Every finding on record at Eventide Lutheran Home

Based on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs and care plan to eliminate/reduce the risk of an accident in bed for 1 of 1 residents (R1). This resulted in actual harm to R1 when she rolled out of bed onto the floor. R1's fall mat was not alongside the bed and her call light was not within reach. As a result, R1 was transported to the emergency department (ED) on 6/12/26, for a laceration to the forehead and a fracture to her right clavicle. The facility had implemented actions to prevent recurrence prior to the survey on 6/23/26, therefore, the citation was issued at past non-compliance. Additionally, the facility failed to provide adequate supervision and secure transportation for R2 who has severe cognitive impairment.Findings include:R1R1's annual minimum data set (MDS) dated [DATE], identified R1 was cognitively intact. R1 was dependent on staff for toileting, bed mobility, and transferring. R1 had anxiety, pain and a history of falls with fractures.R1's care plan revised 6/13/26, identified R1 had a potential for falls related to decreased mobility, a history of falls, and weakness. R1 was alert and orientated to person, place and time. R1's care planned interventions included low bed with fall mat to the floor when R1 was in bed and soft touch call light at the hip to promote use.R1's fall risk predictive factors assessment dated [DATE], indicated R1 had poor recall, judgment, and safety awareness. It further indicated R1 had poor vision status and a history of three or more falls in the past three months.R1s care sheet undated, indicated R1 was a fall risk and was to have low bed and floor mat along with soft touch call light to right hip.R1's physical therapy treatment encounter dated 6/15/26, indicated R1 fell and was receiving skilled services to her right shoulder per providers orders.R1's incident report dated 6/12/26 at 4:45p.m., identified the nurse was alerted via walkie talking that R1 was lying on the floor. R1 was lying on her right side, her head was pointing to the south of her bed approximately a foot away from her bed. R1 had approximately an eight-inch circle of blood at the right of her head hear her right ear area. R1s bedside table base was near her neck and her stationary chair was near her. Nursing Assistant (NA)-A stated the last time NA-A checked on R1 was around 4:00 p.m. R1 used the restroom and NA-A assisted R1 into bed. I was determined based on the scene that R1 had raised her bed in a high position and attempted to self-transfer. R1s call light was in the chair next to the bed. R1 has a history of falls. R1 used her bed controller to put the bed up approximately four feet. NA-A confirmed she had the bed in low position but did not have the fall mat next to the bed. R1 was assessed for injuries. R1 was transferred into her bed with a hoyer sling lift. Medical provider notified of all and head injury. Medical provider ordered R1 to be sent to the ED for evaluation and treatment. R1s spouse was notified of the injury.On 6/12/26, electromagnetic waves (X-ray) revealed R1 had an acute comminuted fracture of the lateral right clavicle, and it appeared somewhat impacted.On 6/12/26, computed tomography (CT) revealed R1 had a right lateral scalp hematoma.Provider Communication Forms revealed the following:-6/12/26, found on floor laying on right side, blood near head coming from laceration back of right ear. Was assisted back to bed, cleaned up. Called on-call medical provider, ordered to be sent in for evaluation and treatment. Returned from ED Friday evening. Has right clavicle fracture with sling. Staples to head laceration. Referral to orthopedics. Signed by primary provider 6/15/26.-6/15/26, immobilizer to right upper extremity (RUE) with Velcro at wrist ordered due to right clavicle fracture. Signed by primary provider 6/15/26.-6/15/26, discontinue physical therapy (PT) and speech therapy (ST). Signed by primary provider 6/15/26.-6/15/26, remove scalp staple on 6/20/26. Signed by provider 6/17/26.-6/16/26, R1 refused 2:00 p.m., dose of Tramadol (medication used for pain), then requested it at 4:00 p.m. Give one time only dose of Tramadol 50mg by mouth for pain. Wait four hours until next does. Signed by provider 6/16/26.[NAME] Internal Medicine Nursing Home APP visit dated 6/15/26, medical provider indicated the visit was related to a hospital discharge. R1 had a right clavicle fracture. R1 was to wear an immobilizer to right upper extremity with Velcro at the wrist for six weeks. R1 will need to follow-up with orthopedics and plan to have a follow-up x-ray in two weeks. R1 had one suture placed and orders were given to remove the scalp staple on 6/20/26, eight days after placement.Progress notes dated 6/1/26 to 6/23/26 revealed the following:-6/3/26 at 10:25 a.m., R1 had her light on and requested help from staff. Staff helped R1 and left room.-6/11/26 at 2:15 p.m., R1 had her light on R1 requested to use the bathroom. R1 didn't need any additional assistance.-6/12/26 at 6:21 p.m., time of fall 4:39 p.m. nurse was alerted via walkie talking that R1 was lying on the floor. R1 was lying on her right side, her head was pointing to the south of her bed approximately a foot away from her bed. R1 had approximately an eight-inch circle of blood at the right of her head hear her right ear area. R1s bedside table base was near her neck, and her stationary chair was near her. Nursing Assistant (NA)-A stated the last time NA-A checked on R1 was around 4:00 p.m. R1 used the restroom and NA-A assisted R1 into bed. R1 was drowsy when first checked, R1 awakened when assessed, R1 had a head laceration somewhere behind her right ear on the scalp which she was bleeding from. R1 assisted into bed with hoyer sling lift and two person assist. Care plan updated to keep bed controls turned off by removing the remote. R1 was unable to control the bed functions safely. Medical doctor notified at 4:50 p.m. Spouse notified at 5:15 p.m.-6/12/26 at 6:38 p.m., R1 was transferred to [NAME] ED via emergency medical transport (EMT) due to fall and head injury. On-call provider notified and ordered transfer for evaluation and treatment at [NAME] ED. Supervisor and husband notified of R1's fall.-6/12/26 at 11:16 p.m., R1 returned from the hospital around 9:30 p.m. Closed displaced fracture of acromial end of right clavicle. Laceration of scalp. R1 has a sling on right hand. CT of head without contrast was done. CT spine cervical without contrast. R1 has been sleeping throughout the night. No complaints of shortness of breath (SOB), no complaints at this time.-6/14/26 at 4:47 p.m., writer completed a bed remote assessment with R1. Nursing delegated to client to complete raising and lowering head of bed, food of bed, and height of bed. Nursing delegated to client to complete putting bed at an appropriate height for transfer. Client was not able to complete any of these tasks safely. Will continue to keep bed remote out of reach of R1.-6/15/26 at 1:37 p.m., writer spoke with R1s spouse and daughter about intervention, and they consented to removing the bed remote for R1s safety.-6/15/26 at 3:46 p.m., elbow, wrist, hand range of motion three times a day. No weight bearing to right arm. Use right arm sling/immobilizer when up. Ok to remove for sleep and comfort.During an observation on 6/23/26 at10:50 a.m., R1 was laying in the bed watching television. R1's bed was in low position and fall mat was on the floor next to the bed. R1's call light was hooked to the railing of the bed. R1s legs were hanging off the edge of the bed. R1 had sling on right shoulder. R1 was unable to answer questions during an interview due to difficulties speaking. During an observation on 6/23/26 at 4:03 p.m., R1 was resting in the bed. R1 had removed the sling from right shoulder. R1s bed was in a low position and fall mat was on the floor. Call light was within reach. During an interview on 6/23/26 at 3:32 p.m., nursing assistance (NA)-A indicated NA-A had completed rounds and was helping another resident. NA-A heard over the walkie that R1 had fallen out of bed and was lying on the floor. NA-A indicated R1 had an open wound and there was blood on the floor. NA-A stated R1 had a history of using the remote to bring the bed up. NA-A further stated when NA-A entered the room R1's bed was in a very high position. NA-A confirmed NA-A had forgotten to place the fall mat next to R1's bed and R1's call light was in the chair. NA-A indicated NA-A received training on care plans and continued to work with co-workers completing walk through checklists of each resident's rooms to ensure safety. NA-A further indicated an all staff meeting was going to take place next month. During an interview on 6/23/26 at 3:40 p.m., medical provider (MP) indicated MP was aware of R1's fall and that R1 was treated in the ED. MP stated R1 sustained a fracture to R1's right clavicle and a laceration to R1's head. MP further stated MP had seen R1 for a follow up on 6/15/26. MP indicated R1 was to wear a sling and would be seen by orthopedics for a follow-up. MP stated she would expect staff to be following the care plan to prevent any accidents and keep residents safe. On 6/23/26 at 3:45 p.m., call made to registered nurse (RN)-A no answer and a voicemail was left. During an interview on 6/23/26 at 4:10 p.m., licensed practical nurse (LPN)-A stated LPN-A was aware of R1's fall. LPN-A indicated LPN-A received education on care plans, falls, and working with NA's to ensure the safety checklists were being followed. LPN-A further indicated the safety checklists were used to ensure all care planned interventions were being followed for each resident. During an interview on 6/23/26 at 4:59 p.m., director of nursing (DON) stated she was aware of R1s fall and that R1 sustained injuries from the fall. DON confirmed R1's fall mat was not along side R1's bed and R1 did not have R1's call light within reach. DON indicated education was done with all staff working on the second floor immediately and shortly thereafter education was provided to all nursing staff. DON further indicated when NA-A returned for NA-A's next shift, NA-A worked with coworkers to complete safety checks on all residents on the second floor. DON stated when R1 returned staff removed R1's bed controller as an intervention for fall safety. DON stated her expectations were for staff to follow all care planned interventions to ensure resident safety. DON further stated care planned interventions were in place to protect the residents from harm.R2R2's quarterly MDS dated [DATE], identified R2 was severely cognitively impaired. R2 was dependent on staff for toileting, bed mobility, and transferring. R1 had Alzheimer's disease and dementia. R2's care plan revised 3/27/26, potential for safety concerns due to risk for elopement. R2s goal indicated R2 will not leave the facility unattended. Interventions in place were to check wander guard placement every shift and to identify triggers as R2 has a history of wandering the halls and using the elevator.R2's elopement risk assessment dated [DATE], indicated R2 was cognitively impaired with poor decision making skills and uses a wander guard.Progress notes dated 3/4/26, revealed R2 saw medical doctor at Essentia Dermatology, had cryotherapy completed to top of scalp and left ear. However, progress notes lacked documentation of the time R2 left the facility, when R2 returned to the facility and if R2 had an escort to R2's appointment. Review of a facility calendar dated 3/4/26, identified R2 had a scheduled ride to Essentia Health Dermatology by First-In Line Mobility with a pickup at 1:30 p.m., on 3/4/26 and a will-call return for transportation back to the facility once the appointment was completed.R2's electronic medical record (EMR) lacked documentation of paperwork sent with R2 for R2's dermatology appointment on 3/4/26.During an observation on 6/23/26 at 2:23 p.m., R2 was sitting in R2's wheelchair in the hallway next to the elevator. R2 had a blanket over R2's chest and R2 was moving back and forth. R2 had a wander guard on R2's right ankle. R2 was unable to answer any questions during the interview. During an observation on 6/23/26 at 4:07 p.m., R2 was sitting in the hallway near the nurses' station drinking a cup of coffee. R2 was moving around in R2's wheelchair. R2 had wander guard on right ankle. During an interview on 6/23/26 at 1:17 p.m., trained medical aid (TMA)-A indicated the NA's got resident's ready for appointments and would bring them to the nurses' station for pick-up. TMA-A stated the secretary was responsible for getting the resident's paperwork ready to take to appointments. TMA-A indicated that the transportation driver would come to the floor to pick the resident up. TMA-A stated if family was going to take the resident to an appointment, staff would bring the resident down to the front door. TMA-A was unsure if R2 required an escort to appointments or if any paperwork was sent to R2's dermatology appointment on 3/4/26.During an interview on 6/23/26 at 1:23 p.m., NA-B stated staff would take the resident up front to where their ride would pick them up. NA-B indicated they let the nurse and secretary know when the residents are ready for their appointments. NA-B indicated if the resident needed an escort the secretary would make sure they would have the escort before leaving the floor. NA-B stated there usually is an envelope at the desk that would go with the resident when they leave. NA-B was unsure if R2 required an escort to appointments or if any paperwork was sent to R2's dermatology appointment on 3/4/26. During an interview on 6/23/26 at 1:28 p.m., RN-B stated that staff just know if a resident required an escort for appointments. RN-B further stated at times, they will let us know if an escort was needed. RN-B indicated some residents who have wander guards can just go to appointments on their own. RN-B stated she was unaware if R2 required an escort for appointments or if an envelope was sent with R2 to his dermatology appointment of 3/4/26. RN-B further stated she was unaware of how R2 returned to the facility after his appt on 3/4/26. During an interview on 6/23/26 at 1:30pm LPN-B indicated the secretary was responsible for setting up appointments. LPN-B further indicated rides are provided to residents based on their insurance. LPN-B stated envelopes are provided to the driver, resident or family with information about the resident and was returned to the facility when the resident arrived back. This paperwork was also used for the provider at the appointment to provide any updated orders. LPN-B further stated each envelope had a sticker at the top that provided a number for the provider to call when the appointment was finished for a return ride back to the facility. LPN-B indicated if a resident was not safe to go to the appointment alone family will be contacted for assistance or and escort would be provided. LPN-B stated determination was made on residents' safety if the resident required an escort. LPN-B further stated there really wasn't a process on the determination, they just know what residents are not safe to be out by themselves. LPN-B looked in R2's EMR and verified R2 had an appointment on 3/4/25 at 2:00 p.m. LPN-B indicated she was unaware R2 was brought back to the facility by the police department. LPN-B was unaware of what time R2 returned to the facility and did not know how long R2 had been gone. LPN-B confirmed LPN-B put a note in regarding R2's appointment but did not know how R2 arrived back at the facility from the appointment. LPN-B indicated R2's daughters would often attend R2's appointments but LPN-B could not confirm if R2's daughters were at the appointment on 3/4/26. LPN LPN-B confirmed R2 had a son but indicated LPN-B just met him for the first time a couple days ago. LPN-B was unsure if an envelope was sent with R2 to his dermatology appointment on 3/4/26. During an interview on 3/4/26 at 1:45 p.m., secretary stated R2 now has an escort for all appointments. Secretary indicated secretary was not in the current position when R2's appointment for 3/4/26 was scheduled. Secretary was unable to confirm if R2 had an escort for the appointment on 3/4/26. Secretary was unable to confirm when and how R2 returned to the facility or if an envelope for the receiving facility was sent with to R2's appointment at the dermatology clinic on 3/4/26.On 6/23/26 at 1:50 p.m., a call to R2's daughter was made and no answer. On 6/23/26 at 1:58 p.m. a call the Fargo Police Department (FPD) was made FPD indicated police reports could be found online by going to www.fargopolice.com. On 6/23/26 at 2:44 p.m., contacted the FPD through online database. 709 requested for police report. On 6/23/26 at 2:48 p.m., call to Nursing Supervisor Essentia Health and left a voicemail. During a phone interview on 6/23/26 at 2:49 p.m. first in line transportation supervisor (FILTS) confirmed R2 was picked up at 1:30 p.m., on 3/4/26. FILTS could not confirm if R2 had an escort or received a return ride to the facility from R2's appointment. FILTS stated envelopes are given to the receiving facility and the receiving facility calls the number when the residents appointment is finished. FILTS could not verify if R2 had an envelope for R2's appointment on 3/4/26. On 6/23/26 at 4:36 p.m., call to Essentia Health Dermatology, no answer.During an interview on 6/23/26 at 4:59 DON indicated DON did not feel there was anyway R2 could have been transported back to the facility by the police department. DON stated R2 was a hoyer lift and would have required the use of a lift to transfer R2. DON stated R2 used transportation to get to R2's appointments and family would generally meet R2 at the appointment. DON indicated family was supposed to meet R2 for his appointment on 3/4/26. DON stated R2's daughter was going to relay the appointment with R2's other daughter but had gotten the dates confused. DON confirmed R2 attended R2's appointment alone. DON stated that the resident returned to the facility as there was a note placed in R2's chart. DON could not confirm how or when R2 arrived back to the facility after R2's appointment. DON indicated the facility used an elopement assessment and that would be considered the safety assessment to ensure residents are or are not safe in the community alone. DON stated residents are never alone. DON further stated the transportation service picks the residents up and brings them to appointment. DON could not confirm if First In Line transportation service stayed with R2 for R2's appointment. DON stated the facility sends paperwork with each resident and that is to be handed off during the appointment and returned to the facility after the appointment. DON could not confirm if R2 had paperwork sent with R2 for R2's appointment on 3/4/26.On 6/24/26 at 7:35 a.m., email received from FPD stating no police report containing R2's name was found for 3/4/26.During a phone interview on 6/24/26 at 8:02 a.m., Nursing supervisor Essentia Health (NSEH) stated nursing staff found R2 sitting alone in the lobby and brought R2 back to R2's appointment on 3/4/26. NSEH indicated FILT did not stay with R2 during his appointment. NSEH stated R2 did not have any documentation or paperwork with R2 from the facility providing any direction for nursing staff. Nursing staff were not aware R2 lived in a nursing home and had cognitive impairments. NSEH stated R2 told staff R2's son was going to pick R2 up after the appointment. NSEH indicated nursing staff assumed this was correct as R2 as R2 did not have any other information with R2. NSEH stated once the appointment was finished, staff brought R2 down to the pickup area for R2 to wait for his ride. HSEH stated nursing staff were not aware they needed to call FILT for a ride back to the facility for R2. HSEH further stated staff continued to check on R2 for approximately two hours in the pick-up area. NSEH indicated during this time, nursing staff attempted to contact R2's daughter but never received a call back. HSEH stated the last time nursing staff went to check on R2, R2 was no longer sitting in the pick-up area so nursing staff assumed R2's son picked R2 up. HSEH indicated on the morning of 3/5/26 the department received a telephone message from 3/4/26 from Eventide. HSEH stated the message was requesting information about R2's appointment. HSEH further stated nursing staff called Eventide back and spoke with LPN-B. HSEH indicated LPN-B stated R2 had been seen at the clinic on 3/4/26. HSEH stated nursing staff told LPN-B that R2 did not come with any paperwork so NSEH were unaware res lived in a nursing home or that R2 did not have a return ride to the facility, LPN-B indicated there was a mix up with R2's daughters who were usually with R2 for appointments. HSEH stated nursing staff told LPN-B that R2 was picked up by R2's son and LPN-B indicated R2 did not have a son. HSEH further stated LPN-B told nursing staff that R2 had been brought back to the facility by the police department. HSEH indicated LPN-B apologized for the mix up and nursing staff faxed paperwork from the appointment to Eventide.The past noncompliance that began on 6/12/26. The deficient practice was corrected by 6/19/26, after the facility implemented a systemic plan. Verification of corrective action was confirmed and interviewed with facility staff and review of training documentation. The nursing assistant involved verified she was promptly re-educated on the importance of following the nursing assistant care sheets. Documentation showed the facility had developed, implemented, and completed a plan to ensure that any staff responsible for providing cares were trained. This was confirmed by review of training records and staff interview. Observation of care in bed observed and verified that staff were following the nursing assistant care sheets. Facility was able to demonstrate monitoring of the corrective action and sustained compliance.Facility Policy titled Care Plans dated 2/10/26, to develop a person-centered care plan in conjunction with the interdisciplinary team and resident/resident representative that reflects the actual care, condition and preferences of each resident. Any changes made to the comprehensive care plan will also be updated in the NAR/CNA care plan.Facility policy titled Falls - Resident dated 2/13/26, all resident will be assessed for fall risk and individualized interventions will be implemented as appropriate to minimized the all risk and reduce injury.Facility policy titled wander guard dated 2/17/26, a wander guard is used to minimize potential resident elopement.Facility policy titled resident medical appointments dated 2/17/26, to arrange a safe transport and escort procedure for those residents whose families are unavailable to transport and/or accompany them to appointments and to provide the provider with appropriate information.

Based on interview and document review, the facility failed to report an incident of neglect of care with serious bodily injury was reported within 2 hours of the State Agency (SA) for 1 of 1 residents (R1) who fell out of bed and sustained a fractured clavicle along with a laceration when staff were not following the care plan.Findings include:R1's annual minimum data set (MDS) dated [DATE], identified R1 was cognitively intact. and was dependent on staff for toileting, bed mobility, and transferring. R1 had anxiety, pain and a history of falls with fractures.R1's care plan revised 6/13/26, identified R1 had a potential for falls related to decreased mobility, a history of falls, and weakness. R1 was alert and orientated to person, place and time. R1's care planned interventions included low bed with fall mat to the floor when R1 was in bed and soft touch call light at the hip to promote use.R1's fall risk predictive factors assessment dated [DATE], indicated R1 had poor recall, judgment, and safety awareness. It further indicated that R1 had poor vision status and a history of three or more falls in the past three months.R1s care sheet undated, indicated R1 was a fall risk and was to have low bed and floor mat along with soft touch call light to right hip.R1's incident report dated 6/12/26 at 4:45p.m., identified the nurse was alerted via walkie talking that R1 was lying on the floor. R1 was lying on her right side, her head was pointing to the south of her bed approximately a foot away from her bed. R1 had approximately an eight-inch circle of blood at the right of her head hear her right ear area. R1s bedside table base was near her neck, and her stationary chair was near her. Nursing Assistant (NA)-A stated the last time NA-A checked on R1 was around 4:00 p.m. R1 used the restroom and NA-A assisted R1 into bed. I was determined based on the scene where R1 had raised her bed in a high position and attempted to self-transfer. R1s call light was in the chair next to the bed. R1 has a history of falls. R1 used her bed controller to put the bed up approximately four feet. NA-A confirmed she had the bed in low position but did not have the fall mat next to the bed. R1 was assessed for injuries. R1 was transferred into her bed with a hoyer sling lift. Medical provider notified of all and head injury. Medical provider ordered R1 to be sent to the ED for evaluation and treatment. R1s spouse was notified of the injury.Progress notes on 6/12/26 at 6:21 p.m., time of fall 4:39 p.m. nurse was alerted via walkie talkie that R1 was lying on the floor. R1 was lying on her right side, her head was pointing to the south of her bed approximately a foot away from her bed. R1 had approximately an eight-inch circle of blood at the right of her head hear her right ear area. R1s bedside table base was near her neck, and her stationary chair was near her. Nursing Assistant (NA)-A stated the last time NA-A checked on R1 was around 4:00 p.m. R1 used the restroom and NA-A assisted R1 into bed. R1 was drowsy when first checked, R1 awakened when assessed, R1 had a head laceration somewhere behind her right ear on the scalp which she was bleeding from. R1 assisted into bed with hoyer sling lift and two person assist. Care plan updated to keep bed controls turned off by removing the remote. R1 was unable to control the bed functions safely. Medical doctor notified at 4:50 p.m. Spouse notified at 5:15 p.m.Progress notes on 6/12/26 at 11:16 p.m., R1 returned from the hospital around 9:30 p.m. Closed displaced fracture of acromial end of right clavicle. Laceration of scalp. R1 has a sling on right hand. CT of head without contrast was done. CT spine cervical without contrast. R1 has been sleeping throughout the night. No complaints of shortness of breath (SOB), no complaints at this time.Incident report received at SA on 6/13/26 at 9:18 a.m.During a phone interview on 6/24/26 at 11:23 a.m., registered nurse (RN)-C indicated R1 had fallen prior to RN-C's shift. RN-C stated when RN-C arrived for RN-C's shift R1 was currently at the hospital. RN-C indicated RN-C did not receive a call from the emergency department (ED) prior to R1 returning to the facility. RN-C further indicated R1 was transported back from the ED by R1's spouse on 6/12/26, around 9:30 p.m. RN-C stated RN-C indicated RN-C was made aware R1 had a clavicle fracture. RN-C further indicated RN-C thought the manager knew about the facture, so RN-C did not call the on-call manager when R1 arrived back at the facility. RN-C indicated RN-C put a progress note in R1's electronic medical record (EMR) after RN-C completed R1's return assessment. RN-C stated RN-C shared in morning report that R1 had sustained a clavicle fracture.During a phone interview on 6/25/26 ,at 12:23 p.m., director of nursing (DON) verified R1 returned to the facility on 6/12/26. DON further indicated RN-C looked through R1's looked through her discharge paperwork and found R1 had sustained a clavicle fracture. DON stated RN-C had thought it had already been communicated so RN-C documented in R1's EMR and passed the information on during morning report. DON stated it was miscommunication. DON confirmed the report was filed the morning of 6/13/26, which was past the two-hour reporting requirements. DON stated it is important that reports are filed following the correct reporting requirements for residents' safety and also to ensure the facilities processes are on time correct. Review of a facility policy titled Vulnerable Adult- Minnesota dated 2/17/26, identified All staff, residents, and families are required to report suspected abuse or neglect of vulnerable adults. The DON or designee shall be responsible for maintaining a log of any suspected and/or actual cases of abuse orneglect. They shall verify that the report to the proper officials has been made and that appropriateintervention has been taken. Policy further identified, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries ofunknown source and misappropriation of resident property are to be reported: Immediately but not later than 2 hours after the allegation is made if the events that cause theallegation involve abuse or result in serious bodily injury.

Based on interview, observation and document review, the facility failed to ensure orders were followed as prescribed by the physician for 1 of 3 residents (R1) reviewed for post-op care after a right great toe amputation. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition with physical behavioral symptoms towards others (hitting, kicking, pushing, scratching, grabbing) and verbal behavioral symptoms directed towards others (screaming, threatening others and cursing). Medical diagnoses included: non-traumatic brain dysfunction, peripheral vascular disease (PVD) (a circulation disorder where blood vessels outside the heart become narrowed, blocked, and can cause pain, cramping, numbness, and poor wound healing), diabetes mellitus (DM), and Alzheimer's. R1's care plan dated 11/12/25, identified a potential for skin breakdown related to dementia, urinary incontinence, history of stage 2 pressure ulcer to right buttock and seborrheic dermatitis, right great toe ulcers and left toe diabetic ulcers. Interventions directed staff to apply Prevalon boots (a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) when going off the unit and to activities. Tubigrips (a brand of elastic tubular bandage used for providing compression and tissue support for conditions like sprains, strains, edema, and post-burn scarring) to bilateral lower extremities as ordered and wrapped bars around foot pedals of Rock n Go (type of wheelchair) with towel for protection. R1's post-op surgical shoe was not included in the care plan. Nursing assistant (NA) care plan dated 11/13/25, identified R1 transferred with assist of two and Hoyer (mechanical device used for transferring), non-ambulatory. Positioning: Prevalon boots when going off unit and to activities. Safety/Falls: gripper socks when in bed or room if not wearing shoes. R1's post-op surgical shoe was not included in the NA care plan. R1's post operative discharge instructions/orders dated 10/30/25, signed off by licensed practical nurse (LPN) on 10/30/25, identified weight bearing as tolerated in post-op shoe (a supportive medical shoe designed to protect and provide comfort for a foot recovering from surgery or injury), may gently wiggle toes within the dressings. R1's progress note dated 10/30/25 at 5:04 p.m., Provider Order: Ice to affected area for 48 to 72 hours and as needed (PRN). Avoid placing ice pack directly on skin. Place the ice pack under the knee of the surgical foot. Elevated leg for 72 hours. Keep dressing clean/dry/intact until follow up appointment on 11/12/25. May shower or bath. Wrap dressing with waterproof protection such as saran wrap or plastic bag. If dressing became soaked with water, contact the foot and ankle clinic. A telephone encounter returned phone call from wound clinic to nursing home dated 11/3/25, who needed a change in wound care order orders for patient's right great toe. He had a right partial hallux (big toe) amputation, hardware removal on 10/30/25. Orders were placed for post-surgery. Recommendations: discontinue wound clinic orders for the right great toe, continue with post-surgical orders placed by provider. R1's progress note dated 11/11/25 at 5:29 a.m. R1 kicked the wall by the secretary desk on 2nd floor before lunch. He had refused to move from that location. Looked at right foot earlier no injury and blood noted at the bottom on left gripper sock. He had a skin tear to tip of left forth toe 0.5 centimeters (cm) by 0.5 cm small amount of bleeding. R1's clinic visit dated 11/12/25, identified R1 with a history of type 2 diabetes with neuropathy, peripheral arterial disease (PAD) (narrowed arteries reduces blood flow to the arms and legs), atrial fibrillation and Alzheimer's. Two weeks post partial amputation of his great toe secondary to osteomyelitis (infection in the bone) and retained hardware. The incision was well coapted (edges of incision were closed) and no signs of dehiscence (splitting or opening) or erythema (redness of the skin). Healing was delayed but the wound edges are healthy and capillary refill to the flap was immediate. Sutures remained intact. During an observation on 11/12/25 at 2:03 p.m., R1 sat at nurse's station in Broda (allows the user to change angle of backrest to reduce pressure points and improve circulation) chair with blue lift sheet underneath him. R1 wore a blue pull-on gripper sock on the left foot and a black open toed post-op shoe on the right foot. The right foot and lower ankle were wrapped with a dressing and Tubigrip. During an observation on 11/13/25 at 8:07 a.m., R1 sat in Broda chair in dining room along with two other residents. He was well groomed and wore gripper socks on both feet. His left foot was placed on the floor in front of the Broad chair and right foot hung just above the floor. R1 did not have post-op shoe on his right foot. During an observation and interview on 11/13/25 at 11:12 p.m., NA-A and NA-B transferred R1 with a Hoyer lift from [NAME] chair onto his bed to off load him for a short period of time. R1's post-op shoe was not on his right foot and was observed on the floor in front of the recliner. R1 was transferred back to the Broda chair via Hoyer. R1's right foot was wrapped with cling/gauze on top of Coban (stretchy dressing wrap) from the ankle to the top of foot, and from ankle to just under right knee had Tubigrip. R1 had gripper socks on both feet. Registered nurse (RN)-A observed the transfer and stated R1 should have had his post-op shoe on right foot when up out of bed. The end of the shoe hung out further then the end of his toes and protected the surgical site during transfers. RN-A placed the post-op shoe on R1's right foot. RN-A was unable to locate surgical shoe order and when it should be applied. RN-A stated it was common sense R1 should have had the post-op shoe on to protect the amputation since he kicked things and could have caused more harm. During an observation on 11/13/25 at 1:30 p.m., R1 laid in bed on his left side. Both feet had blue pull on slippers. The inner lateral side of the right foot involving great toe amputation rested on the bed mattress crossed over by R1's left leg. At 1:59 p.m. NA-A entered R1's room and applied blue Prevalon boots to both of R1's feet. During an observation on 11/13/25 at 2:30 p.m., R1 sat in Broda chair in TV lounge. R1's left foot had a black post-op shoe with Velcro straps across the top of the foot attached to the inner side of the shoe. R1's right foot had on a slip-on gripper sock. During an observation on 11/13/25 at 2:48 p.m., R1 sat in Broda chair in TV lounge with a black post-op shoe on left foot. R1's feet were extended out in front of him, crossed at the ankles with the left foot resting on top of the right foot NA-A sat in a lounge chart documenting and was asked if she had clarified with floor manager the use of R1's surgical shoe. NA-A jumped up and said oh ya, it should have been placed on the right foot not the left and needed to be switched. NA-A sat in front of R1 and offered to switch the post-op shoe from the left foot to the right but R1 refused. NA-A informed staff nurse via walkie that R1 refused and would try again later. During an observation on 11/13/25 at 3:52 p.m., NA-C approached R1 while in TV lounge and asked if she could remove and clean up the post-op shoe. R1 refused. NA-C stated the Velcro was on the wrong side and the shoe and belonged on the right foot instead of the left. R1 agreed and allowed NA-C to remove shoe from left foot and placed on right foot. During an interview on 11/13/25 at 9:54 a.m., LPN-A stated R1 tended to kick walls/doors/staff. R1 had kicked the wall, ended up with a sore right on great toe, and started going to the wound clinic in September 2025. R1 wore shoes on his feet initially and later taken off because they may have caused pressure (per the wound clinic) and shoes replaced with gripper and compression socks, then changed to Tubigrip pulled onto lower legs and toes left exposed. During an interview on 11/13/25 at 11:36 a.m., family member (FM)-B stated she was with R1 when he was being discharged back to the facility after his right big toe amputation surgery. FM-B confirmed the surgical post-op shoe was placed on his right foot over the dressing prior to the transfer back to the facility. FM-B stated the nurse informed her it was used to protect R1's foot and amputation site of his big toe. The shoe looked like an open toed sandal with Velcro used to hold it in place. They placed a pull-on slipper on his left foot. During an interview on 11/13/25 at 12:15 p.m., FM-A stated she visited R1 weekly, and noticed during every visit the black post-op shoe had not been placed on his right foot. R1 had blue pull on socks on both feet during visits. FM-A stated R1's right foot surgical area should have been protected so it healed properly. During an interview on 11/13/25 at 1:45 p.m., NA-B stated R1 punched and kicked. R1 had his big toe removed. NA-B verified R1's care plan did not identify if a post-op shoe should be worn or not. NA-B was unsure as to why and when a post-op shoe would be needed. NA-A stated staff would be expected to protect R1's right foot after surgery and prevent him from hitting things with the end of his foot. During an interview on 11/13/25 at 2:03 p.m., NA-A stated she referred to R1's care plan to take care of him. R1 had behaviors including being combative, not wanting to be changed, touched, or transferred. NA-A indicated since surgery she had not placed anything other than a pull-on slipper over R1's right foot. NA-A stated she had placed the black post-op shoe on R1's left foot, and was pretty sure he should not have anything on his right foot since the amputation of his toe. NA-A stated earlier this morning she had been instructed by the staff nurse over the walkie R1's post-op shoe should be placed on his left foot. NA-A states she placed R1's black post-op shoe on his left foot and R1 wore it all day while up in his chair. NA-A reviewed R1's care sheet and verified no indication of the post-op shoe was included. NA-A indicated R1's care plan identified gripper socks were to be worn in bed or in room if not wearing shoes, and Prevalon boots to be worn when going off unit and to activities. NA-A stated she planned on checking with the floor manager regarding the use of the post-op shoe and which foot she should have placed it on. During an interview on 11/13/25 at 2:58 p.m., RN-B resident care manager stated was hard to protect R1's right toe amputation site with how restless he was. RN-B stated there was nothing currently used to protect R1's right foot after surgery. When up in Broda chair he should have gripper socks on and no shoes. RN-B stated R1's care plan was not updated after his right toe amputation before today and should have been. RN-B stated an open toes shoe was a surgical shoe and there were no orders for it, will need to check on that. Generally, the surgical post-op shoe was used for residents with diabetes for toe protection but if R1 had just received the surgical shoe, most likely should have been used to protect the amputation site and added to the care plan. RN-B stated when R1 returned from surgery the staff nurse would have been expected to process the orders from his discharge papers, follow up with provider if he was to wear the boot and how often. The secretary placed the orders, and the nurse verified them on 10/30/25. On 11/3/25, he had a follow-up and no mention of a post-op shoe. RN-B further stated R1 had a history of kicking things and would have been important to protect the site without pressure applied to his toes/surgical area. Facility policy Care Plan dated 11/2021, identified care plans will be updated, and changes will be made as they occur to ensure the most current plan for the resident. Care plans will be reviewed at least monthly by each discipline and documentation will be made in the electronic medical record indicating that the care plan was reviewed and summarizing the changes made, if any. Any changes made to the comprehensive care plan will also be updated in the NA care plan for accuracy.

