of the new skin alteration on 4/4/26 with orders to monitor and update the wound provider next business day (4/6/26). NP-C wrote new orders for R21 regarding blood pressure on 4/6/26, however she was not personally updated by the facility of R21's new skin alteration on the right first toe, so it was not addressed in her orders. NP-C stated she relied on the nursing staff to provide updates on changes in condition, and no information about the right first toe alteration was in their records between 4/4/26 and 5/4/26.During an interview on 5/6/26 at 12:45 p.m., the director of nursing (DON) stated the facility should have updated the PCP or wound provider on 4/6/26, as identified in the on-call order, and entered into the electronic medical record to ensure consistent monitoring of the skin alteration was completed to ensure follow up.On 5/7/26 at 12:17 p.m., a phone call was placed to NP-B to inquire about his last wound care visit with R21 on 4/16/26 and if he was updated on the new skin alteration on the right first toe.On 5/14/26 at 1:50 p.m., NP-B's medical liaison (ML) returned the previous phone call. The ML stated she reviewed the phone logs and records, and their service was not updated on 4/6/26 or any date thereafter, of R21's new skin alteration on the right first toe, and she would have expected their services to be updated to complete a new assessment and form a treatment plan.The facility's Change in Condition policy dated 5/4/22, identified to promptly notify the resident, his/her attending MD (medical doctor) or other person as indicated by the resident of changes in the resident's condition. The MD should be notified if there was a discovery of injury of unknown source and a need to alter the resident's medical treatment. Additionally, documentation should be entered in the medical record of all information related to the change in condition, the notifications and interventions.

Based on observation, interview and document review, the facility failed to ensure a new skin alteration was comprehensively assessed and monitored consistently in accordance with nursing standards of practice, and that orders for monitoring and referral were entered into the electronic medical record (EMR) for 1 of 2 residents (R21) reviewed for new skin alterations. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified she had severely impaired cognition, no behaviors or rejection of care and was dependent on staff for toileting, bed mobility, transfers and lower body dressing. Diagnoses included diabetes mellitus and non-Alzheimer's dementia. R21 was admitted with an unstageable pressure ulcer/injury, was at risk for developing pressure ulcers/injuries and did not have foot problems. Skin interventions included pressure reducing devices for bed and pressure ulcer/injury care.R21's pressure ulcer Care Area Assessment (CAA) dated 3/10/26, identified she was admitted with left heel unstageable PI (pressure injury), dressing applied, to be seen by the wound nurse.R21's care plan dated 3/31/26, identified she had a pressure ulcer related to immobility with interventions to administer treatments, monitor for effectiveness, provide education, monitor nutrition and pressure relieving mattress on bed. The care plan lacked notation of any toe concerns or interventions.R21's weekly nurse Skin and Body Audit forms identified:-4/4/26, tip of right first toe (the big/great toe) had ischemic (dark or dusky color indicative of insufficient blood flow) tissue measuring 1.2 centimeters (cm) long by 0.9 cm wide.-Wound assessments were not obtained 4/8/26 through 4/13/26, due to R21's hospitalization.-4/21/26, no notation of the right first toe alteration.-4/25/26, hard dark tissue observed on the right first toe. The audit lacked measurements of the skin alteration.-5/2/26, cyanosis and bruising on the right first toe. The audit lacked measurements of the skin alteration.R21's nursing progress note dated 4/4/26 at 14:43 (2:43 p.m.), identified the on-call provider was notified of the ischemic tissue on the tip of the right first toe with instructions to continue monitoring with an update to the PCP wound nurse on Monday (4/6/26).R21's Medication Administration Record (MAR), Treatment Administration Record (TAR) and EMR dated 4/1/26 through 5/4/26, lacked orders to monitor ischemic tissue on the right first toe or to update the PCP wound nurse on 4/6/26. The on-call provider's orders given on 4/4/26, had not been transcribed into the EMR for staff to monitor and document, therefore no further measurements were obtained and the PCP wound nurse was not updated on 4/6/26, of the new skin alteration.R21's consultant wound care nurse practitioner (NP)-B visit note following hospitalization dated 4/16/26, identified an unstageable pressure ulcer to the left heel was healed, no new skin issues were reported to NP-B and to reconsult with any new concerns.R21's consultant wound care NP-A visit note dated 5/5/26, identified a non-pressure wound of the right first toe and full thickness of unknown duration, at least greater than 14 days. The estimated time to heal was one to two months. Care goals included to decrease wound area, improve new tissue growth, prevent infection, close monitoring, debridement, education and off-loading. Wound measurements were 1.2 cm long by 1.8 cm wide. The wound measurements had increased in width by 0.9 cm since it was last measured on 4/4/26. New orders were issued to apply Betadine (an antiseptic) once daily and as needed.During an interview on 5/6/26 at 8:22 a.m., the assistant director of nursing (ADON) reviewed R21's paper chart, EMR and 24-hour nursing report sheets and stated the order on 4/4/26, to update the PCP wound care provider on 4/6/26, should have been completed and was not. Because the order was not transcribed into the EMR, consistent monitoring was not completed of the ischemic right first toe.During an interview on 5/6/26 at 1:07 p.m., consultant wound care NP-A, stated any directions for wound care should be followed. NP-B stated it was not a significant change in the past month to R21's right first toe wound and expected it to be treatable. NP-A stated if R21's skin alteration had been addressed on 4/6/26, as ordered, it could have decreased in size by this time. During an interview on 5/6/26 at 7:51 a.m., licensed practical nurse (LPN)-A stated he could not find documentation the wound had been measured or comprehensively assessed since it was first noticed on 4/4/26. LPN-A stated orders from the weekend on-call providers should be entered into the EMR.During an interview on 5/6/26 at 8:22 a.m., the assistant director of nursing (ADON) reviewed R21's paper chart, electronic chart and 24-hour nursing report sheets and stated the weekend order to monitor the wound and to update the PCP wound care provider on 4/6/26, should have been completed and was not.During an interview on 5/6/26 at 12:03 p.m., senior care NP-C stated in the case of new ischemic skin alterations in a toe, she would expect nursing staff to document at least daily assessments in the medical record of the condition, signs of infection, circulation in the feet, and to update the provider on any worsening. Part of determining the progress or lack of progress in a wound included skin measurements.During an interview on 5/6/26 at 12:45 p.m., the director of nursing (DON) stated that she expected staff to follow the facility policy to complete and document Skin and Body audits every week which would include measurements and progress of the wound. Additionally, providers should be updated on skin alterations to ensure proper follow up.The facility's Skin Care policy dated 3/2025, identified for an existing ulcer, the assessment would: Differentiate the type of ulcer (pressure-related versus non-pressure related) Determine the ulcer's stage Describe the ulcer's characteristics Determine if infection is present Assess pain Note any dressings and treatments that have occurred.Additionally, the comprehensive assessment would initiate care plan directives including daily monitoring of skin with cares, at least weekly documentation in conjunction with bath day, monitoring of the ulcer's characteristics, progress toward healing, and potential complications.

Based on observation, interview, and document review, the facility failed to ensure a resident was safe to have a lift reclining chair for 1 of 1 resident (R92) reviewed for falls. Findings include:R92's admission Minimum Data Set (MDS) dated [DATE], identified R92 had severe cognitive impairment, had lower extremity impairment on one side of the body, had a history of falls, was dependent on staff for transfers, and received antipsychotic, antianxiety, antidepressant, and opioid medications. R92's diagnoses included dementia, disorientation, anxiety, muscle weakness, and right pubis fracture. R92's care plan printed 5/7/26, indicated R92 was HIGH risk for falls r/t [related to] impaired mobility, confusion, dementia and instructed staff to ensure call light was in reach and encourage R92 to use it. The care plan identified R92 had an ADL (activities of daily living) self-care deficit and required two staff to assist with transfers using a [NAME] steady (standing lift) as needed. The care plan did not identify R92 had a lift reclining chair. R92's physical device review dated 4/19/26, identified R92 used a low bed and a walker, however, did not identify an electric recliner chair or any other lift type reclining chair. During observation on 5/7/26 at 8:30 a.m., R92 was not in her room. The lift reclining chair was all the way up to an almost vertical position. During observation on 5/7/26 at 8:40 a.m., R92 transferred from standing with a walker to the lift chair with contact guard assistance by physical therapist assistant (PTA)-B. PTA-B used the lift chair remote to lower the chair to a seated position and then to a reclining position. PTA-B placed the lift chair remote and the call light both on the right side of R92's lap next to each other. During interview on 5/7/26 at 8:41 a.m., PTA-B was not aware of any assessment for safe use of the lift chairs. During interview 5/7/26 at 8:52 a.m., nursing assistant (NA)-H stated R92 required the [NAME] steady lift for transfers from nursing staff and therapy used the lift chair. NA-H stated was not aware if R92 know how to use the lift chair, but she did use the call light on occasion. NA-H stated R92's cognition fluctuated and was not sure she always knew she was pushing the call light. During interview on 5/7/26 at 9:01 a.m., occupational therapy assistant (OTA)-A was not aware of any sort of lift chair assessment for residents. During interview on 5/7/26 at 9:11 a.m., registered nurse (RN)-A stated only nursing staff were supposed to use the lift chair for resident transfers when therapy indicated it was safe for the resident. RN-A further stated instructions for safe use would be on the resident's whiteboard and would also be in the resident's care plan. During interview on 5/7/26 at 9:20 a.m., director of therapy (DT) stated therapist working with the resident would do an informal evaluation of the lift chair and was not aware of any formal assessment. DT further stated was aware of a fall from a lift chair involving a different unidentified resident in long term care some time ago. DT stated maintenance ended up disabling the lift function of the recliner as a result of the findings of that fall investigation. DT further stated periodic evaluations should occur with resident's use of physical devices since their cognition can change. During interview on 5/7/26 at 9:54 a.m., director of nursing (DON) stated the therapy department worked with residents who had lift chairs and was not aware of any formal assessment. DON stated was aware of previous fall from a lift chair when a resident accidently sat on the remote and unintentionally activated the lift function of the chair. DON stated R92 was cognitively impaired and could see her accidentally using the lift chair remote when she intended to push the call light. During follow up interview on 5/7/26 at 11:30 a.m., DON stated the electronic recliner was listed on physical device assessment form and was being used with other residents as a lift chair assessment and the facility would change the wording to indicate lift chair. DON further stated R92 should have had an assessment completed to determine if she was safe to have a lift chair. A facility policy on physical device assessments was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure medication was administered safely for 2 of 2 (R68, R117) who had been assessed as unable to safely self-administer medications.Findings include: R117 R117's care plan dated 4/27/26, indicated R117 had an ADL self-care deficit related to a functional ability decline due to right scapula and rib nonunion (unhealed fracture). The care plan further indicated R117 had altered respiratory status and difficulty breathing related to COPD (chronic obstructive pulmonary disease) and OSA (obstructive sleep apnea). R117's provider orders dated 4/26/26, indicated Calcium Carbonate Antacid Oral Tablet Chewable 1000 MG.Give 1 tablet by mouth one time a day for Supplement. R117's provider orders lacked evidence of Symbicort (budesonide/formoterol) inhaler. R117's electronic medical record (EMR) lacked evidence of orders allowing SAM and medications to be left at bedside. R117's SAM assessment dated [DATE], indicated R177 did not desire to self-administer medications and agreed to have medications administered by the facility. During observation and interview on 5/4/26 at 1:42 p.m., R117 was in their room in recliner with a bedside table adjacent to the chair. There was an unlabeled inhaler and also a small medicine cup with 2 chewable disks inside. R117 stated she used the inhaler on occasion and would take those chewable tablets later. During observation and interview on 5/4/26 at 1:56 p.m., licensed practical nurse (LPN)-C confirmed the medications on R117's bedside table included a Symbicort inhaler and two Tums. LPN-C stated R117 was not assessed as safe for SAM and those medications should not have been left at the bedside. LPN-C stated if a resident refused to take a scheduled medication when offered, it should be removed and not left at the bedside. During interview on 5/6/26 at 1:48 p.m., LPN-A stated would not expect medications to be left at the bedside unless the resident was assessed as safe for SAM. During interview on 5/7/26 at 9:11 a.m., registered nurse (RN)-A stated in order for medications to be left at the bedside, the resident must be assessed as safe for SAM. RN-A stated R117 had not been assessed as safe for SAM and therefore, the medication should not have been left at her bedside. During interview on 5/7/26 at 9:54 a.m., director of nursing (DON) stated medications should not be left at the bedside unless the SAM assessment was completed indicated the resident was safe for SAM. Facility policy Bedside Medication Storage, undated, inidcated, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. R68 R68's quarterly MDS dated [DATE], indicated R68 was cognitively intact, had no hallucinations or delusions. MDS indicated R68 was set up assistance with activity of daily living and supervision with mobility. MDS indicated diagnoses of chronic obstructive pulmonary disease, cellulitis of lower limbs, and left knee surgery. A review of R68's orders indicated the following: -On 1/26/26, R68 may not self-administer medication. -On 3/6/26, required a topical analgesic external gel 4% apply to affected areas. R68's care plan revised on 4/3/26, indicated she was at risk for impaired comfort related to pain. Interventions directed staff to give pain medication as ordered, monitor effectiveness of pain interventions, provide non-pharmacological measures and report unrelieved pain and condition of change to primary care provider. R68's SAM assessment dated [DATE], indicated R68 was not safe to self-administer medications. Furthermore, the comment section indicated R68 hoarded and used multiple over the counter medications. During observation on 05/04/2026 at 5:29 p.m., R68 had Biofreeze (topical analgesic) roll-on located in a bin on bedside table in her room. R68 was sitting in chair and stated she puts it on by herself. During observation on 05/05/2026 at 9:49 a.m., R68 had Biofreeze located in a bin on bedside table in room. During observation on 05/06/2026 at 10:53 a.m. R68 had Biofreeze located in a bin on bedside table in room. Nursing assistant (NA)-I confirmed that there was Biofreeze in R68's room as R68 applied it when it was needed. During interview on 5/6/26 at 11:45 a.m., LPN-B stated residents' medications should be locked up. Additionally, an assessment for SAM was required and order from the physician was necessary for residents to self-administer medications. Facility policy Self-Administration of Medication dated 11/13/17, indicated residents could only self-administer medications after the IDT (interdisciplinary team) had determined which medications could be safely self-administered. The policy further indicated, if a resident was found safe for SAM per the licensed nurse assessment and IDT determination, a provider order would also need to be obtained which would specify which medications could be kept at the bedside. During interview on 5/6/26 at 1:28 p.m., RN-H stated for residents to self-administer medications was a physician order was required. The resident needed to be cognitively able to safely take the medication, know the name of medication, and how often to take it. During interview on 5/7/26 at 10:22 a.m., director of nursing (DON) stated they expected residents who self-administered medications to have a physician's order. The resident needed to be cognitively able to understand the medication and its use. Additionally, a SAM assessment was to be completed quarterly for residents to help determine if they were safely able to self-administer medications.

