Every finding on record at Friendship Village of Bloomington

Based on interview and document review, the facility failed to assess a resident's supervision needs, evaluate interventions, and revise the care plan following a significant incident for 1 of 3 residents (R1) reviewed for supervision and accidents.Findings include:R1's admission record dated 2/23/24, indicated R1's diagnoses included Alzheimer's disease with late onset, dementia, psychotic disturbance and mood disturbance, generalized weakness, altered mental status, and hallucinations. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required substantial/maximal assistance for toileting, transfers, and ambulation.R1's activities of daily living (ADLs) care plan dated 3/08/24, identified R1 as being at risk for wandering due to disorientation to places. The care plan directed staff to identify patterns of wandering, anticipate and meet the residents' needs, reorientation and supervise R1 as needed. R1's updated ADLs care plan, dated 4/13/26, indicated R1 was known to wander into other residents' rooms. The care plan instructed staff to redirect R1 by offering alternative activities as needed.R1's point of care (POC) records were reviewed for the period of July 15, 2026, through July 22, 2026. The review showed staff completed a scheduled task directing them to provide R1 with a stack of washcloths to fold when R1 was restless or wandering as a means of redirection.R1's point of care (POC) behavior monitoring and intervention task records from 7/15/26 through 7/22/26 reviewed showed staff documented the task as completed and checks No behavior observed during the monitoring period.R1's progress note dated 7/14/26 at 12:13 p.m., indicated R1 tended to be most engaged during baking groups and singing groups. The note further indicated R1 was disoriented and wandered often throughout the day. R1's progress note dated 7/22/26 at 8:59 p.m., documented R1 was found sitting naked on the bed of female resident R2 after R2's son alerted staff. The note further indicated R2 was awake, fully clothed, and covered with blanket up to her chest.Review of R1's medical record from April through July 2026 did not identify a comprehensive assessment of R1's wandering behavior to determine the level of supervision needed to prevent R1 from wandering into other residents' rooms, identify behavior patterns, evaluate the effectiveness of existing interventions, or revise interventions following the incident in which R1 was found naked in R2's room.R2's physician regulatory visit note dated 7/9/26 identified R2 diagnoses included history of subdural hematoma with decline leading to hospice enrollment, acute confusion change, restlessness and agitation.R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment and required substantial/maximal assistance for toileting and transfers.During an interview on 7/28/26 at 3:26 p.m., a family member (FM)-A stated during a visit with his mother, R2 on 7/22/26, he observed R1 sitting naked on the edge of R2's bed. FM-A stated he was shocked by what he observed and immediately went to the nursing station to report the incident to the nursing staff. At the nursing station five staff members were sitting there at the time he made the report. FM-A stated R2 had severe cognitive impairment. When he asked R2 about the incident, she responded what this man is doing in her room. FM-A reported he did not believe R2 experienced distress, fear or emotional trauma due to the incident. FM-A explained his primary concern was what interventions the facility was going to implement to increase R1's supervision in order to prevent reoccurrence. FM-A denied any sexual behavior occurred between R1 and R2. FM-A confirmed the facility informed him they would increase monitoring of R1 by conducting checks every 30 minutes and documenting the increased supervision; however, FM-A expressed concern regarding whether the increased monitoring would be consistently implemented.During an interview on 7/28/26 at 4:47 p.m., nursing assistant (NA)-A stated he was working the evening shift on 7/22/26 when R1 was found naked sitting on R2's bed. NA-A explained R1 frequently wandered into other residents' rooms to use their bathrooms. NA-A stated he was at the nursing station when R2's son found R1 naked sitting in R2's bed and reported the incident to staff. NA-A stated he did not know how long R1 had been in R2's room and could not recall when R1 had last been observed. NA-A explained staff were expected to keep R1 within sight at all times. NA-A confirmed he did not receive any education or retraining following the incident.During an interview on 7/28/26 at 4:25 p.m., licensed practical nurse (LPN)-A stated she was working the evening shift on 7/22/26 when R1 was found sitting naked in R2's bed at approximately 5:30 p.m. LPN-A stated this was not the first time R1 had been found in another resident's room. LPN-A stated she recalled a previous incident in which R1 was found lying in another female resident's bed. LPN-A explained nursing staff were expected to reorient R1, provide supervision and keep him engaged in activities in the common area. LPN-A confirmed she did not receive any education or retraining following the incident.During an interview on 7/28/26 at 2:31 