Based on observation, interview and document review, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 3 residents (R22) reviewed for pressure ulcers. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and diagnoses which included hemiplegia (paralysis on one side of the body), aphasia (disorder that affects the ability to communicate), and Parkinson's Disease. Identified R22 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R22 was at risk for pressure ulcers. R22's annual Care Area Assessment (CAA) dated 10/19/24, identified R22 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R22 was incontinent of bowel and bladder. R22's care plan dated 10/14/2016, identified R22 had self care deficits and was at risk for skin breakdown related to stroke and right sided hemiparesis and dependence on staff for repositioning in bed and wheelchair. Identified R22 was to wear Prevalon boots when in bed. R22's Braden Scale for Predicting Pressure Ulcer Risk dated 4/12/25, identified R22 was at moderate risk of developing a pressure ulcer. R22's treatment administration record (TAR) for the month of June 2025, identified R22 was to have Prevalon boots when in bed on every shift. Third floor nursing assistant (NA) care sheet undated, identified R22 was to have Prevalon boots on while in bed. During an observation on 6/23/25 at 12:29 p.m., R22 was lying in bed on her back wearing gripper socks on her feet. Blue Prevalon boots were on a bedside table across the room. During an observation on 6/24/25 at 1:22 p.m., nursing assistant (NA)-A and NA-B sanitized hands and applied gloves, hooked R22 up to the hoyer lift and lifted R22 into bed. NA-A and NA-B rolled R22 onto her side and pulled her pants down to check her incontinent product then turned R22 onto her left side. Blue Prevalon boots continued to be on the bedside table across the room. NA-A- and NA-B removed gloves sanitized hands, and exited R22's room. At no time did NA-A or NA-B offer to place the blue Prevalon boots onto R22's feet. During a joint interview on 6/24/25 at 1:34 p.m., NA-A and NA-B stated they had not offered to put the blue Prevalon boots on R22's feet because R22 only required the blue Prevalon boots on her feet when she went to bed at night. During an interview on 6/24/25 at 1:40 p.m., registered nurse (RN)-A verified R22 was at risk for developing pressure ulcers. RN-A stated R22 was to have blue Prevalon boots at all times while she is in bed per the care plan. RN-A placed the blue Prevalon boots on R22's feet and stated her expectation was the staff placed the blue Prevalon boots on any time R22 was in bed to prevent skin breakdown. During an interview on 6/25/25 at 9:16 a.m., director of nursing (DON) verified R22 was at risk for skin breakdown. DON stated her expectation was that staff would have applied the blue Prevalon boots on R22's feet when in bed per the care plan to prevent skin breakdown. Review of a facility policy titled Skin Assessment revised 12/23, identified the purpose of the skin assessment was to identify current and potential problems. Identified a resident admitted to the facility was to receive the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers, Further identified the goal was that residents who entered the facility without pressure ulcers do not develop pressure ulcers unless their clinical condition demonstrates the pressure ulcer was unavoidable.

Based on interview and document review, the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process, following the initiation of hospice services for 1 of 1 resident (R117) reviewed for hospice. Findings include: R117's quarterly Minimum Data Set (MDS) dated [DATE], identified R117 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia, and traumatic brain injury. Identified R117 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R117's progress notes dated 3/31/25 to 5/19/25, identified R117 was admitted to Ethos Hospice on 4/28/25. R117's electronic medical record (EMR) identified a quarterly MDS was completed on 2/28/25, and a death MDS was completed on 5/19/25. R117 EMR lacked a significant changed MDS was completed when R117 was admitted to hospice. During an interview on 6/25/25 at 11:11 a.m., MDS coordinator confirmed R117 passed away on 5/19/25. MDS coordinator further indicated the significant MDS was missed because the MDS coordinator counted the days wrong. During an interview on 6/25/25 at 11:54 a.m., director of nursing (DON) confirmed the above findings. DON stated that her expectations were to have MDS's completed timely. Review of facility policy titled Resident Assessment Instrument (RAI) process - MDS 3.0 revised 2/25, The RAI was a method for assessing functional capacity and needs, identify problems, needs, and strengths developing intervention. If the interdisciplinary team determined there was a significant change in condition, the MDS Coordinator would notify all disciplines and initiate the significant change in status.

Based on interview, record review, and observation, the facility failed to honor a resident's right to make choices about food choices at meals for 1 of 1 residents (R95) reviewed for choices. Findings include: R95's quarterly Minimum Data Set (MDS) dated [DATE], indicated R95 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R95 required partial assistance with eating and extensive assistance with dressing and personal hygiene. R95 had diagnoses of cerebral infection (stroke), hemiparesis (weakness of one side of the body), anxiety, and depression. R95's care plan revised on 3/12/25, indicated R95 could feed herself after staff assisted with tray setup. Staff to encourage R95 to use her right hand to feed herself and place the tray in the far-right visual felid. R95's diet was changed on 4/3/25, per speech therapy to pureed (smooth blended foods) with nectar thick liquids with hopes of improving intakes. The family preferred that R95 be given cranberry juice to drink instead of any other flavored juices or milk. No water mug with thin liquids. R95's physician order dated 6/10/25, indicated R95 had a Dysphagia (difficulty swallowing) mechanically altered texture and nectar thick consistency. During an interview on 5/23/25 at 11:55 a.m., family member (FM)-A indicated staff would ask other residents what they wanted for the meal but would not ask R95 what she wanted for her meal; staff would not give her options. During an interview/observation on 6/23/25 at 3:10 p.m., nursing assistant (NA)-C went to each resident's room and asked residents which meal choice for supper they wanted however, did not provide R95 options for supper. NA-C indicated there was only one choice for mechanical soft diets and pureed diets. During an interview on 6/25/25 at 7:28 a.m., NA-E indicated all the mechanical soft diets and pureed diets get the same meal and because of this staff did not ask R95 what she wanted to eat each meal. NA-E indicated that R95 was able to verbalize what she liked to eat. During an interview on 6/24/25 at 6:47 p.m., NA-D indicated the kitchen chose what meal option R95 would receive. NA-D indicated the kitchen staff would puree the food in the kitchen before it was brought up to the dining room to be served. During an interview on 6/25/25 at 7:51 a.m., resident care manager (RCM)-A stated an expectation would be for staff to give all residents options for meals. During an interview on 6/25/25 at 10:11 a.m., R95 verified staff did not ask her what she wanted for meals. R95 indicated she normally did not like what was for lunch. At times some staff would make her something else to eat, however, not consistently. During an interview on 6/25/25 at 10:15 a.m., NA-F indicated residents on a dysphasia mechanical diet or food that needed to be ground up, were not provided meal options. NA-F indicated staff had not been asking R95 what she wanted to eat for meals as the kitchen would bring the food already ground up. During an interview on 6/25/25 at 10:29 a.m., DA-A indicated the food was blended in the kitchen and then brought up to the kitchenette for the residents who received a pureed diet. Residents who did not have mechanically altered diets would have two meal choices. Which meal choice was blended was predetermined by the cook. During an interview on 6/24/25 at 5:25 p.m., Cook-B indicated residents who received a pureed or mechanical soft diet would receive the first option on the menu. During an interview on 6/25/25 at 10:37 a.m., Cook-A indicated staff would puree the first meal choice, otherwise the facility was wasting a lot of food. A lot of residents who received a pureed diet were incapable of making a meal choice. Cook-A indicated the normal process was to puree the first meal choice. During an interview on 6/25/25 at 10:38 a.m., dietary manager (DM) indicated if a resident was able to express preferences the facility would try to honor their preferences. The kitchen would keep a record of foods a resident did not like if they were able to verbalize that. If a resident could not verbalize what they did not like the staff would watch for symptoms such as turning the head away when being fed. DM verified that residents who received a pureed diet did not receive meal choice options. During an interview on 6/25/25 at 12:07 a.m., director of nursing (DON) indicated her expectation would be for staff to offer an alternative food option if a resident was not eating their meal. Having choices would be important for nutritional intake and the prevention of dehydration. A policy titled Liberal Geriatric Diets, textures and Consistencies dated 8/24, indicated Eventide uses non-therapeutic (regular) diets to enhance the quality of life for our residents. All therapeutic diet orders such as general adult, diabetic, salt restrictions, heart-healthy, renal, etc. will be changed to a regular diet upon admission, Diets may be adjusted by a registered dietician based on the resident's individual needs and preferences. All orders for high-calorie/high-protein nutritional supplements, snacks, and calorie counts will be discontinued upon admission. The registered dietitian would implement high-calorie/high-portion nutritional supplements and snacks based on the resident individual needs and preferences. Eventide follows texture/liquid modifications as ordered. Texture modifications/liquid consistencies may be downgraded by the dietician and/or nursing as needed. The policy lacked information regarding meal choices.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R95) had adequate hydration within reach. Findings include: R95's quarterly Minimum Data Set (MDS) dated [DATE], indicated R95 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R95 required partial assistance with eating and extensive assistance with dressing and personal hygiene. R95 had a diagnosis of cerebral infection (stroke), hemiparesis (weakness of one side of the body), anxiety, and depression. R95's care plan was revised on 3/12/25, indicating that R95 could feed herself after staff assisted with tray setup. Staff to encourage R95 to use her right hand to feed herself, and place the tray in the far-right visual felid. Dysphasia mechanically altered with nectar thick liquids, on 4/3/25 per speech therapy changed to pureed with nectar thick liquids with hopes of improving intakes. Dislikes strawberries. The family prefers that R95 be given cranberry juice to drink instead of any other flavored juices or milk. No water mug with thin liquids. R95's physician order dated 6/10/25, indicated R95 had a Dysphasia mechanically altered texture and nectar thick consistency. During an interview on 6/23/25 at 11:56 a.m., a family member indicated that R95's water mug had been across the room multiple times when visiting. The family member indicated that R95 could not move her wheelchair across the room to get her water mug. If the water mug was beside R95, then she would have been able to take a drink independently. During an observation on 6/24/25 at 9:43 a.m., R95 was sitting in a wheelchair looking out the window. The side table with the water mug was behind R95 next to the bed, out of reach. During an observation/interview on 6/25/25 at 7:28 a.m., R95 was in bed wake, and R95's nightstand was across the room next to the wall out of reach. NA-E verified that R95 was unable to reach the water mug. NA-E indicated staff normal practice was to keep the water mug next to her. NA-E indicated R95 was able to drink fluids independently, but at times did need assistance. During an observation/interview on 6/25/25 at 11:11 a.m., R95 was in her wheelchair next to the bed and the side table with the water mug was aginst the wall on the left side about three feet away. NA-C confirmed R95 could not reach her side table and water mug on the left side. NA-C confirmed R95 she had left-sided weakness from a stroke. R95 confirmed she was unable to reach the water mug. The water mug was moved to the right side of the wheelchair and R95 was able to demonstrate she could pick up the water mug and bring it to her mouth. During an interview on 6/25/25 at 10:11 a.m., R95 indicated staff did not always leave the water mug within reach. R95 indicated she would get thirsty and would be unable to reach her water mug. During an interview on 6/254/25 at 6:47 p.m., NA-D indicated R95 was able to drink water independently depending on R95's mood that day. During an interview on 6/24/25 at 7:13 p.m., trained medical assistant (TMA)-A indicated R95 could hold her water mug when in reach. During an interview on 6/25/25 at 7:51 a.m., resident care manager (RCM)-A indicated R95 was able to drink independently if the water mug was placed on her right side. During an interview on 6/25/25 at 12:07 p.m., director of nursing (DON) indicated her expectations would have been for staff to place the water within reach to prevent dehydration. Review of the policy titiled: Stnadards of Care dated 8/2024, directed staff to offer fluids when completing scheduled cares (toileting, turning, etc.) Policy lacked information of having water within reach when apporpirate.

Based on observation, interview, and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 residents (R5) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses which included pneumonia, hip fracture, and respiratory failure. R5 was dependent on staff for transfers and toileting hygiene. R5's care plan dated 5/30/25, identified R5 as having an activity of daily living (ADL) self-care performance deficit related to a fracture of the right ankle. R5's care plan interventions included assistance with dressing and grooming and being able to feed self after staff assisted with tray set up. Review of the care plan dated 5/30/25, lacked information regarding the self-administration of medications. Review of R5' s electronic health record (EHR) revealed Formoterol Fumarate inhalation nebulization solution ( a medication prescribed for asthma) 20 micrograms (mcg)/2 milliliters (ml) two times a day for asthma, Ipratropium-Albuterol inhale orally every six hours as needed for shortness of breath. EHR lacked information regarding the self-administration of medications. Review of R5's Order summary Report Dated 6/4/24 directed staff to administer Formoterol Fumarate inhalation nebulization solution 20mcg/2ml two times a day for asthma, Ipratropium-Albuterol inhale orally every six hours as needed for shortness of breath. The order summary report lacked an order to self-administer medications. Review of assessments located in the assessment tab of the EHR lacked an assessment of self-medication assessment. During an observation on 6/23/25 at 12:15 p.m., R5 was sitting in a wheelchair next to the bed with a nebulizer mask on her and a nebulizer machine turned on. No staff were present in the room or outside of the room. During an observation on 6/24/25 at 9:41 a.m., R5 was sitting in a wheelchair next to the bed with a nebulizer mask on her face and the nebulizer machine on. No staff were present in the room or outside of the room. During an interview on 6/24/25 at 11:09, licensed practical nurse (LPN) indicated self-administration assessment of medication were charted under the administration tab in the EHR. LPN looked and was unable to find a self-administration of medication assessment. LPN located an assessment for brief interview for mental status (BIMS). LPN indicated if a resident had a high BIMS score that indicated the resident as cognitively intact. LPN indicated the procedure for a resident to self-administer medications was to ensure a resident was cognitively intact and the resident could demonstrate they could self-administrate medication safely. LPN did not believe the facility needed to obtain a physician order for self-administration of medications. LPN verified that R5 administered her nebulizer independently after being set up by staff. During an interview on 6/25/25 at 7:42 a.m., resident care manager (RCM) indicated the nurses would do an assessment for the self-administration of medication, the facility would obtain a physician order, and would place the self-administration of medication in the care plan. RCM verified that R5 did not have a self-administration medication assessment. RCM also verified that R5 did not have self-administration of medications care planned. During an interview on 6/25/25 at 12:00 p.m., director of nursing (DON) indicated the facility had a self medication policy. The nurse would complete a BIMS assessment of the resident throughout the day. The nurse would assess the resident's performance with holding or keeping the mask on during the nebulizer treatment, if the resident could shut off the nebulizer appropriately, and discuss with the provider. The facility would review self-administrations quarterly or as needed. The DON would expect nurses to follow the policy on self-medication administration to ensure a resident could safely administer the medications. Review of a facility policy titled Medications Self-Administration of Medications dated 3/25, identified if deemed appropriate the resident may participate in the self-administration of medication process. A provider's order was required. The standing order may be utilized but the resident's primary provider must be informed. Medication administration will be monitored and the resident's ability to self-administer medications would be reviewed quarterly, prior to discharging home, and with a significant change in condition or as needed. Procedure: 1. The resident will be asked if they would like to self-administer medications. 2. If the resident declined, documentation would be made in the resident's medical record. 3. If the resident wanted to self-administer medications, the nurse would complete the Self-Administration of Medication Assessment to determine appropriateness. Inhalants or inhalers: The resident must demonstrate competency of use(timing of breathing, depressing the atomizer, position of the mouth for medication administration, length of time to wait between doses, etc.)

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R4) who received assistance with eating in the dining room. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment and had diagnoses which included: hypertension (elevated blood pressure), dementia, and anemia. Identified R4 required staff assistance to eat. R4's care plan dated 11/9/22, identified R4 had self-care performance deficit related to weakness and dementia. R4's interventions included assistance with hygiene, bathing and dressing. Identified R4 required total staff assistance with eating. Identified R4 had a terminal prognosis and received hospice care. During an observation on 6/24/25 at 12:35 p.m., R4 sat in a reclining wheelchair in the dining room at a table. Hospice registered nurse (H-RN) stood near R4's right side, and provided R4 with food from a spoon. -at 12:43 H-RN continued to stand near R4's side while assisting R4 to eat from a spoon. During a phone interview on 6/24/25 at 12:50 p.m., family member (FM)-A stated she did not feel it was a dignified practice for staff to stand while feeding R4. FM-A stated she would have expected staff to sit while assisting R4 to eat. During an interview on 6/24/25 at 12:56 p.m., H-RN verified he had stood up while assisting R4 to eat. H-RN stated R4's chair was big and it was not convenient for him to sit so he stood to assist R4 with her meal. RN-A further stated it was not a dignified practice to stand while assisting residents to eat. During an interview on 6/24/25 at 1:08 p.m., RN-A verified H-RN stood while assisting R4 to eat. RN-A stated her expectation was H-RN would have sat down while feeding R4 to maintain dignity. During an interview on 6/25/25 at 9:18 a.m., director of nursing (DON) stated staff were expected to be seated by residents while assisting with eating as it was important to maintain dignity and promote safety. Review of a facility policy titled Standards of Care revised 8/24, identified standards of care were followed when providing care to all residents. Identified all residents would receive safe, dignified care.