Based on interview and document review the facility failed to immediately respond, investigate timely, and implement resident protections for 2 of 4 residents (R1, R2) following an allegation of verbal, mental and physical abuse of R1 and an allegation of mental abuse and neglect of care of R2, that were both reported to the facility.The immediate jeopardy began on 10/6/25 at 10:30 a.m. when R1's family member (FM)-A reported to social worker (SW)-A an allegation of staff to resident mental and physical abuse. Additionally, on 11/3/25, R2's FM-B reported an allegation of staff to resident mental abuse and neglect of care. The facility failed to report timely the incidents to the State Agency (SA), conduct a thorough investigation, and to implement resident protections to ensure other vulnerable residents at risk of abuse were safe during the investigation.The administrator and assistant director of nursing (ADON) were notified of the immediate jeopardy at 5:07 p.m. on 12/17/25. The immediate jeopardy was removed on 12/18/25, but noncompliance remained at the lower scope and severity level D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:R1R1's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition. R1's care plan dated 8/23/25, indicated a self-care deficit related to dementia and impaired mobility in which R1 required staff assistance to turn and reposition in bed.R1's Grievance Log entry dated 10/6/25, indicated a staff concern related to communication by the nursing assistant (NA). Concern was reported by both the R1 and FM-A.R1's Record of Customer and Family Concern form dated 10/6/25, completed by SW-A indicated FM-A reported a conversation she overhead between R1 and NA-B, in which NA-B stated to R1, What in the hell are you doing? You can't be sitting like that. To the FM-A, it sounded like NA-B was repositioning R1 in bed and overheard R1 say to NA-B, Get your hands off me! FM-A stated it sounded like R1 was being, man-handled by NA-B. The form further indicated R1 was interviewed by SW-A, R1 stated he got into a yelling match with NA-B, and NA-B threw R1's legs against the wall. R1 requested not to work with NA-B again. The form indicated the administrator and DON were notified of the incident on 10/6/25 at 10:30 a.m. The form lacked indication other staff or residents were interviewed during the investigation, measures were taken to protect residents during investigationR1's progress notes dated 9/15/25 to 12/15/25, lacked mention of the incident described in the Grievance Log on 10/6/25, but indicated R1 was transferred to a hospital on [DATE]. State Agency Report dated 12/12/25, indicated R1's concerns about returning to the facility from hospitalization after R1 reported abuse at the facility, and because FM-A had concerns about inappropriate behavior by staff at the facility. During an interview on 12/15/25 at 10:46 a.m., FM-A stated she filed a complaint with the facility weeks prior about NA-B. R1 set his phone down without hanging up. FM-A heard staff enter the room, staff asked what R1 was doing, and stated, Get your ass to bed. Then FM-A heard a crash. FM-A stated R1 told her staff spun him around in bed and hit R1's legs on the wall. FM-A yelled at NA-B through the phone and told NA-B to get his hands off R1 and leave the room. FM-A stated she knew R1 was not happy at the facility. FM-A reported the incident to SW-A. During an interview on 12/16/25 at 4:43 p.m. SW-A stated she received R1's grievance on 10/6/25, when FM-A called her to make a report. The process should have been to investigate the concern with full completion of the Record of Customer and Family Concern Form. The SW-A stated she took the initial verbal report for R1's incident from FM-A, interviewed R1, and interviewed the staff member alleged to have abused R1. NA was identified as NA-B, who denied the allegation. SW-A stated the best practice would have been to interview other residents and suspend NA-B immediately, but acknowledged she had not done that, and left the process up to the nurse manager. The SW-A further acknowledged after reading the allegation, it could be considered abusive behavior by NA-B.R2R2's quarterly MDS dated [DATE] indicated moderate cognitive impairment, and use of a wheelchair for mobility. R2's care plan dated 7/23/25, indicated a self-care deficit for ADLs related to limited mobility, impaired balance, and weakness. R2 required assistance of one staff for toileting, transfers, was at risk of pressure injury related to incontinence, and encouraged call light use to request assistance. R2's Grievance Log entry dated 11/3/25, indicated a care concern related to communication with a NA reported by FM-B.R2's Record of Customer and Family Concern Form dated 11/3/25 indicated the SW-A, DON, and administrator were notified by FM-B on 11/3/25 at 12:04 p.m., by email regarding the incident on 11/1/25 around 8:00 p.m. FM-B stated she was on the phone with R2, and overheard a conversation between NA-A and R2 in response to R2's request for an incontinence brief change. NA-A told R2 staff no longer toilet residents on demand, and needed to wait for rounds to be changed. R2 activated her call light to request a change out of a wet brief, NA-A responded and said, I told you the consequences, get in the chair, and NA-A transferred R2 to her wheelchair. R2 asked NA-A for her phone and NA-A said R2 would not need her phone where she was going, and NA-A wheeled R2 out of the room. FM-A called the facility and learned R2 was sitting by the nurses' station. R2's Record of Customer and Family Concern Form lacked interviews from any residents or other staff. Under a section titled Complaint Details, Nature of Complaint indicated Resident felt forced to sit in a chair in the hallway and perceived punishment for voiding in bed.R2's call light log indicated the call light was activated on 11/1/25 at 5:31 p.m., 6:11 p.m., 7:08 p.m., 7:13 p.m., 7:17 p.m., 7:29 p.m., 7:48 p.m., 8:17 p.m., and 8:35 p.m.R2's progress notes dated 11/1/25 at 10:25 p.m., indicated R2 had a miscommunication with the caregiver when the caregiver was providing care. R2 was soaking wet in bed, and the caregiver got her out of bed to take her to the shower room so the caregiver could change the incontinence brief and wash her because R2 had urine up her back. The resident construed the caregiver wanted to punish her for voiding in bed and called her daughter who expressed displeasure and talked to the supervisor. R2's record lacked a SA report for the alleged abuse. During an interview on 12/15/25 at 2:48 p.m., the anonymous reporter (AR)-A stated R2 called FM-B and reported a concern about having to use the bathroom but was afraid to use the call light because NA-A told her if she used her call light again, NA-A would move R2 to the chair at the end of the hall. AR-A stated FM-B did not believe R2, so she suggested putting her call light on and leave the phone call connected so that FM-B could hear what occurred. While on the phone with FM-B, R2 activated her call light, NA-A answered the light and said to R2 she told her before, if she used her light, she would be moved to a chair. R2 wanted her phone, and NA-A would not allow R2 to have it. R2 was wheeled away, crying and screaming, and the phone call was discontinued. NA-A was removed from R2's care and moved to another floor but continued to work with other vulnerable residents. FM-B called the facility and was told R2 was soaking wet (with urine) and was sitting by the nurses' station in her pajamas and an incontinence brief. AR-A stated R2 would not like to be in a public area in a brief or pajamas, preferred her own clothes, and only wore a brief to sleep at night. R2 was obsessed with always having her phone with her, even to go to the bathroom, and would be upset without it. During an interview on 12/16/25 at 2:05 p.m., NA-A stated on 11/1/25, R2 used her call light several times and reported she was wet. NA-A told R2 she was doing rounds and would come to her when it was her turn. NA-A left R2's room and continued rounds. NA-A stated R2 kept turning on her light, and when R2 activated her call light again around 8:00 p.m., R2 was sitting on the edge of the bed, so NA-A put R2 in a wheelchair wearing her brief and nightgown and wheeled R2 to an area by the nurses' station. NA-A acknowledged R2 typically wore her clothes and underwear, not a brief and nightgown, in the dayroom. NA-A further stated she could not help R2 because she was caring for another resident. NA-A acknowledged R2 asked for her phone, but NA-A couldn't find it, and later found the phone under R2's pillow. NA-A stated the DON and nurse manager told her not to work with R2 anymore, but NA-A didn't know why and stated, Sometimes [R2's] daughter is on the phone and maybe she heard the conversation. NA-A acknowledged R2 sat by the nurses' station in a wet brief and nightgown while NA-A finished caring for another resident and re-made R2's bed, and then NA-A returned to assist R2. During an interview on 12/16/25 at 2:32 p.m., licensed practical nurse (LPN)-A stated he was aware of the incident between R2 and NA-A. LPN-A was told NA-A walked away from the resident when she needed care. LPN-A stated NA-A should have asked for help from another staff and should not have put R2 in a chair by the nurses' station wet, in her pajamas as it was a public space. R2 always had her phone and if she was taken from her room without it, she would be upset. LPN-A further stated he knew NA-A was no longer allowed to care for R2 because R2 was afraid of NA-A related to this incident. During an interview on 12/16/25 at 3:47 p.m., registered nurse (RN)-A stated staff should take a resident to the bathroom upon request and should not wait their turn on rounds. The expectation would be for staff to ask for help from another staff and get R2 out of the wet brief. Further, RN-A stated residents cannot be told not to use their call light. RN-A acknowledged the investigation of the incident should have been complete but was not thorough because other residents and staff were not interviewed. During an interview with R2 on 12/16/25 at 2:58pm, R2 stated she used her call light and must have used it too many times, because the NA told her she did not need her phone where she was going. R2 stated I asked where we were going. I was wet, I was yelling, 'Where are you taking me; I don't want to go there.' It seems like she took me a ways-away. When we got there, I was very upset because she removed me from the room I was in and put me somewhere else. She was not being nice. She was kind of nasty because she made me leave my room and I did not want to. I don't like to leave the room in my nightgown. I was pulled out of the room, asked where I was going, and told I didn't need to worry about where I was going. During an interview on 12/16/25 at 4:43 p.m. SW-A stated R2's Record of Customer and Family Concern form was completed on 11/3/25, but the incident was reported to the DON and administrator on 11/1/25 by staff. The SW-A stated the incident could have been considered abusive, and the SW-A was not sure why the DON and administrator deemed the incident was not reportable. The SW-A acknowledged the verbal communication by the NA-A was not appropriate and could have been considered threatening. The SW-A stated although the DON and administrator knew of R2's incident on 11/1/25, the DON and administrator did not speak to the family about it until 11/3/25. The SW-A stated the process was for the DON or administrator to investigate and report allegations. During an interview on 12/17/25 at 10:58 a.m., the administrator stated the process for investigation and reporting resident allegations was if the facility could fix the problem right away, they would. Staff would collect the data from the incident, and the SW would receive the information from staff and follow up in collaboration with the unit manager. The process was to be completed in seven days. The administrator stated he heard on State-wide provider calls, if a resident was just angry with their interaction with staff, it could just be a customer service issue, but if the resident stated they were afraid of the staff, was when abuse should be reported. The administrator stated the facility asked the staff involved in R2's incident if the incident occurred and NA-A denied the allegation, but the process was for the SW to interview other residents, staff involved, and others in the area. The administrator stated there were no other residents with R2's diagnoses to be interviewed. The administrator acknowledged other residents could report on their care concerns, regardless of diagnosis. Further, the process included suspension of the alleged perpetrator, but in these incidents the facility investigated and didn't find reason to suspend the staff. The administrator stated for R2's allegation, the facility finding was there were inappropriate conversations with the resident, which was a misunderstood conversation. For R1, the finding was staff was providing care too fast. The administrator stated he was unsure if other staff or residents were interviewed for either allegation, or if either alleged perpetrator should have or was suspended, but he did not have the documents available to him because the DON was out on leave. The administrator acknowledged there may be missing data for the Record of Customer and Family Concern Forms and investigation information that was not attached to the form, but did not produce additional data.During an interview on 12/17/25 at 12:43 p.m., LPN-C stated a complete abuse investigation included removing the alleged perpetrator from the schedule, interview the staff involved, the resident involved, and additional staff and residents on the unit. The LPN-A stated if there were additional interviews and documents, they would be attached to the Record of Customer and Family Concern Form. Facility policy, The Reporting and Investigation Procedure dated 11/15/23, indicated the purpose of the policy was to assure prompt reporting and investigation of actual or suspected incidents of maltreatment in order to provide a safe environment for residents. Upon receiving the report, if an employee was the alleged perpetrator they will be suspended pending investigation. The investigation process will begin as soon as possible after the incident was identified and will include interviews of the reporter, witnesses, resident, staff members who had contact with the resident during the period of time of the alleged incident, and may also include the resident's physician, roommate, family members, and visitors as indicated. The immediate jeopardy that began on 10/6/25 was removed on 12/18/25, when it was verified, the facility completed the following actions:-Reviewed and revised policies and procedures related to abuse reporting, protections, and investigating allegations of abuse.-Educated all staff and leadership on the above policies and procedures with competency before next shift worked. Training included conducting thorough investigations. -Assessed all residents for abuse who had contact with implicated staff. -Care plans for R2 and other affected residents were updated to include specific protections and interventions. (R1 was discharged from the facility prior to the survey.)-Staff involved in the allegations were removed from the schedule to eliminate access to resident pending completion of the investigations. -Thorough investigations were completed for the incidents and were reported to the State Agency.