p.m., a registered nurse (RN)-A who served as the charge nurse, stated she was informed by LPN-A that R1 had been found sitting naked in R2's bed after the incident was reported by R2's son. RN-A stated she came over to the room to apologize to R2 and her son and removed R1 from the room. RN-A explained R1 had severe cognitive impairment and a history of wandering into other residents' rooms. RN-A stated nursing staff were required to know R1's whereabouts at all times and keep him engaged in the common area. RN-A reported she did not provide staff with any education following the incident regarding R1's wandering behavior or the corresponding interventions needed to ensure R1's safety. RN-A stated she was not sure who updated R1's care plan following the incident. RN-A explained she did not know how long R1 had been in R2's room while unclothed. RN-A confirmed she did not receive any education or retraining related to the incident.During an interview on 7/29/26 at 12:57 p.m., the director of nursing (DON) stated R1 had a history of wandering into other resident's rooms, and the facility had been trying to work with R1's family to determine what interventions might work better for R1. The DON stated she did not know whether each wandering incident had been reviewed to identify the root cause or whether corresponding interventions had been developed to prevent recurrence. The DON stated she expected staff to reorient and supervise R1, ensure he was engaged in activities during each shift. The DON stated she expected staff to complete a comprehensive assessment to determine the root cause of wandering behaviors. The DON stated she did not know how long R1 had been naked in R2' bed. The DON confirmed the facility did not complete a root cause analysis following the incident and did not provide staff education regarding appropriate supervision. The DON stated she could not find any documentation about whether or not the facility had evaluated the effectiveness of interventions implemented for R1.The Facility Safety and Supervision of Residents Policy dated 10/13/25 indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. The policy directed the facility to implement interventions to reduce accident risk by:Communicating specific interventions to all relevant team members;Providing training as necessary;Monitoring the effectiveness of interventions which include evaluating the effectiveness of interventions, modifying or replacing interventions as needed.Ensuring that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to ensure staff implemented appropriate infection prevention and control practices, including proper hand hygiene while feeding residents, maintaining a clean resident care environment when staff were observed standing on a resident's (R6) mattress, and ensuring resident care items were cleanable and disinfected for a resident (R1) who had pool noodles affixed with tape on their bed and windowsill. Findings include: During observation on 5/4/26 at 12:25 p.m. NA-C was assisting two residents with eating at the same time. NA-C stood up from assisting the residents, scratched his face, touched the counter, obtained straws, and pushed one resident's wheelchair closer to the table before returning to assist the residents with eating without performing hand hygiene. The NA-C placed a straw into unidentified Resident 1's drink and assisted Resident 1, who was seated in a Broda chair and appeared asleep, with drinking. NA-C then assisted unidentified Resident 2, who was seated in a high-back wheelchair, with utensils. NA-C switched between feeding both residents with the same hand, wiped Resident 1's hands, and continued feeding both residents without performing hand hygiene. During the feeding assistance, NA-C repeatedly touched his face and eyes with the same hand used to feed the residents and removed and replaced his eyeglasses multiple times while continuing to assist the residents with eating. During observation on 5/4/26 at 12:38 p.m. NA-C cleaned his eyeglasses at the dining table with a disposable wipe he retrieved from his pocket and then resumed feeding the residents without performing hand hygiene. During an interview on 5/5/26 at 1:02 p.m., the Infection Preventionist (IP) stated expectations for staff assisting residents with eating included proper hand hygiene and prevention of cross contamination. The IP stated staff should not feed more than one resident at a time and indicated that even when different utensils were used, feeding multiple residents simultaneously created a significant contamination risk. The IP stated infection control education and feeding skills training were provided four times per year. The IP further indicated the pool noodles, used on R1's bed and windowsill were cleaned as part of the facility's general cleaning process. The IP stated staff wiped the pool noodles down with disinfectant and left the surface wet for the recommended contact time of approximately four minutes, despite the pool noodles being a porous surface and not a cleanable hard surface. R6 R6's quarterly Minimum Data Set (MDS) dated [DATE] identified R6 with severe cognitive impairment, delusions, and behaviors directed at others. In addition, R6 identified had no impairment of upper and lower