Based on observation, interview and document review, the facility failed to ensure adequate supervision for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in an immediate jeopardy (IJ) when R1 eloped from the facility, and was found 5 hours later, approximately 4 miles from the facility, after dark. The IJ began on 4/16/25 at 6:27 p.m., when R1 exited an alarmed door at the facility and staff failed to respond timely and complete a full property search for R1. R1 was located by the police approximately four miles from the facility at 12:00 a.m. Director of quality and infection prevention and director of clinical services were notified of the IJ at 5:15 p.m. on 4/30/25. The facility implemented corrective action by 4/22/25, prior to the start of the survey and therefore is issued as past non-compliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. He required partial to moderate assistance with shower/bathe, set up/cleanup for eating, oral and personal hygiene, upper/lower body dressing, and independent with toileting hygiene, all transfers, ambulation, and bed mobility. He was frequently incontinent of bladder and continent of bowel. R1's diagnoses included epilepsy, dementia, orthro static hypotension (a drop in blood pressure occurred when a person stood up after sitting or lying down), hemiplegia (weakness on one side of the body), anxiety, chronic obstructive pulmonary disease (COPD), and depression. He was administered antidepressants and diuretics (increased urine output). R1's care plan dated 4/18/25, identified a self-care deficit related to subarachnoid hemorrhage (bleeding occurred in the space between the brain and a protective layer surrounding the brain due to a weak blood vessel), poor safety awareness, anxiety, epilepsy, weakness, rhabdomyolysis (a rare muscle injury where muscles break down), abnormalities of gait and mobility, major depressive disorder (MDD), and bell's palsy (temporary facial paralysis usually on one side of the face). Staff were instructed to assist as needed to change an incontinent product pull-up. He had potential for falls, ambulated with a front wheeled walker (FWW), and required supervision and assistance as needed (PRN). He had potential for safety concerns due to risk for elopement, wandered on the unit, asked about exits, and attempted to open stairway door. Staff were directed to check placement of WanderGuard on left ankle and workability, engage him in activities as much as able, wore jacket occasionally, if seen with one on, complete education about alerting staff if he wanted to leave facility, discuss resident's gratitude, if comments were made about wanting to leave, initiate frequent checks and update all staff on unit, monitor for getting onto elevator. If he approached the elevator, offer to go on a walk with him. Remind him he cannot leave facility unit without telling staff. He wandered frequently and discussed how he wanted to leave. Staff were directed to monitor mood and behavior, offer emotional support, provide 1:1 visit for conflict resolution/problem solving, redirection as needed, and report changes in mood. He was considered a vulnerable adult due to placement in a skilled nursing facility as well as physical impairments. R1's elopement risk assessment dated [DATE], identified he was cognitively impaired with poor decision-making skills, dementia, major depressive disorder, and anxiety. He had verbalized the desire to leave facility, wandered near an exit door, and aimlessly (confused, moves without purpose). Interventions include secured unit, wander guard located on left ankle, utilization of check in /check out log, recreational activities. R1 had two wander/elopement alarms (an electronic device that monitors a resident's movement and alerted staff when movement was detected). R1's Progress Notes on 4/17/25 indicated: -at 12:10 a.m. late entry: left voicemail for his brothers to alert of elopement. Spoke with one brother at 7:00 p.m. Stayed in communication with his brothers through the night. Updated brother upon resident's safe return to facility. -at 12:29 a.m. late entry: returned to facility just before 12:00 a.m. Cognition was at baseline, alert, followed commands, and able to answer questions. He was aware he had been out of the facility for an extended amount of time he described that he walked to get things figured out for him to return to his home and live with his daughter. Did not know specifically where he was going, but reported he was familiar with the area. R1 denied being in any danger or talking to anyone during his walk. A full health status assessment was completed upon return to facility. R's shoes were dry and no evidence of walking through mud or water noted. He stated his leg were tired and was noted to be incontinent of bowel and bladder. Mood upon arrival was stable; stated he was glad to be home and sorry for scaring anyone. Note indicated frequent checks were initiated on resident for the night. -at 3:06 p.m. provider was updated with concerns. The Supplementary Police Report dated 4/17/25, identified a missing person: elderly man with brain injury walked away from the medical retirement home. Numerous efforts were made to locate him but were unsuccessful until an alert was issued to the public. Shortly after the alert was made a citizen indicated they had seen him and he was in Fargo. Details: Dispatch stated the missing person had left approximately 40 minutes prior to being dispatched and was walking with a walker. Upon arrival to the facility, he was informed the missing person suffered from a traumatic brain injury, had symptoms like dementia, memory severely impacted, and unable to care for himself. He was provided a name, description, and photo, and searched the area but was unable to locate him. Facility was requested to review their premises cameras. The last time the missing male was seen on their camera system he was located on 7th street and 14th avenue south and walked east towards 8th street south when he went off camera. Time stamp of when he walked out of facility building was 6:27 p.m. His family was contacted and were concerned about his welfare and unsure if he had his cell phone with him. A ping was conducted, may have possibly been his phone number and showed it was in rural Clay County, and unsuccessful in locating it. During the investigation the concern for his welfare was growing. Based on information from family and facility staff it was believed he would not be able to care for himself or able to find his way back. As the time of him being gone and the falling temperature it was believed if he was not located soon, it could have become lift threatening. A press release was sent out at approximately to the [NAME]/Clay County areas at approximately 11:29 p.m. Once the alert was released numerous calls came in indicating they believed they had seen him and one person indicated he was seen around Big Top Bingo near 25th street and 6th avenue two hours prior. Fargo officer responded to that area and located the resident at approximately 12:00 a.m. on 4/17/25, and within a half hour of the alert being broadcaster. He was cold and had soiled himself in the squad car. He was transported back to the facility without issues. During the investigation facility staff canvassing the area and the community by walking around. A drone was requested and used to actively fly around the local college and along the Red River when he was located. R1's records revealed facility implemented 30-minute checks upon R1's return to the facility on [DATE]. Records reflect checks starting at 12:30 a.m. through 5:00 p.m. 0 4/18/25. The facility 5-day incident report summary dated 4/17/25 at 2:14 p.m., identified R1 was assessed to be a high risk for elopement, had a WanderGuard to his ankle, and alerted staff when he was close to an exit door. At 6:23 p.m. his wander guard triggered a warning at an exit. The receptionist received the warning and immediately called the charge nurse on the unit he resided on and informed the nurse where the alarm was warning. Charge nurse reported she had seen R1 about 10 minutes prior to when the phone call was received. She immediately went to the area and looked for him. At 6:27 p.m. his wander guard was detected at a different exit, which triggered a warning, and his wander guard triggered an alarm. The receptionist called the charge nurse again and told her where his wander guard had alerted. The alarm was triggered on the opposite side of the building. He was active, mobile, walked quickly and was steady on his feet. The staff nurse and another staff member went to that area and began search for him. The receptionist did not see him exit the doors on the camera at that time. It was unknown if he had exited the building. Staff looked inside the building and through the windows and unable to see him in the immediate areas close to the windows or in the parking lot. Charge nurses on the units were contacted and delegated staff to search on each unit. Unit commons, room to room, and outside searches were conducted and he was not found. Charge nurse called DON, she assisted with the search for approximately 10 minutes and camera footage was viewed and R1 was identified exiting the building at 6:26 p.m. based on camera time. He was wearing a red winter jacket, black shirt, long black pants, white tennis shoes with socks and a ball cap. The camera showed R1 exit the building, walked on the sidewalk near the entrance of the assisted living side of the facility. Once he left the facility property the camera did not capture a specific route or direction he went after that. Police, family and executive director were notified and the search parameters widened as time went on. The police officer sent an alert out to the community and he was located by the police offer at 11:57 p.m. approximately 4 miles away from the facility and escorted back. The temperature outside was 62 degrees when he left the building and around 53 degrees when he returned. Upon arrival to facility R1 was immediately assessed from head to toe. No medical treatment was needed and he was unharmed. He stated he planned to go home and wanted to live with his daughter, denied telling anyone about his plan and did not sign out prior to leaving. He stated he was familiar with the area and never felt lost but at some point, was turned around. Frequent checks were completed throughout the night and he slept all night. He was unsure why he took the path he did last night. He was educated about safety, alerting staff if he wanted to leave the unit or go outside, verbalized understanding of this, but education provided to him will be ongoing. His primary care provider was updated and rounded on him this morning. She completed a verbal contract for safety with him stating he will not elope. Staff that had worked at the time of the incident were educated verbally about the incident and steps to prevent a reoccurrence, frequent checks, safety, and his plan of care. The receptionist received immediate verbal education about the importance of a quick response to the alert, stay in the area with the resident. The wander guard system worked as intended, no concerns with the system itself. The staff member had unintended lapsed in response time when the alarm went off. Education on elopement was being discussed at shift changes and a mandatory meeting for all staff has been set up for tomorrow along with additional times to attend next week. All education will be completed by 4/24/25. Resident's care plan will be reviewed and updated to prevent reoccurrence. Resident interviews will be completed and all residents will be assessed for elopement per facility policy. The investigation was ongoing. During an interview/observation on 4/29/25 at 12:44 a.m., R1 laid on bed covered up with a blanket fully dressed in jogging pants and a cap, T-shirt with slip on shoes/slippers without socks with a white wander guard bracelet located on his left ankle. He stated he does not sleep well and walked the floors especially at night. [NAME] was placed next to bed. They did not like when he went outside and placed a wander guard on his ankle. He did not know it picked him up wherever he went. He had left the facility in the evening and did not tell anyone he planned on going out. He was told when he decided to leave the facility he should have told someone and didn't. He left with his walker and found it difficult to walk on the sidewalks and streets. He had been a [NAME] all his life and was doing something he was not supposed to do. It was dark out when he left the facility and had not paid much attention to where he was walking. He crossed intersections and state troopers and cops were out looking for him and he was gone over a couple of hours. All he knew was he wanted to get out of here, tired of being told what to do and staying on this floor. He found it hard to live like that, wanted a break, they were not giving him one, so took it on his own. He really did not know where he was headed. There was a female cop that came down to the river and informed him there was a lot of people looking for him and very happy she found him. He was happy to have been found also, he was freezing. During an interview on 4/30/25 at 9:17 a.m. receptionist (R)-A stated she was the main person who set up the WanderGuard system for resident determined to be at risk and checked the door sensors with a WanderGuard tag weekly. There were five wall sensors to detect a WanderGuard. The wall sensor would detect a resident with a WanderGuard when the resident approached the door, gave a warning beep out loud and then once the resident moved closer and/or opened the exit door the beep changed to a different tone and louder. Her computer would notify her and provided resident tag/wander guard information, their location. There was a map located on the computer that showed where the resident was in the building only on 1st floor after the sensor was set off by a WanderGuard. She had visual access to real time and the ability to see the resident at the door and if within the camera view. She looked to see if the resident was alone or with staff/family and directed her as to if it was an emergency or not. She viewed the monitor and kept an eye on them if was a resident regularly seen. When located by themselves she would go to the door sensor that alarmed and redirect them. Staff are contacted via phone or walkie when assistance was needed due to behaviors and not re-directable. She would stay with the resident until staff arrived. If a resident was seen leaving the building alone, staff would be notified as soon as possible and she would run to the door, stop them from going any further, and stay with them until staff arrived to assist. When she was unable to find the resident after a sensor went off, she would search the area of the sensor, in the hallway, and then go outside to search. Usually takes about 6 minutes of the inside building search by the sensor area. If it was determined an emergency all staff would be alerted, instructed to turn their walkies to channel 10 so that we can all be on the same page and updated. The receptionists were responsible to check the WanderGuards with a tester and confirm a signal was seen and working properly. Review of the testing log identified R1's WanderGuard was tested on [DATE] at 7:48 a.m., and on 4/17/25 at 8:36 a.m. and was identified as working properly. R-A indicated she was not working when R1 exited out of the south entrance doors located over by the assisted living. During an interview on 4/30/25 at 11:40 a.m. R-C stated on 4/16/25 at 6:27 p.m., a sensor alarm went off at the service door located on 2nd floor and notified her it was R1. She called and talked with LPN-A and asked if she had eyes on him. She was on the telephone with another resident's family and when LPN-A called her back, she indicated no. The service elevators sensors were located on all three floors and alarmed when a resident would enter with a WanderGuard on. There was a pin number that had to be entered into the keypad to get onto service elevator. She had gone over to the service elevator on the 1st floor and checked but R1 was not located. LPN-A came down to 1st floor with two NA's and searched the bathrooms next to the chapel area (R1 commonly used those bathrooms) and the link area (hallway entrance that connected the long-term care to the hallway that led to the south entrance door). After she returned to her receptionist desk, she had noticed the wellness exit door alarm had went off and missed it when she was away from her desk looking for R1 by the service area elevators. She was unsure of what time that had occurred due a new sensor alarmed located at the link (front door area) had gone off when she was located at the desk by the computer. LPN-A and her were located at the main reception desk talked briefly and she may have missed seeing R1 exit the building on the camera. LPN-A and NA's walked up the to the south front door entrance/link area and searched for R1 and she stayed at reception desk to monitor the cameras. She stated after LPN-A indicated she was unable to find R1 on 2nd floor she should have been more proactive, went around her desk, checked the hallways better and further down by the wellness center rather than only by the service door. Three separate sensor alarms were activated and identified it was R1 while he moved about on 1st floor and she could have probably prevented him from getting out of the facility or away from the building outside. She was expected to check outside as soon as the alarm went off and unable to locate the resident at the sensor site. She had received education elopement policy and what could have been done differently. Sensor alarms triggered on 4/16/25 1st floor was verified on the receptionist computer during interview with R-C: 1st alarm elevator went off at service door area - 6:23 p.m. 2nd alarm wellness lobby at 6:26 p.m. 3rd alarm on the link area between care center and hallway to front door at 6:27 p.m. During an interview on 4/30/25 at 11:57 a.m. family member (FM)-A stated he was notified of R1's elopement on the evening of 4/16/25, and prior to that he had not left the faciity on his own. He stated R1 stated recently had a hard time dealing with the situation, had a stroke three years ago and short-term memory loss. R1 had told him he did not know what was going on unable to remember, agitated, not one to be tired down/kept inside and was restless. He was good at making up stories so believable he believed what he told people to be the truth and used as a coping mechanism. R1 would have not been safe out in the community that night or any night. FM-A stated he did not feel that R1 was fully safe at the facility and could have easily eloped again. Once he had gotten out on 4/16/25 unknown if he really knew where he was going. FM-A had inquired about a IPOD clip on that would be used to track him outside the building, was informed it was against the facility policy for a tracker to be used. R1 was extremely cold when located hours later at almost 12:00 a.m., we were scared for him. The facility was working hard to keep him safe but may need to be moved if his needs are unable to be met During an interview on 4/30/25 at 12:21 p.m. NA-C stated R1 had dementia and an impaired memory. Staff were expected to have completed safety round every two hours. NA-C worked on 4/16/25 and checked on R1 at 2:30 p.m. and 3:00 p.m. and was laying down on his bed, conversed with him. No mention about leaving the facility that day. At approximately just after 4:00 p.m. he was in the TV room and walked back to his room. We conversed again, asked him if he needed anything, talked about the weather, had a hard time staying in once place for sure. Did not exhibit exit seeking behaviors. NA-C got busy, helped another resident get up for supper and fed a resident. Another NA informed me she was heading to R1's room to get his roommate for supper, since he had forgotten. R1 was still in his room unsure of time. R1 was known to walk the hallways frequently especially at night. R1 had not attempted to leave the floor while he worked. Last time he saw R1 was at 4:00 p.m. After NA-C had finished feeding the resident in the dining room, he was asked by the staff nurse when R1 was seen last time. R1's room, hallway was searched and was told to stop what we were doing and headed downstairs in a panic (was assigned to him) and looked, unable to locate him. NA-C had checked inside the building on 1st floor then went outside for a brief second from the main entrance into the parking lot and searched for him and then was informed to go back upstairs and helped other residents. R1 wound not have been safe out in the community by himself due to his impaired cognition and lack of memory. During an interview on 4/30/25 at 12:49 p.m. licensed practical nurse (LPN)-A stated R1's cognition varies and he was forgetful. He walked the hallways frequently with the walker. Staff were expected to check on him at least every two hours. Last time she saw R1 on 4/16/25 was approximately 15 to 20 minutes prior to when he left the facility walking in the hallway in the west wing . He wore a coat and occasionally wore that because he got cold, fully clothed, not sure about what was on his feet (usually wore slip on loafers with a hard sole) and a baseball cap. At 6:27 p.m. she received a call from R-C and was informed a sensor alarm had gone off by the north corridor elevator. She went over to the north hallway on 2nd floor and to his room and unable to locate him. Approximately 3 minutes had gone by and she received another call from R-C indicating another door sensor alarm had gone off by the link hallway (hallway that links the care center (LTC)) that led to the south entrance door. She went down to the 1st floor immediately and searched in that area, and he was not located She visually looked out from the font door window and windows in the entry way, but did not go outside at this point. She notified all staff in the building and then called the DON at approximately 6:35 p.m. and then assisted with the search outside of the building, in the parking lot and around the front of the building for a couple of minutes. The DON viewed the camera footage and verified he had exited the south front doors. She remained on 1st floor over by the assisted living. A receptionist from the assisted living apartments alerted us that she had seen R1 walking on the sidewalk outside the apartments located on the south end of the building. He passed by the pillar and they lost view of him. Staff continued to check inside and outside the building. At 7:15 p.m. the police department was notified by R-C. She stated the receptionist at the main street desk would have been expected to check the alarming door right away and that was not done. She should have gone outside immediately to stop him from getting too far. LPN-A then indicated, R1 would not have been safe out in the community by himself due to his poor memory and there was a potential he could have been harmed. He was gone from the facility from 6:27 p.m. and was not found and brought back until shortly before midnight. During an interview on 4/30/25 at 3:06 p.m. with nurse practitioner (NP) stated R1 required 24/7 supervision and would have not been safe out in the community by himself. The facility can speak the policy he was determined to leave the building, physically active, and cognitively impaired. The facility policy and procedures are aimed at preventing this from happening. During the survey the administrator and director of nursing (DON) were out of the office and unavailable for interviews. Facility policy Elopement Prevention and Missing Residents dated 4/2024, identified the facility will assure the health, safety and welfare of all residents who are placed in our care. If a resident is missing a search will be conducted. Prevention: each resident is assessed for elopement risk upon admission/hospital return and as needed . if a wander guard is placed the elopement risk assessment will be completed quarterly, with significant changes and as needed to determine continued appropriateness. Missing resident: Immediate response: record time the person is discovered to be missing, when and where they were seen last. Continue to keep a log of events. Verify the resident had been signed out of the facility or on an outing. Immediately report to the nurse manager/on-call. Notify all staff working: attention all staff, missing person alert (location). Please report to the nearest nurse's station for further instruction. Make copies of the missing resident's photograph if available. Conduct a thorough search of the facility and grounds. Assign staff members a specific area to be search. Search room-to-room, under beds and furniture, in walk-in refrigerators/freezers, closets, storage rooms, outside facility grounds, and anywhere a frighten person maybe hiding. Instruct staff members to report back after their assigned areas have been checked and continue to check back every 15 minutes for updates. After initial search or as soon as possible: nurse manager/on-call will notify DON, who will notify the executive director (ED), who will notify law enforcement (call 911). Provide description of the resident and a photograph, including the clothing resident was wearing, mobility and cognitive status. The DON or designee will notify the resident's responsible party. Facility searches unsuccessful: ED or designee will collaborate with law enforcement and assign available staff to start neighborhood search and carry a picture of the missing resident. Upon finding the resident: charge nurse will assess the resident for injuries, complete the elopement risk assessment and document findings. Care plan will be reviewed and updated. ED or designee will notify all staff members, residents, and other responders/searchers that the resident had been found. Complete an incident report and DON or designee will file a vulnerable adult report if indicated. Take immediate action to decrease risk of repeated event with resident involved or others. The past noncompliance immediate jeopardy began on 4/16/25. The immediate jeopardy was removed and the deficient practice corrected by 4/22/25, after the facility implemented a systemic plan that included the following actions: The facility took the following action to correct the immediate jeopardy and is therefore cited at past non-compliance. -facility began immediate investigation. -upon R1's return to facility a complete head to toe assessment was completed and every 30-minute safety checks were implemented due to risk of reoccurrence on 4/17/25 from 12:30 a.m. through 5:00 p.m. -All staff mandatory meetings have been held on 5 different times. Education included: elopement, missing resident, facility policies and procedures, and this specific incident and interventions had been discussed. -Frequent checks will be completed if statements are made about leaving. -Elopement checks will be completed if R1 makes statements about leaving. -Elopement drills will be conducted. -Wander guard system was checked and in working order. -Policies were reviewed, elopement and missing resident. no changes needed. -Other high elopement resident charts and care plans were reviewed, and triggers and interventions were added as needed. -Pictures of high-risk elopement residents had been dispersed to all departments to review routinely. Pictures updated with any changes.

Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene and personal protective equipment (PPE) practices were performed during a high contact care activity for 2 of 3 residents (R1, R5) in enhanced barrier precautions (EBP) with an indwelling device. Findings include: Primary provider visit dated 2/4/25 at 8:00 p.m. identified assessment/plan: neurogenic bladder - continue with suprapubic catheter (a flexible tube placed through an incision in the abdomen instead of from the urethra to empty urine from the bladder into a collection bag) (SP), Mirabegron 25 milligrams (mg) (medication for bladder spasms). Nursing was responsible for catheter cares. No recent urinary tract infection (UTI) concerns. R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition without behaviors. She had upper impairment on one side, lower impairment on both sides and used a wheelchair for mobility. She required partial/moderate assistance with upper body dressing, personal hygiene, roll left and right, substantial/maximum assistance with toileting hygiene, shower/bathe, lower body dressing, and dependent upon staff for putting on and taking off footwear and all transfers. She had an indwelling urinary catheter and always incontinent of bowel. Medical diagnoses included congestive heart failure (CHF), neurogenic bladder, arthritis, osteoporosis, multiple sclerosis, anxiety, and depression. R1's current care plan identified R1 was at risk for infection related to SP catheter placement and chronic/long term use due to a neuromuscular dysfunction of the bladder. Staff were instructed to have provided EBP for all catheter cares and emptying, good hand hygiene, catheter cares per policy, monitor for signs/symptoms (s/sx) of UTI, encourage fluids, and position catheter bag and tubing below the level of the bladder. R5's significant change MDS dated [DATE], identified severely impaired cognition, altered level of consciousness and inattention (easily distractible or had difficulty keeping track of what was said) that fluctuated. She had behaviors symptoms every one to three days that included: physical directed toward others (hitting, kicking, pushing, scratching, grabbing), verbal directed towards others (threatening, screaming, cursing at others), and other symptoms not directed towards others (hitting or scratching self, disrobing in public, throwing or smearing food or body wastes, or verbal/vocal symptoms like screaming, disruptive sounds). She required substantial/maximal assistance with toileting hygiene, shower/bathe, upper and lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and all transfers. Used a manual wheelchair for mobility. She had an indwelling urinary catheter and frequently incontinent of bowel. Medical diagnoses included CHF, neurogenic bladder, arthritis, osteoarthritis, and epilepsy (seizure disorder). R5's current care plan identified she was at risk for infection related to indwelling urinary catheter due to neurogenic bladder. She is on EBP. Staff were directed to use good hand hygiene, catheter cares per policy, observe for signs of catheter associated urinary tract infection (CAUTI), and encourage fluids. During an observation on 4/1/25 at 1:15 p.m. nursing assistant (NA)-A pushed R1 in her wheelchair from dining room back to her room. Located on the wall in the hallway on right side of R1's door was a STOP sign titled EBP and instructed providers and staff to perform hand hygiene upon entering and exiting the room, and gown and gloves be placed on for all high-risk activities (dressing, bathing/showering, transferring in room or tub room, providing hygiene, changing briefs, and toileting, changing linens, device care and use of the urinary catheters, central lines, feeding tubes, and tracheostomies, wound care and dressing changes). NA-A walked back out into the hallway and grabbed the total lift machine, sanitized her hands, applied an isolation gown and gloves. She entered R1's bathroom and carried an empty graduate pitcher and alcohol swabs. She placed a paper towel onto the floor and the graduate pitcher on top. She removed the urinary catheter collection bag from the privacy bag and hooked it on the lower bar of the lift machine. She pulled the end of the drainage tube out of the holder, wiped off the end of the tubing with the alcohol swab, unclamped the tubing and drained 400 milliliters (ml) of yellow urine with a strong odor into the collection container, and clamped the tubing. The end of the tubing was wiped with an alcohol swab and placed back into the holder. She emptied the urine into the toilet in the bathroom, rinsed out the container with water and placed it back into a clear bag that hung by the toilet on the wall. She removed her gloves and without sanitizing her hands placed a pair of clean gloves on. NA-A and NA-B connected he loops from the lift sheet onto the lift machine, transferred R1 back to bed, and removed the loops from the machine. Together they turned R1 over onto her side and removed the lift sheet from underneath her. NA-A used her gloved hands and lowered the head of the bed with the remote control, covered R1 with a blanket, and moved the bedside table over R1's abdomen. She removed her gown, placed it in the hamper located in R1's room, removed her gloves, exited the room, and sanitized her hands in the hallway. During an interview on 4/1/25 at 2:45 p.m. NA-B stated staff were expected to follow the facility policy EBP while they provided cares and worked with the urinary catheters to help prevent the spread of infection. Staff were expected to have applied a gown and gloves, removed gloves after completing cares, gloves became soiled, and/or emptying a urinary catheter, wash or sanitize their hands prior to the placement of a clean pair of gloves to help prevent infection. During an interview on 4/1/25 at 3:09 p.m. NA-A stated R1 was placed in EBP because she had a urinary catheter. She had placed a gown and gloves on prior to entering the room and emptied urinary catheter while R1 sat in the wheelchair. There was 400 ml of yellow urine in the graduate pitcher, dumped the urine in the toilet and rinsed the container out. She removed her gloves and without sanitizing her hands placed a clean pair of gloves on. She left the bathroom and continued to work with the resident, then removed her gloves and gown, and sanitized her hands. She stated would have been really important to have washed her hands after she removed the dirty gloves and applied a clean pair to help prevent the spread of germs. She had forgotten to wash her hands. During an interview on 4/1/25 at 4:05 p.m. licensed practical nurse (LPN)-A stated staff were expected to have placed a gown and gloves on prior to entering an EBP room when planned to complete cares and emptying a urinary catheter. Staff would be expected to remove their gloves after working with a resident's catheter and urine, wash their hands, prior to when clean gloves were applied. Those steps were expected, especially when staff went from dirty to clean, would have helped prevent the transfer of bacteria and infection. During an observation on 4/2/25 at 9:57 a.m. NA-C entered R5's room. Located on the wall in the hallway on right side of R5's doorway was a STOP sign titled EBP and instructed providers and staff to perform hand hygiene upon entering and exiting the room and placed gown and gloves on before all high-risk activities were completed. NA-C entered R5's room, gown and gloves were not applied. She explained the indwelling catheter would be emptied and applied a pair of clean gloves. She placed a paper towel on the floor, graduate pitcher retrieved from the bathroom was placed on top of the paper towel and opened an alcohol swab. She removed end of the catheter tube from the holder and wiped off the end port with an alcohol swab. She unclicked the clamp on the tubing and emptied the urine from the collection bag into the graduate pitcher. She clicked the clamp closed, wiped off the end port with an alcohol swab, and placed the end in the holder located on the front of the collection bag. She emptied 400 ml of clear yellow urine into the toilet and without rinsing out the collection container placed it on the back side of the toilet. She removed her gloves and washed her hands with soap and water, flushed the toilet, grabbed a tied bag of garbage, and exited R5's room. During an interview on 4/2/25 at 10:05 a.m. NA-C stated R5 was placed in EBP due to her urinary catheter, infection, and helped prevent the spread of germs. Staff were expected to wear a gown and gloves when they provided any type of care, including emptying the urinary catheter to help prevent the spread of germs. She stated she did not wear an isolation gown while she worked with R5's urinary catheter and it was a mistake; she had forgotten to put on one. The graduate pitcher should have been rinsed out after the urine was dumped in the toilet to keep it clean, disinfected, and for infection control. She had gone back later and rinsed it. During an interview on 4/2/25 at 11:14 a.m. registered nurse (RN)-A director of quality and infection prevention stated residents with indwelling urinary catheters are placed in EBP to help prevent the spread of infection. Hand hygiene should be completed prior and after resident contact, when hands were visibly soiled, before every clean procedure, before and after gloving, take off gloves appropriately without getting the hands solid, to help prevent the spread of infection. Staff would be expected to wear an isolation gown and gloves when entering a resident's room placed in enhanced barrier precautions when cares were to be completed and emptying the indwelling urinary catheter to help prevent the spread of infection. She would have promoted staff to have rinsed out the collection container once the urine was disposed of in the toilet to have helped prevent odor and hopefully inhibit the growth of bacteria. During an interview on 4/2/25 at 1:28 p.m. director of nursing (DON) stated EBP are used with those residents that had indwelling urinary catheters to prevent the spread of germs and multi-drug-resistant organisms (MDRO) (organisms that are resistant to typical antibiotic treatments and can cause infection). Staff would be expected to have completed hand hygiene prior to the application of the gloves and once they completed working with the indwelling urinary catheter gloves should have been removed, hand hygiene completed prior to a new application of clean gloves. This would have helped spread the germs and protected staff and residents. When a resident was placed in enhance barrier precautions staff were expected to wear a gown and gloves during prolonged exposure such as catheter cares and/or transfers of the resident to help prevent the spread of germs and MDROs. Facility policy Hand Hygiene dated 11/2024, identified proper hand hygiene will be followed before and after resident contact (before you leave the room), before every clean procedure, after every dirty procedure, and as needed. Purpose: hand hygiene is a general term that applied to either hand washing or alcohol-based hand rub (ABHR). The purpose was to prevent the spread of infection.

Based on observation, interview and document review, the facility failed to follow care planned interventions to ensure resident's safety for 1 of 3 residents (R1) who had a history of falls. This resulted in actual harm for R1 when he fell from the wheelchair, was sent to the emergency department (ED) and sustained a left humerus fracture. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition with diagnoses of type two diabetes, dementia, anxiety and depression. Identified R1 required extensive assistance with activities of daily (ADL's) including transfers, bed mobility and toilet use. R1's care plan undated, identified R1 had a potential for falls related to history of frequent falls, impaired mobility, unsteady gait, diabetes, acute encephalopathy, and dementia. Identified R1 had a closed three-part fracture of left proximal humerus. The staff were directed to remove foot pedals from R1's wheelchair when in room and to not leave R1 alone in wheelchair in room. Review of R1's progress notes on 2/20/25, identified: -At 4:45 p.m., licensed practical nurse (LPN)-A was called to R1's room and found R1 on the floor. The wheelchair was next to the bed facing the television. Catheter bag was in holder below the wheelchair and pedals were still on the wheelchair. R1's head was under roommate's bed. R1's feet were in front of his wheelchair. R1 stated he was trying to get back in the bed. R1 was complaining of pain to the left shoulder with limited range of motion to the shoulder. Call placed to provider and order received to send R1 to the emergency department (ED) for evaluation. -At 7:45 p.m., ED informed facility R1 had a left acute, proximal left humerus fracture with some angulation and impaction (the top part of the upper arm bone, which was shaped like a ball, was broken). Review of R1's progress notes from 2/12/25 to 2/22/25, identified the following: -2/12/25 at 16:30 p.m., R1 was sent to ED for evaluation of stroke like symptoms. The progress noted lacked documentation about R1 having a fall. -2/16/25 at 4:42 p.m., R1 had a fall on 2/12/25, not 2/16/25. The progress note further stated staff found R1 laying on the floor in his room at 3:50 p.m., with the wheelchair next to him. Staff had seen R1 in wheelchair in his room ten minutes before the fall occurred. R1 was unable to provide staff details on the fall and was sent to the ED for evaluation of altered mental status. -2/18/25 at 1:38 p.m., IDT reviewed R1's fall that occurred on 2/12/25 and the root cause was R1 experienced an acute change in health status. The progress note lacked documentation of interventions put in place. -2/21/25 at 12:35 a.m., R1 returned from the ED with orders provided to facility to ice left shoulder three times a day for the next three days and keep R1's left arm in a sling. -2/22/25 at 9:22 a.m., R1's fall on 2/20/25, reviewed during interdisciplinary team (IDT) meeting. Root cause of fall was that the resident stated he was wanting to get back into bed and fell trying to self-transfer. Resident had just gotten out of bed and into wheelchair with staff assist and seen in wheelchair 15 minutes prior to being on the floor. Resident had wheelchair pedals on wheelchair and also his catheter bag in the dignity bag under his wheelchair still at time of fall. Probable that resident could have tripped over one of them when trying to self-transfer. Foot pedals to be removed from wheelchair while resident is sitting in his room. R1's ED visit on 2/20/25, identified a closed fracture of proximal end of left humerus from a fall. R1's x-ray imaging order on 2/20/25 at 5:56 p.m., identified R1 had a fall with shoulder pain. Findings/Impression: Acute, proximal left humerus fracture with some angulation and impaction. During an observation on 3/11/25 at 9:31 a.m., R1 was laying in bed with a sling to the left arm, wheelchair over by dresser with foot pedals off. At 2:09 p.m., R1 was brought to his room after lunch and transferred to bed with a hoyer lift. R1's wheelchair was placed next to the bed, brakes on, his foot pedals were removed. The Facility Risk Predictive Factors assessment dated [DATE], identified R1 had poor recall, judgment and safety awareness. R1 required the use of assistive devices for mobility and three or more falls in the past three months. Fall risk score was 20 and indicated high risk for falls. Another Facility Risk Predictive Factors assessment dated [DATE], identified R1 had diminished safety awareness, required the use of assistive devices for mobility and one-two falls in the past three months. Fall risk score was 11 and indicated at risk for falls. Nursing assistant care plan dated 3/12/25, identified R1 was to have foot pedals removed from the wheelchair while in his room. Do not leave R1 alone in room in wheelchair. During an interview on 3/11/25 at 4:14 p.m., registered nurse (RN)-A stated R1 had a history of falls and a broken arm resulting from a recent fall. RN-A confirmed use of a care plan sheet with individual interventions for each resident for falls prevention and that he carried the care plan sheet with him each day of work. RN-A confirmed the care sheet identified R1 was to have foot pedals removed from the wheelchair when in his room. During an interview on 3/11/25 at 4:45 p.m., executive director confirmed R1 had a fall on 2/20/25. R1 fell from his wheelchair in his room, was taken to the ED, and returned to the facility with a left proximal humerus fracture. Executive director verified R1 had foot pedals on the wheelchair and tripped over the pedals or the catheter and fell . Executive director stated education for staff was provided immediately at shift change and education was sent out via email to staff. Executive director stated safety audits were being performed by the leadership team to ensure care plan interventions were being followed. On 3/12/25 at 9:49 a.m., the director of nursing (DON) returned a call to surveyor and verified R1 fell on [DATE], out of his wheelchair and at that time an intervention was put into place to remove pedals from R1's wheelchair while in his room. DON verified the pedals were on the wheelchair on 2/20/25, when R1 had an unwitnessed fall in his room from the wheelchair. DON verified R1 went to the ED on 2/20/25, after the fall and returned to the facility with a left proximal humerus fracture. DON stated care plan interventions included the keeping the pedals off R1's wheelchair while in his room were reviewed with staff at shift change and a mandatory meeting was completed with staff discussing falls and care plans. DON stated her expectations were staff would keep a resident safe if there was a fall, stay with the resident and call for help. DON confirmed the expectation staff would follow the care plan. DON would expect the nurse to assess the resident and surroundings and try to determine the root cause of the fall. The nurse would call the provider and family if a suspected injury resulted from the fall to determine further treatment. DON confirmed this was important to keep the resident safe after a fall and to prevent the fall from happening again. On 3/12/25 at 3:32 p.m., nurse practitioner (NP) returned a call to surveyor and verified R1 fell at the facility on 2/20/25, resulting in a left proximal humerus fracture. All nursing staff were sent out an email on 2/20/25 at 10:05 p.m., regarding R1's fall. All nursing staff were reminded that R1's foot pedals were to be removed from the wheelchair when R1 was sitting in his room. If staff were not transporting R1, foot pedals would be removed. Attached to the email was a copy of R1's ED report. Facility staff education meeting undated, identified education would be provided to employees on state prep, falls, and care plans. A facility policy titled Falls, revised 3/22, identified all residents would be assessed for fall risk and interventions implemented as appropriate. A comprehensive assessment would be completed with every fall to determine the root cause and to develop individualized interventions. A fall was identified as an unplanned descent to the floor with or without injury to the resident. A fall risk predictive factors assessment would be completed after each fall. If the fall score was 10 or greater the resident may be considered at high risk for potential falls and staff were to initiate the care plan for high risk for injury, list specific interventions based on assessment risk, identify interventions on the NA care plan.