Based on interview and document review, the facility failed to ensure annual performance reviews were completed for 4 of 5 nursing assistants (NA-A, NA-B, NA-C, and NA-D) whose personnel files were reviewed. This deficient practice had potential to affect all residents who currently resided in the nursing home and who could receive care from this staff. Findings include:The following nursing assistant (NA)'s personnel records were reviewed for annual performance reviews and identified the following:NA-A was hired on 7/12/13. NA-A's last performance review was dated 10/4/22.NA-B was hired on 2/5/21. NA-B's last performance review was dated 2/5/23.NA-C was hired on 5/24/22. NA-C's last performance review was dated 7/18/23.NA-D was hired on 8/20/21. The facility was unable to provide documentation NA-D had received a performance review.During an interview on 12/18/25 at 5:31p.m., the administrator stated performance reviews should be completed by nurse managers on an annual basis. The director of nursing (DON) oversaw the completion of the performance reviews. Administrator confirmed documentation of more recent performance reviews could not be located for NA-A, NA-B, NA-C and NA-D.The DON was unavailable for interview.The employee handbook informed the facility will provide annual reviews of work performance on or around an employee's anniversary date of employment.

Based on interview and document review, the facility failed to promote dignity while providing care for 3 of 4 residents (R1, R2, R3) reviewed who required assistance with activities of daily living. Findings include: R1R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and required supervision or partial assistance to move from a seated to lying position. R1's Record of Customer and Family Concern form dated 10/6/25, completed by social worker (SW)-A indicated family member (FM)-A reported a conversation she overhead between R1 and nursing assistant (NA)-B, in which NA-B stated to R1, What in the hell are you doing? You can't be sitting like that. To FM-A, it sounded like NA-B was repositioning R1 in bed and FM-A overheard R1 say to NA-B, Get your hands off of me, and it sounded like R1 was being man-handled by NA-B. The form further indicated R1 was interviewed by SW-A, and stated he got into a yelling match with NA-B, and NA-B threw R1's legs against the wall. R1 requested not to work with NA-B again.During an interview on 12/15/25 at 10:46 a.m., FM-A stated she filed a complaint with the facility weeks prior about NA-B. R1 set his phone down without hanging up. FM-A heard staff enter the room, staff asked what R1 was doing, and stated, Get your ass to bed. Then FM-A heard a crash. FM-A stated R1 told her staff spun him around in bed and hit R1's legs on the wall. FM-A yelled at NA-B through the phone and told NA-B to get his hands off R1 and leave the room. FM-A stated she knew R1 was not happy at the facility. During an interview on 12/17/25 at 10:58 a.m., the administrator stated R1's allegation was that staff was going too fast with him. If a resident was upset with their interaction with staff, it was a customer service issue. R2R2's quarterly MDS dated [DATE], indicated moderate cognitive impairment, and use of a wheelchair for mobility. R2's care plan dated 7/23/25, indicated a self-care deficit for ADLs related to limited mobility, impaired balance, and weakness. R2 required assistance of one staff for toileting, transfers, was at risk of pressure injury related to incontinence, and encouraged call light use to request assistance.R2's Record of Customer and Family Concern Form dated 11/3/25, indicated SW-A, director of nursing (DON), and administrator were notified by FM-B on 11/3/25 at 12:04 p.m., by email regarding the incident on 11/1/25 around 8:00 p.m. FM-B stated she was on the phone with R2, and overheard a conversation between NA-A and R2 in response to R2's request for an incontinence brief change. NA-A told R2, staff no longer toilet residents on demand, and R2 needed to wait for rounds to be changed. The NA-A said, I told you the consequences, get in the chair. NA-A then transferred R2 to her wheelchair. R2 asked NA-A for her phone and NA-A told R2, she would not need her phone where she [R2] was going. NA-A wheeled R2 out of the room. FM-A called the facility and learned R2 was sitting by the nurses' station.R2's progress note dated 11/1/25 at 10:25 p.m., indicated R2 had a miscommunication with the caregiver when the caregiver was providing care. R2 was soaking wet in bed, and the caregiver got her out of bed to take her to the shower room so the caregiver could change the incontinence brief and wash her because R2 had urine up her back. The resident construed the caregiver wanted to punish her for voiding in bed and called her daughter who expressed displeasure and talked to the supervisor. During an interview on 12/16/25 at 2:05 p.m., NA-A stated on 11/1/25 R2 used her call light several times and reported she was wet. NA-A told R2 she was doing rounds and would come to her when it was her turn, NA-A left R2's room, and continued rounds. NA-A stated R2 kept turning on her light, and when R2 activated her call light again around 8:00 p.m., R2 was sitting on the edge of the bed, so NA-A put R2 in a wheelchair wearing her brief and nightgown and wheeled R2 to an area by the nurses' station, but acknowledged R2 typically wore her clothes and underwear, not a brief and nightgown, in the dayroom. NA-A further stated she could not help R2 because she was caring for another resident. NA-A acknowledged R2 asked for her phone, but NA-A couldn't find it, and later found the phone under R2's pillow. NA-A stated the DON and nurse manager told her not to work with R2 anymore, but NA-A didn't know why and stated, Sometimes [R2's] daughter is on the phone and maybe she heard the conversation. NA-A acknowledged R2 sat by the nurses' station in a wet brief and nightgown while NA-A finished caring for another resident and re-made R2's bed, and then NA-A returned to assist R2. During an interview on 12/16/25 at 2:32 p.m., licensed practical nurse (LPN)-A stated NA-A should not have put R2 in a chair by the nurses' station wet, in her pajamas as it was a public space. R2 always had her phone and if she was taken from her room without it, she would be upset.During an interview on 12/16/25 at 3:15 p.m., LPN-B stated if a NA told a resident they were not allowed to use the call light or put the resident in a public place while wet, the resident would be anxious and afraid to use a call light again and would likely feel embarrassed.During an interview on 12/16/25 at 3:47 p.m., registered nurse (RN)-A stated staff should take a resident to the bathroom upon request and should not make them wait their turn on rounds. The expectation would be for staff to ask for help from another staff and get R2 out of the wet brief. Further, RN-A stated R2 would not like to sit in the nurses' station in a wet brief and nightgown. RN-A stated the NA should have been provided education about how to talk with residents in a manner that does not seem punitive, and to explain to the resident what she was doing and why she was doing it. During an interview on 12/16/25 at 4:43 p.m. SW-A stated the verbal communication from NA-A to R2 was not appropriate and could have been considered threatening, and R2 would have felt degraded sitting in the common area in her wet brief and nightgown. During an interview on 12/17/25 at 10:58 a.m., the administrator stated there was an inappropriate conversation between NA-A and R2.R3R3's discharge MDS dated [DATE], indicated moderate cognitive impairment, impaired mobility, and diagnoses including arthritis and dementia. ADLs were not assessed. R3's Record of Customer and Family Concern Form dated 11/6/25, indicated FM-C reported an incident in which R3 reported he was sleeping, a NA entered the room and asked R3 to get up for dinner and hit R3 hard on the legs three times with an open hand. The from indicated R3 was upset about being handled roughly.R3's care plan dated 11/12/25, indicated a self-care performance deficit related to impaired cognition and limited mobility. R3 required assistance from one staff to turn and reposition in bed and transfers to move between surfaces. R3 was encouraged to use the call light for assistance. R3's progress notes dated 11/5/25 at 9:35 p.m., indicated FM-C reported to staff the NA was hitting his legs when helping R3. During an interview on 12/16/25 at 3:15 p.m., LPN-B stated staff could not hit residents on the leg to awaken them, but instead should tap them on the shoulder, call the resident by name, tell them who you are, and how you would like to help them.During an interview on 12/17/25 at 10:58 a.m., the administrator stated R3 was not an accurate reporter, so family reported for him, and due to sundowning (a pattern of increased confusion, agitation, anxiety, and restlessness that worsens in the late afternoon or evening primarily affecting people who have dementia), and that any kind of touch may seem different than it should be.The Dignity policy dated 10/15/24, indicated all resident should be treated with dignity, respect, and consideration always. Staff should address residents by their preferred name and title. Adaptive clothing and assistive devices were used respectfully and appropriately. Care is provided in a manner that minimizes unnecessary exposure or embarrassment.

Based on interview and document review, the facility failed to report allegations of physical and verbal abuse immediately (within two hours) to the State Agency (SA) for 3 of 4 residents (R1, R2, R3) after family members and/or residents reported the alleged abuse. Findings include:R1R1's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition. R1's care plan dated 8/23/25, indicated a self-care deficit related to dementia and impaired mobility in which R1 required staff assistance to turn and reposition in bed.R1's Grievance Log entry dated 10/6/25, indicated a staff concern related to communication by the nursing assistant (NA) reported by both the R1 and family member (FM)-A. R1's Record of Customer and Family Concern form dated 10/6/25, completed by social worker (SW)-A indicated FM-A reported a conversation she overhead between R1 and NA-B, in which NA-B stated to R1, What in the hell are you doing? You can't be sitting like that. To the FM-A, it sounded like NA-B was repositioning R1 in bed and FM-A overheard R1 say to NA-B, Get your hands off of me, and it sounded like R1 was being man-handled by NA-B. The form further indicated R1 was interviewed by SW-A, and stated he got into a yelling match with NA-B, and NA-B threw R1's legs against the wall. R1 requested not to work with NA-B again. The form indicated the administrator and director of nursing (DON) were notified of the incident on 10/6/25 at 10:30 a.m. R1's SA Report dated 12/12/25, indicated concerns about R1 returning to the facility after hospitalization after R1 reported abuse at the facility, and FM-A had concerns about inappropriate behavior by staff at the facility. The facility did not file the SA report. During an interview on 12/15/25 at 10:35 a.m., SW-B stated she was not sure if a report was made to the SA about the potential abuse but hoped the facility had. R1 did not want to go back to the facility because of the abuse. During an interview on 12/15/25 at 10:46 a.m., FM-A stated she filed a complaint with the facility weeks prior about a NA-B. R1 would set his phone down and not hang up, and FM-A heard staff enter the room, asked what R1 was doing, and stated, Get your ass to bed, then FM-A heard a crash. FM-A stated R1 told her staff spun him around in bed and hit R1's legs on the wall. FM-A yelled at NA-B through the phone and told NA-B to get his hands off R1 and leave the room. FM-A reported the incident to SW-A. During an interview on 12/16/25 at 4:43 p.m. SW-A stated she received R1's grievance on 10/6/25, the process should have been to investigate the concern with full completion of the Record of Customer and Family Concern Form. The SW-A stated she took the initial verbal report for R1's incident from FM-A, interviewed R1, and interviewed the staff member alleged to have abused R1 who was NA-B, who denied the allegation. The SW-A acknowledged after reading the allegation, it could be considered abusive behavior by the NA. R2R2's quarterly MDS dated [DATE] indicated moderate cognitive impairment, and use of a wheelchair for mobility. R2's Grievance Log entry dated 11/3/25, indicated a care concern related to communication with a NA reported by FM-B. R2's Record of Customer and Family Concern Form dated 11/3/25 indicated the SW-A, DON, and administrator were notified by FM-B on 11/3/25 at 12:04 p.m., by email regarding the incident on 11/1/25 around 8:00 p.m. FM-B stated she was on the phone with R2, and overheard a conversation between NA-A and R2 in response to R2's request for an incontinence brief change, NA-A told R2 staff no longer toilet residents on demand, and R2 needed to wait for rounds to be changed. The NA-A said, I told you the consequences, get in the chair, and NA-A transferred R2 to her wheelchair. R2 asked NA-A for her phone and NA-A said R2 would not need her phone where she was going, and NA-A wheeled R2 out of the room. FM-A called the facility and learned R2 was sitting by the nurses' station. R2's call light log indicated the call light was activated on 11/1/25 at 5:31 p.m., 6:11 p.m., 7:08 p.m., 7:13 p.m., 7:17 p.m., 7:29 p.m., 7:48 p.m., 8:17 p.m., and 8:35 p.m. R2's care plan dated 7/23/25, indicated a self-care deficit for ADLs related to limited mobility, impaired balance, and weakness. R2 required assistance of one staff for toileting, transfers, was at risk of pressure injury related to incontinence, and encouraged call light use to request assistance. R2's progress notes dated 11/1/25 at 10:25 p.m., indicated R2 had a miscommunication with the caregiver when the caregiver was providing care. R2 was soaking wet in bed, and the caregiver got her out of bed to take her to the shower room so the caregiver could change the incontinence brief and wash her because R2 had urine up her back. The resident construed the caregiver wanted to punish her for voiding in bed, and called her daughter who expressed displeasure and talked to the supervisor. The facility lacked a SA report for the alleged abuse. During an interview on 12/15/25 at 2:48 p.m., the anonymous reporter (AR)-A stated R2 called FM-B and reported a concern about having to use the bathroom but was afraid to use the call light because NA-A told her if she used her call light again, NA-A would move R2 to the chair at the end of the hall. R2 activated her call light, NA-A answered the light and said to R2 she told her before, if she used her light, she would be moved to a chair. R2 wanted her phone, and NA-A would not allow R2 to have it. R2 was wheeled away, crying and screaming, and the phone call was discontinued. NA-A was removed from R2's care and moved to another floor but was not suspended. FM-B called the facility and was told R2 was soaking wet (with urine) and was sitting by the nurses' station in her pajamas and an incontinence brief. AR-A stated R2 would not like to be in a public area in a brief or pajamas, preferred her own clothes, and only wore a brief to sleep at night. R2 was obsessed with always having her phone with her, even to go to the bathroom, and would be upset without it. During an interview on 12/16/25 at 2:05 p.m., NA-A stated on 11/1/25 R2 used her call light several times and reported she was wet. NA-A told R2 she was doing rounds and would come to her when it was her turn, NA-A left R2's room, and continued rounds. NA-A stated R2 kept turning on her light, and when R2 activated her call light again around 8:00 p.m., R2 was sitting on the edge of the bed, so NA-A put R2 in a wheelchair wearing her brief and nightgown and wheeled R2 to an area by the nurses' station, but acknowledged R2 typically wore her clothes and underwear, not a brief and nightgown, in the dayroom. NA-A further stated she could not help R2 because she was caring for another resident. NA-A acknowledged R2 asked for her phone, but NA-A couldn't find it, and later found the phone under R2's pillow. NA-A stated the DON and nurse manager told her not to work with R2 anymore, but NA-A didn't know why and stated, Sometimes [R2's] daughter is on the phone and maybe she heard the conversation. NA-A acknowledged R2 sat by the nurses' station in a wet brief and nightgown while NA-A finished caring for another resident and re-made R2's bed, and then NA-A returned to assist R2. During an interview on 12/16/25 at 2:32 p.m., licensed practical nurse (LPN)-A stated he was aware of the incident between R2 and NA-A and was told NA-A walked away from the resident when she needed care. LPN-A stated NA-A should have asked for help from another staff and should not have put R2 in a chair by the nurses' station wet, in her pajamas as it was a public space. R2 always had her phone and if she was taken from her room without it, she would be upset. LPN-A further stated he knew NA-A was no longer allowed to care for R2 because R2 was afraid of NA-A after NA-A removed her from her room wet and didn't help her. During an interview on 12/16/25 at 3:15 p.m., LPN-B stated if a NA told a resident they were not allowed to use the call light or put in a public place while wet, the NA should be disciplined, the action would be considered abuse, and the incident should have been reported within two hours to the SA. The resident would be anxious and afraid to use a call light again. The social worker would report that immediately. During an interview on 12/16/25 at 3:47 p.m., registered nurse (RN)-A stated staff should take a resident to the bathroom upon request and should not wait their turn on rounds. The expectation would be for staff to ask for help from another staff and get R2 out of the wet brief. Further, RN-A stated residents cannot be told not to use their call light. Additionally, NA-A's statement about consequences could be seen as punitive, should have been reported as potential abuse, and did not know why it was not reported. During an interview on 12/16/25 at 4:43 p.m. SW-A stated R2's Record of Customer and Family Concern form was completed on 11/3/25 but the incident was reported to the DON and administrator on 11/1/25 by staff. The SW-A stated the incident could have been considered abusive, and the SW-A was not sure why the DON and administrator deemed the incident was not reportable. The SW-A acknowledged the verbal communication by the NA-A was not appropriate and could have been considered threatening. The SW-A stated the process was for the DON or administrator to investigate and report allegations. SW-A stated abuse allegations were reportable to the SA within two hours. R3R3's discharge MDS dated [DATE] indicated moderate cognitive impairment. R3's Grievance Log entry dated 11/6/25, indicated a care concern reported by FM-C, a care concern when R3 was getting up for dinner. R3's Record of Customer and Family Concern Form dated 11/6/25, indicated FM-C reported an incident in which R3 reported he was sleeping, a NA entered the room and asked R3 to get up for dinner and hit R3 hard on the legs three times with an open hand. The form indicated the administrator and DON knew about the incident on 11/5/25 on the p.m. shift (did not indicate a time). The form indicated the incident was reported to the SA as abuse or neglect. An attached incident summary indicated the incident occurred on 11/5/25 at 4:45 p.m., and facility administrative staff were aware of the incident on 11/5/25 at 6:30 p.m., and was reported to the SA on 11/6/25. The Actions Taken Immediately Following the Incident section of the form revealed the SA report was submitted 11/6/25, Within the required 24-hour window. The SA report was reviewed and received on 11/6/25 at 11:56 a.m., and was not received within the two hour reporting window for abuse. During an interview on 12/17/25 at 10:58 a.m., the administrator stated the process for investigation and reporting resident allegations was if the facility could fix the problem right away, they would. Staff would collect the data from the incident, and the SW would receive the information from staff and follow up in collaboration with the unit manager. The process was to be completed in 7 days. The administrator stated he heard on State-wide provider calls, if a resident was just angry with their interaction with staff, it could just be a customer service issue, but if the resident stated they were afraid of the staff, was when abuse should be reported. The administrator stated the facility asked the staff involved in R2's incident if the incident occurred and NA-A denied the allegation, but the process was for the SW to interview other residents, staff involved, and others in the area. Further, the administrator stated there were no other residents with R2's diagnoses to be interviewed. The administrator acknowledged other residents could report on their care concerns, regardless of diagnosis. Further, the process included the alleged abuser was suspended, but in these incidents the facility investigated and didn't find reason to suspend the staff or report them to the SA. For R2's allegation the facility finding was there were inappropriate conversations with the resident, which was a misunderstood conversation. For R1, the finding was staff was providing care too fast. The administrator stated he was unsure if other staff or residents were interviewed for either allegation, or if either alleged abuser should have or was suspended, but he did not have the documents available to him because the DON was out on leave. The administrator acknowledged there may be missing data for the Record of Customer and Family Concern Forms and investigation information that was not attached to the form, but did not produce additional data. Additionally, the administrator stated the SA report for alleged abuse was in the required time frame of 24 hours, per facility policy. The Reporting and Investigation Procedure dated 11/15/23, indicated the purpose of the policy was to assure prompt reporting and investigation of actual or suspected incidents of maltreatment in order to provide a safe environment for residents. Upon receiving the report, if an employee was the alleged perpetrator they will be suspended pending investigation. The Office of Heath Facility Complaints will be notified per state procedures for any potential abuse or neglect that may have occurred, and abuse must be reported immediately but not later than two hours.