extremities, required partial to moderate assistance with personal care and dressing. Also, R6's diagnoses included dementia with behavioral disturbances, anxiety, affective disorder (psychiatric condition that affects emotional state), diabetes, and hearing loss. During observation and interview on 5/5/26 at 1:08 p.m., R6 was in a wheelchair and was wheeled from the hallway into a shared bathroom by nursing assistant (NA)-A. NA-A then used a transfer belt to assist in transferring R6 onto the toilet. After several minutes, NA-A attempted to assist R6 from toilet to wheelchair but R6 did not follow requests or commands. NA-A then asked NA-B to assist with transferring R6 to wheelchair. After this was done, both NA-A and NA-B wheeled R6 to bed which was two twin mattresses on the floor of bedroom. NA-A and NA-B used a transfer belt to assist R6 from wheelchair to stand and then pivoted him to sit down on mattress. During the transfer, NA-A stepped on and also kneeled onto the mattresses to assist R6 to lay down. NA-A stated she did not know of another way to help R6 during transfer to the mattresses without stepping on the mattresses. During observation and interview on 5/6/26 at 9:47 a.m., NA-E and NA-D entered R6's room and woke R6 up for breakfast. NA-D picked up two fall mats that surrounded R6s mattresses and then placed a wheelchair to the side of the mattresses and locked the wheels. NA-D then stepped onto the top of R6's mattresses with her shoes on and knelt down to assist NA-E with positioning the Hoyer sling under R6. NA-D lifted up entire bottom of one of the twin mattresses on the floor, that R6 was lying on, and NA-E rolled the Hoyer forward with one leg of the Hoyer under the mattress. NA-D stood up on top of the mattresses again and then both aides assisted R6 with arms inside the sling. NA-D lifted R6 up off the mattresses using the Hoyer while NA-E walked around to the wheelchair and positioned R6 into wheelchair as he was being lowered by the Hoyer. NA-D stated she had to stand on the mattresses to assist R6 with transfer from bed to the wheelchair. During interview with Registered Nurse (RN)-A on 5/6/26 at 12:36 p.m., RN-A stated expectation of staff to never stand on a mattress due to, safety and infection control. During interview with Director of Nursing (DON) on 5/6/26 at 1:06 p.m., DON stated expectation of staff to not have feet on the mattress due to infection control. R1 R1's quarterly MDS dated [DATE], indicated R1 had severely impaired cognition and was diagnosed with cancer, kidney disease, and respiratory failure. R1 was dependent/required maximal assistance for activities of daily living. During an observation on 5/4/26 at 3:27 p.m., R1 was observed lying in bed. R1 was observed to have pool noodles that had a slit cut down one side and were then affixed to the edge of his windowsill, headboard, and footboard with tape that was curling with brown/black matter observed under the edges. The pool noodles and tape were observed with a thin layer of dust on top of them. During an observation on 5/6/26 at 12:22 p.m., in R1's room, there were pool noodles that had a slit cut down one side and were then affixed to the edge of his windowsill, headboard, and footboard with tape that was curling with brown/black matter observed under the edges. The pool noodles and tape were observed with a thin layer of dust on top of them. During an interview on 5/6/26 at 12:22 p.m., housekeeper (H)-A stated she used a bleach solution to clean the pool noodles in R1's room but because the noodles were so porous, she didn't want to saturate the noodles so she made sure she used a minimal amount of the solution and the solution didn't sit a long period of time, so less than a minute. A facility policy titled Infection Prevention and Control Program, reviewed 1/2026, indicated the mission of the program was to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 3 of 5 residents (R59, R3 and R12) reviewed for comprehensive care plan. Findings include: R12's significant change Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment and needed extensive to total assistance for all activities of daily living. The MDS indicated R12's preferences of books, newspapers, music, animals, news, being with groups of people, going outside, and attending religious services were all very important. R12's activity assessment dated [DATE], indicated R12 would prefer to spend leisure time both individually and in group activities and prioritize therapy, resting, or recovery over leisure activities. The assessment indicated R12 would like to participate in outings such as leisure drives/tours and restaurants. The assessment indicated R12 identified with the Lutheran church and was interested in worship services. The assessment indicated R12 would like to spend time in nature, doing independent activities such as prayer, etc., and listening to modern music for relaxation, anxiety, or pain management. The assessment indicated R12 liked to play games, read, would like an invitation to attend group discussions, liked to stay aware of the news by television and newspapers, wished to connect with team members, and participate in social activities. R12's care plan dated 4/21/26, was reviewed and did not include information about activity