Based on observation, interview and document review, the facility failed to ensure a safe transfer using a full body mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in harm for R1 when she fell from the lift during a transfer, sustained a laceration to the back of her scalp and contusion (a bruise caused by blood vessels under the skin that break and bleed due to an injury such as a blow or impact) of the sacrum (a bone that connects the lumbar spine and the pelvis). R1 was sent to the emergency department (ED) and required four staples to the scalp. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: Volaro Series 4 Lift Operators Manual dated 3/2019, identified the Volaro lift was designed for patient transfer only. Make sure all four loops from the sling are properly nested in the bottom of the hooks before lifting or transferring a resident and all four retainer springs are functioning correctly. Lift legs must be fully extended into the wide position when lifting a resident. Instructions provided identified when a resident was transferred from bed to chair: roll the person to their side and lay the folded sling behind them. Align the bottom of the back of the sling by the tailbone. Roll the person to their side and pull the rest of the sling through, straightening any wrinkles. Bring material under the legs the same way as if they were in the chair. Crisscross the inside flaps and thread the straps through the main loops. Bring the lift in, adjust the base to the widest position, and lower hanger near the center of the person being transferred. Keep the lift in the widest position possible at all times, especially when transferring a person who is uncooperative or combative. Bend the knees and hook up the color-coded loops that were previously used to bring them to a sitting position. Press the button to raise the lift just high enough to clear the bed and make sure the material under the leg stays straight toward the knee, keeping out as many wrinkles as possible. Note: Raise until there is tension on the straps and then double-check to make sure the loops are nested in the bottom of the hooks. If the base is in the narrow position, adjust it to the widest position once you are clear from the bed and always before turning the lift. Once the patient is over the chair, lower and guide them by the built-in handles on the sling to bring them back far into the chair. Note: Use only the lift handle bars to move the lift. Pulling or pushing on the person or the beam will cause the lift to be unstable. R1's diagnoses list undated, identified dementia, recurrent dislocation left hip, history of repeated falls, difficulty in walking, osteoporosis, back pain, and personal history of other pathological fractures. R1's fall risk assessment dated [DATE], identified poor recall, judgment, safety awareness. R1 required the use of assistive devices for mobility, no falls in the past three months. Fall risk score was nine and indicated at risk for falls. R1's care plan dated 11/14/24, identified she had a potential for falls related to senile degeneration to the brain, weakness, different environment than home setting, and dementia. Staff were directed to monitor for changes in mobility and provide appropriate follow up, transfer with Volaro, and assist of two with medium Volaro sling. R1 was alert and oriented to self but did not typically talk or respond when asked questions. Staff were directed to have allowed R1 time to communicate, speak clearly and directly when spoken to, and use consistent approach that explained procedures in short, clear, and simple sentences. R1 had a self-care deficit and privacy for all cares was to be provided. Camera was placed in R1's room by family with dignity shield declined during cares. R1's progress notes on 11/27/24, identified: -At 9:23 a.m. writer arrived to R1's room around 8:05 a.m. and noted she was on the floor. Charge nurse was already present and applied pressure to head laceration. Emergency medical service (EMS) had just arrived, and report was given. Writer assisted with transfer to the stretcher. No obvious injuries except for head laceration. R1 was at her baseline cognition when EMS arrived. Vitals not obtained due to care needed for head laceration and assistance with transport to ED as soon as able. Writer spoke with daughter, updated, and had observed the fall. Root cause of fall was related to loop placement on the lift hook. Appropriate actions for follow up being completed. R1 will be monitored for pain, injury, or other concerns post fall. Will await return from ED. -At 7:11 p.m. Fall: time of fall at 7:50 a.m. Description of event: two aids transferred her from bed to the wheelchair and she fell from the mechanical lift. Fall was witnessed and resident hit her head. Action Plan/Intervention: Recertification of mechanical lift usage. Practitioner notified at 7:59 a.m. and family. -At 7:18 p.m. R1 came back from hospital with staples to her head to be removed in 7 to 10 days. Keep pressure on wound for 24 hours. R1's ED visit on 11/27/24 at 9:07 a.m. identified R1 had significant dementia, previous lumbar fractures presented to ED for evaluation of possible injury sustained in a fall. R1 apparently suffered a fall during a transfer with a mechanical lift. R1 struck the back of her head and had a lot of bleeding and no loss of consciousness. Physical assessment confirmed a 1.5-centimeter (cm) laceration cephalohematoma (blood collection underneath the scalp) to right occipital scalp and mental status at baseline. R1's laceration was repaired with four staples. Cat Scan (CT) (an imagining test that used x-rays and a computer to create detailed pictures of organs, bones, and tissues) completed and identified no acute fractures or dislocations, and an area of hematoma with no active bleeding. Clinical impressions included laceration of scalp and contusion of sacrum. R1's pelvic CT scan without contrast completed on 11/27/24 identified indication for scan was blunt polytrauma (injury to multiple body parts), evaluation for fractures. Findings: no pelvic fracture and high attenuation collection, superficial to the lower sacrum measuring 2.3 x 7.1 x 6.6 centimeters (cm), likely representing hematoma. Facility investigation dated 11/27/24 at 10:59 a.m. identified incident description by charge nurse: R1 was being transferred from her bed to her wheelchair in a mechanical lift. Two staff present. R1 was on the floor lying with her feet toward the door and between the legs of the mechanical lift. There was blood on the floor under her head about the size of an 8-inch dinner plate. At 7:55 a.m. the charge nurse called the resident care manager (RCM). Upon entering R1's room she laid on her back with her hips and legs leaning to the left. R1 had been lifted up with assist of two and a mechanical lift. The mechanical lift sling was noted still hooked up to the mechanical lift machine with the right bottom strap dangling down towards the floor. Sling was later assessed, completely intact, no damage prior to being hooked up to mechanical lift. Nursing assistance (NA) knelt next to R1 and told RCM not sure what went wrong but indicated the strap fell off. R1 was non-verbal and did not move extremities well at baseline. Neuro check completed and normal. A puddle of blood was noted surrounding R1's head that came from the lower back side of her head. RCM held a clean towel against R1's and provided pressure to the laceration. R1 unable to provide description of incident. The two NAs involved in incident and all nursing staff in the building were immediately given mechanical lift competencies once resident left with EMS until all nursing had been signed off on their competencies. It appeared that the sling was not appropriately hooked up on the right lower side of the mechanical lift sling which caused R1 to slip out of the right side of the sling to the floor. Did someone say this, where did you get this statement from? All nursing staff were sent out an email on 11/27/24 at 4:25 p.m. regarding R1's fall from the mechanical lift. All nursing staff were informed they were required to have completed a mechanical lift competency prior to their next shift worked. Attached to the email was a copy of the mechanical lift competency for all staff to use along with a picture of the sling positioned correctly and another picture of where the sling was positioned incorrectly. Nursing staff were reminded to check and double check the straps/loops are secure and all on. A little tug on the strap should be completed to help verify it is in place. When a second person came in to assist with the transfer all the straps are to be checked they are on and secure prior to the start of the transfer. Mechanical lift audits had been started on 12/3/24 and continued through 12/6/24, a total of eight completed thus far and identified: Resident/staff, sling hooked up to mechanical lift correctly prior to transfer, staff double checked straps and looks to ensure they were nested into the loop, and signature/comments/education. No concerns were identified during the eight audits. During an interview on 12/9/24 at 12:47 p.m. family member (FM) stated R1 had a camera in her room and recorded the fall on 11/27/24. FM stated she viewed the footage, and it showed NA was in room by herself with R1, placed the mechanical lift sling underneath her then hooked it up to the mechanical lift. FM stated another NA entered R1's room and the straps/loops were not checked. FM stated once the staff moved her off the bed to be transferred to the wheelchair she started to lean/fall on the right side, the lower right strap came off, NA attempted to hold R1's bottom, left leg was hooked, dangled in the air on the strap that remained attached to the lift, slid down out of the sling, was dropped onto the floor, and hit her head. FM stated additional staff entered the room and identified there was blood everywhere. FM stated another staff entered the room, knelt beside R1 and pressure was held to the back of her head. FM stated was very difficult for her to watch the video and was unable to view it again. FM stated the fall happened so fast, R1 was unable to verbalize much, knew what was going on, and was whimpering. FM stated CT was completed on R1's hips and back, had not received results. FM stated R1 was sent to ED, had a laceration to the back of her head and received four staples. FM stated the recorded fall was offered and viewed by the administrator and DON. During an interview/observation 12/9/24 at 1:41 p.m. NA-C demonstrated how the mechanical lift should be attached to the straps/loops. NA-C stated for a safe transfer with the mechanical lift you must have all four straps/loops from the lift sling snapped into the hooks from the outside and around to ensure it stayed hooked on the mechanical lift. NA-C stated we were expected to double check prior to the start of the lift and again once the resident was lifted off the bed /chair, pause to make sure the loops were intact and stayed where they needed to be to prevent falls. During an interview/observation 12/9/24 at 3:10 p.m. NA-A stated R1 had fallen from the mechanical lift on 11/27/24, during a transfer. NA-A demonstrated/reenacted R1's incident with the mechanical lift and lift sheet in an unoccupied bed/room. NA-A placed the lift sling on the bed and stated R1 laid on top of it. NA-A pushed the mechanical lift over to the bed and stated so that the swivel bar was over the resident. NA-A stated she was unaware the mechanical lift legs were to have been in the wide position when under the bed and while she hooked up resident to the mechanical lift. NA-A stated she thought it was only when the resident was moved in the lift then pointed out a sticker that had been placed on the mechanical lift and revealed: lift patient only with floor lift legs in wide position to prevent chance of tipping. NA-A stated she did not open the legs of the mechanical lift while she lifted R1 out of bed that day. NA-A stated would have been important because with the mechanical lift legs positioned wide resident's weight was dispersed more evenly and less risk of the resident being tipped over while in the lift. NA-A stated she hooked up the straps/loops from the lift sling to the two top hooks first on the mechanical lift. NA-A stated she pulled back the clasp and placed top loops into the mechanical lift hook and snapped the clasps in place. NA-A stated criss crossed the lower straps between R1's thighs and hooked straps/loops to the mechanical lift. NA-A stated she thought the clasps snapped closed and the lower loops freely hung in the loop on the mechanical lift but when reviewed what happened during the transfer the only explanation was the loop on the right side was not positioned fully in the mechanical lift hook and instead caught in between the clasp and the hook, which made the mechanical lift transfer unsafe and resulted in R1's fall. NA-A stated she sent a message via walkie for assistance to transfer R1 from the bed to the wheelchair. NA-A stated NA-B entered the room and stood by the bed on R1's right side located up by her head. NA-A stated the straps/loops were not double checked prior to the start of the transfer. NA-A stated R1 was lifted off the bed and mechanical lift legs remained in narrow position until she was high enough to clear the bed (approximately five feet). NA-A stated NA-B positioned the sling with R1 in it so that her legs were off the bed, and she faced the lift and herself. NA-A stated she pulled the mechanical lift backwards away from the bed approximately three feet, opened the legs of the mechanical lift so that the wheelchair could fit between them. NA-A stated she stood on left side of mechanical lift and NA-B stood on right side and with the weight of R1's legs suddenly her right leg dropped, right strap/loop fell from the mechanical lift hook, her upper body and head slipped out from her right side of the sling where it was detached from the mechanical lift. NA-A stated she placed her hand on R1's back, stepped over the mechanical lift leg, and tried to grab her right leg. NA-A stated NA-B tried to brace R1 under the sling with her hands. NA-A stated she grabbed R1's head and that was when R1's body slide out of the sling, center backside of her head hit the ground first from approximately one foot off the ground. NA-A stated R1's feet partially rested on the metal base of the mechanical lift. NA-A stated NA-B sent a message on the walkies to alert staff nurse. NA-A stated R1 laid in a puddle of blood surrounding her head approximately eight inches in diameter and soaked her clothing on her back. NA-A stated R1's eyes started to water and visually looked like she started to cry. NA-A stated R1 was not knocked out when she hit the floor. NA-A stated staff nurse arrived in R1's room and placed a towel with pressure onto the back of her head to help control the bleeding. NA-A stated the fall was caused by her error, the one loop of the sling was not secured in the mechanical lift hook on the swivel bar, slipped out, should have been more careful, and rechecked them. NA-A stated she received education immediately regarding how to safely use a mechanical lift competency and demonstrate it back to show she had an understanding of the education. During an interview on 12/9/24 at 4:20 p.m. licensed practical nurse (LPN)-A stated R1 was a mechanical lift transfer with assist of two staff. LPN-A stated worked on 11/27/24 and received a call on her walkie from NA-A that indicated assistance was needed in R1's room. LPN-A stated entered room and completed a quick assessment along with the floor manager and then called 911. LPN-A stated R1's eyes were wide open and pupils reactive and she laid in a pool of blood approximately eight inches in diameter. LPN-A stated he saw three sling straps/loops that remained hooked on the mechanical lift, and one was not. LPN-A stated he was informed by NAs involved R1 had slipped out from the bottom of the sling, and they were unable to stop the fall. LPN-A stated unable to move or turn R1, waited for ambulance personnel to arrive in case she had more injuries. During an interview on 12/10/24 at 11:15 a.m. NA-B stated on 11/27/25 received a message via walkie assistance was needed with R1. NA-B entered R1's room and noted she laid in bed already hooked up to the mechanical lift. NA-B placed R1's wheelchair closer to the bed, stood towards the end of the bed, and did not check the straps/loops prior to the transfer. NA-B stated she had not checked the straps/loops before when another NA had hooked them up and assumed it had been done properly and safely. NA-B stated unsure if the legs of the mechanical lift were opened when NA-A lifted R1 off the bed, NA-B lifted R1's feet off the bed. NA-B stated R1 was moved away from the bed in the mechanical lift approximately five feet and everything seemed normal. NA-B stated unsure if she continued to hold onto R1's feet when the leg strap (unsure of which one) on one side gave out, fell to the floor, unsure of what hit first but was not her head. NA-B stated R1 laid on the floor with blood around her head. NA-A stated the strap/loop was not hooked up properly and should have been checked again prior to the transfer. NA-A stated felt she was in shock when it happened, hard to remember all the details, and was the worst thing she had seen in her life, when a resident got hurt like that. NA-B stated she had received education right away after the fall on 11/27/24, the proper way to use the mechanical lift , placement of the mechanical lift sling and placement of the loops, when the mechanical lift wheels should be locked, and then demonstrated those steps back to show we knew how to do it. During an interview on 12/10/24 at 1:55 p.m. DON stated on 11/27/24, NA-A lifted R1 up with the mechanical lift, there was tension on the sling and then as soon as R1's body was turned because the sling loop was not positioned on all the way and fell off the hook. DON stated R1's right side went down, and she fell to the floor. DON stated both NAs tried but were unable to stop R1 from falling gradually and it went fast once the loop let go. DON stated R1 fell approximately three feet, hit her upper back then her head. DON stated R1 sustained a laceration to back of her head, sent to ED, and treated. DON stated the fall could have been prevented if staff would have doubled checked the mechanical lift strap. DON stated immediately after the fall staff education and audits were initiated. DON stated all nursing staff were educated except for approximately five to seven staff employed as needed (PRN) and planned on education provided prior to their next shift. During an interview on 12/10/24 at 4:20 p.m. medical doctor (MD)-A stated R1 was brought into ED due to a fall at the facility during a transfer with sustained a laceration to the back of her head, caused harm, and required treatment for it. During an interview on 12/10/24 at 4:25 p.m. medical doctor/radiologist MD-B stated the CT of R1's pelvis completed on 11/27/24, findings identified high attenuation collection, superficial to the lower sacrum measuring 2.3 x 7.1 x 6.6 centimeters (cm), likely representing hematoma. acute or early subacute chronic. MD-B stated this could have resulted from the fall on 11/27/24. Mechanical lift Sling Application and Lift Use Competency Evaluation and Education dated 12/2021, identified procedure/criteria for use of the lift machine: -Select correct sling and size (per care plan and/or sling sizing chart). -Slide sling down to seat of chair to tailbone area; do not place under resident's buttocks. -Slide leg sections of sling along outer thighs, then tuck under thighs. - Bring leg support straps up between legs, and cross to attach at opposite side of mechanical lift swivel bar. -Attach sling straps to swivel bar (same length/loop on each side). -Attach shoulder straps first, then leg straps to swivel bar. -Ensure straps are secured before lifting resident. Lift resident high enough to cause tension on the straps. Then double check strap placement and security before continuing lift. -Do no lock wheels (unless lifting from floor or sloped surface). -Keep base at its widest setting. -Keep resident at lowest height necessary. -Always requires presence of two staff members (over age of 18). -Mechanical lift lifts are for transfers only: never transport a resident in a lift. To prevent tipping. Do not push or pull-on mechanical lift beam or on resident.

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. This deficient practice had the potential to affect all 116 residents who received food and beverages from the refrigerators and freezers. Findings include : On 4/8/24 at 11:30 a.m., during the initial tour of the kitchen area with the culinary coordinator (CC), the following concerns were identified: Walk in produce cooler: -nine hard boiled eggs were in a Ziploc bag without a notation of a date. -1/2 large container of enchilada sauce with crusty black flakes around the lid with an open date of 1/1/24. -1/2 bottle of mustard with yellow crusty flakes around the lid and an open date of 10/3/23. -1/4 bag of whipped topping with no notation of an open date. Walk in egg and dairy cooler: -20 hard boiled eggs were in a Ziploc bag without a notation of a date. -1/4 bottle cherries with an open date of 1/16/24. -one open block of butter with no notation of an open date. -15 pieces of summer sausage in a Ziploc bag without notation of an open date. -20 slices of Swiss cheese in an opened Ziploc bag without notation of an open date. - four hard boiled eggs were in a Ziploc bag without notation of a date. - Fresh tray of twelve eggs in a container which contained spilled egg yolks. - four pieces of gluten free bread in a bag with an expiration date of 4/1/24. - 16 nectar thick ice cubes without notation of a date. Juice Cooler: -1/2 container thickened cranberry no notation of a date. Main freezer: -Several tator tots in a Ziploc bag with no notation of a date. -Peppers in a Ziploc bag with no notation of a date. -18 Pureed cinnamon rolls with large ice crystals and no notation of a date. - five breaded fish patties in a plastic bag with no notation of a date. Hall freezer: -one cupcake with no notation of a date -container of lefse with a moderate sized rip in the aluminum foil covering. Basement freezer: -28 pieces of breaded fish in a plastic bag without notation of a date. First floor Kitchen refrigerator: -one container of nectar thick water with no notation of a date. -one full container of orange juice without a cover. First floor kitchen freezer: -1/2 large container of vanilla ice cream without notation of an open date with ice crystals present around the cover. During an interview on 4/8/24 at 12:15 p.m., CC confirmed the above findings and indicated the residents had recently been served the above items. CC stated all the above items should have been discarded. CC indicated her expectation was that all items would have been dated when opened and discarded appropriately. During an interview on 4/9/24 at 2:33 p.m., registered dietician (RD) stated her expectation was that all food was dated when opened and discarded per facility policy. Review of a facility policy titled Cold Storage revised 1/18, indicated the facility was to ensure all perishable refrigerated and frozen items were stored according to state and federal regulations. In addition, it identified all food must be labeled, dated and properly sealed.

Based on observation, interview, and document review the facility failed to maintain wheelchairs in a clean and sanitary manner for 1 of residents (R68) reviewed who utilized wheelchairs. In addition, the facility failed to maintain a standing lift shared by residents in a clean and sanitary manner. Findings include: R68's annual Minimum Data Set (MDS) dated [DATE], identified R68 had moderate cognitive impairment and had diagnosis which included hypertension (elevated blood pressure), non traumatic brain dysfunction and arthritis. Identified R68 required staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Further identified R68 utilized a manual wheelchair for mobility. During an observation on 4/9/24 at 9:29 a.m., R68 was seated in his wheelchair at the nurses' station and the left foot pedal of his wheelchair contained a large dried brown food like substance of which covered half of the foot pedal. During an observation on 4/10/24 at 7:40 a.m., R68 was seated in his wheelchair at the nurses' station and left foot pedal continued to have a large dried brown food like substance. During an observation on 4/10/24 at 7:41 a.m., a standing lift which was located in the hallway on the second floor of the facility had a large area of dried brown food like substance on the lower end of the standing lift plate of the lift. During an interview on 4/10/24 at 7:50 a.m., nursing assistant (NA)-E confirmed the presence of a dried brown food like substance on R68's left wheelchair pedal and on the foot plate of the standing lift. NA-E stated she was unsure who was responsible for cleaning wheelchairs and lifts. During an interview on 4/10/24 at 7:52 a.m., housekeeper (HK) confirmed the presence of a dried brown food like substance on R68's left wheelchair pedal and the foot plate of the standing lift. HK stated he knew there was a process for cleaning wheelchairs however was unsure what the process was. HK indicated it was the responsibility of housekeeping to completed a deep clean of the lifts at least weekly. During an interview on 4/10/24 at 10:56 a.m., director of nursing (DON) stated the night shift was responsible to clean resident wheelchairs on their bath day and in between as needed. DON indicated it was housekeeping's responsibility to clean the lifts. A facility policy on cleaning wheelchairs and lifts was requested however, one was not received.

Based on observation, interview and document review, the facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene per Centers for Disease Control and Prevention (CDC) to prevent and/or minimize further spread of COVID-19 for 2 of 3 residents (R45 and R59) reviewed for transmission based precautions. In addition, the facility failed to ensure catheter drainage bags were not placed on the floor for 1 of 1 residents (R62) reviewed for catheters. Findings include: Review of CDC guidance dated 3/18/24, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic indicated health care providers who entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety & Health) approved particulate respirator with N95 filters or higher (an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and has very efficient filtration of airborne particles), gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Additionally, when transporting a resident who had suspected or confirmed SARS-CoV-2 infection, the transporter should continue to wear their respirator. The transporter should also continue to use eye protection if there was potential that the patient might not be able to tolerate their well-fitting source control device for the duration of transport. PPE USE Review of R45's and R59's Rapid Covid -19 lab results revealed the following: R45's Rapid Covid-19 test dated 4/1/24, indicated R45 was positive for Covid-19. R59's Rapid Covid -19 test dated 4/2/24, indicated R59 was positive for Covid-19. During an observation on 4/8/24 at 12:51 p.m., R45's and R59's door contained a sign that said Enhanced Droplet Precautions Everyone Must clean their hands, including before entering and when leaving the room. N95 mask, face shield, gown, and gloves are required when entering this room. Remove PPE and perform hand hygiene when exiting the room. In addition, the sign contained a picture of an N95 mask, face shield, gown, and gloves. During a continuous observation on 4/8/24 at 1:44 p.m., nursing assistant (NA)-A exited R45's room and removed (doffed) her N95 mask, put on a clean surgical mask, touched her hair and entered R45's room and placed a mask on R45. NA-A proceeded to wheel R45 down the length of the hallway to the tub room wearing only a surgical mask and no eye protection. At no time during the above observation did NA-A perform hand hygiene. - At 1:49 p.m., infection preventionist (IP) approached NA-A and informed her she should have worn an N95 and eye protection during transport and once she was in the tub room would need to additionally put on (don) a gown and gloves. During an observation on 4/10/24 at 7:11 a.m., NA-B exited R45's room, doffed her N95 and placed it directly on top of a box of clean gloves. NA-B proceeded to sanitize her eyewear with a disinfectant wipe then placed her eyewear on top of her head. At no time did NA-B sanitize her hands. During an interview on 4/10/24 at 7:13 a.m., NA-B verified she had placed her N95 on top of a clean box of gloves after exiting R45's room and had not sanitized her hands. NA-B stated her usual practice was to place her N95 in the garbage after exiting R45's room and then sanitize her hands. During an observation on 4/10/24 at 9:00 a.m., NA-C donned an N95 and placed the lower strap behind her head and left the lower strap in the front on top of the nose part of the N95. Surveyor intervened as NA-C was ready to enter R59's room and NA-C verified R59 her N95 was not being worn appropriately and placed the lower strap of the N95 behind her head before entering R59's room. CATHETER BAG R62's significant change MDS dated [DATE], identified R62 had severe cognitive impairment and diagnoses which included benign prostatic hyperplasia (enlarged prostate) (BPH), elevated blood pressure (HTN), and dementia. Indicated R62 required extensive assistance for activities of daily living (ADL's) which included toileting, transfers, and dressing. Identified R62 required the use of an indwelling catheter. R62's care plan dated 2/15/23, indicated R62 was at increased risk for infection related to foley catheter use. Directed staff to provide catheter cares per policy, keep drainage bag below the level of the bladder and monitor for signs of infection. During an observation on 4/9/24 at 5:15 p.m., R62 was lying on his back with bed in low position. R62's urinary catheter drainage bag which contained bright yellow urine was observed with the opening spout resting directly on the floor and was not covered. During an interview on 4/9/24 at 5:30 p.m., NA-D verified R62's urinary catheter drainage bag was lying directly on the floor. NA-D stated usual practice was to place R62's urinary catheter drainage bag in a dignity bag or in a basin so that the bag did not touch the floor when the bed was in low position. During an interview on 4/9/24 at 5:33 p.m., licensed practical nurse (LPN)-A verified R62's urinary catheter bag was lying directly on the floor. LPN-A stated her expectation was that R62's urinary drainage bag would have been placed in a dignity bag or in a basin so that the bag would not have touched the floor. During an interview on 4/10/24 at 10:42 a.m., infection preventionist (IP) verified R45 and R59 recently both had tested positive for COVID-19. IP verified NA-A had only worn a surgical mask while transporting R45 down the hallway for her bath. IP stated her expectation was that NA-A would have washed her hands when she exited R45's room and after she had removed her N95. IP stated NA-A should have worn an N95 and a face shield while transporting R45 down the hallway. IP stated urinary catheter drainage bags should have been placed in a dignity bag or a basin so they were not touching the floor. IP stated her expectation was all staff would don and doff PPE appropriately. IP indicated the facility followed CDC guideline for PPE usage regarding COVID -19. During an interview on 4/10/24 at 11:10 a.m., director of nursing (DON) verified R45 and R59 both currently tested positive for COVID-19. DON stated her expectation was all staff would don and doff PPE appropriately at all times. DON further stated hand hygiene should be performed appropriately and urinary catheter drainage bags should have been placed in a dignity bag or a basin off the floor to help prevent contamination of the urine drainage bag which could have caused a urinary tract infection. A facility policy titled Coronavirus (COVID-19) revised 5/23, indicated the facility was to follow recommendations for residents with COVID-19 set by the CDC and Minnesota Department of Health (MDH). Policy stated when working in a room with a resident who was positive for COVID-19, staff were to wear an N95 mask, gown, protective eyewear and gloves and that enhanced droplet precautions were followed. Policy identified hand hygiene was a necessary component of preventing the transmission with alcohol based hand rubs being the preferred method of hand hygiene. A facility policy titled Policy and Procedure: Catheter- Indwelling revised 1/24, indicated residents with indwelling catheters known as foley catheters were cared for by staff according to accepted practice. Identified the drainage bag of the catheter should never be placed on the floor, or the bag may become contaminated. .