Based on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 3 of 5 nursing assistants (NA-A, NA-C, NA-D) reviewed for annual training.Findings include:The following nursing assistants (NA)'s personnel files were reviewed for annual training and identified the following:NA-B's Relias education (facility's computer-based education system) indicated on 12/18/25, NA-B had 8.6 hours of the required 12 hours of training in the last 12 months.NA-C's Relias education indicated on 12/18/25, NA-C had four hours of the required 12 hours of training in the last 12 months.NA-D's Relias education indicated on 12/18/25, NA-D had zero hours of the required 12 hours of training in the last 12 months.During an interview on 12/18/25 at 4:00 p.m., staff development (SD) stated annual education should be completed in person during a staff's anniversary month. If a staff person does not attend in person, they would be assigned online training. At the end of the year calendar year, SD reviewed all staff education for completion and assigned online training as needed. A staff person would have 30 days to complete the online training. SD confirmed NA-A, NA-C and NA-D had not completed the require annual training in the last 12 months and had not been assigned the online training.During an interview on 12/18/25 at 5:31 p.m., administrator stated all staff are required to attend in-person annual training. In-person trainings were held monthly, and it was the responsibility of the staff development department to let staff members know what month they needed to attend. The annual training should be completed annually. The Nurse Aide In-Services and Training policy dated 1/20/2024 instructed nurse aides will complete a minimum of 12 hours of in-service annually and complete all required training within established timeframes. Completion of orientation, annual in-services, and additional training was documented and maintained in the employee personnel file. The facility would monitor compliance with training requirements and address gaps as needed.

Based on interview and document review the facility failed to monitor and assess for presence of signs/symptoms of urinary tract infections and for antibiotic effectiveness and/or adverse reactions for 2 of 3 residents (R1, R2) reviewed for change of condition. Findings include R1's discharge Minimum Data Set (MDS) dated [DATE] indicated impaired cognition, with diagnoses included lumbar (lower back) vertebra fracture and encephalopathy (confusion). R1 was frequently incontinent of bowel and bladder and needed assistance of 1 person with activities of daily living.R1's health status notes dated 9/5/25 indicated an order was obtained for a urinalysis with culture (UA/UC) but R1's family member (FM-A) did not want to wait for the facility to complete the order. FM-A had R1 tested at an outside medical facility. R1 returned with a diagnosis of UTI with an order for oral antibiotic medication.In review of R1's record there it was not evident R1 was monitored and/or evaluated for presence of/increase in/or decrease of urinary tract infection symptoms aside from vital signs such as increased incontinence, retention, burning during and/or after urination, presence of foul odors, discoloration, frequency, and urgency. Additionally, there was also no consistent documentation for monitoring the side effects of the antibiotic. R1's skilled charting note dated 9/6/25 indicated R1 started taking an antibiotic for UTI. R1's skilled charting note dated 9/7/25 indicated R1 was taking antibiotics for UTI. Vital signs were within R1's baseline. R1's skilled charting note dated 9/8/25 did not address urinary or antibiotic status. R1's provider notes dated 9/8/25 indicated an abnormal urinalysis with empiric (treatment when a healthcare provider suspects an infection but lacks complete information) treatment with oral antibiotic. R1 had reported to provider a little burning with urination. R2's care area assessments (CAA) dated 12/19/24 indicated R2 had triggered for a urinary incontinence CAA and indicated urinary incontinence would be addressed in the care plan. R2's quarterly MDS dated [DATE] indicated intact cognition with diagnoses included congestive heart failure and depression. R2 was continent of bowel and frequently incontinent of bladder. R2's care plan dated 9/17/25 did not include a bowel/bladder focus that addressed the incontinence. R2's health status notes dated 9/17/25 indicated an order was received for a UA/UC. The test was completed and R2 was diagnosed with a UTI and given an order for oral antibiotics for 5 days (through 9/22/25). The notes do not indicate what UTI symptoms R2 was displaying.R2's health status note dated 9/17/25 at 9:50 p.m., indicated R2 had received her first dose of antibiotic but lacked information regarding signs or symptoms of UTI or reaction to oral antibiotic. In review of R1's record between 9/17/25 through 9/22/25 it was not evident R1 was monitored and/or evaluated for presence of/increase in/or decrease of urinary tract infection symptoms aside from vital signs such as increased incontinence, retention, burning during and/or after urination, presence of foul odors, discoloration, frequency, and urgency. Additionally, there was also no consistent documentation for monitoring the side effects of the antibiotic. It could not be ascertained if R1's urinary symptoms had resolved and/or if the antibiotic was effective after the 5 day antibiotic course. R2's health status note dated 10/1/25 indicated R2 had been experiencing feelings of burning on urination and increased urinary frequency. A UA/UC order was obtained and the test completed. R2's EMR did not include health status notes on 10/2/25.R2's health status note dated 10/3/25 indicated R3 had started an antibiotic for UTI.R2's EMR lacked health status notes on 10/4/25, 10/5/25,10/6/25 and 10/7/25.R2's health status note dated 10/8/25 indicated R2 had felt unwell that morning and had an unusual for her incontinent episode of loose stool. During an interview on 10/10/25 licensed practical nurse (LPN)-A stated after a resident has been diagnosed with a UTI a health status note should be written every shift with vital signs and whether or not the resident is experiencing any UTI symptoms. If the resident is on an antibiotic, the note should include any reaction to the antibiotic. Some possible side effects of an antibiotic include stomachache, diarrhea and not feeling well.During an interview on 10/10/25 at 12:04 p.m., registered nurse (RN)-A stated after a resident has been diagnosed with a UTI a nurse's note should be written every shift with the resident's vital signs, UTI symptoms the resident was experiencing, any adverse side effects from the antibiotic, and a resident's intake and output.During an interview on 10/10/25 at 12:34 p.m., RN-B stated after a resident has been diagnosed with a UTI, they should be monitored for improvement of UTI symptoms, vital signs, and anything else the provider ordered. Improvement in symptoms or reaction to antibiotic would be difficult to determine without looking at previous health status notes. RN-B confirmed there was no information regarding R2's signs or symptoms of UTI or reaction to oral antibiotic.During an interview on 10/10/25 at 12:53 p.m., RN-C stated when requesting an order for a UA/UC, the nurse should document the symptoms the resident is experiencing and anything else the nurse observed. Documentation of vital signs, symptoms of UTI and side effects from the antibiotic should be completed daily. RN-C confirmed nothing was captured in R3's notes regarding urinary symptoms. RN-C would expect to see documentation even if R3 was having no symptoms and no reaction to the antibiotic to confirm the infection was resolving and confirm there was no negative reaction to the antibiotic.During an interview on 10/10/25 at 3:34 p.m., director of nursing (DON) confirmed R1's notes indicate she had a UTI, but no indication of monitoring for urinary symptoms. DON also confirmed R2's EMR indicated symptoms of burning and urgency on 10/1/25 with an antibiotic started on 10/3/25 but lacked follow up as to how R2 was feeling or if she was having any reaction to the antibiotic. A UTI is considered a change in condition and should have documentation including initial symptoms, contacting the provider, orders obtained and follow-up monitoring. A resident with a UTI should be monitored for signs and symptoms to see whether the discomfort resolved or not.During an interview on 10/10/25 at 3:45 p.m., medical doctor (MD) stated a resident with a UTI should be monitored for signs and symptoms of UTI and any negative reaction to the antibiotic. If the resident is not improving, the antibiotic might need to be changed.The Change in Condition policy dated 5/4/22 instructed the nurse will document in the medical record all information relative to the change in condition, the notifications, and interventions when applicable. The Urinary Tract Infection policy dated 9/2/24 instructed nurses are responsible for assessing residents for signs and symptoms of UTIs, implementing care plans and documenting interventions. All assessments, interventions and resident responses will be recorded in the medical record.