goals, participation, or interventions implemented to meet R12's activity needs. During an interview on 5/6/26 at 12:33 p.m., the long-term care activities lead (A)-A confirmed he had reviewed R12's medical record and stated that R12 didn't have an active activities care plan. A-A stated that, along with a significant change MDS, activity staff would complete an activities assessment, and this would be used to create/revise the activities care plan. A-A stated it was possible that the resident was a transitional care unit (TCU) resident, and with the transition to long-term care, the activities care plan had been dropped and not re-added. During an interview on 5/7/26 at 10:03 a.m., the administrator stated she would refer to the activities team for the specifics of creating an activities care plan but would expect residents to have an active activities care plan. R59 – BiPAP (bilevel positive airway pressure device - a non-invasive ventilation machine to help breathing) R59's quarterly MDS assessment dated [DATE], identified R5 had intact cognition with no hallucinations or delusions. During an observation on 5/4/26 at 4:41 p.m., a BiPAP machine was observed sitting on R59's side table by her bed. There was a gallon of water next to the machine. R59 indicated staff assist with her with the machine at night. R59's care plan, printed 5/6/26, identified R59 had an activity of daily living (ADL) self-care performance deficit related to multiple sclerosis and impaired balance and required extensive staff assistance for all ADLs except transfers which R59 required total staff assistance and Hoyer (mechanical lift used for residents who cannot bear weight) for transfers. The care plan lacked any evidence that R59 required or used a BiPAP machine. During an interview on 5/5/26 at 2:02 p.m., NA-F stated they were aware R59 had a CPAP machine. NA-F stated they were unsure of what type of assistance R59 needed as they did not assist R59 with the machine as they did not work the night shift. During a follow up interview on 5/6/26 at 8:16 a.m., R59 stated she previously had CPAP (a machine that provides continuous positive pressure via mask to help with conditions like obstructive sleep apnea) and was changed to a BiPAP machine. R59 stated she was unsure when the change was made but it was a long while ago. R59 stated staff assisted her putting the mask on and off as she could not do this independently and they turned the machine on and off for her. R59 stated she was not sure if the mask got wiped down after each use. R59 stated she ordered all her own supplies for the machine, and the facility didn't have anything to do with this. During an interview on 5/6/26 at 8:33 a.m., licensed practical nurse (LPN)-B stated nursing assisted with R59 putting on the mask and taking it off along with turning the CPAP machine on and off. LPN-B stated they changed the water. LPN-B stated the water chamber should be filled weekly along with the changing of the mask and tubing. LPN-B stated this would all be documented on the MAR. During an interview on 5/6/26 at 10:21 a.m., registered nurse manager (RN)-C verified if a resident had a CPAP or BiPAP machine this should be on the care plan. RN-C verified R59's did not contain this. During an interview on 5/6/26 at 12:45 p.m., director of nursing (DON) stated they would expect if a resident was using a BiPAP machine it would be on the care plan as this was important for coordination of care. DON verified this was not on R59's care plan and should be. R3 - Catheter R3's admission MDS assessment dated [DATE], identified R3 had intact cognition with no hallucinations or delusions. Furthermore, indicated R3 had an indwelling catheter. During an interview on 5/4/26 at 12:17 p.m., R3 stated that he had a catheter (foley catheter- a thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) prior to admission. R3 stated that since moving to facility, the catheter had been changed to a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen into the bladder to drain urine) due to the infections he had been getting. R3 verified staff assist with the catheter. R3's care plan, printed 5/6/26, indicated the following: -(R3) is incontinent of bladder related to neurogenic bladder with the following interventions: - Brief Use: the resident uses disposable briefs, Change per schedule and prn. -Clean peri area with each incontinence episode. -Incontinent: check at least q 2 hrs. and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episode. -Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R3's care plan lacked evidence R3 has a suprapubic catheter. Furthermore, lacks evidence of who is responsible for the catheter care and changing of catheter bag. During an interview on 5/6/26 at 10:07 a.m., registered nurse manager (RN)-C stated R3 did have a suprapubic catheter which had been changed from the foley catheter that he had been admitted with. RN-C verified if a resident had a catheter this information should be on a care plan along with who was responsible for the catheter. RN-C requested to follow up on the catheter. No additional information regarding R3's care plan was provided. During an interview on 5/6/26 at 12:51 p.m., director of nursing (DON) stated they would expect if a resident had a catheter, that information would be on the care plan as this was important for coordination of care. DON was requested to review R3's care plan for any catheter information. No additional information was provided. A facility policy titled Comprehensive Care plan revised 9/6/22, identified the following: The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; m. Identify the professional services that are responsible for each element of care;