Based on observation, interview and document review, the facility failed to ensure interventions were implemented to reduce the fall risk for 1 of 3 residents (R2) reviewed for accidents. This deficient practice caused actual harm when R2 fell and sustained a left fractured patella (knee cap). Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition with no behaviors, extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. R2 was not on a toileting program, had frequent bladder incontinence and continent of bowel. R2 received anticoagulants and antidepressants 7 out of the 7 days during the look back period. R2 had three falls since admission, one without injury and two with minor injuries. R2's diagnoses dated 9/15/23, identified spinal stenosis (narrowing) lumbar region with neurogenic claudication (nerves get pinched within the center of the lumbar spine, causing intermittent leg pain), radiculopathy (injury or damage to nerve roots in the area where they leave the spine) lumbar region, low back pain, retention of urine, lumbago with sciatica left side (pain, usually on one side, felt in the lumbar spine, thighs and buttocks, and may radiate to the ankles or toes), polyarthritis (a term used when at least five joints are affected with arthritis), obesity, left foot drop, and need for assistance with personal care. R2's orders dated 9/13/23 identified: -WBAT (weight bearing as tolerated) only when brace is on. NWB (non-weight bearing) when brace is off every shift. Date order 9/5/23. -Left knee T-scooped hinged brace locked in extension. Remove brace only for hygiene cares every shift. Date order 9/5/23. -Make sure the instep strap is worn properly snug. Please make sure the lining of the shoe is not in the shoe when R1 was wearing her ankle foot orthosis (AFO) (hard brace worn on lower leg/foot that provides gait stability, help compensate for muscle weakness, and improves overall walking safety). Start 1 to 2 hours today-adding 1 hour per day. If the little toe stays irritated, then may need to stretch her shoe overnight. Date order 10/24/22. R2's care plan last updated 9/14/23, identified R2 had the potential for falls related to L3 (lumbar spine level 3) pelvic fusion (procedure performed to encourage bones to grown together to provide more stability to the area) with interbody L4-S1 (area between the lumbar spine and the sacral spine in the lower back) and laminectomy (removal of spinal bone to relieve compression on the spinal cord). Staff were directed to provide assistance of one with toileting, AFO and donning of the AFO. R2 must have AFOs on for all transfers and ambulation (date initiated 5/20/22). Staff were to remind R2 to wear shoe with AFO's at all times when transferring/standing (date initiated 2/20/23 and removed on 9/14/23). Toileting: Independent with a FWW (front wheeled walker), assist PRN (as needed) (date initiated: 05/20/2022 and removed on 9/14/23). Ambulation: Independent in room with FWW, continue with supervision assist of one in hallways/walk to dine. Encourage to wear AFO braces (date Initiated: 05/20/2022 and removed independent ambulation on 9/14/23). Staff were also directed to anticipate and meet R2's needs. R2's care plan nursing assistant (NA) care sheet dated 9/14/23, identified independent with a FWW (front wheeled walker), transfers assist of 1, right and left AFO. R2's fall assessment dated [DATE], identified R2 required use of assistive devices scored 5 on assessment. R2 was at risk for falls. R2's fall assessment dated [DATE], identified R2 had 1 to 2 falls in the past 3 months, required use of assistive devices, and scored 7 on assessment. R2 was at risk for falls. R2's progress notes identified: -7/14/23 at 9:00 p.m. NA checked on R2 to assist with evening cares and found R2 on her knees on floor in her room at bedside and attempted to get back up. R2 had shoes on and no AFOs were on her feet. R2 stated she had picked out clothes in the closet and walked back, left ankle rolled, lost balance, and fell . R2 was asked why the AFOS were not on, and indicated they hurt, and she removed them. Action plan/intervention: education provided to always assure AFO brace to both legs when up ambulating to support ankles, notified therapy to see if adjustments could be made to AFOs. Practitioner notified. -7/15/23 at 11:01 am. fall update: reviewed R2's fall and root cause of fall was resident was not wearing AFO braces to legs, removed them because they hurt her feet. R2 was independent with transfers and ambulation with front wheeled walker in her room. Immediate intervention placed to educate resident on the need to keep AFO braces on when she transferred or ambulated in her room. R2 agreed with intervention and notified therapy AFO braces hurt her feet to see if adjustments could have been made. -8/19/23 at 4:45 p.m. TMA (trained medication aide) heard a noise in R2's room, entered and found her lying on right side on the floor at the foot of her bed. R2's legs were extended outward towards the door, walker tipped over directly in front of her. R2 had tried to transfer out of her electric wheelchair and into her manual wheelchair located directly in front of her. R2 stood up to walk and her shoe caught on the title of the floor, caused her to trip, lost balance, hit right elbow against the foot of bed, and thought she had also hit her head. R2's right elbow had a light purple bruise and a bit of swelling and one hour later a very small raised light purple discoloration area noted on the right anterior parietal lobe (top back of head). Action Plan/Intervention: R2's care plan was followed as written. Root cause of fall seemed to be the tennis shoes R2 had been wearing the time of the fall. R2 indicated she would no longer wear those tennis shoes. Practitioner notified. -8/21/23 at 4:14 p.m. fall update: fall from 8/19/23 was discussed with nurse leadership. Care plan was followed at time of fall. Root cause of fall R2's foot did not raise when ambulating from electric wheelchair to manual wheelchair. R2 interviewed and indicated she had on her purple shoes when she went to therapy and they were not the issue, declined those shoes to be removed from room and stated currently seen by therapy for that. R2 indicated sometimes when she walked her foot did not pick up like it should, when AFOs were worn did not have issues when she walked. Education was provided to resident to not ambulate without her AFOS on and perform stand turn and sit transfers and avoid ambulating or completely turned around to get into the chairs. R2 voiced understanding. -9/1/23 at 9:21 p.m. R2 found on floor parallel to her bed and faced her manual wheelchair located at the head of bed. R2 ambulated from electric scooter to her manual wheelchair, while ambulating tennis shoes got stuck on the floor, R2 lost control of her balance, and came down onto floor with both knees. R2 complained of pain in her leg (left or right was not identified) post fall both knees were noted to be bruised. Practitioner notified. -9/2/23 at 5:12 p.m., Fall update: fall from 9/1/23 reviewed along with care plan interventions. R2 currently independent with transfers and ambulation in room. R2 had AFO braces due to foot drop and was encouraged to wear during transfers and ambulation. R2 had been at therapy earlier in the day and had a new pair of shoes on (ones she had worn during the fall) and cannot wear the AFOs while she completed exercises. R2 forgot to change them after returning to her room. When AFOs were not worn placed R2 at increased risk for falling due to ankle weakness and gait instability from her diagnosis of foot drop. R2 took 4 steps, knew she was going to fall from her ankle not working, caused her to trip, and she went down slowly. R2 felt not wearing the AFO braces had been the cause of her fall. Therapy was updated and AFO braces were to be applied after therapy sessions to prevent reoccurrence. R2 verbalized understanding the importance of wearing the AFOs and agreed to have those placed back on after therapy sessions. R2's primary medical doctor (MD) follow-up rounds dated 9/1/23, identified continued to have issues with foot drop. R2 noted right foot drop had been somewhat worse since surgery. R2 had known left sided foot drop. Neurosurgery recommended AFO for right foot drop. R2's wellness center documentation dated 9/1/23, identified R2 entered facility to complete exercises at 12:50 p.m. R2's toileting record dated 9/1/23, identified R2 required extensive assistance at: 2:14 p.m., 4:05 p.m., 5:06 p.m., 8:37 p.m. R2's toileting record identified extensive assistance was given at 8:37 p.m. prior to fall at 9:10 p.m. R2's medical record did not identify whether the AFO's were applied during toileting. R2's eating record dated 9/1/23, identified R2 ate supper at 6:08 p.m. R2's Nurse practitioner (NP) visit progress notes dated 9/5/23, identified NP visited R2 in nursing home today and R2 reported pain to the left lateral side of her kneed moderate in severity, worsened by movement and palpitation. R2 had a history of left knee replacement. R2's x-ray showed a closed nondisplaced transverse fracture of left patella. Orthopedics were consulted and recommended weight bearing as tolerated in a t-scope hinged knee brace locked in extension times 6 weeks, off for hygiene only. Repeat x-rays in 2 weeks. These are generally not surgical fractures. During an interview/observation on 9/13/23 at 11:30 a.m., R2 sat in her room in wheelchair, with brace on left thigh to her ankle. R2's AFO was not on her right lower leg/foot and noted to be located on the floor next to the bedside stand. R2 stated they will not allow me to be independent anymore and needed to have staff with when going to the bathroom to prevent falls. R2 stated on the day of her fall she had gone from her electric wheelchair to regular wheelchair with only 4 steps to take however had taken 3 steps and her right foot got stuck on the floor and rolled ankle over onto the side. R2 stated she had bilateral foot drop and wore AFOs on both lower legs but had advanced and understood she was allowed to move around in her room without the AFOs. R2 stated she had just returned from therapy, did not have the AFOs on, and should have asked staff for help. R2 indicted the AFOs supported her ankle and foot and prevented foot drop. R2 stated she was lifted off the floor with a total lift machine and x-ray confirmed a fracture of the left knee cap. During observation on 9/13/23 at 2:33 p.m., R2 sat in recliner with both feet elevated. R2's AFOs remained located on the floor next to the bedside stand. During an observation/interview on 9/14/23 at 8:05 a.m., R2 sat in her wheelchair and indicted she just got done with morning cares where staff assisted me. R2 confirmed she was unable to apply her own AFO's and did not use them during the transfer this morning adding, they must have forgotten to apply them. R2 indicated after back surgery it was difficult to bend over and reach down which may it hard to pick up items off the floor, pointing to AFO's located on the floor next to her recliner. R2 stated since the fracture of her kneecap she had a brace on the left leg and only wore one AFO on the right foot. During an observation on 9/14/23 at 9:20 a.m., R2 sat in wheelchair in her room without AFO on right foot. Both AFO's remained on the floor next to the recliner while she ate breakfast. During a follow up interview on 9/15/23 at 11:56 a.m., R2 stated she had always been willing to try and wear the AFOs but required reminders and assistance with putting it on. R2 stated there was no way she was able to have placed the AFO on, her back would not have allowed her to. R2 stated she had eaten supper in her room that evening prior to the fall on 9/1/23. During an interview on 9/14/23 at 12:15 p.m., physical therapist (PT) stated R2 had bilateral foot drop and AFOs to stop the foot from exceeding into an excessive plantar flexion (the movement of the foot in a downward motion away from the body and a movement is crucial in many actions including the everyday action of walking) due to weak or inability to pull the foot/ankle into a dorsiflexion. PT stated R2 could potentially catch her toes on the floor or surface, dragging the toes, and essentially result in foot drop, and therefore potentially cause a fall. PT stated prior to R2's last fall she should have worn AFOs while up walking or transferring. PT verified R2 was evaluated and assessed within the last plan of care and was unable to place the AFOs on by herself. PT indicated nursing were responsible for the application of the AFOs. PT stated communication with nursing would be expected to be in the plan of care. PT also stated nursing staff would be expected to assist R2 with the application of the AFOS prior to transfers and ambulation. During an interview on 9/14/23 at 12:50 p.m., nursing assistant (NA)-A stated had taken R2 to bathroom this morning and twice again after that. NA-A indicted R2 was no longer independent with transfers since her last fall on 9/1/23. NA-A verified R2 was unable to stand on the right leg or move the wheelchair out of the way. NA-A stated R2's care plan sheet indicated she was independent with toileting and AFO right and left, but it had not been updated yet. NA-A stated R2 informed NA-A she only needed to wear AFO on the right foot when ambulating. NA-A indicted the shoes R2 had on did not work with the AFO and she was unable to apply the AFO by herself. NA-A verified she had transferred R2 three times today without the AFO on her right foot and should have applied AFO to help stabilize the ankle and prevent foot drop. NA-A stated R2 usually asked during the day to have the AFO placed on her foot bud did not today. NA-A stated she just figured R2 felt she probably did not need the AFO on. During an interview 9/14/23 at 2:40 p.m., registered nurse (RN)-A stated R2's AFO's were not on her lower legs during the falls on 8/14/23, or 9/1/23. RN-A verified the AFO's were not listed on the treatment documentation. RN-A also stated once the order was received for the AFO's the nurse should have entered AFO's under treatment section on point click care (PCC). RN-A indicated nursing was responsible and held accountable to assure the AFO's were on consistently and properly. RN-A stated R2 had been pretty much consistent and wore ted hose daily and daily weight checks and did not believe R2 refused to wear the AFO's. During an interview on 9/15/23 at 9:30 a.m., NP stated R2 had bilateral foot drop and had been followed by a neurologist. NP stated R2 had spinal stenosis and a fusion of the lower back April 2022. NP verified R2 received AFO's to be applied and worn when ambulating and during transfers. NP stated R2 had the right to refuse orders such as the AFOs however staff would be expected to document refusal. NP also stated R2 had osteoporotic (weakening of the bones) and agreed with neurosurgery R2 needed assistance that kept her toes up and helped the foot drop to avoid further falls R2 would benefit from wearing the AFOS. During an interview on 9/15/23 at 12:15 p.m., licensed practical nurse (LPN)-A stated R2 would head down to therapy and bring a different pair of tennis shoes and when R2 returned to her room she had the other pair of tennis shoes along with the AFOs laid in her lap. LPN-A stated R2 removed her own AFO's but was unable to reapply them. LPN-A verified R2 was cognitively intact and requested assistance when they needed to be applied. LPN-A was unsure whether the NA's placed the AFO's on R2 and had not check on that. LPN-A stated R2 had foot drop, AFO's helped prevent the foot drop, and R2 occasionally refused to wear AFOs but was not well documented. During an interview on 9/15/23 at 1:30 p.m., wellness center coordinator (WCC) stated R2 needed AFOs on when she transferred and ambulated but not at rest. WCC stated she removed R2's AFOS, was difficult for her to bend over. WCC stated on 9/1/23 prior to her fall there were times when she pushed herself down the hallway with her feet and arrived at the wellness center without her AFOs. WCC indicated R2's memory had not been the best at times and had forgot to bring her AFOS with her when she came down to the wellness center. WCC stated R2 made a lot of progress in therapy and needed to wear the AFOs to avoid losing the progress she had already made while she transferred or ambulated. During an interview on 9/15/23 at 3:08 p.m., RN-B stated R2 was cognitively intact and identified what happened on all 3 falls: 7/14/23, ankle rolled, R2 removed the AFO's prior to the fall and was a contributing factor. R2 was provided education to keep AFO's on when up, 8/19/23, fall tried to transfer from electric wheelchair to manual wheelchair without AFO's on, education provided to R2 should ambulate with AFO's on and instructed how to stand pivot without having to ambulate, 9/1/23 fall AFO's were not applied during a self-transfer from electric wheelchair to the manual wheelchair. RN-B stated R2 was unable to place the AFO's on her lower legs/feet, required assistance, and was able to request help. RN-B also stated staff were expected to anticipate and provide cues for R2's needs (food, toileting, bathing, application of devices/AFO's) even though she was cognitively intact. During an interview on 9/15/23 at 4:49 p.m., director of nursing (DON) stated R2 was cognitively intact and unable to apply the AFO's herself. DON stated she expected nursing staff to anticipate R2 needs which included application of the AFO's and check in with R2 in which assistance would be provided to apply the AFO's and transfers to the toilet. DON indicated R2 occasionally forgot to ask for assistance with the application of the AFO's. DON verified R2 had three falls without AFO's applied, AFO's helped with foot drop, was a contributing factor which placed R2 at increased right for falls. DON stated documentation of the application of the AFO's was not a typical process we have done however moving forward it has been added to the nursing tasks. Facility policy titled Falls-Resident dated 3/2022, identified all residents would be assessed for fall risk and interventions implemented as appropriate. A comprehensive assessment will be completed with every fall to determine the root cause and to develop individualized interventions. Resident's care plan interventions will be updated after each fall. Facility policy titled Care Plans dated 11/2021, identified a person-centered care plan in conjunction with the interdisciplinary team and resident will be developed that reflects the actual care, condition, and preferences of each resident, revised at least monthly, and changes will be also made as they occur to ensure the most current plan for the resident.

Based on observation, interview, and document review, the facility failed to ensure foods were properly stored for 1 of 2 dry storage areas and 1 of 3 walk in freezers. This had the potential to affect 121 of the 122 residents that received food from the kitchen. Findings include: On 8/14/23 at 11:31 a.m., during an initial tour of the facility with dietary manager (DM) the following concerns were identified in the dry storage area and the walk in freezers: - four large boxes of ice cream bars had been placed on the middle of the floor of the walk in freezer which was attached to the walk in meat cooler. Basement dry Storage: The following items had been placed on the floor of the dry storage area: - four cases of lemon lime pop. - two cases of diet coke. - five large cans of baked beans. - two cases of oreo cookies. - one case of smucker's jelly jams. - one case of cake mix. - two cases of tomato soup. The culinary coordinator (CC) confirmed the above findings and indicated the facility had received their shipment of supplies last Friday. Basement walk in freezer: The following items had been placed on the floor of the walk in freezer: - had a case of [NAME] dean sausage. - had a case of wild fish. - had a case of biscuits. - had a case of broccoli. - had a case of strawberries. - had a case of carrots. - had a case of tater tots - had a case of scrabbled eggs. - had a case of crab meat, - had several cases of waffles. - had a case of coffee. - had a whole kernel corn. - had cases of shredded hash browns. - had a case of whip topping. The DM confirmed the above findings and indicated the facility had received their shipment of supplies last Friday. During an interview on 8/16/23 at 11:47 a.m., DM confirmed the above findings and indicated the facility received shipments every Tuesday and Friday. The DM indicated food should not be stored on the floor and dietary staff should be putting it away as soon as possible. The DM stated when food was not stored properly, there was a potential for food borne illness related to possible leaks on the floor, not a clean environment, rodents chewing and getting into the food and possible contamination of the food. During an interview on 8/16/23 at 11:55 a.m. the CC indicated the facility received shipments of food on Tuesdays and Fridays and usually dietary staff would put the food items away when they were delivered. The CC stated dietary staff should be putting the food items away as soon as possible due to infection control concerns, water on the floor and rodents. The CC indicated food being left on the floor could become contaminated and could cause a food borne illness. Review of facility policy titled, Cold Storage revised on 1/18, indicated all foods were to be stored at least six inches off the floor.

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R49, R1, R9, R10, and R111) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Pneumococcal Vaccine Timing for Adults, dated 3/15/2023, from the CDC identified adults [AGE] years of age or older who had previously received the Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive one dose of 20-valent Pneumococcal Conjugate Vaccine (PCV20) or one dose of 15-valent Pneumococcal Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent dose of PPSV23. Adults [AGE] years of age or older who had previously received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) should receive one dose PCV20 or PPSV23. The dose of PCV20 or PPSV23 should be administered at lease one year after the most recent PCV13 dose. Adults [AGE] years of age or older who had previously received the PCV13 and one or more doses of the PPSV23 should receive one dose of PCV20. The dose of PCV20 should be administered at least one year after the most recent dose of PPSV23. Review of R49's Minnesota Immunization Information Connection (MIIC) identified R49 had received the PPSV23 vaccination on 6/11/2018. R49's medical record lacked documentation R49 had been offered or received PCV20 or PCV15 vaccinations. Review of R1's MIIC identified R1 had received the PCV13 vaccination on 9/16/21. R1's medical record lacked documentation R1 had been offered or received the PCV20 or PPSV23 vaccinations. Review of R9's MIIC identified R9 had received the PVC13 on 12/8/15 and the PPSV23 on 10/31/94, 10/9/09, and 12/20/16. R9's medical record lacked documentation R9 had been offered or received the PCV20. Review of R10's MIIC identified R10 had received the PVC13 on 3/3/15, and the PPSV23 on 1/4/02. R10's medical record lacked documentation R10 had been offered or received the PCV20. Review of R111's Certification of Immunization identified R111 had received the PCV13 on 4/15/19, and the PPSV23 on 4/19/22. R111's medical record lacked documentation R111 had been offered or received the PCV20. During an interview on 8/16/23, at 3:59 p.m. the director of nursing (DON), interim infection preventionist (IIP), and vice president of clinical services(VPCS) confirmed the updated pneumococcal guidelines issued by the CDC on 3/15/23. VPCS and DON reviewed residents' immunization records and confirmed the medical records lacked documentation of PVC15, PVC20, and PPSV23 vaccinations. The DON stated her expectation was residents would be offered or receive pneumococcal vaccinations according to CDC guidelines. Review of facility policy titled, Pneumococcal Vaccinations updated 9/22, identified all residents would be offered pneumococcal vaccinations to aid in prevention of pneumococcal infections. Upon admission, residents would be provided information on the pneumococcal vaccinations and would be offered pneumococcal vaccinations after reviewing the residents pneumococcal vaccination history. Administration of pneumococcal vaccinations or revaccination would be made in accordance to CDC recommendations at time of the vaccination.

Based on observation, interview, and document review the facility failed to provide housekeeping services to ensure a clean environment for 2 of 2 residents (R65, R69) who had pervasive urine odors in the room. Findings include: R65 During observations on 8/14/23 at 1:43 p.m., R65 was laying on her back and was covered with a blanket sleeping. R65 had a catheter, which was placed in a privacy bag laying on the floor by the foot of her bed on the left side. R65's room had a strong urine odor which permeated out of her room and into the hallway. - at 1:58 R65 remained in the same position and the strong urine odor continued to permeate out of her room and into the hallway of the south wing on the first floor. During observations on 8/15/23 at 8:45 a.m., R65 was seated in her geri chair, call light in reach, the catheter was present in a privacy bag and hooked to her geri chair. R65 indicated she did not know how long she had her catheter in place and stated she has had infections in the past. R65's room continued to have a strong urine odor which permeated out of her room and into the hallway. - at 3:15 p.m., R65 was lying in bed resting and continued to have strong urine odor which permeated out of her room and into the hallway. - at 3:32 p.m., R65's room remained the same and housekeeping staff were observed to exit another resident's room and wheeled her cleaning cart into the soiled utility room. The staff were not observed to enter R65's room. - at 3:59 p.m., R65's room remained the same. - at 4:35 p.m., R65's was seated in her geri chair watching TV, with catheter in privacy bag hooked to her chair and the urine odor remained the same. During observations on 8/16/23 at 7:22 a.m., R65 was seated in her geri chair resting with her eyes closed, call light in reach, her catheter was placed in a privacy bag and hooked to her geri chair. R65's room continued to have a strong urine smell which permeated out into the hallway. - at 7:39 a.m., R65's and her room remained the same. - at 7:53 a.m. R65's and her room remained the same. During an interview on 8/16/23 at 7:42 a.m., house keeper (HK)-A indicated housekeeping staff cleaned resident rooms on a daily basis during the week and on the weekends the rooms were only cleaned when there was a spill or when something needed to be cleaned. HK-A indicated she only worked on the south wing of the first floor. In a follow up interview at 12:28 p.m., HK-A confirmed R65's room smelled of strong urine odor and indicated R65 had a catheter bag. HK-A stated when nursing staff emptied or changed the bag, it leaked onto the floor. HK-A indicated house keeping staff attempted to remove the urine smell by cleaning and it would go away at times. HK-A stated she had used an air freshener in the past and indicated she had not been directed on what else to do to remove the pervasive odor. During an interview on 8/16/23 at 12:36 p.m., licensed practical nurse (LPN)-A confirmed R65's room did smell of urine at times due to her having a supra-pubic catheter and having a very strong urine smell. LPN-A indicated at times staff would use a spray to assist with the odor removal in R65's room and indicated some days were worse than others. During an interview on 8/16/23 at 12:49 p.m. the administrator indicated her expectation of staff would be to minimize odors due to dignity issues. The administrator stated she would expect staff to try various things to minimize the odors in resident rooms such as air fresheners, cleaning rooms more, changing of linens, clothes, and to find out what the source of odor was and to fix it. Review of facility policy titled, Proper Cleaning of a Room revised on 4/2017, indicated the facility would ensure that all room were infection free and would clean all surfaces and floors in rooms. 48583 R69 Findings include: During observations on 8/15/23, at 9:05 a.m., R69 was seated in his recliner chair listening to music while looking out the window. R69's room had a strong urine/foul odor which permeated throughout the room and bathroom. - at 10:17 a.m. continued to have the same strong urine/foul odor and resident assumed the same position. - at 3:35 p.m. R69's room had finished being cleaned by housekeeping and R69's room continued to have the same strong urine/foul odor. - at 4:45 p.m. continued to have the same strong urine/foul odor and resident assumed the same position. During an interveiw and observation on 8/16/23, at 1:44 p.m. house keeper (HK)-A stated residents' rooms were cleaned on a daily basis during the week and only when needed on the weekends. HK-A confirmed R69's room had a strong urine/foul odor on 8/14/23 and 8/16/23. HK-A stated R69's room had a strong urine/foul odor in the past and had a couple air fresheners placed under his dresser to help eliminate the strong urine/foul odor. HK-A stated R69 did not leave his room often however when HK-A was working and R69 left his room, she would attempt to deep clean R69's room to help reduce the strong urine/foul odor. HK-A indicated maintenance had not been contacted about R69's strong urine/foul odor. During an interview on 8/16/23, at 1:54 p.m. the administrator and vice president of clinical services indicated her expectations were for house keeping staff to clean each resident's room daily to ensure they were clean and to minimize odors due to dignity issues. The administrator stated she would expect nursing staff to work with house keeping and the house keeping supervisor to locate the source of the odor and to remove it. Review of facility policy titled, Proper Cleaning of a Room revised on 4/2017, indicated the facility would ensure that all rooms were infection free and staff would clean all surfaces and floors in rooms.

Based on observation, interview, and document review, the facility failed to ensure residents were free from accident and hazards as possible for three of 10 residents (R47, R45 and R118) reviewed for accidents. The facility failed to provide adequate supervision to prevent falls for R47 and R45; and failed to assess R118 for smoking safety measures. This deficient practice resulted in actual harm for R47 who suffered a scalp laceration and hematoma which required medical intervention. Findings include: FALLS R47 Review of R47's undated Admission Record identified she had been admitted to the facility on [DATE]. Review of her diagnoses indicated R47 had a history of falling upon admission, adult failure to thrive, other symptoms and signs involving cognitive functions and awareness, anxiety disorder, other abnormalities of gait and mobility, [CONDITION(S)], and dizziness and giddiness. Review of R47's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 was cognitively intact. The MDS indicated R47 required limited assistance of one staff for transfers and walking in her room; extensive assistance of one staff for toilet use and personal hygiene; was not steady but able to stabilize herself when moving from a seated to standing position and moving on and off the toilet. Review of R47's care plan revealed a care plan intervention of mat on the floor next to bed, initiated on 09/23/19, and resolved on 03/08/20. The care plan indicated R47 was at high risk for falls due to history of falls and history of self transferring. The care plan identified R47 required stand by assist of one with transfers. Review of R47's form titled Fall Risk Predictive Factors, dated 3/26/20, revealed R47 scored 15, indicating she was at high risk for falls. Specifically, the resident triggered for diminished safety awareness, impaired mobility, balance problems while standing and walking, being legally blind, taking medications with known adverse reactions of falls, and having disease processes which contributed to falls. Review of R47's progress notes from 6/11/20, to 6/12/20, revealed the following: -6/11/20, at 8:00 p.m. indicated R47 was found on the floor in her room with a cut and swelling to the back of the head. -6/12/20, at 10:34 a.m., late entry identified staff found resident lying on the floor with head facing the closet. A laceration and swelling of three cm (centimeters) by two cm was noted to the back of the left lower part of her head. Resident was being toileted, and nursing assistant (NA) left resident in the bathroom and went to assist another resident. R47 attempted to self-transfer to her bed and she tripped over the fall mat that was placed in front of her bed. The root cause of the fall was determined to be the resident had been left unattended and a fall mat created obstruction of movement for R47. R47 described a throbbing pain of 8/10 to the back of her head. R47 was assisted into a stretcher by two emergency response staff. The fall mat was removed from R47's room and education had been provided to NA by nursing staff. Review of an undated and untitled document included in the folder titled Final Report for R47's 6/11/20, fall identified by registered nurse (RN)-A as the pocket care plan in use by the NAs at the time the fall, instructed staff to not leave R47 alone in the bathroom. Further review of the document indicated no fall mat was planned for the resident. Review of the investigation summary for R47's 6/11/20, fall identified R47 was not to be left alone in the bathroom. The summary indicated previous fall interventions (low bed and fall mat) were discontinued in March due to R47 beginning to self-transfer in the evening hours as a fall mat and low bed would place R47 at increased risk for falls. On the evening of 6/11/20, R47 was noted to be self-transferring from her bed to the bathroom, direct care staff intervened and assisted her to the toilet. R47 was left alone in the bathroom while the direct care staff left to attend to another resident in the hallway. During that time, R47 attempted to get herself off of the toilet and transfer with her walker back to her bed. While doing so, R47 tripped over a fall mat that was on the floor and fell backwards hitting her head on the ground. Charge nurse performed a physical assessment and noted a deep laceration to her skull that was bleeding large amounts of blood. Order was obtained to transfer R47 to the ER (emergency room ) for further assessment of the head injury. Charge nurse noticed immediately the floor mat was on the ground and asked direct care staff to review the care plan. It was noted the care plan was not followed by that specific staff member. Areas of the care plan that were not followed included: resident was left unattended in the bathroom and the floor mat was put down. Upon further interviewing, it was noted the direct care staff member stated she had not reviewed R47's care plan and put interventions in place she recalled from the previous time she worked with R47. R47 was admitted for observation in the hospital and was diagnosed with a scalp hematoma. Staples were placed in her head and she was sent back to facility. An interview with RN-A on 3/09/22, at 11:11 a.m. revealed she did not recall the incident per se, however after reviewing R47's EMR stated the facility determined the resident's fall and subsequent injury were the result of the staff not following R47's care plan. RN-A indicated the facility determined the NA had not read the resident's care plan prior to providing care, which did not meet her expectation in terms of fall prevention. The NA determined to have not followed R47's care plan no longer worked at the facility at the time of the survey and was unavailable for interview. An interview with the administrator on 3/10/22, at 12:26 p.m. identified she had not been in her current role at the time of R47's fall, however it was her expectation staff would follow the care plans written for the residents, to include adequate supervision to prevent falls and structuring the resident's environment to minimize accident hazards. R45 Review of R45's Admission Record revealed she was most recently admitted to the facility on [DATE]. Review of her diagnoses identified R45 had dementia without behavioral disturbances, a need for assistance with personal care, unspecified abnormalities of gait and mobility, and muscle weakness. Review of R45's quarterly MDS dated [DATE], revealed R45 was severely cognitively impaired. The MDS indicated R45 had no rejection of care or other behaviors; required extensive assistance of one staff person for transfers and toilet use; and was not steady and only able to stabilize with human assistance with moving on and off the toilet. The MDS identified R45 had two or more falls since the prior assessment and one of the falls resulted in an injury. Review of R45's care plan identified R45 was at risk for falls related to history of falls and dementia and instructed staff to offer the toilet every hour beginning on 9/16/20. The care plan indicated R45 transferred with stand by assistance of one staff. Review of form titled Third Floor Care Plan printed on 3/8/22, instructed staff to offer toileting every hour and as needed due to frequent attempts to self-transfer. Review of R45's Progress Notes from 9/29/21, to 3/8/22, revealed the following: R45 had falls with no injury attempting to get on or off the toilet on 9/29/21, at 11:30 a.m., 10/05/21, at 5:15 a.m., 12/03/21, at 7:40 p.m., 1/20/22, at 11:22 a.m. and 2/10/22, at 9:53 p.m. A continuous observation of R45 on 3/08/22, between 2:26 p.m. and 5:00 p.m. (two and a half hours) revealed: On 3/08/22, at 2:26 p.m. R45 was in her room. Her wheelchair was next to her bed, and she transferred without assistance from her bed to her wheelchair. At 2:28 p.m., R45 was seated in her wheelchair in the doorway to her room, peering out into the hallway. R45 remained there until 2:30 p.m., then stated to no one in particular she was going back into her room to watch a movie. On 3/08/22, at 2:52 p.m. NA-B entered R45's room to freshen her water. NA-B did not offer R45 assistance to the toilet. At 2:54 p.m., NA-C entered R45's room looking for NA-B. R45 asked NA-C about items on her activity calendar. NA-C stated she would find out and NA-B and NA-C exited R45's room. NA-C returned to R45's room at 2:56 p.m. with the response to R45's question about activities and exited the room. NA-C was not observed to offer R45 assistance to the toilet. On 3/08/22, at 3:01 p.m., NA-B, NA-A, and NA-C were noted to be outside R45's room. NA-B provided shift to shift report to NA-A and NA-C. NA-B stated R45 had been toileted. On 3/08/22, at 3:56 p.m. R45 came to the door of her room in her wheelchair, saw NA-C and motioned her to her room. R45 asked NA-C what time it was and what was for dinner. NA-C responded to R45's questions and left the room without offering the toilet. On 3/08/22, at 5:00 p.m. licensed practical nurse (LPN)- B approached R45 as she sat in the doorway to her room in her wheelchair and offered to take her to dinner. R45 agreed and LPN-B wheeled R45 to the dining room. LPN-B was not observed to offer R45 the toilet. An interview with NA-D on 3/09/22, at 11:00 a.m. NA-D stated she was one of the NAs responsible for R45's care that day and was familiar with R45's care needs. NA-D verified she had not offered R45 the toilet every hour because the resident took herself independently. NA-D stated she was unaware R45 had fallen getting to and from the toilet. An interview with NA-E on 3/09/22, at 11:05 a.m. identified she was one of the NAs responsible for R45's care that day and was familiar with R45's care needs. NA-E confirmed she had not offered R45 the toilet every hour because she believed R45 took herself independently. NA-E stated she was unaware R45 had fallen getting to and from the toilet. NA-E indicated she became aware of each resident's care needs via verbal report from the previous shift, and from reading the care plan document the NAs received at the beginning of each shift. NA-E removed the days' care plan from her uniform pocket, and after reviewing it stated, Oh, I guess I am supposed to help her. To be honest, I get a verbal report from the previous shift but because I know this resident, I don't always read the care plan. An interview with RN-A on 3/9/22, at 11:11 a.m. who was the Resident Care Manager (RCM) for the third floor, identified it was her expectation the NAs working with R45 follow the care plan. 100 percent. The only time they can do anything differently is if they think a resident needs more help than the care plan says. Then they can provide the help they think the resident needs, but they have to tell the charge nurse afterwards. They can never provide less, though. RN-A stated she was familiar with R45 and her fall history and had taken place in the Interdisciplinary Team (IDT) discussion where the determination was made to assist R45 to the toilet every hour. RNA stated, She falls in the bathroom a lot. This was our plan to prevent further falls. When informed of the surveyor observation that the resident was not offered or assisted to use the toilet for two and a half hours, RNA stated, That absolutely does not meet my expectation in any way, shape, or form. An interview with the administrator on 3/10/22, at 12:26 p.m. revealed it was her expectation the NAs would follow the resident care plans for fall prevention, and if the care plan was not followed the expectation was not met. Review of the facility's policy titled Falls revised 03/22, identified all residents would be assessed for fall risk and interventions implemented as appropriate. Review of the facility's policy titled Standards of Care revised 04/2021, identified each staff member providing direct nursing care would have in their possession throughout their shift the written plan of care for each resident and would perform specific cares. SMOKING R118 Review of R118's annual MDS dated [DATE], indicated R118 was cognitively intact, and used tobacco products. Review of the 1/24/20, facility form titled Diagnosis revealed R118 had [CONDITION(S)], unspecified affecting right dominant side, unspecified convulsions, tremor unspecified, and personal history of traumatic brain injury. Review of R118's care plan dated 1/24/20, revealed a focus area for a potential for safety concerns due to R118 going outside off property to smoke cigarettes. Education had been provided to R118 regarding the risks associated with this in which he reported he understood. The focus area identified a smoking assessment had been completed upon admission. R118 was able to light his own cigarette and able to handle the mechanics of smoking safely. Cigarettes and lighters were to be kept in the med [medication] cart and locked up. R118 was educated that staff needed to be present with him when he left to smoke and he needed to sign out with the nurses prior to leaving the building. Review of the 1/24/20, to 3/08/22, Assessments tab located in the EMR revealed no smoking or safety assessment to assess if resident was able to keep his smoking materials on his person. Review of the 1/30/20, admission note identified staff met with R118's wife to review admission paperwork. R118's wife handled business affairs and R118 was able to make day to day decisions but due to a brain injury wife handled finances. R118 was a smoker and was aware the facility was a non-smoking campus. Wife had talked to R118 about that and she stated he understood. The staff reminded R118's wife to make sure the nurses kept his cigarettes and lighters. Review of the 12/28/21, communication note located in the EMR under the progress note revealed staff had a conversation with resident regarding smoking outside of facility. Staff discussed Eventide was a Smoke free facility and he could not smoke on Eventide property. Discussed that he had been observed smoking near building. R118 acknowledged he had been closer to building. Staff reiterated to R118 he could not do that. R118 verbalized understanding and then explained where he went to smoke, which was an accepted location not on property or in front of resident windows on 8th street. Staff stated it was getting colder, and he needed to wear appropriate clothing to go outside. R118 showed staff his hat, gloves, and coat. Staff encouraged R118 to limit his time outside when it was very cold and he verbalized understanding. Staff encouraged him to keep his phone on him when going outside and ensured wheelchair was powered. Staff strongly educated him that he needed to alert staff when going out, so staff were aware to check on him if needed. R118 verbalized understanding of the education. Review of the 6/15/21, communication note located in the EMR under the progress note revealed R118 was at 8th and 16th streets and was waving at cars to honk at him. Staff walked out and he was further down on 16th street away from busy traffic. When asked where he went to smoke, R118 stated 8th and 16th or 7th and 16th. Staff asked him to use the 7th and 16th streets since it was less busy. R118 agreed. Review of the facility form titled List of Residents Who Smoke, located in the facility survey book, revealed Designated Smoking Times, & Locations Eventide on 8th is a non-smoking campus and we don't have any residents who smoke. On 3/09/22, at 9:55 a.m., RN-B stated R118 went outside to smoke on a sidewalk off premises along the main street. RN-B stated R118 signed himself out and carried his cell phone. RN-B walked the surveyor close to the location and pointed R118 out as he sat in his electric wheelchair on the sidewalk by himself. On 3/09/22, at 1:05 p.m., R118 was observed in his electric wheelchair in his room placing a pack of cigarettes in his coat pocket. On 3/09/22, at 12:48 p.m., RN-A asked about a smoking assessment for R118. She confirmed there was not a smoking assessment for R118. During an interview on 3/09/22, at 3:12 p.m., RN-C stated R118 kept the smoking materials, cigarettes and lighter, on him. RN-C indicated she was unaware of any safety assessment for R118 except checking his clothes for burn marks. At 3:40 p.m., RN-C approached the surveyor and stated, we don't do smoking assessments on R118 because we are a non-smoking facility and that's his business. He goes off the property and keeps his cigarettes and lighter on his person. When asked to see R118's smoking materials, she stated oh no, that's his business. You'll have to ask him. On 3/09/22, at 3:42 p.m., R118 was observed in his room sitting in his electric wheelchair. R118 showed his pack of cigarettes and lighter to the surveyor after he was asked if he kept them. He stated his lighter was a BIC lighter (Pocket lighter made with isobutane fuel) and did not use matches. On 3/10/22, at 9:25 a.m., the sign-out book was reviewed again and the last sign-out day/time for R118 was 3/04/22, when R118's wife signed. Review of the facility's smoking policy, revised 11/2014, revealed it was Eventide's policy that all buildings and grounds were smoke-free. Purpose: To promote and maintain a safe and healthy environment for all residents, visitors, and employees. Procedure: 1. Residents and visitors may not smoke in the apartments, hallways, common areas, or on Eventide grounds. Anyone seen smoking would be asked to put their cigarette out immediately and be informed of the policy. 2. Residents/representatives were informed of the policy prior to signing a reservation agreement and again when signing a lease. 3. Failure of a resident to abide by the policy would result in an eviction notice.