Based on observation, interview and document review, the facility failed to ensure frozen food items were stored in a manner to prevent cross contamination in 2 of 3 unit kitchenettes reviewed. Findings include: During observation on 3/5/25 at 10:49 a.m., the second-floor kitchenette was reviewed. In the kitchenette's freezer, there was an opened plastic bag of frozen, pre-cooked bacon that was not sealed but was dated 3/3. Additionally, there was a resealable gallon-sized bag of frozen, pre-cooked sausage links that was dated 3/3. There was also a sealed plastic bag of frozen, pre-cooked pancakes that had a thick layer of white, ice crystals inside on the pancakes. Nursing assistant (NA)-J reviewed the items in the freezer and confirmed the dates and stated the unit usually went through the food items in 3 days per policy. When asked about the opened bags of bacon and sausage links, NA-J stated someone from the main kitchen came each morning and went through the freezer and removed undated and old food items. During observation on 3/5/25 at 1:32 p.m., the first-floor kitchenette was reviewed. In the kitchenette's freezer, there was an opened and unsealed bag of frozen, pre-cooked bacon. The bag was dated 3/4 but not able to be resealed in it's original packaging, leaving the bacon open to air in the freezer. Per interview on 3/5/25 at 1:43 p.m. with culinary supervisor (CS), kitchen staff were expected to remove outdated food items or items that look bad. CS confirmed kitchen staff rounded on the unit kitchenettes in the morning and looked through the freezers and refrigerators to replenish what the units needed. CS also expected everything in the fridge and freezer to be covered or sealed. During follow-up tour and interview on 3/5/25 at 2:41 p.m., CS and culinary manager (CM) verified the opened food packages in the second-floor kitchenette freezer. CM confirmed kitchen staff rounded each morning on the unit kitchenettes to replenish food items and stated someone should have removed the bacon, sausage links, and pancakes. Additionally, CM stated nursing staff utilized the kitchenettes and were also expected to remove outdated and opened items. CM stated, the expectation would be if you're seeing something that is unlabeled or opened and you weren't sure how long it had been open or it did not have a bag, you should take it out or call the kitchen at least if you have questions. CM stated food items that were stored improperly posed the risk of cross-contamination and infection control. Per interview on 3/6/25 at 1:41 p.m., the administrator expected food to be labeled and sealed appropriately to prevent cross contamination. Per facility policy titled Episcopal Homes Refrigerator and Food Storage Policy and Procedure dated 11/24, all food products not in their original containers would be placed in approved, seamless, tightly sealed containers. Staff were directed to properly re-seal packages of frozen foods to prevent freezer burn and spoilage.

Based on observation, interview and record review, the facility failed to comprehensively assess a new skin alteration and changes in a surgical incision for 1 of 1 residents (R24) who developed gangrenous toe that required surgical treatment. Furthermore, the facility failed ensure coordination of care for a hospice patient with a change in condition for 1 of 1 residents (R25) reviewed for hospice. Findings include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of kidney failure, required dialysis (treatment to filter the blood), diabetes, and vascular disease. Furthermore, R24 was at risk for skin breakdown. R24's care plan revised 11/15/24, indicated R2 had an unstageable right heel ulcer. Staff were directed to follow policies/procedures for prevention and treatment and prevention of wounds. Staff were also directed to monitor, document and report as needed any skin changes. R24's nursing progress note dated 2/8/25 at 2:11 p.m., indicated R24 had a blackened malodorous (foul smelling) right little toe. The toe was covered with a dressing and indicated the nurse practitioner will be updated on 2/10/25. The note lacked indication of family or provider notification of R24's toe. R24's nursing progress note dated 2/9/25 at 9:31 p.m., indicated R24's right pinky toe looked gangrenous (infected) and the nurse manager would assess on 2/10/25 for further management. The note lacked indication of family or provider notification of R24's toe. R24's nursing progress note dated 2/10/25 at 12:40 p.m., indicated R24's right pinky toe noted to be black, necrotic, and foul smelling. Nurse practitioner (NP)-B assessed and sent R24 to the emergency room (ER) for further evaluation. R24's medical record lacked indication a comprehensive assessment of R24's toe had been completed or documented prior to sending to the ER for further evaluation. R24's hospital progress note dated 2/10/25 at 10:09 a.m., indicated R24 had ischemic (insufficient blood flow) changes to the right 5th toe and had full thickness dry gangrene (condition where decreased blood flow causes tissue death) to the 5th toe that extended over the 5th metatarsal head (top or start if the bone in the midfoot). R24 will require at least a partial foot amputation. R24's hospital progress note dated 2/13/25 at 6:17 a.m., indicated R24 had a metatarsal amputation (procedure to remove the toes and part of the mid-foot) of the right foot. The incision and flap were well healing thus far however R24 was high risk for the surgical flap to fail due to vascular disease. R24's hospital discharge order dated 2/19/25, directed staff to perform dressing changes to R24's right foot surgical wound twice daily. R24's weekly skin audit dated 2/19/25, indicated R24 had a surgical incision and did not indicate any complications or concerns with the incision. R24's weekly skin audit dated 3/5/25, indicated R24 had a surgical incision on the right foot. The audit did not indicate any complications or concerns with the incision. A review of R24's electronic medical record (EMR) from 2/28/25- 3/4/25, lacked indication R24's surgical incision had any changes or complications. An observation on 3/5/25 at 12:59 p.m., registered nurse (RN)-E entered R24's room to perform wound cares. After performing hand hygiene and donning gloves and gown, RN-E removed the ace bandage from R24's right foot and cut loose the kerlix wrap. Gauze on the top of the foot was then removed and the surgical incision was visualized. There was scant bloody draining on the gauze removed and sutures in place. The incision did not appear fully approximated was foul smelling. There was dark black tissue along the incision site and R24's foot had a darkening color through the top of it almost to the ankle. RN-E verified the black tissue around the surgical incision and discoloration of R24's foot. When interviewed on 3/5/25 at 2:07 p.m., registered nurse RN-E stated initially, a nursing assistant (NA) notified them of a black area of the 5th toe during cares on 2/8/25. RN-E stated the toe was monitored over the weekend and nurse practitioner (NP)-B and family were notified the following Monday (2/10/25). RN-E stated when R24's right little toe was first observed, there was a small black area on the side of the toe. RN-E had documented a progress note and verified there was not a discription of size or measurements of the area. RN-E verified the note and stated to monitor for increased size, measurements and location would have been helpful to be able to tell how it was progressing. When completing the dressing change today, RN-E stated the surgical wound looked much worse than the last time they worked with R24 on 2/28/25. RN-E verified there was a lot of black tissue and the entire top of R24's foot was discolored and dark. RN-E was not aware of when R24's surgical incision had started to worsen and verified there was no documentation or assessment of it. When interviewed on 3/5/25 at 3:44 p.m., NP-B stated they provide regulatory visits on Mondays and was first notified of R24's right little toe then. NP-B further stated R24 was not on the list to bee seen that day and was asked to assess the toe when I had a chance. NP-B reviewed documentation and verified no calls had been place to the on-call service for R24 since January and there was no notification when the black part of the toe was first discovered. NP-B stated there was a low threshold for sending R24 to the ER for evaluation due to R24 having vascular disease and poor healing for thier heel wounds. NP-B stated for surgical incisions, typically, the surgical team would be notified of any complications or changes. When interviewed on 3/6/25 at 10:05 a.m., RN-D stated when a skin alteration was first identified was noted for a resident, staff were expected to at least put a progress note in and update the provider and family. An assessment should be completed for anything newly found. RN-D stated any changes to the surgical incision should also be documented and the provider notified. RN-D was not aware of when the changes to R24's surgical incision started and verified there was no documentation of it. RN-D had emailed NP-B about the worsening surgical incision on 3/5/25 after RN-E brought it to their attention but had forgotten to document the communication. RN-E was not sure if R24's surgical team were notified. When interviewed on 3/6/25 at 11:37 a.m., the Director of Nursing (DON) stated when any skin alteration was found, a body audit assessment should be completed and the provider notified as warranted. DON further stated with surgical incisions or already identified wounds, staff were expected to document any signs of poor healing, what it looks like, smells, suture problems, and take measurements if needed. R24's provider should have been notified when the toe was first seen and when changes to the surgical incision was noted. When interviewed on 3/6/25 at 2:15 p.m., RN-F verified R24 was last seen in clinic with the surgical team on 2/24/25. RN-F further stated there was not any notification of any wound changes since that appointment until today. A facility policy for non-pressure wound care was requested however was not recieved. 49617 R25 Hospice Collaboration R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition and was on hospice care. The MDS identified her diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities), hemiplegia or hemiparesis (one-sided weakness or paralysis), a seizure disorder, and intellectual disabilities (developmental conditions affecting cognitive functioning and adaptive behavior). Additionally, the MDS reported she was taking an anticonvulsant medication. R25's care plan dated 7/15/24, identified she was on hospice related to a terminal illness and indicated staff would follow the hospice and facility coordinated plan of care. Additionally, the care plan indicated hospice nursing care would coordinate with and supplement facility-provided nursing care, and hospice, family, and providers would be informed of all R25's changes on condition. A progress note dated 9/9/24, indicated seizure activity noted this AM. A progress note dated 11/2/24, indicated the hospice nurse was updated about R25's seizure activity but that she had returned to normal without medication. A progress note dated 12/16/24, indicated she had seizure activity. A progress note dated 12/21/24, indicated R25 had a seizure while hospice nurse was around, she handled it. A progress note dated 1/3/25, indicated a seizure noted around 11:25 am this morning. A provider progress note dated 2/6/25, indicated staff reported no concerns during the provider's visit, and under the assessment and plan for R25's seizure disorder, the provider wrote, chronic. Last reported seizure was in August 2024, with no new orders given. During interview on 3/5/25 at 8:42 a.m., R25's hospice case manager (HCM) verified responsibility over her case management and stated the hospice team was responsible for all her medications except her Keppra, (an anticonvulsant medication used to treat seizures), that's the only one we don't cover. HCM stated R25's Keppra was monitored by her primary provider. HCM recalled R25 had a seizure at least once a month and stated she would get a loading dose of lorazepam (a rescue medication used to rapidly stop seizures) before facility staff would update HCM. HCM stated there had been no contact with the hospice providers by R25's primary providers regarding her seizures or medication changes. HCM stated during weekly hospice visits, I check with the nurses, sometimes I will check with the nurse manager as well, and indicated they also sent weekly reports to the facility with updates to her plan of care. HCM stated, as far as I am aware, the [primary] provider is updated on her seizure activity and her overall health status. During interview on 3/6/25 at 9:37 a.m., consultant pharmacist (CP) stated for the Keppra medication, therapeutic lab levels were rarely drawn because it is so safe. CP indicated it would be provider-driven that a lab level be drawn and stated, I would expect if a resident was seizing, I would be making sure the provider was aware, seeing what they're saying; is there a reason the provider wasn't saying anything? I would expect if a resident was having seizures, that the provider would be reviewing the medication and the dose to adjust that. CP was unaware of R25's documented seizure activity and questioned if she had seizures. During subsequent interview on 3/6/25 at 10:31 a.m., CP directed attention to a provider note dated 2/6/25, and stated because the provider wrote in their assessment and plan they were monitoring R25's chronic seizures, that means they are looking at it and reviewing and stated historically, providers would only do labs if there was a negative outcome. However, if there were no seizures or negative outcomes, the lab isn't really required. During interview on 3/6/25 at 10:44 a.m., registered nurse (RN)-A stated when a resident was on hospice, we call them first. RN-A stated for R25, most of her medications were managed by hospice except for her Keppra. RN-A explained when R25 had a seizure, they first assessed her and ensured her safety, then administered her lorazepam medication and updated her hospice team. RN-A stated there was not a liaison between the hospice team and R25's primary care provider who managed her Keppra medication. RN-A stated the floor nursing staff communicated with the nurse manager and it would go up from there. RN-A stated the hospice team was good at communicating with the floor staff if there were concerns or changes to her plan of care and we communicate that with our team. Per interview on 3/6/25 at 11:32 a.m., RN-B expected staff to update hospice first with any change in condition for a hospice resident and if it is anything they are not covering, hospice would refer that back to the providers here. RN-B stated because our providers are here so often, we do update them but stated it may be a more informal, verbal report. RN-B reviewed R25's progress notes and confirmed the documented seizure activity on the dates 9/9/24, 11/2/24, 12/6/24, 12/21/24, and 1/3/25. RN-B reviewed the provider progress note on 2/6/25, and confirmed the provider's documentation that R25 had no seizure activity since August 2024. RN-B was unsure why the provider note did not include the documented seizure activity from the progress notes. Per interview on 3/6/25 at 1:46 p.m., the director of nursing (DON) expected hospice to collaborate with the nurse manager immediately to determine a resident's plan of care once signed onto hospice. The DON stated the communication between the hospice team and primary providers should be going through the nurse managers, but stated there could be problems with that since the nurse managers are not always available. The DON expected nursing staff to communicate changes of condition with the hospice providers and if the hospice team was not managing that aspect of a resident's care, they should defer to the attending provider. The DON stated, we would encourage our nurses to be updating the providers, and the hospice team should also remind the nurses to update the primary provider. The DON reviewed R25's progress notes and confirmed the documented seizure activity and the provider progress note dated 2/6/25. The DON stated, this does seem tricky with the shared management. The DON stated although nurses were encouraged to update the primary providers, sometimes they would believe if they updated hospice, the work is done. During interview on 3/6/25 at 3:03 p.m., R25's nurse practitioner (NP)-A verified responsibility for the provider note dated 2/6/25, and stated there had been no updates from the facility regarding the seizure activity documented in her progress notes. NP-A stated, If I had been notified of the seizures, and they had been true seizures, I would have notified my MD [medical doctor], due to being new in the field. Furthermore, NP-A expected staff to provide verbal updates when on-site, then I could go back and review the notes. We rely heavily on those progress notes. Per interview on 3/7/25 at 7:47 a.m., with R25's medical doctor (MD)-B, there were no updates received about her seizure activity. MD-B stated, I am not typically involved in the hospice IDG communications. I don't believe we were updated about her seizure activity. MD-B expected an update from facility staff, however, stated I don't know that I would have changed anything with her care. MD-B denied concerns for her safety and stated her care was being managed fine. MD-B stated, I think we should have been updated and I think maybe this is a learning point for staff there. Per Nursing Facility Services Agreement for Routine Hospice Care dated 3/20/23, the facility should ensure that all facility services are provided competently and efficiently in a timely manner. Facility services should meet or exceed the standards of care for providers of such services and should be in compliance will all applicable laws, rules, regulations, professional standards and licensure requirements. The agreement indicated hospice and facility should communicate with one another regularly and as needed for each particular hospice patient and each party was responsible for documenting such communications in its respective clinical records to ensure the needs of hospice patients were met 24 hours per day. Furthermore, the agreement indicated the facility should designate a member of the facility's interdisciplinary team who would be responsible for working with hospice to coordinate care provided by facility staff and hospice staff. The policy directed that team member to collaborate with hospice and coordinate with facility staff participating in the care planning process; communicate with hospice and other healthcare providers participating in the provision of care for the terminal illness and other conditions to ensure quality of care; and to ensure the facility communicates with the hospice medical director, the hospice patient's attending physician, and other practitioners participating in the provision of care to the hospice patient as needed to coordinate care provided by other physicians.