Based on interview and document review, the facility failed to ensure timely completion of a required annual Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed (R7), which had the potential to result in inaccurate assessment data and/or improper care planning.Findings include:R7's most recent MDS assessment, a quarterly assessment dated [DATE], was reviewed. Based on the assessment schedule, an annual MDS assessment was required to be completed following the 12/2/25 quarterly assessment.R7's electronic medical record (EMR) and MDS assessments lacked evidence the required annual MDS assessment was completed within the federally required timeframe. During an interview on 5/5/26 at 12:28 PM, MDS Coordinator and RN-B, stated there was a report in the EMR system that was run monthly on the 15th to track upcoming MDS assessments. After generating the report, a schedule with due dates for nursing staff to gather data and identify ARDs was completed. RN-B further stated he was unsure how R7 fell through the cracks, acknowledged that it appeared an annual assessment was missed, and indicated he would complete it immediately.

Based on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were fully addressed, including providing a rationale in the resident's medical record if no changes in medication were to be made for 1 of 5 residents (R5) reviewed for unnecessary medications. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderately impaired cognition and was diagnosed with diabetes, Alzheimer's disease, and anxiety.R5's pharmacist Consultation Report dated 11/5/25, indicated R5 received 6 milligrams (mg) of melatonin at bedtime since 7/21/23 for insomnia. The report indicated that melatonin was not recommended for sleep onset or sleep maintenance insomnia in adults. The report indicated that melatonin does not induce or maintain sleep but helps to set the hour of sleep and should not be used beyond six weeks. The report indicated the adverse reactions of melatonin include confusion, daytime drowsiness, dizziness, vivid dreams or nightmares, and increased bed wetting. The pharmacist recommended discontinuing R5's melatonin by giving 3 mg at bedtime for seven days and then discontinuing the medication. The note was signed by the provider on 11/10/25 with a box checked indicating they declined the recommendations above and do not wish to implement changes due to the reasons below, with a handwritten rationale of need to review with psychiatry.R5's pharmacist Consultation Report dated 12/2/25, indicated R5 received six milligrams (mg) of melatonin at bedtime and had experienced a fall on 11/22/25. The report indicated that melatonin does not induce or maintain sleep but helps to set the hour of sleep and should be discontinued once the hour of sleep is set, usually after six weeks. The pharmacist recommended discontinuing R5's melatonin. The report was signed by the provider on 12/11/25 with a box checked indicating they had re-evaluated this therapy and do not wish to implement changes due to the reasons below, with a handwritten rationale of followed by psychiatry.R5's Psychiatric evaluation note dated 1/12/26, indicated R5 was lying in bed sleeping and was difficult to wake on assessment. The note indicated she was tired and only opened her eyes for a few moments. The note indicated to continue melatonin 6 mg at bedtime but did not include a rationale for not following the pharmacist's recommendation.R5's order summary dated 4/17/26, included an order dated 11/26/25 for R5 to receive 6 mg of melatonin at bedtime for insomnia.During an interview on 5/6/26 at 9:31 a.m., the consultant pharmacist (CP) stated he had been working to take residents off of melatonin because of its possible side effects such as dizziness, confusion, vivid dreams and nightmares which can lead to more falls out of bed. The CP stated that unless the psychiatry group worked for the facility, it was almost impossible to get a response from them. At 10:01 a.m., the CP stated that he had reviewed R5's medical record and believed that he had referred to R5's psychiatry note dated 1/12/26 when deciding not to re-recommend discontinuing melatonin. The CP stated the note had said to continue to melatonin, so he had accepted this as a response to his recommendation.During an interview on 5/7/26 at 8:51 a.m., the director of nursing (DON) stated pharmacist regimen reviews would first be provided to the primary provider, and then if the facility did not get a response, they would notify the medical director. The DON stated she did not believe the medical director had been notified regarding R5's melatonin recommendations as the primary provided was aware of the recommendation and had given a response that referred the recommendation to someone else.A drug regimen review policy was requested from the facility but was not received.