Based on interview and document review, the facility failed to implement their policy related to cardio-pulmonary resuscitation (CPR) for 1 of 3 residents (R1) reviewed for death. Although staff initiated CPR, they did not call 911 or continue CPR, for R1 when he had no pulse or respirations. The deficiency was identified as a past non compliance Immediate Jeopardy (IJ) situation. The IJ began on [DATE], when the facility failed to continue CPR for R1 when his heart stopped and he had no respirations. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was identified as Past Noncompliance. Findings include: Review of the professional guidelines from The (YEAR) American Heart Association (AHA) guidelines indicated: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of EMS in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. R1's face sheet identified an admission to the facility date of [DATE]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had [DIAGNOSES REDACTED]. R1's MDS indicated R1 had moderate cognitive impairment, required extensive assistance with activities of daily living (ADLs). R1's care plan, initiated [DATE], indicated R1 was a Code level 1 (desired CPR), a fall risk and was independent with ambulation and transfers with use of a walker (worked with therapy). R1's care plan listed his goal was to discharge from the facility to an assisted living facility with his wife or to remain at the facility. R1's Uniform Code Level Directives for Cardiopulmonary resuscitation was dated [DATE], and directed a Code Level 1: All available reasonable technology is used in the event of cardiac or respiratory arrest. The form was signed by the responsible party [DATE] and by the physician on [DATE]. R1's signed Medication Review Report, signed [DATE], identified R1 was a code level 1 status Review of the nursing progress notes dated [DATE] at 7:48 a.m. indicated R1 was resting in bed [DATE], at 12:15 a.m. At 1:45 a.m. a thump was heard by nursing assistant (NA)-A and investigated. NA-A found R1 on the floor and alerted the nurse (registered nurse (RN)-C, the author of the nursing progress note). R1 did not respond to verbal stimuli or touch, and when attempted to check the resident's vital signs, they did not register on the machine, there was no heart beat, carotid or radial pulses. The note indicated resident was a code 1, thus 1 round of CPR was performed. The note indicated R1 continued to have no response and no response to sternal rub, and was becoming increasing cold to touch and mottled in both lower extremities. R1 was pronounced dead at 1:55 a.m. The progress notes further indicate the on call physician was notified, manager on call, family was notified and Ramsey County Coroner's office was contacted and authorized release of the body. Review of the death summary signed by the physician [DATE], indicated cause of death to be undetermined natural causes. When interviewed via telephone on [DATE], at 8:10 a.m., RN-C verified she was the nurse working on the floor that R1 resided on at time of event, and reported the nursing assistant (NA)-A alerted her to come to R1's room. RN-C stated R1 was observed laying against his closet in a position indicating he may have slid down, based on how his head rested. RN-C further stated, she was unsure if R1 had fallen or slid down the closet and had his torso fall later causing the thump NA-A heard. RN-C stated R1 was cold, but she had initiated one round of CPR compressions and 2 breaths before she stopped providing CPR to R1. RN-C verified 911 was not called. RN-C stated, I should have continued CPR and called 911. I am only on casual status and am not up to date on all policies. RN-C stated she thought R1 had been gone for awhile based on his skin temperature and coloring (waxy). RN-C denied any injuries for R1 and indicated he did not have a history of falls in the facility. RN-C stated she had been trained on one unit of the facility, and had been told she would be trained on the other units as time went by, but that had not yet happened and she worked everywhere. RN-C said she'd received retraining onsite by RN-D immediately after this incident. RN-C also verified she had current CPR certification and was due for renewal (MONTH) 2019. During an interview on [DATE], at 10:40 a.m. the RN-B (director of clinical services) confirmed R1 was a code level 1 and explained the differences between witnessed and unwitnessed for Code 1. She indicated she felt R1 had a witnessed event and CPR should have been continued and 911 called. During an interview on [DATE] at 1:00 p.m., RN-A (director of clinical education), stated CPR was started per protocol for CODE 1 status for R1 but was stopped after one round. RN-A stated, I'd expect CPR be initiated, 911 be called, and for staff to continue CPR until the medics get here. That did not happen. RN-A verified there was immediate staff retraining onsite in regards to the CPR policy provided by RN- D to RN-C and all other nursing staff throughout that weekend. During a telephone interview on [DATE] at 12:27 P.M., RN-D confirmed she was the on-call RN for the weekend and during the early morning hours of [DATE] she had received a notification call from LPN-A of R1's death. RN-D came to the facility and conducted interviews with the staff immediately. RN-D stated chest compressions and respirations were provided to the resident and then stopped after one round. RN-D stated RN-C had reported R1 did not respond to the CPR efforts after one round and had described R1 as becoming waxy. RN-D stated, Once CPR is initiated, you keep on. In addition, RN-D stated, Since we heard the event, we needed to do CPR. RN-D verified she had immediately initiated re-education for all licensed staff immediately after the incident, ensuring each new shift coming on duty throughout the weekend received the education. RN-D further verified she had contacted administration and filed a report with the Office of Health Facility Complaints as mandated due to the alleged neglect of care. Review of the facility documentation titled Education Nurses-Unexpected Deaths/CPR Policies listed all licensed nursing staff working over the weekend from [DATE] through [DATE]. During an interview on [DATE], at 1:30 p.m., RN-E indicated she had recently been retrained on the Unexpected death/CPR policies and was able to identify Code 1 and Code 2 status and when to start and/or stop CPR. During an interview on [DATE], at 1:40 p.m., RN-F indicated she had been retrained on the Unexpected death/CPR policies and was able to identify Code 1 and Code 2 status and when to start and/or stop CPR. During an interview on [DATE], at 1:55 p.m., RN-G indicated she had been retrained on the Unexpected death/CPR policies and was able to identify Code 1 and Code 2 status and when to start and/or stop CPR. During an interview on [DATE], at 1:55 p.m., LPN-B indicated she had been retrained on the Unexpected death/CPR policies and was able to identify Code 1 and Code 2 status and when to start and/or stop CPR. Review of the facility's CPR/AED/CODE LEVEL Status policy revised ,[DATE] included: An Automated External Defibrillator (AED) will be available for use in the event of a sudden [MEDICAL CONDITION] of residents, and other persons who are 8 years of age or older, who have a [MEDICAL CONDITION] in the nursing home home. All licensed nurses of Eventide will be CPR/AED certified. CPR with the use of the AED will be initiated as recommended by the American Heart Association. The policy further directed all new residents and /or responsible party would upon admission, hospital return, and annually, have a Uniform Code Level discussed and signed and documentation would be made in the resident's chart. The policy further directed: CPR will not be done on an unwitnessed arrest of a resident with complete absence of signs of life, or someone who has chosen a Code level 2 status (do not resuscitate). The past noncompliance immediate jeopardy began on [DATE], when the facility failed to implement their policy, and the resident's directive, related to cardio-pulmonary resuscitation (CPR) for R1. Although staff initiated CPR, they did not call 911 or continue CPR for R1 when he had no pulse or respirations. The immediate jeopardy was removed and the deficient practice corrected by [DATE], when the facility had implemented a systemic plan of correction that included re-educating the facility's licensed nursing staff regarding the Facility's CPR Code I and Code II status and when to call 911; and re-education regarding resident wrist bracelets being labeled with green dots to indicate full code.

Based on observation, interview and document review, the facility failed to conduct comprehensive fall assessments to determine a root cause analysis, identify patterns of falls and effective interventions; and failed to consistently implement interventions to prevent additional falls, for 4 of 4 residents (R7, R131, R70 and R202) in the resident sample who had a history of [REDACTED]. This deficient practice resulted in an immediate jeopardy for R7, R131 and R202 who sustained multiple fractures with falls. The immediate jeopardy began on 5/2/19, when R131 had not been comprehensively assessed for the root cause of repeated falls with fractures and appropriate interventions implemented and was identified on 8/9/19. The facility administrator and director of nursing (DON) were notified of the immediate jeopardy at 4:47 p.m. on 8/9/19. The immediate jeopardy was removed at 1:34 p.m. on 8/11/19, but noncompliance remained at a H scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R7 R7's annual MDS dated [DATE], identified R7 had [DIAGNOSES REDACTED]. The MDS identified R7 had moderate cognitive impairment and required extensive assistance with ADL's, which included; bed mobility, transfers, toileting and walking. The MDS identified R7 was unable to maintain her balance during transition without physical assitance. The MDS identified R7 had two or more falls without injury and two falls with a major injury since the last assessment (4/17/19.) R7's quarterly MDS dated [DATE], identified R7 had moderate cognitive impairment and was independent in transfers and ambulation. The MDS identified R7 required supervision with bed mobility and locomotion off of the unit. The MDs identified R7 was able to independently maintain her balance during transitions and had one fall without an injury since her last quarterly assessment. R7's annual Care Area assessment dated [DATE], identified R7 had a [DIAGNOSES REDACTED]. The CAA identified R7 required extensive assistance with ADL's and indicated R7's participation in ADL's fluctuated due to her impaired cognition. The CAA identified R7 was at risk for falls and had several falls in the last quarter with and without injury. R7's CAA indicated interventions were in place to prevent falls and/or injury related to falls. The CAA identified R7 had a [MEDICAL CONDITION], though did not identify how R7 had obtained the [MEDICAL CONDITION] and had received physical therapy services four times a week. R7's care plan revised 7/16/19, identified R7 had a potential risk of falls related to impaired mobility and history of falls. The care plan revealed R7 had a fall on 5/6/19, which resulted in a dislocated left shoulder and a fall on 5/10/19, which resulted in a fractured right femur. The care plan revealed R7 was to bear weight as tolerated and listed various interventions for fall prevention which included; transfer with assistance of one and walker, gripper socks when not wearing shoes, keep water mug next to bed, Geri-hips (padded garment worn around the hips) and anti-roll back device to wheelchair. R7's undated nursing assistant care guide, revealed R7 required assistance with transfers, assist of one with toileting every two hours and revealed the following safety interventions: gripper socks at all times when not wearing shoes, anti-roll back device on wheelchair, remove wheelchair pedals unless transporting resident, Geri-hips on at all times, non-skid strips next to bed and a foot cradle to keep bedding off of her feet. R7's nursing assistant care guide lacked direction to keep her water mug within reach. R7's Fall Risk Assessment, dated 5/19/19, identified R7 was at risk for falls identified by the following factors: diminished safety awareness, ambulatory and incontinent, required use of an assistive device, had three or more falls in the last three months and received high risk medications. The risk assessment lacked an analysis of R7's risk factors, patterns of falls, injury with falls or current and tried interventions. R7's Fall Risk Assessment, dated 7/10/19, identified R7 was at risk for falls identified by the following factors: diminished safety awareness, ambulatory and incontinent, required use of an assistive device, had one to two falls in the last three months and received high risk medications. The risk assessment lacked an analysis of R7's risk factors, patterns of falls, injury with falls or current and tried interventions. R7's medical record lacked any comprehensive assessments of R7's falls. During an observation on 8/9/19, at 11:21 a.m. R7 was lying in bed partially covered by her sheet and bedspread laying on her left side facing the door. R7's wheelchair was parked near the lower 1/2 of her bed at a 45 degree angle, and several two inch wide by 12 inch long non skid strips were affixed to the floor next to the bed. R7's overbed table had two mugs of water on the edge farthest of the overbed table which was approximately three feet away from R7. R7's call light rested on the floor at the foot of the bed, and a second call light was clipped to the call box mounted in the middle of the wall several feet from her bed, out of reach for R7. At that time, nursing assistant (NA)-F briefly entered R7's room, and set a paper plate with a piece of toast on her bed next to R7. NA-F briefly talked to R7 and exited the room, and R7's water mugs and call lights remained in the same position, out of reach for R7. On 8/9/19, 11:48 a.m. R7 remained in bed, her call light light remained on the floor, and her water mugs remained on the over the bed table, out of her reach. Review of R7's progress notes from 10/21/2018, to 8/9/19, revealed the following: -10/21/18, at 6:10 a.m. found on the floor of her bathroom and indicated she had slipped on the floor of the bathroom. The note listed R7 had been independent with ambulation and toileting at the time of the fall. R7's care plan had been reviewed and no new interventions were initiated at the time. R7's fall note lacked a comprehensive analysis of the fall, such as environmental factors, incontinence, cognition and balance. -12/23/18, at 12:33 p.m. R7 reported to staff she had fallen sometime during the night or early morning, and had fallen on her knees. R7 had denied hitting her head, though indicated she had pain 10/10 (numeric pain scale from 0-10, 0 being no pain and 10 being the worst pain imaginable) in her knees. At 4:33 p.m. R7 reported to staff she had fallen two or three times during the night and early morning. R7 was noted to have several bruises; 1.2 centimeter (cm) by 1 cm light purple bruise below her left knee, 1.8 cm by 1.3 cm dark purple bruise on her right upper hip, and a 9 cm by 11 cm light bruise which was forming on her left upper arm. The note indicated R7 was unsteady with her four wheeled walker and would be referred to physical therapy. -4/16/19, at 7:05 p.m. staff had witnessed R7 ambulating in a common area with a walker. R7's walker got too far out in front of her, had fallen face down on the floor, had not hit her head and had a blood pressure of 183/104 at the time of the fall. R7 had reported she was coming to the nurses' station because she had a headache. She was reminded to keep her walker close to her while walking and had demonstrated to the author how to keep her walker close. The note identified R7 remained a potential risk for falls and no new interventions were implemented. The note lacked information on what type of walker R7 used at the time of the fall, pain or neurological assessment. Further, the note lacked a comprehensive analysis of R7's fall to determine a root cause analysis and identify a potential pattern of falls. -5/2/19, at 10:30 p.m. found face down on the floor, in the hallway by her room, with a four wheeled walker in front of her and feet behind her and stated the walker had gotten away from her. The note revealed R7 was unable to move her left arm, had numbness from her neck to her fingers and pain with range of motion and blood pressure was 191/102 at the time of the fall. The note indicated R7 was at risk for falls, had dementia and a history of falls. The note listed R7 had past falls with the four wheeled walker and a physical therapy (PT) evaluation would be requested. -5/3/19, at 12:31 a.m. Sent to the hospital by ambulance. A later note revealed R7 had returned to the facility with a [DIAGNOSES REDACTED]. R7's blood pressure's upon return to the facility were as follows: -10:30 a.m. 130/85 -12:00 p.m. 153/103 -3:45 p.m. 123/76 The note indicated R7's four wheeled walker had been evaluated by (PT) and had been replaced with a two wheeled walker due to faulty brakes and R7's inability to keep a four wheeled walker within safe distance. The note lacked any information on R7's ability to safely ambulate independently or further blood pressure monitoring. -5/4/19, at 6:00 p.m. found lying on the floor of her room with her walker three feet in front of her, had increased confusion, disorientation and a blood pressure of 168/97. Walker was 3 feet out of reach and did not appear as though she had been using it at the time of fall. R7 had been incontinent of a large amount of urine and was unable to stand on her right leg. R7 was not aware she had fallen and was sent to the emergency room for evaluation. The note lacked a comprehensive analysis of R7's fall to determine a root cause analysis and identify a potential pattern of falls. 5/6/19, at 12:00 p.m. returned to the facility from the hospital, and did not identify the [DIAGNOSES REDACTED]. -left upper arm 5.0 cm by 9.0 cm, 3.0 cm by 3.0 cm, and 15 cm by 9 cm. -left forearm 2.0 cm by 2.0 cm -right forearm 4.0 cm by 4.0 cm, 3.0 cm by 3.0 cm. -right hip, 5.0 cm by 2.0 cm The note lacked any comprehensive assessment to identify potential root cause, patterns of falls and review of R7's fall interventions. Further, the note lacked indication of whether R7's significant bruising had been a result of her fall on 5/4/19. -5/9/19, at 1:00 p.m. found on the floor of her room with her walker three feet away from her. The note revealed R7 appeared to have attempted to walk towards her computer. The note identified R7 was hollering out in pain, holding her right thigh/lower hip, had decreased range of motion of her right leg and unable to fully extend leg. The note revealed R7 was not fully oriented and was sent to the emergency department by ambulance. A further note identified R7's blood pressure was 98/59 at the time of the fall. The note lacked a comprehensive analysis of R7's fall to determine a root cause analysis and identify a potential pattern of falls. -5/14/19, R7 returned to the facility via stretcher and fall interventions were discussed with family. The note indicated R7 had impaired mobility and identified the following fall interventions were to be implemented; low bed and floor mat. A note on 5/13/19, indicated R7's room had moved to a room closer to the nurses station due to her increase in falls and confusion. -6/6/19, R7 had been assisted to the bathroom, was left in the bathroom and had ambulated by herself back to her bed. The note revealed R7 had been educated on the risks of self-transferring, however had dementia and a history of non-compliance. The note lacked any other interventions attempted to prevent/reduce R7's self-transfers. -6/17/19, at 5:00 a.m. R7 was heard hollering for help from her bathroom, found hanging onto the right side of the bathroom door and facility staff assisted her to the floor. The note identified R7 had indicated she had ambulated herself to the bathroom and was unable to make it back from the bathroom. The note revealed R7 had complained of pain to her right leg and was sent for x-rays of her right leg. The note revealed no new interventions were implemented following R7's fall. The note lacked a comprehensive assessment to determine a root cause analysis and identify potential patterns to reduce R7's risk for falls. A later note revealed R7 would unsafely transfer daily. -7/16/19, at 4:00 p.m. found seated on the floor of her room with a wheelchair in front of her, towards her left side. The note indicated R7 had reported she had attempted to get a drink or something, had tripped over her wheelchair foot pedals, which were in the down position on wheelchair, and had landed on her knees. R7's blood pressure was noted to be 168/100, at the time of the fall. The note indicated R7's wheelchair footrests were to be off unless R7 was being transported. The note lacked a thorough comprehensive assessment into the root cause of R7's fall, further blood pressure monitoring or a potential pattern of her falls. -7/17/19, at 1:45 a.m. found lying on the floor of her room by her bed with gripper socks on. R7's wheelchair was locked next to her bed, and her walker was across her room. The note revealed R7 was observed by facility staff at 10:30 p.m. lying in bed with her walker next to her bed. The note revealed R7 was not sure what she had been trying to do, though indicated she maybe wanted water, and indicated her water cup was not within reach. The note indicated R7's blood pressure at the time of the fall was 98/67, remained a potential risk for falls. R7 was educated on the importance of calling for help and the use of her call light. Further, the note revealed R7's water mug was to be kept within reach. R7's note lacked a comprehensive analysis of the fall, potential pattern of falls and her cognition at the time of the fall. A later note revealed R7 had increased pain to her right hip, was sent for x-rays which showed [MEDICAL CONDITION] changes, but no new fracture. -7/21/19, at 4:15 p.m. nurse heard R7 hollering help from room, was found lying on the floor of her room with her walker at the end of the bed and a wheelchair at her bedside. The note revealed R7's call light had been within reach, had not been used, R7 had indicated she had walked over to her couch and her knees gave out. The note revealed R7 had braced herself with her hands and complained of wrist pain. R7's blood pressure at the time of the fall was noted to be 165/104. The note indicated Geri-hips had been applied as an intervention. R7's note lacked a comprehensive analysis of the fall, potential pattern of falls and her cognition at the time of the fall. The note further lacked any blood pressure monitoring. -7/25/19, at 5:47 a.m. found seated at the edge of her bed, with her pants, incontinent brief down to her knees and had been incontinent of bowel. The note revealed two staff members had attempted to assist R7 with incontinence cares, though R7 had refused. The note indicated R7 had been left in her room, seated at the edge of her bed, and staff would re-approach her before the day shift got to work. -7/28/19, at 5:24 p.m. R7 had been found to have routinely self-transferred numerous times throughout the shift. Facility staff had witnessed R7 standing alone in her room as well as using a wheeled over the bed table as walker towards the bathroom, like a walker. The note indicated R7 had increased confusion and was not able to recognize her room and asking to pack her bags to leave. The note revealed facility staff frequently checked on R7, attempt to catch resident when she is up, assist with toileting, distraction and reminded her to use her call light. -7/29/19, at 2:16 p.m. found in her room, she had self-transferred herself from her bed to a wheelchair and was seated sideways in the wheelchair. R7's right knee had been resting on the upper connected part of the wheelchair foot rest and had two new bruises to her right knee. The note revealed R7 had been reminded not to self-transfer and to use her call light. -8/1/19, at 2:00 a.m. staff heard R7 yelling help from her room, found on the floor of her room, lying on her right side with her right arm underneath her. R7 stated she had been fixing the sheets on her bed, next thing she was on the floor. The note indicated R7's blood pressure at the time of the fall was 192/105 lying, 188/100 sitting, temperature was 100.3, and R7 complained of back pain. The note revealed R7 had a potential risk for falls related to mobility, history of falls and impulsivity. The note indicated a low bed and a lipped mattress would be more of a hazard than a safety intervention, no new interventions were implemented at that time. R7's medical record lacked a comprehensive assessment of any of the thirteen aforementioned falls which included root cause analysis, determination of any patterns of the falls, review of current intervention for appropriateness and routinely implementing fall interventions. On 8/9/19, at 11:21 a.m. NA-F stated R7 had recently broken her hip following a fall. NA-F stated R7 was at risk for falls and had several fall interventions in place which included; R7's wheelchair was to be kept next to her bed, gripper sock were to be worn when R7 was not wearing shoes, hip protectors and floor grippers. She stated R7 had been moved closer to the nurses station after she had fallen and fractured her hip. NA-F stated R7 had continued to fall after she was moved closer to the nurses station. NA-F stated R7 routinely would transfer herself and would be found standing in her doorway at times. NA-F stated she felt R7 was unable to remember to use her call light and notify staff of her needs. She indicated she felt R7 was able to recognize people and where she was though felt R7 would not be able to remember education or instructions given to her. On 8/9/19, at 11:33 a.m. NA-G stated R7 currently required extensive assistance with ADL's of transfers, bed mobility and ambulation. NA-G stated R7 used to be independent up until six months ago, when R7 began to decline. NA-G stated R7 had multiple falls in the past and had broken her hip within the last few months. NA-G stated R7 had various interventions in place which the facility routinely used for residents which had a history of [REDACTED]. NA-G stated she felt R7's cognition fluctuated throughout the day and indicated she felt R7 would be unable to recall any type of instruction within moments. On 8/9/19, at 11:38 a.m. licensed practical nurse (LPN)- D, stated R7 required assistance with transfers and mobility. She indicated R7 had recently had a [MEDICAL CONDITION] and had a decline in mobility as a result. LPN-D stated R7 was at risk for falls as she continued to self-transfer and felt she had impulsive behaviors. She stated R7's cognition fluctuated over the course of the day, but overall she felt R7 had impaired cognition. LPN-D stated she felt R7 would not be able to recall instructions or education given to her for very long and felt R7 was not a reliable historian. LPN-D stated R7 had numerous fall interventions in place, which included removing her wheelchair pedals when R7 was seated in it, call light within reach, periodic safety checks, skid strips on the floor next to her bed, anti-roll back devices on her wheelchair and assisting with walking. On 8/9/19, at 11:55 a.m. R7's medical record was reviewed with the DON. She confirmed R7's medical record lacked a comprehensive assessment for any of the aforementioned falls. The DON confirmed R7's aforementioned thirteen falls lacked a comprehensive assessment which would include information such as R7's toileting needs, incontinence, cognition, safety awareness, mobility needs, pain assessment. The DON confirmed on eight of R7's thirteen falls, she had an abnormal blood pressure and would have expected R7's blood pressure to have been checked and orthostatic blood pressures (blood pressure checked lying, sitting, standing to assess for a potential drop in blood pressure,) and expected facility staff to have notified R7's primary MD of the abnormal readings. She stated she felt the interventions that had been put into place after R7's falls were inappropriate and had been derived from assumption and not from a comprehensive assessment. The DON confirmed none of R7's falls had a root cause analysis completed, nor had a pattern ever been identified, such as toileting, time of day, pain, thirst, hunger and use of a walker. The DON stated she had been very concerned about the facility's process of assessing resident falls when she started as interim DON back in (MONTH) of 2019, had voiced her concerns and had received bite back, from facility staff. The DON stated she felt staff had been implementing generic interventions from a checklist form without identifying whether the intervention was appropriate. On 8/12/19, at 11:10 a.m. during a telephone interview with R7's nurse practitioner (NP)-A, stated she was not sure of the specifics of R7's falls, nor was she aware of what assessments were completed or interventions were in place following R7's falls. She stated she relied on the facility staff to inform her of pertinent findings regarding R7's falls, such as an increase in confusion, changes in cognition, pain, abnormal blood pressure and any neurological changes. NP-A stated she would consider a comprehensive assessment to include a complete head to toe assessment, neurological assessment, potential cause of fall and would expect patterns of falls to be recognized and interventions implemented based on the assessment. Further, NP -A stated she would expect appropriate care planned interventions to be followed. On 8/12/19, at 1:37 p.m. the facility medical director stated the facility had a fall program in place and he had expected facility staff to follow the facility policy and procedure related to falls. He indicated he expected a thorough comprehensive assessment to be completed following resident falls in order to complete a root cause analysis, determine possible patterns and implement appropriate interventions. The medical director stated he felt Geri-hips were ineffective for preventing hip injuries and was unaware the facility used them for residents. He indicated he had recently been made aware providers had not been receiving complete information regarding resident falls and felt the facility currently had a systems implementation problem related to falls. The medical director felt the facility fall prevention and resident safety program was effective, however he stated facility staff were not implementing the program. On 8/12/19, at 1:46 p.m. during a telephone interview with R7's primary physician MD-A, she stated she was familiar with R7 and had been aware R7 had multiple falls in the facility which had resulted in a dislocated shoulder and a fractured right hip. She stated she would expect facility staff to determine, if possible, what R7 was falling, if there was a pattern to her falls and to complete a thorough comprehensive assessment of her condition at the time of the fall and post-fall. MD-A stated she would expect facility staff to determine appropriate interventions based on R7's comprehensive falls assessment. She indicated R7 was not a reliable historian and it would be up to the facility staff to determine the root cause of R7's falls. Further, she stated she would expect R7's blood pressures to be monitored for 48-72 hours following a fall with an abnormal blood pressure, and would further expect to be notified. R202 R202's quarterly MDS dated [DATE], identified R202 had [DIAGNOSES REDACTED]. The MDS identified R202 had severe cognitive impairment and required supervision with eating and extensive assistance with all other activities of daily living (ADL) which included; bed mobility, transfers, toileting and walking and received hospice services. The MDS identified R202 had falls since admission to the facility, two or more with no noted injuries and two or more with injuries, except major injuries. R202's admission MDS dated [DATE], identified R202 had severe cognitive impairment and required supervision with eating and extensive assistance with all other ADLs and received hospice services. The MDS identified R202 had a fall in the past month prior to admission, a fall in the past two to six months prior to admission, both with injury and no falls since admission to the facility. R202's annual CAA dated 3/10/19, identified R202 had an increased potential of fall risk due to cognitive impairment, visual impairment, impaired ADL abilities, urinary incontinence, behaviors of wandering, and use of [MEDICAL CONDITION] medication. The CAA identified R202 's increased fall risk placed R202 at increased risk of injury, needs not being met, anxiety and social isolation. The CAA indicated interventions were in place to prevent falls and/or injury related to falls and the care plan would be followed to minimize risks. The CAA further indicated any changes in R202's abilities would have follow up as indicated. The resident was at risk for physical decline related to pain and potential for advancement of medical condition. R202's Fall Risk Predictive Factors Assessment, dated 3/6/19, identified R202 was at risk for falls identified by the following factors: diminished safety awareness, poor recall, judgment, safety awareness, ambulatory and incontinent, balance problem while standing, balance problem while walking, required use of an assistive device, had one to two falls in the past three months. The risk assessment lacked an analysis of R7's risk factors, patterns of falls, injury with falls or current and tried interventions. R202's Fall Risk Predictive Factors Assessment, dated 6/4/19, identified R202 was at risk for falls identified by the following factors: poor recall, judgment, safety awareness, ambulatory and incontinent, required use of an assistive device, had three or more falls in the past three months and received high risk medications. The risk assessment lacked an analysis of R7's risk factors, patterns of falls, injury with falls or current and tried interventions. Review of R202's care plan, revised 6/24/19, revealed R202 had a potential risk of falls related to [MEDICAL CONDITION] brain, dementia, and type II Diabetes. R202's care plan listed various interventions which included Geri hips (an undergarment with pockets for thin foam padding over each hip) on at all times, gripper socks on when in bed, toilet at 6:30 a.m., make sure foot of recliner is lowered and locked into place, unless R202 is sitting and elevating feet, do not put to bed prior to 9:00 p.m. Review of R202's progress notes from 3/20/19, to 7/27/19, identified R202's following 17 falls: - 3/20/19, at 7:30 a.m. found in her room laying on the floor next to the bed, urine, stool and an incontinent brief were found on the floor, R202 stated she was attempting to go to the bathroom and had slid off the side of the bed. The note identified R202 received two scrapes on the lower left extremity, the care plan had been reviewed and no new interventions were initiated at the time. - 4/9/19, at 6:00 p.m. found on the floor in the doorway of her room. R202 had indicated the wheeled walker had gotten away from her when walking independently. The note indicated an intervention of R202's 4 wheeled walker replaced with a 2 wheeled walker at this time. - 4/12/19, at 12:25 a.m. found on the floor, her gown was wet with urine and did not have a brief on. R202 indicated she was going to the bathroom but slipped and fell . The note indicated R202 obtained a laceration of the upper lip, skin tears on the left forearm, the care plan was reviewed with no new interventions identified and R202 was educated on use of the call light. - 5/8/19, at 11:25 a.m. found on the floor in her room between the foot of the bed and the dresser. R202 stated she had fallen in the bathroom after she had finished toileting, had hit her head and crawled to where she was found. The note identified a new intervention of Geri hips worn at all times. - 5/18/19, at 7:10 p.m. found on the floor in the doorway between her bathroom and room. The note indicated R202 did not sustain an injury from this fall and the new intervention was the use of Geri hips initiated for a second time. -5/20/19, at 2:55 p.m. R202 was observed by staff to slide from the reclining chair off the foot rest to the floor. The note indicated R202 did not sustain an injury and a new intervention was initiated to ensure the foot rest was locked in place except when R202 elevated her feet. - 6/1/19, at 9:45 a.m. R202 was observed standing independently with her walker in a common area next to the fish tank. R202 turned her walker around and attempted to sit on it, fell backwards and hit her head on the wall. The note indicated R202 received a small bump on her head which was treated with ice and no new interventions identified. - 6/13/19, at 7:00 p.m. R202 again was observed standing independently with her walker in a common area and fell when she attempted to sit on the walker. The note identified the care plan was reviewed, the interventions found to be appropriate and no changes were made. - 6/19/19, at 3:35 a.m. found on the floor in her room in the doorway between the bedroom and bathroom. The note identified R202 received skin tears to her right shin, the care plan was reviewed, interventions deemed appropriate. - 6/21/19, at 6:45 a.m. found on the floor in her room with her pants pulled down on her thighs. R202 initially stated she was going to the bathroom and then stated she was coming from the bathroom when she fell . R202 was incontinent of urine in her brief. The note identified a new fall intervention of toileting R202 at 6:30 a.m. - 6/28/19, at 11:35 p.m. found on the floor in her bathroom. The note indicated no injury was sustained from this fall, the care plan was reviewed and found to be appropriate with no changes. - 6/30/19, at 8:00 p.m. R202 fell while self transferring in the common area. The note indicated R202 complained of pain but no observed injuries, care plan reviewed and no changes made. -7/3/19, at 4:40 a.m. found in her room on the floor near the closet doors. R202 did not have clothes or a brief on. Stool was on the floor and it appeared as though R202 stepped in the stool which caused her to slip and fall. The note indicated R202's care plan was reviewed and no new interventions identified. -7/8/19, at 9:10 a.m. found on the floor in the hall. R202's walker was found in another resident's room. The note indicated no injury, care plan reviewed, and R202 was given education for use of the walker at all times. - 7/11/19, at 8:45 p.m. found on the floor at the end of her bed. The note indicated no injury from this fall, an intervention placed for R202 not to be placed in bed before 9:00 p.m. - 7/13/19, at 7:30 a.m. R202 was found sitting on the floor in the common area between the fish tank and another resident. R202 received a hematoma to the left side of her head and complaint of hip pain. An x-ray was completed and inconclusive for a fracture. Family chose not to pursue further treatment. - 7/23/19, at 5:04 a.m. found on the floor in the center of her room. R202's left leg was shorter than the right and was rotated. Review of this incident revealed at the time of the fall the care plan was not followed and the intervention of Geri hips worn at all times was not implemented. Family chose to keep R202 comfortable at the facility with no further treatment. On 7/27/19, R202 passed away at the facility. R202's medical record lacked a comprehensive assessment of her multiple falls to determine any patterns, tr