Based on observation, interview and document review, the facility failed to ensure a safe smoking environment was provided for 2 of 2 residents (R50 and R55) reviewed for smoking. Findings include: R50's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care, and independent with eating and oral hygiene. Manual wheelchair was used independently. R50's Selfcare/Mobility Care Area Assessment (CAA) dated 12/19/24 identified a diagnosis of tobacco use. E50 has no impairment to extremities and was able to voice needs and used call light appropriately. The resident was often independent with ADLs (activities of daily living) and received assist as needed. R50's care plan dated 11/20/19, identified current smoking status. The care plan identified he was able to light his own cigarette, keep his lighter at the bedside, and smoke independently with use of a smoking apron. Staff were directed to encourage him to use his smoking apron. The plan of care lacked description of safe disposal of smoking materials. R50's Smoking Safety Screen dated 12/18/24, identified he smoked in the morning, afternoon and evening, could light own cigarettes, and a smoking apron was used for adaptive equipment. Plan of care included assure resident was safe while smoking. The safety screen lacked description of safe disposal of smoking materials. During an observation on 3/3/25 at 9:41 a.m., R50 self-propelled his wheelchair toward his room with his smoking apron on. R50 stated he was a smoker, but the ashtray (smoking materials disposal receptacle) kept being messed with so he had to put his cigarette butts out on the ground by stomping them with his foot. He said it had occurred for a month or so, off and on. During a tour of the designated smoking area and interview on 3/03/25 at 9:48 a.m., with maintenance staff (M)-A, there was no ashtray or container to dispose of smoking materials. Approximately 20 cigarette butts of various brands and colors were laying on the ground and on the dried grass and leaves about 15 feet from the facility entrance. M-A stated it was an ongoing problem where people would mess with or steal the ashtray. M-A stated the cigarette butts should be disposed of in an approved container for fire safety purposes. During an observation on 3/3/25 at 10:54 a.m., R50 was in his room getting ready to go outside for a cigarette. He removed two cigarettes from a full pack and put those two into an empty pack. R50 left his room with his smoking apron still on the bed. During an observation on 3/3/25 at 10:56 a.m., R50 told nursing assistant (NA)-A he was going outside for a smoke. NA-A did not remind R50 to put on his smoking apron. During an observation and interview on 3/3/25 at 11:02 a.m., R50 reached the designated smoking area and started a cigarette. at 11:20 a.m., he extinguished the cigarette by rolling the butt between his fingers until the ash fell out on the ground. His pants had several small holes that resembled old burn holes in the groin area of his pants. R50 had not ashed on himself during this smoking observation. There continued to be no smoking material disposal receptacle available. During an interview together on 3/3/25 at 11:24 a.m., NA-C stated R50 needed a smoking apron on, he had it on earlier in the morning but she did not check if he had it on for his 11:02 a.m., cigarette. NA-A stated he needed the apron on because ash would fall off and burn his clothing, and R50 was independent with managing his smoking apron. She also agreed she did not check if he had his smoking apron on for his 11:02 a.m., cigarette. During an interview on 3/3/25 at 11:29 a.m., the assistant director of nursing (ADON) said lack of a smoking receptacle was a fire hazard and he would go speak to maintenance now. During a follow up interview on 3/3/25 at 1:47 p.m., the ADON stated he talked to the administrator and was told the smoking materials disposal receptacles by the designated smoking area kept getting stolen . The ADON stated a new smoking disposal receptacle was ordered. 42586 R55 R55's quartely Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of type II diabetes, chronic obstructive pulmonary disease (COPD), and tobacco use. It further indicated R55 required set up assistance with most activities of daily living (ADLs) and was independent with mobility. During interview on 3/4/25 at 3:29 p.m., R55 stated he was on smoking restrictions because of dental surgery, but he didn't always follow it. He further stated he put his cigarette butts out on the sidewalk or on the side of the garbage can outside and threw them away in the trash can. He stated they (facility) just got a smoking receptacle yesterday but they hadn't had one in a while before then. During an interview on 3/6/25 at 8:05 a.m., the administrator stated maintenance was here on the weekends and should have checked to see if the smoking area was in safe condition during daily rounds. Additionally, nursing should ensure smoking aprons were in place if that was what the smoking safety screen identified. During an interview on 3/6/25 at 8:52 a.m., the director of maintenance services (DMS) stated every morning staff would do a walk through and clean up the grounds. He said checking for a smoking materials disposal receptacle was also part of their process but not documented. The facility's smoking policy dated 5/28/24, identified no smoking of any kind allowed on campus grounds, all smoking at least 25 feet from entrance on city sidewalk, smoking waste and materials must be cleaned up and kept free from sight from others. The Life Safety Code, state fire code, and MN (Minnesota) clean indoor air act would be followed.

Based on observation, interview, and record review, the facility failed to ensure a dialysis fistula site was maintained according to professional standards of care for 1 of 2 residents (R24) reviewed for dialysis. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of kidney failure, diabetes, and vascular disease. Furthermore, R24 required dialysis (treatment to filter the blood when in kidney failure). R24's provider and nursing orders reviewed on 3/5/25, lacked indication of where R24's fistula was located or if R24 had restrictions for blood pressure on their left arm. R24's care plan revised 9/20/24, indicated R24 required dialysis 3 times a week. R24's care plan lacked indication R24 had restrictions for blood pressure on their left arm. An observation on 3/5/25 at 10:23 a.m., trained medication assistant (TMA)-A entered R24's room to provide medication. R24 was sitting in their wheelchair and was very sleepy. Registered nurse (RN)-E requested vital signs. TMA-A obtained a vital sign machine and re-entered R24's room. TMA-A placed a blood pressure cuff on R24's left arm above the elbow and obtained a blood pressure. When interviewed on 3/5/25 at 2:03 p.m., TMA-A verified the blood pressure was taken on the left arm and was not aware of any restrictions for taking blood pressures for R24. TMA-A was not sure if a blood pressure could be taken on the same arm as a dialysis fistula site and would need to verify with the nurse. When interviewed on 3/5/24 at 2:07 p.m., RN-E stated TMA-A should not have taken the blood pressure on R24's left arm. RN-E further stated R24 was wearing a sweatshirt and TMA-A may not have noticed it. When interviewed on 3/6/25 at 10:05 a.m., RN-D stated blood pressures should not be taken over the fistula site or on the arm of the fistula site. RN-D further stated the order for blood pressures had not been ordered for R24 but was now placed. RN-D stated care sheets were not used on the short term stay unit as residents discharged and admitted frequently. However, the information was included on the nurse 24-hour sheet which nurse and TMA's have access to. RN-D stated there was only a verbal process for nursing assistants and a better process of communication may be needed. When interviewed on 3/6/25 at 11:43 a.m., the Director of Nursing (DON) expected staff to take blood pressures on the opposite arm of the fistula for residents with dialysis. This should be included in the orders, included on the 24-hour sheet for the nurses and TMAs, and reported to the NAs. A facility policy titled Dialysis dated 1/1/15, directed staff to follow all provider orders for dialysis. The policy did not address any standards of care for dialysis residents.

Based on interview and record review, the facility failed to ensure provider notification occurred when a skin altercation was identified for 1 of 1 residents (R24) reviewed for surgical incision care. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of kidney failure, diabetes, and vascular disease. Furthermore, R24 was at risk for skin breakdown. R24's nursing progress note dated 2/8/25 at 2:11 p.m., indicated R24 had a blackened malodorous (foul smelling) right little toe. The toe was covered with a non-adherent dressing and indicated the nurse practitioner will be updated on 2/10/25. The note lacked indication of family or provider notification of R24's toe. R24's nursing progress note dated 2/9/25 at 9:31 p.m., indicated R24's right pinky toe looked gangrenous (infected) and the nurse manager would assess on 2/10/25 for further management. The note lacked indication of family or provider notification of R24's toe. R24's nursing progress note dated 2/10/25 at 12:40 p.m., indicated R24's right pinky toe noted to be black, necrotic, and foul smelling. Nurse practitioner (NP)-A assessed and sent R24 to the hospital for further evaluation and R24 had ssurgery for toe amputation. R24's provider order dated 2/21/25, directed staff to perform dressing changes to R24's right foot surgical wound twice daily. A review of R24's electronic medical record (EMR) from 2/28/25- 3/5/25, lacked indication R24's surgical incision had any changes or R24's provider or surgical team were notified. When interviewed on 3/5/25 at 2:07 p.m., registered nurse (RN)-E stated a nursing assistant (NA) notified them of the toe during cares on 2/8/25. RN-E stated the toe was monitored over the weekend and nurse practitioner (NP)-B and family were notified on Monday 2/10/25. RN-E stated when first notified, there was a small black area on the side of the toe. When completing the dressing change today, RN-E stated the surgical wound looked much worse than the last time they worked with R24 on 2/28/25. RN-E verified there was a lot of black tissue and the entire top of R24's foot was discolored and dark. When interviewed on 3/5/25 at 3:44 p.m., NP-B stated they provide regulatory visits on Mondays and was first notified of R24's right little toe then. NP-B further stated R24 was not on the list to bee seen that day and NP-B was asked to assess the toe when they had a chance. NP-B reviewed documentation and verified no calls had been place to the on-call service for R24 since January and there was no notification when the black part of the toe was first discovered. Furthermore, NP-B expected staff to notify the providers when the toe was first noticed so treatment/monitoring orders would be placed or to send R24 in for further evaluation right away. NP-B stated for surgical incisions, the surgical team should be notified of any complications. When interviewed on 3/6/25 at 10:05 a.m., RN-D stated when a skin alteration was first identified for a resident, staff were expected to at least put a progress note in and update the provider and family. RN-D stated any changes to the surgical incision should also have been documented and the provider notified. RN-D was not aware of when the changes to R24's surgical incision started and had emailed NP-B about the worsening surgical incision on 3/5/25 after RN-E brought it to their attention. RN-D verified R24's provider and family were not notified at the time the skin was noted or when changes to the surgical incision were noted. When interviewed on 3/6/25 at 11:37 a.m., the Director of Nursing (DON) stated when a skin alteration was found, a body audit assessment should be completed and the provider notified as warranted. DON further stated, R24's provider should have been notified when the toe was first seen and when changes to the surgical incision were noted. When interviewed on 3/6/25 at 2:15 p.m., RN-F verified R24 was last seen in clinic with the surgical team on 2/24/25. RN-F further stated there was not any notification of any wound changes since that appointment until 3/6/25. A facility policy titled Change in Condition revised 5/4/22, directed staff to promptly notify the residents provider or on call provider when there was a need to alter the resident's medical treatments.

Based on interview and record review the facility failed to prevent three pressure ulcers for 1 of 3 residents (R1) reviewed for skin integrity. R1 was harmed when he developed three pressure ulcers that went without treatment, staff were aware but did not implement a treatment plan. The hospital identified the pressure ulcers when R1 was admitted for wound care and subsequent surgical debridement. Findings include: R1's care plan dated 10/28/23 - 5/28/24 did not indicate any focus, goals, or interventions for potential or actual skin integrity concerns when three pressure ulcers were discovered on 5/16/24 during a hospital admission. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 10 indicating R1 was cognitively impaired. R1 required moderate assistance with toileting and transfer activities. He required maximum assistance with dressing and grooming. R1 was ambulatory with the use of a walker. R1's diagnoses were chronic atrial fibrillation (cardiac arrhythmia), anemia, hypertension (high blood pressure), renal (kidney) failure, diabetes type II, Non-Alzheimer's Dementia, long term use of anticoagulants (blood thinners) and edema. The MDS indicated R1 was at risk for pressure ulcers but did not have any pressure ulcers or wounds. R1 had a pressure reducing device on his bed. R1's weekly skin body audit dated 5/1/24 at 1:45 p.m. indicated a skin deficit was noted. The audit indicated R1 had bruising to the right and left antecubital (area around the elbows), lower back, buttock, right and left lower leg bruising and a wound on the right lower leg. The audit does not note any pressure ulcers. R1's list of weekly skin body audits did not show any documentation of a body audit completed on 5/8/14. R1's weekly skin body audit dated 5/15/24 indicated R1 had bruising of the right and left antecubital and his buttocks. R1 had a wound to the rear of his right lower leg and a wound to the right ankle on the outer side. The audit does not note any pressure ulcers. Hospital Emergency department review of systems note dated 5/16/24 indicated R1 had a large ulceration that was necrotic appearing on his right posterior calf and a small ulceration over his right posterior heel. Hospital assessment and plan dated 5/17/24 indicated the principal problem was a necrotic right leg wound. He would be inpatient for extensive right lower leg wound and smaller necrotic left lower leg wound. Mepilexes were applied to several wounds on his bilateral lower extremities including his heels. Aflex (protective) boots applied to both feet. Hospital Wound Initial Assessment Note dated 5/19/24 at 12:49 p.m. indicated R1 had three a pressure injury that were acquired in the nursing facility. -Pressure ulcer to right buttock. The base was 100% non-blanchable tissue. The peri-wound (skin surround the wound) was intact. There was no drainage. -Pressure ulcer to left heel. The wound base was 100% red moist tissue. The peri-wound had loss of epidermis. The measurements were length (L) 3 centimeters (cm) x width (W) 3 cm x depth (D) 0.2 cm. The heel pressure ulcer had a small amount of blood drainage with no odor. -Pressure ulcer to the right heel. The wound was full thickness (damage extends below all layers or skin in the subcutaneous tissue or beyond into the muscle, bone, tendons, etc.) The wound base was 100% grey, with slough. The peri-wound had loss of epidermis. The wound measured L 4 cm. x W 3.5 cm and D 0.3 cm with a small amount of drainage, a mild odor and mild pain. The wound was unstageable (the wound was covered by a layer of dead tissue and the doctor cannot see the base of the wound). Upon interview on 5/28/24 at 11:11 a.m. registered nurse (RN)-E a hospital wound nurse described R1's pressure ulcer as: The right buttock pressure ulcer was a shallow Stage II (broken through the top layer or skin). The right heel pressure ulcer was unstageable due to the dead tissue covering the wound. The left heel pressure ulcer was a Stage III (exposed muscle and subcutaneous fat). Upon interview on 5/28/24 at 11:32 a.m. nursing assistant (NA)-A stated he did not notice a pressure ulcer to R1's buttock, but the area was red, and he would apply barrier cream when he worked. He stated R1 around the week of 5/6/24 was in his bed more than usual and the staff used an EZ-stand mechanical lift to get him up and a wheelchair for ambulation around the unit. Prior to this R1 self-transferred and wandered most of the day by walking. NA-A felt the reason for his decline was either the wound on his heels or that he was having pain from a few recent falls. NA-A stated he did not report to a nurse about the heel sores that he just knew to float the heels while R1 was in bed and turn and reposition him if he was to remain in bed for long periods of time. NA-A described the heel wounds as redness and the top layer of skin missing. Upon interview on 5/29/24 at 9:51 a.m. registered nurse (RN)-A stated the skin audit on 5/15/24 R1's right heel had a white covered area over the heel. She denied documenting a wound description or measurements. Upon interview on 5/29/24 at 11:20 a.m. nursing assistant (NA)-B stated a few days before R1 was sent to the hospital she noticed the skin on R1's right heel was gone, and she did notify the nurse but could not recall which nurse. She stated R1 stopped ambulating about a week before he was sent to the hospital. It was when he was bedridden she noticed the right heel pressure injury. Upon interview on 5/29/24 at 1:47 p.m. the assistant director of nursing (ADON) sated he was of the pressure ulcers to R1's buttock or bilateral heels. Upon interview on 5/29/25 at 1:55 p.m. the Administrator stated he was not aware R1 had wounds until 5/20/24 when he received an update from the hospital. He stated the facility made a plan to educate staff on wounds. The director of nursing (DON) was on the vacation during the survey and the education would be completed upon her return. A facility protocol titled Wound care protocol indicated to prevent wounds the staff was do daily skin inspection. If a Stage I, II, or III wound was identified to notify the physician and obtain orders and a diagnosis.