Based on interview and record review, the facility failed to ensure accurate orders, accurate and complete respiratory care documentation and resident-specific ordered settings for the use and management of a BIPAP device (bilevel positive airway pressure device - a non-invasive ventilation machine to help breathing) for 1 of 1 resident (R59) reviewed for respiratory care. Findings include:R59's quarterly MDS assessment dated [DATE], identified R5 had intact cognition with no hallucinations or delusions. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator (to include BiPAP and CPAP in section G2 and G3 below) was not marked with a check mark to indicate use. Under section Z1: none of the above: was marked with a check.During an observation on 5/4/26 at 4:41 p.m., a BiPAP machine was observed sitting on R59's side table by her bed. There was a gallon of water next to the machine. R59 indicated staff assist with her with the machine at night.R59's care plan, printed 5/6/26, identified R59 had an activity of daily living (ADL) self-care performance deficit related to multiple sclerosis and impaired balance and required extensive staff assistance for all ADLs except transfers which R59 required total staff assistance and Hoyer (mechanical lift used for residents who can not bear weight) for transfers. The care plan lacked evidence that R59 required or used a BiPAP machine. R59's Order Summary, printed 5/6/26, lacked orders for use of a BiPAP machine, specific settings for BiPAP machine, when to use the BiPAP machine, cleaning of machine/mask, and tubing/filter changes. F59's May Medication Administration Record (MAR), printed 5/6/26, included the following order: ok to resume CPAP with home settings every night shift with a start date of 2/5/26. R59's MAR lacked evidence R59 was ordered or used a BiPAP machine. Furthermore, lacked evidence of cleaning of mask, assisting resident to use BiPAP machine, changing of tubing and/or filters for BiPAP machine. R59's after visit summary, dated 3/10/26, included the following order: BiPAP machine for home use with pressure: IPAP (inspiratory positive airway pressure) 20 centimeter (cm) H20 (water column), EPAP (expiratory positive airway pressure) 16smH20 for obstructive sleep apnea. See qualify BIPAP titration study from 8/4/25. R59's Task Log was reviewed and lacked evidence of staff assisting with BiPAP machine in any way.R59's progress notes for 3/1/26 to 5/4/26 were reviewed and lacked evidence of BiPAP machine orders, mask cleaning or changes, tubing changes, or assistance provided to R59.During an interview on 5/5/26 at 2:02 p.m., NA-F stated they were aware R59 had a CPAP machine. NA-F stated they were unsure of what type of assistance R59 needs as they did not assist R59 with the machine as they did not work the night shift. During a follow up interview on 5/6/26 at 8:16 a.m., R59 stated she previously had CPAP (a machine that provides continuous positive pressure via mask to help with conditions like obstructive sleep apnea) and was changed to a BiPAP machine. R59 stated she was unsure when the change was made but it was a long while ago. R59 stated staff assisted her putting the mask on and off as she could not do this independently and they turned the machine on and off for her. R59 stated she was not sure if the mask got wiped down after each use. R59 stated she ordered all her own supplies for the machine, and the facility didn't have anything to do with this.During an interview on 5/6/26 at 8:33 a.m., licensed practical nurse (LPN)-B stated nursing assisted R59 with putting on the mask and taking it off along with turning the CPAP machine on and off. LPN-B stated they changed the water. LPN-B stated the water chamber should be filled weekly along with the changing of the mask and tubing. LPN-B stated this would all be documented on the MAR.During an interview on 5/6/26 at 10:21 a.m., registered nurse manager (RN)-C verified staff have been assisting R59 with the CPAP machine. After review of R59's medical record, RN-C verified there was no monitoring in place of staff assisting R59, tube changes, mask cleaning or changes or setting for the machine.During a phone