Based on observation, interview and document review the facility failed to implement care planned interventions for pain management for 1 of 1 resident (R133) who exhibited severe pain during cares. This deficient practice resulted in actual harm for R133 when she experienced untreated severe pain, with groaning, crying and crying out in pain for a total of 1 hour and 15 minutes. Findings include: R133's admission Minimum Data Set ((MDS) dated [DATE], identified R133 had [DIAGNOSES REDACTED].) The MDS revealed R133 had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included; transfers, toileting, dressing, bathing and personal hygiene. The MDS identified R133 had difficulty making herself understood. The MDS identified R133 had no pain during the assessment period. R133's admission Care Area Assessment (CAA) dated, [DATE], identified R133 had a recent stroke with [MEDICAL CONDITION], right sided [MEDICAL CONDITION] and had severely impaired cognition. The CAA identified R133 was able to respond to yes/no answers and was oriented to self only. The CAA identified R133 required extensive assistance with all ADL's and staff were to anticipate her needs. The CAA did not identify R133 had any pain or was at risk for pain/discomfort. R133's Pain assessment dated [DATE], had current generalized pain exhibited by facial grimacing and moaning when repositioned in bed. R133's pain assessment identified movement exacerbated her pain and the following interventions had been effective; distraction, provide rest periods, position for discomfort. Further, R133's pain assessment identified she was unable to verbalize or rate her pain, though appeared comfortable when lying in bed. R133's Pain assessment dated [DATE], identified R133 had recent, generalized pain and was unable to verbalize her pain. R133's pain assessment identified she exhibited grimacing and moaning during repositioning. R133's pain assessment lacked a location, potential precipitating factors of R133's and interventions used to manage R133's pain. R133's Pain assessment dated [DATE], identified R133 had current pain, pain in the last quarter which was generalized. The pain assessment indicated R133 was unable to describe or rate her pain, had a history of [REDACTED]. The assessment identified non-pharmacological interventions which had been used of distraction, provide rest periods and positioning for comfort. R133's pain assessment identified R133 would grimace and moan, non-verbal signs of pain during repositioning. Further, R133's pain assessment identified R133 appeared more relaxed when in chair or bed resting. R133's current unsigned physician orders, revealed an order for [REDACTED]. R133's care plan revised [DATE], revealed R133 required extensive assistance with ADL's of dressing, grooming, personal hygiene, bed mobility and transfers with a mechanical lift. The care plan revealed R133 had a potential for discomfort related to right sided [MEDICAL CONDITION], impaired mobility and rhabdomyolysis(breakdown of skeletal muscle due to direct or indirect muscle injury) and indicated R133 generally denied pain. The care plan identified various interventions for pain which included; administer pain medications as ordered, monitor for effectiveness, utilize appropriate non-pharmacological interventions to manage pain that included rest, repositioning, warm blankets, music and cold packs. During continuous observations on [DATE], at 7:09 a.m. to 8:24 a m. the following was observed: -at 7:09 a.m. R133 was lying in bed on her back, her eyes were closed and she had a blanket which covered her from her feet to her chest. R133's breathing was rapid, she moaned with her lips tightened, face grimaced and her brow was furrowed. R133 held onto a grab bar which was affixed to the left side of her bed with a firm grasp, her knuckles were white with pressure. -at 7:26 a.m. R133 remained lying in bed, her eyes were closed, she continued to hold onto the grab bar with her left hand, and she was covered with a blanket from her feet to her chest. At that time, nursing assistant (NA)-M entered her room and proceeded to assist R133 with morning cares. NA-M approached R133's bed, reached down, grabbed her left hand from the grab bar and removed R133's fingers from the bar. R133 groaned and her face tightened, NA-M then rested R133's hand/arm on the bed. NA-M then reached for R133's right arm, which had a tan compression sleeve halfway on (worn to decrease/prevent [MEDICAL CONDITION],) and NA-M indicated R133 wore the sleeve daily. At that time, R133 groaned loudly, her jaw tightened, lips were tightly shut, her brow furrowed and R133 verbally moaned. NA-M began to pull the compression sleeve back onto R133's left hand/arm, when R133 cried out, stated ouch, ouch, ouch, NA-M reassured R133 she was almost done and proceeded to donn the compression sleeve on R133's right arm. R133 continued to deeply groan, let out low moans and tears began to run down from her eyes onto her cheeks. NA-M then asked R133 if she wanted the nurse, in which R133 replied, no, however, R133 continued to sate, ouch, ouch, ouch and tears continued to run down her cheeks. R133 continued to deeply groan, when NA-M asked if she was ok, in which R133 replied, no. At 7:30 a.m. NA-M stated she would call for assistance, used her walkie talkie and called for assistance. NA-M then stated, she felt R133 was in a lot more pain than usual. -at 7:36 a.m. NA-N entered R133's room and proceeded to assist R133 with morning cares along with NA-M. R133 continued to have tears down her face, moaned and her jaw and eyes were clenched. At that time, NA-M asked R133 where her pain was, in which R133 did not respond. NA-M then reached for R133's right arm, proceeded to pull the compression sleeve up R133's right arm, R133 gutturally groaned, grimaced, her brow was furrowed, jaw and lips were clenched tightly, NA-M continued to apologize to R133 as she continued to pull the compression sleeve up her left arm. -at 7:48 a.m. NA-N stated she had not worked with R133 prior to that day and was not familiar with her enough to know if her pain was typical for her. NA-N then proceeded to provide morning cares to R133, who had continued to moan, deeply groan and grimaced. At 7:54 a.m. R133 was turned onto her right side, observed to have redness to her buttocks. NA-M then called the unit registered nurse, RN-B for a skin check. -at 8:00 a.m. R133 remained in her bed, on her right side, with NA-M on the right side and NM-N on the left side of her bed. At that time, RN-B entered R133's room, proceeded to check R133's skin. RN-B touched R133's right hand, which had the compression sleeve partway up her arm, when R133 groaned deeply, furrowed her brow, tightened her jaw and mouth. RN-B apologized to R133, though did not ask her about her pain. RN-B completed R133's skin inspection, and left R133's room. Both NA-M and NA-N continued to assist R133 with dressing, while R133 continued to cry out, repeatedly stated, no, no, no, no, each time NA-N and NA-M turned R133 to her sides, or moved R133's right arm. R133 was then assisted to transfer from her bed to a wheelchair with the use of a full bodied mechanical lift with the assistance of NA-M and NA-N. Throughout the transfer R133's brow was furrowed, her eyes and jaw were clenched shut and she continued to deeply groan. -at 8:22 a.m. R133 was seated in a wheelchair, the compression sleeve was halfway up her right arm. NA-M proceeded to pull the compression stocking the rest of the way up R133's arm, R133 cried out, ouch, ouch, ouch, her brow furrowed, eyes were clenched and R133 attempted to reach for her right arm with her left arm. NA-M continued to apologize to R133 and indicated she was almost done. R133's arm was then placed in an arm cradle (a platform on the arm rest of a wheelchair used for positioning,) by NA-M, who then proceeded to assist R133 to brush her hair. -at 8:24 a.m. R133 was seated in a wheelchair, wheeled to the dining room by NA-M, her eyes were open. R133 no longer exhibited signs of acute pain, such as crying, moaning and groaning. On [DATE], from 7:09 a.m. to 8:24 a.m. R133 was observed in acute pain and no staff were observed to offer non-pharmacological or medicinal interventions as care planned. Further, no staff were observed to notify RN-C of R133's acute pain with cares. Review of R133's Medication Administration Record [REDACTED]. R133's MAR indicated [REDACTED]. R133's MAR indicated [REDACTED]. On [DATE], at 8:30 a.m. NA-M stated R133 was dependent on facility staff for all of her needs. NA-M stated she felt R133 was not able to verbalize her needs and wishes. NA-M stated she felt R133 usually had some pain/discomfort with movement, though felt that day, R133 had increased pain/discomfort. NA-M stated she had thought she reported R133's non-verbal indicators of pain to RN-B while R133's skin check was completed. On [DATE], at 12:47 p.m. NA-L stated R133 was totally dependent on facility staff for her cares and required staff to anticipate her needs. NA-L stated R133 had discomfort with movement, especially her right arm. NA-L stated R133's discomfort seemed to subside when cares and/or movement was done. NA-L stated when R133 had exhibited signs of pain in the past, such as moaning, groaning, and grimacing, on a daily basis, though had not observed R133 having cried with pain. On [DATE], at 9:30 a.m. licensed practical nurse (LPN)-F stated R133 was dependent on facility staff for all of her ADL's and indicated staff were to anticipate R133's needs. She indicated R133 was able to answer questions and indicated she had, within the last few days, provided R133 with as needed Tylenol for pain. LPN-F stated R133 did not receive scheduled pain medication or [MEDICATION NAME] pain medications. On [DATE], at 9:53 a.m. registered nurse (RN)-C confirmed R133 was dependent on staff for her ADL's, and required staff to anticipate her needs. RN-C stated R133 has had pain in her right arm/hand upon admission and has had intermittent pain with movement. RN-C stated R133 wore a compression sleeve on her right arm due to right sided [MEDICAL CONDITION] and previous [MEDICAL CONDITION]. She indicated she would expect NA's to notify the medication nurse or charge nurse if R133 was exhibiting symptoms of pain and then would have expected the nurse to assess R133's pain and implement interventions. RN-C stated R133 did not have an order for [REDACTED]. On [DATE], at 9:58 a.m. registered nurse manager (NM)-C stated she would expect NA's to notify the nurse if R133 had exhibited signs or symptoms of pain. NM-C confirmed R133's care plan listed various non-pharmacological interventions for pain, along with medication administration and expected staff to offer R133 pain relief interventions. NM-C indicated she would also have expected the nurse to have asked R133 about her pain when cares were provided. NM-C stated she felt R133 could answer questions appropriately, however she felt R133 was not always able to offer information. Further, NM-C stated she expected, due to R133's [MEDICAL CONDITION], nursing staff to observe for non-verbal indicators of pain and offer interventions to improve R133's comfort. On [DATE], at 10:10 a.m. the director of nursing (DON) confirmed observations of R133's moaning, groaning, grimacing and crying were indicative of non-verbal indicators of pain. The DON stated she expected R133's nurse to have been notified of R133's signs of pain immediately and expected the nurse to assess R133's pain. The DON stated she expected non-pharmacological interventions to have been attempted along with medication administration if the non-pharmacological interventions were ineffective. She indicated she would have expected R133's physician to have been contacted if she was having unusual pain, or new onset or intensity of pain. Further, the DON stated if R133 had a pattern to her pain, such as with repositioning or during cares, she expected R133's pain assessment to reflect that along with interventions in place for prevention of pain and discomfort. Review of a facility policy titled, Pain Management protocols, revised ,[DATE], identified it was the facility's policy for all residents of the facility would be provided with pain management which included; recognition of pain, appropriate intervention in a timely manner, ongoing assessment of pain and resident care staff skilled in the concepts of pain management. Further, the facility policy identified all resident care staff were to report pain stated by the resident to the nurse, observe for non-verbal indicators of pain which included; changes in facial expression, vocalizations such as moaning, screaming and physical movement.