Based on interview and record review the facility failed to ensure treatment, monitoring, and care in accordance with professional standards of practice were provided for 1 of 3 residents (R1) reviewed when skin ulcerations developed. R1's primary physician was not immediately notified when the first wound was discovered or when the wound had a significant change. R1 was admitted to the hospital with wounds on both legs requiring surgical interventions. The facility was only aware of the wound on R1's right leg. Findings include: R1's care plan dated 10/28/23 - 5/28/24 did not indicate any focus, goals or interventions for potential skin integrity concerns or actual focus, goals, or interventions when a wound was discovered on 5/1/24. R1's nursing assistant skin monitoring documentation dated 4/29/24-5/28/24 indicated on 4/30/24, 5/1/24, 5/2/24, 5/5/24, 5/8/24, and 5/10/24 R1 had a skin tear. The audit did not provide any other information regarding a skin tear documented. In addition, the form indicated on 5/10/24, 5/14/24 and 5/15/24 R1 had an open area. The audit did not provide any other information regarding the open area. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 10 indicating R1 was cognitively impaired. R1 required moderate assistance with toileting and transfer activities. He required maximum assistance with dressing and grooming. R1 was ambulatory with the use of a walker. R1's diagnoses were chronic atrial fibrillation (cardiac arrhythmia), anemia, hypertension (high blood pressure), renal (kidney) failure, diabetes type II, Non-Alzheimer's Dementia, long term use of anticoagulants (blood thinners) and edema. The MDS indicated R1 was at risk for pressure ulcers but did not have any pressure ulcers or wounds. R1 had a pressure reducing device on his bed. R1's weekly skin body audit dated 5/1/24 at 1:45 p.m. indicated a skin deficit was noted. The form indicated for the nurse to describe the deficiency and to call the wound nurse if the finding was the first occurrence. The audit indicated R1 had bruising to the right and left antecubital (area around the elbows), lower back, buttock, right and left lower leg bruising and a wound on the right lower leg. The columns for length, width and depth measurements were left blank. A note indicated bruises were noted all over R1's body and dry wound on his right low leg, cleaned and covered with Mepilex. R1's progress note dated 5/6/24 11:38 a.m. indicated a call was placed to R1's triage regarding right leg having a lots of drainage from two big patches on the right outer aspect. In addition, a urine culture >100,000 colonies were called and faxed to the Primary Care Provider (PCP). R1's progress note dated 5/6/24 indicated R1 was ordered Macrobid (antibiotic) 100 milligram (mg) by mouth twice daily for weeping blisters on R1's right leg until 5/14/24. R1's physician order sheet dated 5/7/24 indicated treatment for R1's blisters to right leg, was to wash area daily with mild soap and pat dry. Ok to cover with Mepilex (a dressing to cover wounds to secure an prevent movement of the primary dressing) if draining, allow the fluid to drain, if significant drainage then cover with ABD pad (a pad for heavy drainage) and wrap with Kerlix and secure until resolution, update if area around blister/blisters itself starts to look inflamed, surrounding tissue becomes hot to the touch, and/or drainage becomes purulent (pus), bloody or otherwise appears infected. R1's list of weekly skin body audits did not show any documentation of a body audit completed on 5/8/14. R1's progress note dated 5/12/24 at 2:07 p.m. indicated R1's dressing was changed to bilateral (both legs) low extremities as ordered, dressing was soaked with fluids and had a foul smell to it. The blisters were open, and the wounds had some black and dark yellowish coverings all over. R1's progress note dated 5/12/24 at 2:17 p.m. indicated a voicemail was for the nurse manager, also the assistant director of nursing (ADON) to follow-up with the wound doctor. R1's progress note dated 5/13/24 at 11:28 a.m. indicated R1's nurse practitioner (NP) looked at R1's wounds and recommended the wound care team to evaluate and treat the bilateral lower extremity wounds, due to likely needing debridement due to slough and eschar (dead tissue). R1's weekly skin body audit dated 5/15/24 indicated R1 had bruising of the right and left antecubital and his buttocks. R1 had a wound to the rear of his right lower leg and a wound to the right ankle on the outer side. The length, width and depth measurements were left blank. A note indicated the dressing was changed on the right lower leg and ankle. The old dressing was soaked with drainage. Emergency Department note dated 5/16/24 at 5:54 p.m. indicated R1 had a large ulceration that was necrotic (dead tissue) appearing on his right posterior calf and a small ulceration over his right posterior heel. He also had a necrotic wound appearing on his left posterior calf. Hospital history and physical dated 5/17/24 indicated R1 presented from his nursing home for evaluation of lower extremity wounds. Per report, he has had wounds on his legs for about a month. Unclear how these occurred. Apparently, he had local wound at the facility, but the patient's physician requested evaluation at the hospital. R1 had an extensive necrotic wound on the posterolateral right lower extremity and smaller necrotic wound on posterior left lower extremity. Hospital assessment and plan dated 5/17/24 indicated the principal problem was a necrotic right leg wound. He would be inpatient for extensive right lower leg wound and smaller necrotic left lower leg wound. R1 was started on intravenous Vancomycin (broad spectrum antibiotic). R1 had blood cultures in process and a consultation was ordered for General Surgery and Plastic Surgery. R1 arrived from the emergency department with an ABD pat wrapped in kerlix on his right lower extremity saturated, which was changed. Mepilexes were applied to several wounds on his bilateral lower extremities including his heels. Aflex (protective) boots were applied to both of his feet. General Surgery Consultation Plan dated 5/17/24 indicated R1 would likely need debridement of the wounds in the operating room. R1's Power of Attorney (POA) was called and decided to hold surgery in an attempt for wounds to heal on their own. Hospital Wound Initial Assessment Note dated 5/19/24 at 12:49 p.m. indicated wound #1 was on the right lateral posterior lower leg. The wound was full thickness, the base was 90% dry adherent, brown eschar, 10% white moist slough. The peri wound: denuded (loss of epidermis) and erythema (redness) measurements were length (L) 17 centimeters (cm) x width (W) 12 cm x depth (D) 0.5 cm. the drainage amount was small. Wound #2 left posterior lower leg with an unknown etiology, full thickness. The wound base was 100% necrotic tissue-black, adherent eschar, demarcation at the wound edge with purulent drainage. The periwound area had erythema with a small amount of drainage, the drainage was purulent, malodorous the wound had moderate odor. Plastic surgery consultation note dated 5/16/24 indicated dressing changes were going to be ordered for both lower extremities and in the next 24-48 hours discuss appropriately of wound vacuum assistance therapy (VAC) therapy. R1 would benefit from skin grafting given the size of the wounds. Surgical note dated 5/20/24 family gave verbal consent for debridement of the bilateral lower extremity wounds via surgical procedure. General Surgery Post-Operative Progress note dated 5/21/24 at 10:29 a.m. indicated R1 had excisional debridement of bilateral lower extremity wounds. Tissue culture was growing gram positive-cocci and gram-negative bacilli. Post-surgical plan for wound care was to re-consult regarding ongoing wound recommendations, continue wound cares per their recommendations and for Plastic Surgery to be involved regarding future inventions with the wound depending on the POA's decisions. Upon interview on 5/28/24 at 8:06 a.m. family member (FM)-A stated she became aware that R1 had a wound at his care conference on 5/14/24. The reason she was told at that point about the wound was to consent to R1 seeing the wound care team. She stated that as a nurse she was aware that the facility had noticed a wound and did not report that to her. She stated she spoke with the care team who saw R1 and was told that they were notified of a wound on 5/6/24 and provided orders of Macrobid 100 mg twice daily and a dressing change. FM-A stated R1 was found to have wounds on both legs, both his heels and his buttock when he arrived at the hospital. I wish I wouldn't have looked at the photos, they disgust and sadden me at the same time. This was a sentinel event. She stated making decisions for R1 were difficult due to his age, mental status, kidney function and diabetes, but decided on a surgical intervention. Upon interview on 5/28/24 at 11:32 a.m. nursing assistant (NA)-A stated he was aware that R1 required nursing to do a daily dressing change on R1's right leg. He stated the wound would weep through the dressing at least once during his shift so he would ask the nurses rechange the dressing and he would have to change R1's clothing and sometimes his bed. Upon interview on 5/28/24 at 1:29 p.m. R1's Nurse Practitioner (NP) stated the first she knew of a wound the was on 5/6/24 at 11:07 a.m. when she received a page about urinalysis results and that R1 had skin integrity issues. The skin issues were described as a new blister on his right lower leg with no edema, clear drainage, no redness or swelling. She stated she ordered Macrobid 100 mg twice a day and a daily dressing change. She stated she did round the facility every Monday and on 5/13/24 with the same nurse who sent her a message on 5/6/24 who asked her to see R1 as he had concerns about the wound. The NP stated she saw both legs were wrapped in Kerlix. She was unaware of any concerns with R1's left leg. The nurse unwrapped both legs and on the right anterior leg below the knee to the ankle was fully sloughed. She could not see any depth to the wound. She stated the left leg appeared the same, but not as large. She asked the nurse When did this start? licensed practical nurse (LPN)-A responded, last week when I paged you, The NP stated he needs debridement on his legs due a wound, this was not a blister. She lifted his legs to look at his heels and ordered wound care for his heels bilaterally for the pressure ulcers. The NP messaged the ADON to order wound care as soon as possible. She stated it was not until 5/16/24 that the wound nurse visited R1 and reached out to the NP because R1's right leg was necrotic, and he required hospitalization . The NP wrote an order to send R1 to the hospital immediately. The NP stated from 5/6/24 until 5/13/24 R1 had an acute change of the right leg and the addition of a wound to the left leg, and they were not reported to her. She stated if she were notified earlier instead of waiting until she rounded, she could have ordered wound care earlier. The NP stated she was also not aware that R1 had declined. Upon interview on 5/28/24 at 2:15 p.m. LPN-A stated he worked on the dementia unit once a week. On 5/6/24 he noticed R1 had his right leg wrapped with saturated Kerlix. He removed the dressing and noticed a blistered he described as about the size of a quarter. He looked for an order to see if he were to administer a treatment and was unable to find one. He notified the NP to get orders. He stated he did not work on the dementia unit again until the following Monday 5/13/24 and R1 was using his wheelchair. He had staff use the EZ-stand to lay R1 down in bed so he could complete his dressing change treatment. He stated he pulled off saturated dressing from both of R1's lower extremities and the wound on the right leg was from R1's knee to his foot and now there was a black wound on his left lower extremity. He knew the NP was onsite so he got her, so she could visualize the wounds. He stated she ordered the wound care team immediately, stating R1 needed debridement. Upon interview on 5/29/24 at 9:51 a.m. registered nurse (RN)-A stated she completed the skin audit on R1 5/1/24. He had so many bruises, but then she noticed a wound on his right lower extremity, describing the wound as very pink, no drainage and larger than a quarter. She cleaned the wound and covered it with Kerlix. She denied obtaining wound measurements or notifying the provider of the change to his skin integrity. RN-A worked with R1 again on 5/15/24 and completed a skin audit. She stated on 5/15/24 R1 was too weak for a shower so the nursing assistant completed a bed bath. When RN-A observed the skin, she stated the wound was now totally different, it was on the back of his right leg and from his knee to his foot and half of the wound was red and the other half of the wound was white. RN-A immediately called the ADON and asked if he was aware of R1's wound as it was large and new to her. The ADON told her that the wound nurse would see R1 soon. Upon interview on 5/29/24 at 10:09 a.m. a hospital registered wound nurse (RN)-B stated she completed R1's initial wound assessment at the hospital on 5/19. She stated he had significant infected wounds on both legs that required surgical intervention to remove necrotic tissue. She stated she was uncertain of the etiology of the leg wounds. She stated to prevent the wounds from getting to the level that they did she believed routine skin assessments were not performed because the state the wounds were in didn't happen overnight. The facility should have contacted the wound nurse or PCP for the infection sooner than they did. Upon interview on 5/29/24 at 11:20 a.m. NA-B stated she recalled R1 having a wound on his right leg. She stated she noticed a small circular red area before the nurses started wrapping R1's legs because she put compression hose on R1 in the mornings. She stated then his leg became swollen and drainage the staff stopped putting the compression hose on him, which she believed was around the end of 4/2024. Upon interview on 5/29/24 the Medical Director stated after he reviewed R1's records and interviewed the family and a few staff members he felt that R1's situation was a communication issue. He stated he believed that at times nursing staff does not want to tell a provider You need to come in and evaluate. He stated he also believed the facility was not aware of how long it would take the wound team to start the cares. The order was placed on 5/13/24 and the wound care nurse did not evaluate until 5/16/24. He stated on his record review he believed the wound started on 5/1/24, and orders were started on 5/6/24, but then a skin audit was missed on 5/8/24 and then not again until 5/15/24. The director stated he had not spoken with the NP or the PCP, however he would want to discuss the choice of antibiotic treatment and that they did not visualize the wound. He stated the NP or the PCP only see's patient's every 60 days and rely on the facility staff for all concerns in between and that is where the communication needs improvement. If the residents need to be seen more often the staff needs to complete their assessments and be reaching out to the providers. We should have stepped on the gas sooner with his wounds. R1 had a lot of acute issues, and he was a DNR/DNI with comfort cares and since R1 was not complaining of pain, the facility could have felt like they were meeting his needs. I still am doing a root cause analysis. The facility needs consistent staff on that unit, however that is a concern in all facilities of not having consistent staff. This will be worked on at QAPI. Upon interview on 5/29/24 at 1:47 the ADON stated any skin integrity concerns should be reported when it first arises. He believed 5/1/24 was the date the wound could have started with a fall that R1 had, he denied ability to find any documentation on R1's fall incident reports that indicated any injury to the lower extremities. He stated when staff finds a weeping wound, they are to clean it and cover it until they receive treatment orders from the provider. The ADON stated he was aware that there was a wound with drainage on R1's right leg on 5/4/24 or 5/5/24 the weekend before the nurse reported the wound to the NP. The ADON stated he expects staff to obtain the required information on the skin audits so the wound status can be tracked. The ADON received a call on 5/12/24 which was a Sunday about the wound worsening, so the facility waited until 5/13/24 a Monday when the NP was onsite to show her the wound. The ADON denied assessing the wound at any time since 5/1/24 and did not visualize the wound until the wound nurse saw R1 on 5/16/24 requesting he be sent to the hospital. The ADON stated he did not notice the wound on R1's left leg. The ADON was not aware that R1 declined from ambulating to requiring assistance with transfers and using a wheelchair. He stated the nurses can make those decisions about using a lift or not, but he is the one who updated the care plans and denied that the skin integrity concerns, and the EZ-stand use were on the care plan. The ADON stated there are a lot of nurses who work on the dementia unit and as he was investigating R1's concerns he noticed seven different nurses working in the past seven days. A facility Policy titled Skin Care dated 1/2015 indicated each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care related to skin care.