interview on 5/6/26 at 11:01 a.m., clinic staff (staff) verified that R59 was a patient at the clinic (Lung and Sleep Clinic). Staff verified R59 used a BiPAP machine based upon their provider orders. During an interview on 5/6/26 at 12:45 p.m., director of nursing (DON) stated they were unaware of any residents who utilize a BiPAP machine. DON requested to follow up. During a follow up interview on 5/6/26 at 1:15 p.m., after review of R59's medical record, DON verified that R59 had an order for a BiPAP machine and was using a BiPAP machine. DON verified the current orders were for a CPAP machine which didn't include settings. DON stated anything the staff were doing to assist a resident such as putting on or taking of the mask needed to be documented along with monitoring the changing of tubing and cleaning of the mask and verified this was not being done for R59. DON stated this would be expected to be done as it was expected for coordination of care. No additional information was provided. A facility policy regarding respiratory care / BiPAP use was requested but not received.

Based on interview and document review, the facility failed to ensure proper orders were obtained and adequate coordination in place to care for a resident with a suprapubic catheter for 1 of 1 residents (R3) reviewed who used a catheter.Findings include:R3's admission MDS assessment dated [DATE], identified R3 had intact cognition with no hallucinations or delusions. Furthermore, indicated R3 had an indwelling catheter.During an interview on 5/4/26 at 12:17 p.m., R3 stated that he had a catheter (foley catheter- a thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) prior to admission. R3 stated that since moving to facility, the catheter had been changed to a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen into the bladder to drain urine) due to the infections he had been getting. R3 verified staff assist with the catheter.R3's care plan, printed 5/6/26, indicated the following:-(R3) is incontinent of bladder related to neurogenic bladder with the following interventions:- Brief Use: the resident uses disposable briefs, Change per schedule and prn.-Clean peri area with each incontinence episode.-Incontinent: check at least q 2 hrs. and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episode.-Monitor/document for s/sx UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.R3's care plan lacked evidence that R3 has a suprapubic (SP) catheter and lacked evidence of who was responsible for the catheter cares and changing of catheter bag. R3's April's MAR/TAR included the following orders:-Clarify with provider for catheter size two times a day with a start day of 3/12/26. Marked as completed all days except 4/11/26 and 4/21/26 which was marked with a 9 indicating a progress note.-Change catheter drainage bag and tubing every night shift on Sunday with start date of 3/1/26 which was marked as completed on days ordered.-Last SP catheter change was 4/22/26 at urologist office, every day shift with a start day of 4/23/26 which was marked as completed 4/23/26 to 4/30/26-SP Catheter: clean around the SP catheter exit side with soap and water, pat dry under disk, change gauze bandage around the SP catheter site daily or as needed to keep the site clean and dry one time a day with a start day of 3/10/26. Marked as completed all days except 3 shifts which were left blank.-Call Midwest Radiology (number listed) if drainage from catheter suddenly stops or significantly decreases, catheter appears to be falling out, fallen out, becomes clogged or breaks. Significant leaking around SP catheter exit site every shift starting 3/10/26. Marked as completed all days except 7 shifts which were left blank.-Contact clinician if fever greater than 101 degrees, foul smelling, yellow/green drainage from SP catheter exit site, significant bleeding at the SP catheter exit site, significant or worsening pain at the SP catheter exit or abdomen every shift starting 3/10/26. Marked as completed all shifts except 7 shifts which were left blank.