Based on observation, interview and document review, the facility failed to ensure a comprehensive nutritional assessment and implementation of interventions were implemented to prevent weight loss, decline in condition, for 1 of 2 residents (R136) reviewed for use of a tube feeding and significant weight loss. This deficient practice caused actual harm to R136 when she lost 6.57% of her weight within 19 days of her stay, had ongoing anorexia, nausea, developed shortness of breath, increased secretions and labored breathing as her health status deteriorated, and R136 subsequently required hospitalization and treatment. Findings include: R136's admission Minimum Data Set (MDS) assessment dated [DATE], identified R136 had [DIAGNOSES REDACTED]. The MDS identified R136 had intact cognition and required extensive assistance with activities of daily living which included bed mobility, transfers, dressing and required set up assistance with eating. The MDS also indicated R136 's weight upon admission was 107 pounds (lbs), and indicated R136 had no/unknown history of significant weight loss in the last one to six months. Further, the MDS identified R136 received over 50% of her nutrition and fluids from enteral feedings. R136's admission Care Area Assessment (CAA) dated 7/20/19, identified R136 was admitted following a hospitalization for malnourishment. The CAA identified R136's admission weight at 106.6 pounds 7/17/19. The CAA indicated as of 7/26/19, R136 weighed 105 pounds, (1.6 lb weight loss in 9 days.) The CAA indicated R136 received the following calories, protein and hydration from bolus (intermittent) tube feedings; 80% of her estimated daily kilocalorie (kcal, kilogram per calorie) needs, 88% of her daily protein needs and 100% of her daily hydration needs. The CAA indicated R136 also ate an oral diet of dysphagia mechanically altered with honey thick liquids and indicated R136 had poor oral food intakes. The CAA further identified R136 had a reported lack of appetite and had weighed approximately 130 lbs a year ago, but had lost weight due to poor appetite. R136's admission nutrition note dated 7/16/19, identified R136 had a PEG (percutaneous endoscopic gastrostomy) tube placed on 7/3/19, while hospitalized prior to her admission to the facility due to R136 being unable to consume sufficient oral intake. The assessment indicated R136 had received continuous tube feedings during her hospitalization and was changed to bolus feedings a few days before discharge. The assessment identified R136 was receiving 237 milliliters (ml) of [MEDICATION NAME] 1.2 (nutritional supplement for PEG/enteral tube feeding,) four times a day. The assessment identified R136's bolus feedings provided her with 1140 kcal's, 53 grams of protein and 780 ml of water. The assessment identified R136 was also to receive 180 ml of water flushes four times a day for a total of 1500 ml of water. The admission nutritional not further revealed R136 had weighed 110 lbs upon admission to the hospital, but did not identify R136's weight upon her discharge from the hospital. Further, the assessment identified during R136's hospitalization her identified calorie goals were 1400-1500 kcal and 50-60 grams of protein. R136's admission nutrition assessment was dated 7/26/19, and identified R136 had experienced a recent significant weight loss, received routine bolus feedings of [MEDICATION NAME] 1.2 four times a day, and received water flushes four times daily. R136's nutrition assessment identified R136 had continued to have difficulty with nausea, vomiting and poor appetite. The nutritional assessment identified R136's bolus feedings did not meet her estimated daily caloric or protein needs. and indicated R136 would receive additional calories and protein by oral intake. Further, R136's nutritional assessment identified a trial of a magic cup (calorie dense nutritional supplement) would be implemented to assist R136 in meeting her nutritional needs. R136's care plan revised 8/5/19, revealed R136 was independent with oral food intake after set up, but was totally dependent on facility staff for nutrition by tube feeding. R136's care plan also identified she was at risk for potential complications of PEG tube and directed facility staff to monitor her weight as ordered. R136's care plan revealed she had a potential for nutrition problems related to anorexia, low body weight, enteral feedings and altered diet. The care plan also indicated R136 received a dysphagia mechanically altered diet with honey thick liquids orally, and [MEDICATION NAME] 1.2 one carton, four times daily and water flushes of 180 ml four times daily by PEG. The care plan indicated R136's weights were to be taken as ordered, the resident would receive a magic cup at noon daily, and staff were to encourage intake of food and fluids at meals. R136's nursing assistant care guide dated 8/7/19, revealed R136 was able to feed herself after set up, required supervision with meals and encouragement to eat. The care guide also revealed R136 was on a mechanically altered diet with honey thick liquids. The care guide did not identify the frequency of R136's weights, or any added monitoring of her oral intakes. Review of R136's hospital discharge summary dated 7/13/19, identified R136 had been hospitalized for [REDACTED]. The summary indicated R136 was started on tube feedings which were initially continuous, but were then switched to bolus, and R136 was able to maintain her weight with the prescribed bolus feedings. The hospital discharge summary also indicated R136's weight was 132 lbs at discharge. Review of R136's weights from 7/13/19, to 8/6/19, were as follows: -7/13/19, 106.6 lbs -7/15/19, 109.6 lbs -7/17/19, 106.6 lbs -7/26/19, 105 lbs -7/30/19, 108.5 lbs -8/2/19, 100.2 lbs -8/5/19, 99.6 lbs R136's lost 6.57% of her body weight from 7/13-8/5/19, or 9.12 % of her body weight from 7/15-8/5/19. There was no indication facility staff had questioned the resident's hospital discharge weight. On 8/5/19, at 2:31 p.m. R136 was lying in bed, with her head of bed elevated to a seated position and wore a hospital gown. R136's clavicle bones protruded under her neck, shoulder, elbow, knee and hip bones protruded from her body, she had hallowed cheeks and sunken eyes. At that time, R136 stated she had an aneurysm a few months ago, had a stint placed and recently had a feeding tube placed in her stomach due to her inability to eat. R136 stated she'd had a significant weight loss of over 30 lbs in the last year. R136 stated she had concerns the facility staff would administer her bolus tube feedings late and indicated she continued to have difficulty with eating and drinking. R136 stated she felt nauseated and dizzy on a daily basis and could not keep any food down, and stated she continued to lose weight and was very concerned with her continued weight loss. On 8/5/19, at 7:26 p.m. during a follow up observation and interview, R136 was observed lying in bed with a hospital gown on, the head of the bed was elevated approximately 90 degrees. As before, R136's bony prominences protruded from her body and she had hallowed cheeks and sunken eyes. During this interview, R136 stated she was not currently receiving an oral nutritional supplement, but had tried one a couple of times a few weeks ago. Again, R136 stated she was unable to eat an adequate amount of food and indicated she worried about her health. On 8/7/19, at 7:11 a.m. R136 was lying in bed, her eyes closed, her family member (FM)-A was seated in a wheelchair next to her bed. At that time, R136's FM-A stated he was very concerned with R136's continued weight loss. FM-A stated he had spoken with one of the nurses approximately a week ago and voiced his concerns with R136's weight loss, and requested she have more bolus feedings. FM-A stated he had been told by the nurse R136 did not have a physicians order to increase her tube feedings and indicated the facility nurse had explained R136's medical doctor would have to increase her bolus tube feedings. FM-A stated he was very concerned about R136's continued nausea, lack of appetite and continued weight loss. On 8/7/19, at 8:25 a.m. R136 turned on her call light, nursing assistant (NA)-L entered her room and proceeded to assist R136 with toileting. R136 complained of dizziness when she stood, and her posture was observed to be hunched over. R136 walked to the bathroom, while NA-L held onto a gait belt, and complained of continued dizziness. R136 walked to the toilet with NA-L to the bathroom. NA-L helped R136 pull down her underwear, revealing R136's pelvic, hip, sacral and spinal bones protruding from her body. R136's legs shook when she walked and when she was assisted to sit on the toilet. On 8/7/19, at 8:50 a.m. R136 was seated in a wheelchair in the dining room at a circular table. R136 was served eggs, hot cereal, water and juice. R136 was heard to have a very wet sounding cough, and her right arm shook as she picked up her utensils to eat. R136 ate two bites of her eggs and two bites of her cereal before stating she was not able to eat anymore. At 8:56 a.m. on 8/7/19, dietary aid (DA)-A was present in the dining room and stated R136's intakes were recorded on her meal slip by percentage. He indicated he would mark 0-25% for R136's breakfast as she did take a couple of bites of her food. At 8:59 a.m. on 8/7/19, R136 remained seated in her wheelchair in the dining room, when the facility's MDS coordinator (MDSC)-A approached her and asked R136 if she could take a few more bites. R136 stated she could not, she was not feeling well and wanted to lay down. MDSC-A then wheeled R136 out of the dining room and to her bedroom where she informed R136 she would find someone to help her into bed. MDSC-A handed R136 her call light and left the room. On 8/7/19, at 9:12 a.m. R136 was seated in a wheelchair in her room, she had her head tilted down towards her chest, her head rested on her left hand. At that time, R136 stated she was very dizzy and had no appetite, R136 then closed her eyes. At 9:24 a.m. R136 remained seated in her wheelchair with her head on her right hand and her eyes closed. At that time registered nurse (RN)-B entered her room and proceeded to administer R136's medications and bolus tube feeding of [MEDICATION NAME] 1.2, eight ounces. R136 did not raise her head, open her eyes nor did she respond when RN-B spoke to her. On 8/7/19, at 9:28 a.m. RN-B stated he felt R136 tolerated the bolus tube feedings very well and stated he felt R136 had not been receiving enough nutrition as she continued to lose weight. RN-B stated R136's appetite was very poor and she would often only take a few bites throughout the day. He stated R136's bolus feedings had been increased from four times a day to five times a day on 8/6/19, due to the resident's continued weight loss. RN-B stated he was unsure of how often R136 was weighed and stated the facility's dietician monitored R136's weight. In addition, RN-B stated he would monitor resident weights if he needed the weight for medication, but had not been monitoring R136 for continued weight loss. RN-B stated R136 had a consult for hospice services, though she had not decided if she wanted to pursue the option. RN-B also stated R136's medical doctor (MD) had asked to wait for the hospice referral to see if an added anti-nausea medication would help. RN-B stated R136 was not currently receiving hospice services. On 8/7/19, at 11:50 a.m. R136 was observed lying in bed, with the head of her bed elevated at approximately 90 degrees. R136's eyes were closed, she was moaning and was covered with a sheet from her feet to her abdomen. A few minutes later, the lunch meal was served in the dining room. The dietician was observed to walk into the dining room and asked a staff member if R136 was planning to eat. The dietician then walked out of the dining room. The dietician was not observed to enter R136's room to speak to her. No staff were observed to encourage or offer R136 to eat lunch. R136 had no intake for lunch. On 8/7/19, at 12:39 p.m. NA-L stated R136 was on a routine weekly weighing schedule, and stated he had been asked to get a few additional weights. NA-L stated as of that day, R136 weighed 100 lbs, adding that R136 had dropped from 104 lbs the week prior. NA-L stated R136 routinely reported she felt nauseated, dizzy and had no appetite. NA-L stated he felt if R136 was able to get out to the dining room right away in the morning, she would eat a bit more. NA-L stated he felt R136 needed a lot of encouragement to eat and drink, and with encouragement he felt R136 ate more. NA-L stated he had notified the charge nurse when he had noticed she had lost more weight. On 8/7/19, at 1:55 p.m. during a follow up interview with R136's FM-A, FM-A stated R136 had been sent to the hospital by ambulance that day due to difficulty breathing. FM-A stated he felt R136 had felt too sick to eat anything on a regular basis and said he felt if staff had monitored R136's weight and food intakes, she may have improved versus declining. FM-A stated he had spoken with R136's medical doctor on the last visit, though was unable to recall if they had discussed her weight and intakes. On 8/7/19, at 2:30 p.m. the facility's dietician confirmed she had completed one nutritional assessment, 7/26/19. The also stated she had reviewed R136's hospital discharge summary and had not noticed R136's weight upon hospital discharge was 132 lbs. The dietician stated she did not feel that weight was accurate, but confirmed she had not contacted the hospital regarding R136's hospital discharge weight and R136's facility admission weight of 106 lbs. She stated she thought R136 was likely 110 lbs when she left the hospital. The dietician stated R136 was receiving a majority of her nutrition from PEG tube bolus feedings, approximately 80% of her estimated daily caloric needs. She stated she felt R136 was able to make up the other required calories from oral intake. During the same interview, the dietician confirmed R136's weights from admission to current as follows: 7/13/19, 106.6 lbs, 7/15/19, 109.6 lbs, 7/17/19, 106.6 lbs, 7/26/19, 105 lbs, 7/30/19, 108.5 lbs, 8/2/19, 100.2 lbs, 8/5/19, 99.6 lbs. The dietician confirmed R136 had lost 6.57% of her total body weight since her admission. She also confirmed R136 had gained weight, up to 109.6 lbs, which would then reflect a 9.12% weight loss in less than 30 days. The dietician stated she had monitored R136's intakes (percentage) since her admission and had felt her intakes were adequate to maintain her weight. However, she verified R136's intakes were documented by percentage of intake, and did not identify what food was consumed. The dietician confirmed she was unable to accurately assess how many calories R136 was getting from her oral intake by looking at the percentages recorded. The dietician further confirmed she had not requested an increase in R136's bolus feedings until 8/6/19 when she had reviewed R136's most recent weights and had decided R136 was not getting sufficient calories from oral intake. On 8/8/19, at 3:06 p.m. NA-M stated R136 routinely stayed in her room during meals and would frequently refuse to eat due to nausea and dizziness. NA-M stated when R136 did eat, her intakes were routinely less than 25%. NA-M stated she had not weighed R136 and was unaware if she had lost weight. On 8/8/19, at 3:14 p.m. the registered nurse manager (NM)-C confirmed R136 had experienced weight loss since her admission, acknowledging R136's weights fluctuated up and down at times. NM-C stated R136 had overall lost weight. NM-C stated the facility's dietician had ordered to increase R136's bolus tube feedings to 5 times a day on 8/6/19, due to continued weight loss. NM-C stated at that time, R136 was weighed weekly, and by request from the dietician. She confirmed R136 did not have an order for [REDACTED]. She indicated she was aware R136 had very poor appetite and low intakes. She indicated the facility dietician directed all intakes and weight recordings unless ordered by a physician. NM-C confirmed R136's primary physician had not been notified of her continued weight loss. R136's physician progress notes [REDACTED]. The note revealed R136 complained of dizziness and had some symptoms indicative of moderate depression. The note revealed R136 was educated on the importance of diet and exercise, continued to receive PEG tube bolus feedings and oral intake. The note indicated R136 was started on an anti-depressant medication for moderate depressive symptoms. The physician progress notes [REDACTED]. R136's physician progress notes [REDACTED]. The note revealed R136 had been eating and received PEG tube feedings. The note revealed R136 continued to complain of nausea and was ordered [MEDICATION NAME] (anti-nausea medication) as needed, and R136 was ordered to receive another anti-nausea medication ([MEDICATION NAME]) on a scheduled basis. The note revealed a request for a Hospice consult was also placed per R136's request. The physician progress notes [REDACTED]. On 8/8/19, at 12:44 p.m. during a telephone interview, MD-B confirmed she had not been notified of R136's continued weight loss. MD-B stated she had seen R136 in the facility for a routine visit and had discussed R136's complaints of dizziness, nausea and depression. She indicated she would have expected the facility to monitor R136's weight more frequently and had expected the facility to ensure R136's oral intakes were sufficient to prevent further weight loss and provide R136 with adequate nutrition. MD-B stated if she had known R136 had been losing weight, she would have ordered an increase in the frequency of her PEG tube feedings or even started her back on continuous feedings until her weight stabilized. Further, MD-B stated she had ordered a hospice consult for R136 due to severe nausea however, had also wanted to wait to see if the [MEDICATION NAME] (anti-nausea medication) would help. MD-B stated she did not feel R136 would necessarily be terminal if her weights would remain stable. Review of the facility's 12/2017 policy, Weight Changes, Assessment and Documentation, described the facility's policy to monitor and assess all residents who experienced a significant weight change to promote optimal nutritional health. The policy revealed it was the purpose of the policy to prevent any unplanned weight changes and identified a procedure which included the following: - weight obtained and documented weekly and more often as needed - if nursing noted a significant weight change they would notify the facility dietician - dietitian is to review all weights at least monthly - any resident experiencing significant weight loss/gain of 5% or more in one month, 7.5% in three months, and/or 10% in six months would be assessed by the dietician. -resident's physician/practioner would by notified of the significant changes in weight - nutritional supplements or other nutritional interventions would be implemented by the dietician as appropriate. The policy did not identify measures related to weight loss for a resident with enteral nutrition, such as a PEG tube.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement appropriate interventions to prevent pressure ulcers and/or promote healing of pressure ulcers for 2 of 5 residents (R105, R30) reviewed for pressure ulcers. This resulted in actual harm for R105 who developed an unstageable pressure ulcer while in the facility. Findings include: R105's quarterly Minimum Data Set ((MDS) dated [DATE], identified R105 had [DIAGNOSES REDACTED]. The MDS indicated R105 had severe cognitive impairment and required extensive to total assistance with all activities of daily living (ADL's). Further, the MDS identified R105 was at risk for development of pressure ulcers however, did not have any pressure ulcers at that time. R105's significant change MDS dated [DATE], identified R105 had [DIAGNOSES REDACTED]. The MDS indicated R105 had severe cognitive impairment and required extensive to total assistance with all ADL's. R105's Pressure Ulcer Care Area Assessment (CAA) dated 6/8/2015, identified R105 required assistance with bed mobility, turning and repositioning. The CAA identified R105 had a pressure ulcer on the right great toe. The CAA identified R105 was requiring more assistance due to Alzheimer's/dementia, generalized weakness, recent left above the knee amputation, arthritis and depression. Further, the CAA identified contributing factors for increased risk for skin breakdown/pressure areas and slow improvement of current area included risk for infection, risk for abnormal labs, decreased mobility, risk for altered nutrition/hydration, history of pressure ulcers in past, bowel and bladder incontinence, debility and age. The CAA identified R105's Braden Scale for Predicting Pressure Sore Risk (a tool to identify risk for developing pressure ulcers) indicated a risk score of 13 on 6/2/15 which indicated at risk. The CAA identified R105 currently had a pressure ulcer on the right great toe, and identified R105 was on a turning and repositioning schedule every hour and as needed and to float the right foot on the pillow. R105's Urinary Incontinence and Indwelling Catheter CAA dated 6/8/15, identified R105 had a fall on 4/5/15, resulted in a [MEDICAL CONDITION] leg and required a leg cast. R105 developed pressure ulcers due to the cast, which required readjustments of the cast. The cast was eventually removed and a brace was put into place. R105's left leg fracture continued to not heal and was admitted to the hospital on [DATE] for a scheduled amputation of the left leg. R105's care plan, last revised 7/20/15, identified R105 was at risk for skin breakdown related to impaired cognition, impaired mobility, history of a [MEDICAL CONDITIONS], dementia and incontinence. The care plan identified R105 had a history of [REDACTED]. may also present as an intact or open/ruptured serum-filled blister). The care plan also indicated the wound to the right second toe and right buttocks, and that R105 currently had a stage 3 pressure ulcer to the right toe bunion area which had resulted from rubbing on left foot cast. In addition, the care plan listed various interventions which included to turn and reposition every 2 hours and as needed, off-loading pressure for at least one minute, assistance of two staff for bed mobility, float right heel at all times in bed, and a pressure relief mattress. The care plan lacked any interventions prior to 4/17/15, to protect R105's right lower extremity skin integrity due to risks of the cast on the left lower extremity. Review of R105's East Care Plan provided by the facility, and identified as a care sheet for nursing assistants, directed staff to float right heel at all times, reposition every 2 hours and as needed, and identified R105 as non ambulatory. Review of R105's comprehensive skin assessment documented in 4/13/15 progress notes, indicated R105 had no open skin areas. The assessment identified R105 was at risk for skin breakdown and bruising due to impaired mobility, fracture to the left leg, impaired cognition, incontinence of the bowel and bladder, and daily use of [MEDICATION NAME] (blood thinner). A Braden Scale for Predicting Pressure Sore Risk was a 12, which placed R105 at high risk. The documentation identified R105's care plan had been reviewed, and no changes were made at that time, as appropriate interventions where in place. Review of R105's progress notes from 4/1/15 to 8/19/15, lacked documentation of any further comprehensive skin assessments completed after 4/14/15. Review of R105's Tissue Tolerance Test (TTT) (tool used to determine the skin's ability to tolerate pressure and to determine appropriate repositioning schedule)-lying, dated 4/12/15, revealed R105's left leg had been casted due to recent fracture and the test determined R105 required assist of 3 staff to reposition every 2 hours and as needed (PRN). The form identified no changes were done to the current care plan at that time. Review of R105's TTT-lying, dated 4/15/15, revealed skin was intact at that time, no open or pressure areas and left leg remained casted. The form included every 2 hours repositioning and PRN and identified no changes to the current care plan was done at that time. Review of R105's TTT-lying, dated 4/21/15, revealed R105 had an open wound to the inner right foot on bunion from rubbing on cast on the left foot. The form identified the care plan was changed at that time to include to separate legs with a pillow. On 8/19/15, at 7:03 a.m. R105 was observed lying on the left side in bed, with covers pulled up to shoulders. R105's right foot/bunion area was turned inward and rested on the mattress of the bed. At 7:30 a.m., R105 remained lying on the left side covered with a blanket, with the right foot/bunion area turned inward, both the inner aspect of the foot and heel were observed to rest directly on the mattress. At that time, nursing assistant (NA)-D and nursing assistant (NA)-E entered the room and started R105's morning cares. NA-D and NA-E removed a splint from R105's left hand, pulled down the blankets, removed pillow from under R105's left knee stump and a pillow was removed from behind R105's back. R105's right foot/bunion area remained turned inward, with both the inner aspect of foot and heel resting directly on the mattress. R105's right foot/bunion area was observed with a less than one centimeter in diameter, light brown, intact scab with pink skin surrounding the scab present on the right great toe/bunion area. R105 did not have a pillow in place to elevate the right foot, and R105's pressure ulcer on right great toe rested directly on the mattress. R105's right foot/bunion area and heel continued to rest on the mattress during the remainder of morning cares. Registered nurse (RN)-F briefly entered the room and administered medication to R105 and proceeded to exit the room. RN-F did not reposition R105's foot/bunion area and did not direct staff to reposition R105's foot/bunion area from resting directly on the mattress. At 7:45 a.m. on 8/19/15, NA-D and NA-E were observed to assist R105 to roll from side to side to dress R105's upper body, then proceeded to reposition R105 in the bed and completed incontinence and perineal cares, and dressed the lower half of R105's body. On 08/19/15, at 7:51 a.m. NA-D confirmed R105 had an open area at the bunion/sore on the side of the right foot. NA-D stated staff try to keep the area off the bed and open to the air. NA-D stated R105 required assist of two staff for bed mobility, transfers and utilized a hoyer (full mechanical lift). At 8:03 a.m., NA-D and NA-E transferred R105 from bed to recliner chair utilizing a mechanical lift. NA-D applied a gripper sock to R105's right foot and repositioned the resident in the reclining chair. R105's right foot was positioned to rest directly on the surface of the leg rest of the recliner. At 9:10 a.m., R105 remained in the reclining chair in the room, with R105's right foot directly resting on the foot rest of the chair. At 10:07 a.m., R105 was observed to be lying flat in the reclining chair in her room. R105's right foot and heel remained resting directly on the surface of the leg rest of the recliner. R105's right heel/foot was observed to rest directly on the recliner, without use of a pillow or pressure relieving device for the entire observation from 8:03 a.m. to 10:07 a.m. On 8/19/15, at 8:37 a.m. RN-F confirmed R105 currently had a pressure area on right toe, and indicated she was unsure of the current stage or status of the pressure ulcer. RN-F stated the interventions for the pressure ulcer included floating the right heel all the time while in bed, and no shoes only slipper to right foot. On 8/19/15, at 9:50 a.m. NA-E confirmed R105's right lower leg, right heel and right inner foot and toe were directly on the mattress upon removing blankets prior to performing morning cares. NA-E verified no pillow was present under R105's right foot,leg or near the right foot or leg to be used for positioning. NA-E confirmed there was a pillow behind R105's back and under the left stump/leg, and stated R105 had a sore on her right foot. NA-E confirmed staff were directed to use pillows to elevate R105's right foot. NA-E indicated the facility utilized a computerized system for documentation for R105's repositioning schedule and was not aware the last time R105 had been repositioned prior to completion of R105's morning cares. Review of R105's Point Of Care (POC) Response History log dated 8/19/15, for turn and reposition for R105 revealed R105 had been repositioned at 1:57 a.m., at 8:00 a.m., and 10:00 a.m. On 8/19/15, at 12:39 p.m. RN-G stated R105's abrasion had worsened to a pressure ulcer on the right great toe while in the hospital from rubbing the right foot bunion area onto the cast. RN-G stated the wound has gone through multiple stages, and was currently a scab, an unstageable pressure ulcer. RN-G indicated the current interventions included turning and repositioning every two hours and offloading, and to float the right foot/bunion area off the bed on a pillow. RN-G reported the facility's wound team performed wound care rounding to ensure identified interventions were in place and stated she was aware R105 had been observed with the right foot/bunion area and leg resting directly on the bed in the past. She indicated a pillow or cushion had not been utilized as directed by the care plan. RN-G reported in June of 2015, staff were re-educated to float (elevate off mattress) R105's right foot/bunion area and leg while in bed because of the current pressure ulcer and R105 remained at risk for further pressure ulcers. RN-G stated she would expect staff to float R105's foot off surfaces at all times. Review of R105's Admission Assessment form dated 4/23/15, identified R105 had returned to he facility after surgery to left lower extremity. The form identified R105 had an abrasion to right inner bunion and a pinpoint scab on the right inner ankle. The form identified the pressure ulcer on the right bunion area as an abrasion, not a pressure ulcer. Review of R105's Wound Care Flow Sheets from 6/11/15 to 8/19/15, revealed the following: -4/24/15, stage 2 pressure ulcer on right greater toe present, which measured 1.0 centimeters (cm) in length, 1.6 cm wide and red to dark red in color and had a light scab over the top. The form listed various interventions which included float heels on cushion, and repositioning schedule every 2 hours and PRN. -5/19/15, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black)) pressure ulcer on right outer great toe, which measured 1.2 cm in length, 1.4 cm wide, 1.4 by 1.8 area of yellow slough with red to pink skin surrounding slough and listed various interventions which included every 2 hour repositioning, and to float heels on cushion. -6/6/15, stage 3 (full thickness tissue loss subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer on right outer great toe, which measure 1.0 cm in length, 1.0 cm wide and 0.2 cm deep, red/white in color, and listed various interventions which included to float right heel at all times and repositioning schedule every 1 hour and PRN with 2 staff. -6/11/15, stage 3 pressure ulcer on right outer great toe present, which measured 0.4 cm in length, 0.5 cm wide , had [MEDICATION NAME] tissue, was pink/red and listed various interventions which included repositioning every 1 hour with 2 staff and float right heel at all times. -6/24/15, stage 3 pressure ulcer on right outer great toe present, which measure 1.0 cm in length, 0.9 cm wide and 0.1 cm deep, had light yellow/pink scab and listed various interventions which included repositioning every 1 hour with 2 staff and float right heel at all times. 7/3/1,5 stage 3 pressure ulcer on right outer great toe present, which measured 1.0 cm in length, 0.6 cm wide and 0.1 cm deep, had light yellow/pink scab and listed various interventions which included repositioning every 1 hour with 2 staff and float right heel at all times. 7/29/15, stage 3 pressure ulcer to right bunion, which measured 0.5 cm in length, 0.5 cm wide, light yellow/brown in color and listed various interventions which included repositioning every 1 hour with 2 staff and float right heel at all times. -8/12/15, stage 3 pressure ulcer to right bunion, which measured 0.4 cm in length, 0.5 cm wide, had brown scab and listed various interventions which included repositioning every 1 hour with 2 staff and float right heel at all times. Review of R105's progress notes from 4/14/15 to 8/19/15, revealed the following: -4/14/15, R105's left leg casted, non-weight bearing status. Required assistance of three for positioning. -4/15/15, weekly skin check after bath on 4/14/15. R105's skin intact at that time. no red or pressure areas noted. Cast on left leg due to fracture. R105 is assist of three to reposition every two hours in bed and as needed, R105 is incontinent of bowel and bladder, staff check and change every two hours and as needed. -4/17/15, right foot noted to be bleeding. Small area of skin had been rubbed off from rubbing on cast, area measured 1.5 and was located on the inner aspect of right foot on bunion. Blood noted to inside of cast on left leg. Cleansed with NS (normal saline), applied Allevyn foam dressing to area for protection, to be changed every three days and as needed. Nurse manager assessed area on 4/17/15, skin red, slight blood noted, area of skin is noted to be an abrasion, lines up with R105's left leg cast that is on. -4/24/15, R105 hospitalized ,[DATE] & 4/23 received new cast, new cast goes down to ankle, prior cast went down to the left toes. Wound team assessed R105's right outer great toe bunion area after return from the hospital, previous to hospitalization area was an abrasion, now a stage 2 pressure ulcer with pithily tissue noted and red. -5/2/15, family came to get nurse stating resident had new pressure sore noted to left lower extremity. Nurse notes upon assessment resident noted to have sore to left heel 1.2 cm x 0.8 cm. Family stated this is an old sore that is smaller than it was. Family pointed out a new sore on the back of R105's left lower leg just above the heel where the bottom of the cast meets the skin. The area measured 3 cm x 3.5 cm of red area with a brown colored firm sore in center which measured 1.2 cm by 1 cm. Nurse applied padded dressing to area, sliding padding as far under casted area as possible. The note identified R105's bony prominence on the inner right foot area was open which measured 1 cm x 1 cm, white in color with light red surrounding area. -5/8/15, back of left heel 1.2 cm x 0.8 cm and back of left lower leg above heel 3 cm x 3.5 cm area redness with 1.2 cm brown sore in center. -5/26/15, R105 had returned from hospital after left above the knee amputation due to non healing pressure ulcers. Pressure sore to right foot inner bony prominence of great toe which measured 1.5 cm x 1.5 cm. On 8/20/15, at 7:58 a.m. RN-F indicated she was unaware staff were not following R105's care plan to float the foot/heel at all times. RN-F indicated facility staff utilized a computerized system for documenting R105's repositioning schedule and confirmed the documentation on 8/19/15, revealed R105 had not been repositioned timely. She stated, If it is not documented, it is not done. On 8/20/15, at 1:59 p.m. RN-E stated R105 had required extensive assistance of two or three for bed mobility at the time R105 had a cast on left leg. RN-E stated she was working the day R105 was discovered with blood on the right toe, confirmed the skin damage was from rubbing against R105's left leg cast and was considered an abrasion at that time. RN-E confirmed R105's care plan at that time did not direct staff to separate legs and feet with pillow and stated after the abrasion was discovered, staff attempted to keep R105's legs apart with a pillow. RN-E stated positioning with a pillow between the legs would not be specifically identified on the care plan and would be considered part of bed mobility. RN-E confirmed R105's care plan prior to the development of the pressure ulcer on the right great toe/bunion area did not include any identified interventions to prevent the further development of pressure ulcers for R105. On 8/19/15, at 2:26 p.m. the director of nursing (DON) verified she expected all staff to implement care plan interventions to prevent pressure ulcers and promote healing of pressure ulcers. The DON confirmed staff were expected to have elevated R105's foot while in bed. She indicated the facility utilized a computerized system for documenting cares provided and indicated she felt the staff were not consistently documenting in the system. The DON stated the facility is starting to roll out a new project with ipads which will would make it easier for staff to document each time cares are provided. Review of the facility's Skin Assessment policy dated 1/03 with a revision date of 7/2015, identified a resident admitted to the facility will receive the necessary treatment and services to promote healing and prevent new ulcers from occurring. The facility goal was all residents who enter the facility without pressure ulcers do not develop them unless the clinical condition demonstrates the pressure ulcer was unavoidable. Further the policy identified a resident who scored a Braden of high risk (10-12) or higher to protect heels. In conclusion, the policy identified if a problem is identified the nurse will notify the practitioner within 24 hours for documentation and orders. The decision tree attached to the policy also directed staff to obtain MD (medical doctor) orders for treatment, initiate the wound care flow sheet, weekly skin assessments, put on TAR (treatment administration record), perform a comprehensive assessment in progress notes and update the care plan. R30's quarterly Minimum Data Set ((MDS) dated [DATE], identified R30 had [DIAGNOSES REDACTED]. The MDS identified R30 had severe cognitive impairment, required extensive assistance or was totally dependent on staff for all activities of daily living (ADLs), was always incontinent and was at risk for developing pressure ulcers. R30's Care Area Assessment (CAA) dated 9/9/14, identified R30 had Alzheimer's dementia, advanced age, [MEDICAL CONDITION], pain and [MEDICAL CONDITION] which caused R30 to be non-ambulatory. The CAA further identified R30 had a history of [REDACTED]. R30's skin interventions included: apply [MEDICATION NAME] to legs and arms, turn and reposition every 2 hours, use a ROHO cushion (wheelchair seat air cushion) in her wheelchair. R30's care plan (CP) dated 8/5/15, identified R30 was at risk for skin breakdown due to dementia, incontinence, impaired cognition, knee brace use, impaired mobility, bunion pain with right shoe, and history of stage II pressure ulcer to coccyx. The goal was to minimize her risk for pressure ulcers. CP interventions included: turn and reposition every 2 hours and as needed, skin assessments per policy, lotion arms and legs twice per day with cares, observe for skin changes when providing cares and provide prompt treatment, treatments as ordered to any areas of impaired skin integrity, and ROHO cushion in her wheelchair. The CP failed to identify R30's newly developed stage III pressure ulcer to left 2nd toe, or the [MEDICATION NAME] to protect the current pressure ulcer. Review of progress notes from 8/8/15 to 8/14/15, revealed: -On 8/8/15, R30's weekly skin check had been completed and skin was intact. -On 8/13/15, a rehab aide came to the nurse and stated during range of motion (ROM) R30 was yelling out in pain. Staff touched toes and pain noted. A 0.8 cm by .9 cm abrasion was noted, area was blanchable, not hard, notified Clinical Manager (CM)-A and applied bandage to left second toe. -On 8/14/15, CM-A assessed R30's left toe, 0.5 cm by 0.4 cm, by <.01 cm., wound bed adherent with granulation tissue present, [MEDICATION NAME] applied. Review of R30's Tissue Tolerance Test (TTT), dated 8/15/15, identified a pressure sore to the left second toe with interventions of turning and repositioning every 2 hours and [MEDICATION NAME] to toe. On 08/19/15, during continuous observation from 7:30 a.m. to 10:07 a.m., R30 remained in the same position in her tilt and recline wheelchair for 2 hours and 37 minutes without repositioning and lacked application of [MEDICATION NAME] to the left toe. -7:30 a.m. nursing assistant (NA)-A and nursing assistant student (NAS)-A entered R30's room and woke R30 from sleep to perform morning cares. NA-A stated they used a hoyer lift for her as she is a total assist with transfers. NA-stated R30 used to wear a little sleeve, foamy thing on her toe, but the toe looked better now and confirmed R30 did not have the foam sleeve on at present time. R30's 2nd toe on left foot, was observed to have a small blackened, scabbed area on top of her 2nd toe. The 2nd toe was sticking up and above other toes, resting on top of first toe with no [MEDICATION NAME] present. NAS-A applied Ted hose and put gripper socks over both feet. A [MEDICATION NAME] dressing was not observed to be applied to her toe prior to the application of the Ted hose or gripper socks. NA-A applied a knee brace to R30's left knee and proceeded to place the left heel back on the bed. NAS-A assisted R30 to transfer into a recline and tilt wheelchair. A ROHO cushion was observed on the seat of the chair. After R30 was seated, NAS-A assisted R30 to the dining room. -7:45 a.m. R30 seated in her wheelchair at a dining room table in the back of the dining room. R30 remained in the same position in the wheelchair with gripper socks and Ted hose on both feet on the footrests of the wheelchair. - 8:14 a.m. R30 remained seated in the wheelchair at the dining room table. -8:43 a.m. R30 seated at the dining room table in her wheelchair. 9:17 a.m. R30 seated at the dining room table in her wheelchair. -9:46 a.m. R30 seated at the dining room table in her wheelchair. -10:07 a.m. facility staff wheeled R30 away from the table, and positioned R30's wheelchair facing the dining room doorway. R30 remained seated in the same position in the wheelchair. R30 had not been repositioned from 7:30 a.m. to 10:07 a.m. (2 hours and 37 minutes) when observations ended. Staff did not apply [MEDICATION NAME] to R30's left toe for the entire observation. On 08/19/15, at 1:15 p.m. NA-B confirmed R30's current CP, and stated she was unaware R30 was on a current repositioning program. NA-B stated she was unaware R30 was to have a [MEDICATION NAME] for her toe. On 08/19/15, at 1:49 p.m. NA-A stated she had last repositioned R30 at 10:30 a.m. and had not repositioned R30 from 7:30 a.m. until 10:30 a.m. (3 hours). She was unaware R30 was on a repositioning program or was to have a [MEDICATION NAME] on her toe. On 08/19/15, at 2:45 p.m. CM-A, CM-B, Minimum Data Set Nurse (MDSN)-B and registered nurse (RN)-C (Wound Team), confirmed the team had just completed R30's weekly wound evaluation. The group confirmed R30 had developed a stage III pressure ulcer to her left 2nd toe because her toe crossed over the great toe and the bone was right there. They stated initially the open area was assessed as an abrasion, and after the wound team assessed the area it was identified as a new stage III pressure ulcer. No one on the team was able to confirm at that time if her care plan identified the pressure ulcer, or if she was on a repositioning program. The group confirmed R30's [MEDICATION NAME] had not been on R30's toe all day until wound rounds when they put it on. They stated the [MEDICATION NAME] was an intervention to be utilized to treat R30's her pressure ulcer, but there was not an order from the physician for it. The group stated there should be doctor's orders for the pressure ulcer, but they were not sure. CM-A stated she would check and provide any additional information. On 08/20/15, at 8:00 a.m. during a follow-up interview, CM-A confirmed R30's CP and stated the pressure ulcer and the [MEDICATION NAME] were not identified on R30's CP or R30's treatment administration record (TAR) until after the interview on 8/19/15. CM-A confirmed R30 had developed a new stage III pressure ulcer to her left second toe from the pressure of the big toe on 8/14/15, and the physician had not been notified and the care plan had not been updated. She also stated R30's tissue tolerance test had been done on 8/15/15, but the CP and orders were not changed. She stated she wrote a note to the general nurse practitioner (GNP) on 8/14/15, but the GNP went on maternity leave and did not get it. She confirmed the physician had not been notified until 8/19/15 of the pressure ulcer. She reviewed the most recent MDS and confirmed R30 was at risk for pressure ulcers, and the MDS incorrectly identified not history of pressure ulcers. She confirmed R30's CP did identify she was to be repositioned every 2 hours, and was at risk for skin breakdown. She stated she would expect R30 to be repositioned every 2 hours. Review of the facility policy titled, Skin Assessment, dated revised 7/2015 identified a resident admitted to the facility would receive the necessary treatment and services to promote healing and prevent new ulcers from occurring. Further it identified, a resident who was admitted to the facility without pressure ulcers would not develop them unless the clinical condition demonstrates the pressure ulcer was unavoidable. The policy identified if a problem was identified the nurse would notify the practitioner within 24 hours for documentation and orders. The decision tree attached to the policy also directed staff to obtain MD orders for treatment, initiate the wound care flow sheet, weekly skin assessments,transcribe the order to the resident's TAR, perform a comprehensive assessment and update the care plan.

Based on documentation review, interview and policy review, the facility failed to provide the highest practicable level of care for 1 of 3 (#1) residents in the sample when staff transferred the resident with a standing lift instead of a hoyer lift as directed by the plan of care. The action caused increased shoulder pain for Resident #1 which required additional narcotic medication. Findings include: Review of Resident #1's record revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's current plan of care with a target date of 11/23/11, revealed the resident was non-ambulatory, required the assistance of two staff and a mechanical hoyer lift for transfers including hoyer transfers to and from the tub chair, and was dependent on one to two staff for all activities of daily living. The care plan stated Resident #1 was alert and oriented with periods of confusion but was able to communicate her needs. The care plan indicated Resident #1 had potential for discomfort related to impaired mobility and severe [MEDICAL CONDITION] joint disease. Review of the facilities Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1 received [MEDICATION NAME] 10/500 mg every four hours as needed for break through pain. Review of the facility's nursing documentation dated 8/31/11, at 3:00 p.m. stated Resident #1's current pain rating was 0. Review of the facility's incident report dated 9/9/11, revealed Resident #1 was experiencing extreme pain of the resident's shoulder. Resident #1 told staff the previous night after her bath, two staff used the standing lift instead of the hoyer lift to transfer the resident off the tub chair. In addition, the staff transferred Resident #1 with the standing lift to her room across the hallway instead of transferring the resident to her wheelchair for transport. The documentation indicated Resident #1 had contractures and hadn't been able to stand for several years which made the use of a standing lift unsafe for the resident. The incident report stated Resident #1 had decreased range of motion to the right arm and shoulder with grimacing during movement. Review of the facility's MAR for September 2011, revealed after the inappropriate transfer, Resident #1 requested and received an as needed [MEDICATION NAME] at 11:07 p.m. on 9/8/11. There was no documentation of an assessment of the pain when the as needed [MEDICATION NAME] was given to Resident #1. Review of the facility's nursing documentation dated 9/9/11, at 2:30 p.m. revealed Resident #1 complained of intense pain of the right shoulder rating the pain at 10. Resident #1 stated the pain was tolerable only if she laid completely still. The physician's assistant for Resident #1 was notified and the [MEDICATION NAME] was increased to 75 mcg/hr. In addition, Resident #1 was transported to an emergency room for evaluation and x-ray of the right shoulder. Review of the x-ray report dated 9/9/11, revealed Resident #1 had no acute injury related to the transfer. Resident #1 was interviewed on 9/26/11, at 5:30 p.m. and stated the pain in her right shoulder was intense after the transfer with the standing lift. Resident #1 said she had never used that lift before and did not understand why staff used it this time. Interview with Employee (A)/Nursing Assistant at 2:50 p.m. on 10/5/11, revealed she was aware Resident #1 required the hoyer lift for all transfers and confirmed she failed to follow the resident's plan of care. Employee (A) said she was very familiar with Resident #1's cares and gave no explanation for utilizing the standing lift instead of the hoyer lift. Employee (A) stated Resident #1 complained of right shoulder pain immediately after the transfer. Interview with Employee (B)/Nursing Assistant at 4:10 p.m. on 10/5/11, revealed he had transferred Resident #1 to the tub room with the hoyer lift and was aware the resident required the hoyer lift for all transfers. Employee (B) offered no explanation for utilizing the standing lift except he didn't know how to get the lift sheet under the resident after the bath and he was in a hurry. Employee (A) confirmed Resident #1 had complained of right shoulder pain after the transfer and he notified the nurse of the pain but not the inappropriate transfer. Interview with the Director of Nursing (DON) at 12:00 p.m. on 9/26/11, revealed staff should have been aware that Resident #1 required a hoyer lift for transfers. The DON stated Resident #1 had contractures due to arthritis which made the use of a standing lift nearly impossible. In addition, the staff transported Resident #1 to her room with the standing lift which is never done. Staff were to transfer Resident #1 to her wheelchair in the tub room and transport the resident to her room in her chair. Review of the facility's policy and procedure titled Hoyer/Electronic Lift/Stand-Up with a revision date of 12/09, stated, "...A Hoyer/Electronic Lift will be used to transfer a resident whenever it is unsafe to transfer that resident due to inability to stand, large body weight...a hoyer will be used only as a transfer device and not for transporting...". The policy failed to address that a standing lift will not be utilized for transporting a resident.