Based on interview and document review, the facility failed to assess 1 of 1 residents (R1) for entrapment risk when a new air mattress was placed on the bed with siderails, this created an immediate jeopardy situation for R1 when R1 became entrapped between the mattress and siderail and died . The immediate jeopardy began on [DATE], when staff set up a new air mattress on R1's bed, and failed to assess for risk of entrapment and whether R1 was safe to use the new air mattress in conjunction with the bed rails. R1 died the morning of [DATE], when her neck became entrapped between the mattress and the side rail. The immediate jeopardy was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 10:58 a.m. on [DATE]. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey due to immediate actions taken by the facility, and was therefore Past Noncompliance. Findings include: The Guidance for Industry and FDA (Federal Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Risk 2006, indicated bed systems should be reassessed when accessories such as mattresses are replaced. A neck may become trapped in a space of less than 2 ,[DATE] inches, or a head in less than 4 ,[DATE] inches. Zone 3 is described as the space between the rail and the mattress. The space between the rail and the mattress should be less than 4 ,[DATE] inches taking into account mattress compressibility, any lateral shift of the mattress or rail and degree of play from loosened rails. Powered air mattress replacements and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose additional risk of entrapment when used with conventional hospital bed systems. Vulnerable patients to becoming entrapped include those who are frail, elderly or confused. The User-Service Manual Joerns Assist Device and Side Rails Vari-Care Models, included, Warning: Risk of Serious Injury or Death .Vari-Care assist devices or side rails should not be used if ANY openings within the bed system allow a resident to get his/her head or neck lodged within these openings. Failure to do so could result in serious injury or death. When assessing the risk for entrapment, you need to consider your bed, mattress, head/foot panels, assist devices and other accessories, as a system. It is also extremely important to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. R1's quarterly Minimum Data Set ((MDS) dated [DATE], included severe cognitive impairment with [DIAGNOSES REDACTED]. R1 required extensive assistance of 2 staff for all activities of daily living (ADL's) and did not have a life expectancy of less than 6 months. R1's progress note dated [DATE], 7:20 a.m. included, Around 3:00 a.m. writer was called to R1's room (R1's room number) in Gilber House. Writer observed elder's legs on the floor and the head between rail and mattress, left hand on the floor. 911 and Ramsey County Medical Examiner called. Family notified by DON (director of nursing). Medical Examiner talked to POA (power of attorney) and got consent to remove the body. Medical Examiner interviewed staff and the body was removed from the Facility about 0500 (5:00 a.m.). R1's incident report dated [DATE], included, At approximately 3:00 a.m. resident was found by the nursing assistant during rounds to be unresponsive. Facility administration, the medical examiner and police were notified. Resident's neck was found to be compressed against the bed rail. Resident's body was taken to the medical examiner's office for autopsy. The investigative report dated [DATE], included, A new bed rail assessment prior to the placement of a new air mattress on the resident bed frame was not completed. R1's Minnesota Documentation of Death report included date of death as [DATE], with immediate cause of death, asphyxia and, neck compression. The manner of death was an accident, head/neck was caught between mattress and bed rail. R1's most recent siderail assessment was dated [DATE], and included, R1 was nonambulatory, had an alteration in safety awareness due to cognitive impairment, and had a history of [REDACTED]. The assessment indicated, Side Rail serves as enabler to promote independence, and to use, bilateral, uses siderails for side to side repositioning. The space for medical indication for use was only indicated N/A. All side rail assessments for R1 were reviewed. The assessments were dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. None of R1's siderail assessments included, any alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate, or informed consent from R1 or R1's representative. None of these assessments assessed R1 for entrapment risk or indicated how those risks would be mitigated. R1's care plan revised [DATE], included, under activities of daily living section, a need for assistance for all ADL's and included, Side rails: half rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. R1's care plan identified a high risk for falls and directed staff, Resident will have hourly checks during NOC (night) (when anxiety seems to elevated (sik)) to ensure safety. The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, ,[DATE] side rails as ordered, handrails on walls, personal items within reach). R1's care plan included R1 was at risk for pressure ulcer development, but did not direct staff to utilize a low air loss or alternating pressure mattress on bed. Even though R1's care plan included,observe for injury or entrapment related to side rail use, the care plan failed to direct staff on how to mitigate these risks or if the benefit of the rails outweighed the entrapment risk. R1's Nurse Practitioner (NP) progress note dated [DATE], included a recent cognitive and physical decline. R1's progress notes dated [DATE], described how R1 tested positive for COVID-19, and was transferred to a different unit for care. R1's progress note dated [DATE], described a small open area found on the right ankle. Progress notes on [DATE], noted R1 had recovered and was able to move back to R1's normal room. When interviewed on [DATE], at 11:05 a.m. the administrator stated R1 developed a skin issue while sick with COVID-19. After recovering from COVID-19, R1 transferred back to her regular room. On [DATE], R1 was given an alternating pressure air mattress (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that the contact points with the body are reduced) to help with the pressure ulcer. When interviewed on [DATE], at 1:58 p.m. registered nurse (RN)-A stated side rail assessments were supposed to be completed quarterly, and confirmed that the most recent side rail assessment completed for R1 was in February 2020. No side rail assessment had been completed after replacing the regular mattress with the alternating pressure air mattress. Nursing is responsible for assessing the resident, the need for the siderail, the benefits and the risks and developing an individualized care plan. The facility policy for side rails dated [DATE], included, Half-side rails will be used only after an assessment has been made indicating a benefit to the resident's functional status. Continued use of the half-side rail will be reassessed periodically to determine if the side rail enhance the resident's mobility while in bed or restricts the residents freedom of movement. The policy also included that maintenance monitors all side rails for gaps between the mattress and side rail, checks the mechanics of each side rail. The policy failed to include the need to perform a resident assessment for risk of entrapment, discussing the risks and benefits with the resident or their representative and obtaining informed consent, attempting alternatives prior to installing side rails, or a re-assessment if new devices/mattress is placed. When interviewed on [DATE], at 2:14 p.m. nursing assistant (NA)-C stated they had worked the afternoon shift before R1 became entrapped between the bed rail and mattress, R1 had declined some lately and required full staff assistance to move in bed and had not been using the siderails to assist with turning side to side lately. When interviewed on [DATE], at 2:35 p.m. the director of rehab stated R1 had a functional decline recently. Therapy would review siderails and inform nursing if something appeared unsafe, however, the director of rehab had not worked with R1 after receiving the new air mattress. When interviewed on [DATE], at 4:09 p.m. the administrator stated the air mattress was ordered and delivered on [DATE]. The administrator explained normally the facility's air mattress vendor would deliver and install the air mattress, but because of the COVID-19 pandemic, the vendor was not deemed essential to enter the building. Instead, a nursing assistant installed R1's air mattress on [DATE]. The administrator stated one issue the facility found during their investigation, was that the mattress was placed on [DATE], and had not been inspected by maintenance before R1 slept in the bed that night. Maintenance typically looked at the bed with the mattress, and side rails, to ensure safety, but had not checked the bed with the new mattress. Review of the work history report from the maintenance computer system showed a bed and mattress check for R1's unit on [DATE]. The Logbook Documentation showed the following steps for the bed and mattress check: 1. Inspect remote and make sure all buttons are working and that the bed is lifting/lowering like it should. 2. Make sure that bed rails are firmly attached to bed frame and fix as needed. 3. See if all boards are properly screwed to the frame of the bed. 4. Look for wires that are frayed or exposed and replace or remove bed so as not to be used until fixed, if necessary. When interviewed on [DATE], at 9:04 a.m. maintenance worker (M)-A stated the side rails were checked by ensuring pins were in place, the bed was snug to it, there were no gaps, and everything was tight. M-A stated he did not use a device to measure the spaces around the rails prior to the accident, but rather visually looked for gaps. M-A said this was the first air mattress that was placed during COVID-19 pandemic, and the mattress vendor was not allowed in the building to install the bed. R1's mattress came and was applied to the bed without their knowledge, therefore the bed had not been rechecked before R1 was placed into bed. When interviewed on [DATE], at 3:10 p.m. NA-C stated an air mattress arrived for R1 on [DATE], and NA-C put it together following the instruction manual that came with the mattress. NA-C placed it on R1's bed, connected it to the power and the mattress inflated. NA-C was not aware of any setting to add the patients weight, or how to check for entrapment risks. The Alternating Pressure & True Low Air Loss Mattress Replacement System Operating Instruction Manual, undated, included directions to attach the mattress and chose settings for comfort level and to use the comfort control keys to set the required patient weight position. When interviewed on [DATE], at 10:14 a.m. R1's family member (F)-E described having been told by the facility that R1 was possibly trying to get out of bed, and got stuck and died . F-E did not think R1 had the strength to do that, as staff helped R1 get in and out of bed. Lately, R1 had been more confused, but still had moments of lucidity. F-E did not recall the facility discussing any risk or benefits of siderail use with her. When interviewed on [DATE], at 9:43 a.m. the vice president of clinical support (VPCS) and the regional manager (RM) of the air mattress vendor explained how the air mattresses worked, and how they were typically set up. RM said after the accident, he was asked to visit the facility and look at all the air mattresses in the building. R1's mattress was appropriately placed and tied down at the corners. It was set at a lower pressure setting than normal, but this would not be unsafe. They normally set up the mattress for customer service, but this was not necessary. When ordering the mattress, the facility includes the bed size and patient weight and they are able to chose the correct mattress to send out. The facility would be responsible for the settings on the mattress for the resident needs, and for assessing resident safety. The immediate jeopardy (IJ) that began on [DATE], was removed and the deficient practice corrected on [DATE], when the facility took the following steps to remove the IJ and correct the deficient practice: All residents who utilized side rails were assessed for entrapment risk, many were determined to no longer be appropriate and removed on [DATE] and [DATE]. Only two residents R2 and R3 were deemed to be medically appropriate for siderail use, they were assessed for entrapment risk, risks and benefits were reviewed with resident or their representative, and physician orders [REDACTED]. The facility policy for side rail use and pressure relieving mattress use policy was updated to include a side rail assessment will be completed prior to use of a replacement mattress. A new Episcopal Church Home Side Rail Risk Benefit Agreement was created. No new mattresses would be placed prior to education of all staff on the new policy. All staff would be educated prior to working their next shift and a formal education was scheduled for all staff. The Quality Assurance Committee reviewed the incident. Observation, interviews and document review verified compliance on [DATE].