-May flush with 60cc sterile H20 if not draining properly as needed with a start date of 2/26/26. R3's May Medication Administration Record (MAR/TAR) for 5/1/26-5/5/26 included the following orders:-Clarify with provider for catheter size two times a day with a start day of 3/12/26. Marked as completed 5/1/26 to 5/5/26 except 5/2/26 which was marked with a 9 indicating a progress note.-Change catheter drainage bag and tubing every night shift on Sunday with start date of 3/1/26 which was marked as completed on 5/3/26.-Last SP catheter change was 4/22/26 at urologist office, every day shift with a start day of 4/23/26 which was marked as completed 5/1/26 to 5/5/26.-SP Catheter: clean around the SP catheter exit side with soap and water, pat dry under disk, change gauze bandage around the SP catheter site daily or as needed to keep the site clean and dry one time a day with a start day of 3/10/26. Marked as completed on 5/1/26 and 5/2/26 with 5/3/26-5/5/26 left blank.-Call Midwest Radiology (number listed) if drainage from catheter suddenly stops or significantly decreases, catheter appears to be falling out, fallen out, becomes clogged or breaks. Significant leaking around SP catheter exit site every shift starting 3/10/26. Marked as completed day shift 5/1/26 through 5/4/26, evening shift 5/1/26 and 5/2/26, night shift 5/1/26 through 5/4/26 with 5/3/26 and 5/4/26 evening blank and 5/5/26 blank.-Contact clinician if fever greater than 101 degrees, foul smelling, yellow/green drainage from SP catheter exit site, significant bleeding a the SP catheter exit site, significant or worsening pain at the SP catheter exit or abdomen every shift starting 3/10/26. Marked as completed day shift 5/1/26 through 5/4/26, evening shift 5/1/26 and 5/2/26, night shift 5/1/26 through 5/4/26 with 5/3/26 and 5/4/26 evening blank and 5/5/26 blank.-May flush with 60 cubic centimeter (cc) sterile H20 if not draining properly as needed with a start date of 2/26/26. R3's progress notes for 4/1/26 to 5/6/26 identified the following:-4/11/26: Clarify with provider for catheter size two times a day - no additional note-4/12/26: resident refused catheter care-4/21/26: Clarify with provider for catheter size two times a day resident has an s/p catheter-4/22/26: returned from urology appointment. Successful SP cath exchange.-4/29/26: Genitourinary: catheter character: patent catheter size: 16 fr.-5/2/26: Clarify with provider for catheter size two times a day see PCC-5/5/26: Clarify with provider for catheter size two times a day PCC-5/6/26: spoke with interventional radiology who stated R3's catheter size is 18F and deferred any additional questions to Health Partners urology. Call placed to urology nurse who stated R3 will be seen about 6 weeks in clinic after 4/22/26 change where the next catheter change will be completed. After that change by the PA (physician assistant), the facility may be approved to do catheter changes but prior to that R3 needs to be seen in clinic for any issues. During an interview on 5/6/26 at 8:28 a.m., licensed practical nurse (LPN)-B stated R3's last SP catheter change was 4/22/26 which was done at the urologist office. LPN-B stated she believed that the facility was going to start performing the catheter changes. LPN-B verified there were no orders to change R3's catheter and no current catheter size identified in the orders. LPN-B stated she knew the catheter was a 16F as she had looked at it during the dressing changes daily. LPN-B verified an order to clarify catheter size starting in March and no catheter size was listed. LPN-B stated if there was trouble with R3's catheter, they would call the number listed on the order, but they were unaware if this number was answered 24 hours a day or what would happen in the middle of the night or weekends. During an interview on 5/6/26 at 10:07 a.m., registered nurse manager (RN)-C stated R3 came to the facility with a foley catheter which was changed to a SP catheter on 3/9/26. RN-C stated the last catheter change was 4/22/26. RN-C reviewed all R3's current orders and medical records. RN-C verified there were no orders or documentation on what size catheter R3 currently had. RN-C stated she was unsure if the facility would be responsible for changing the SP catheter, or if the number on the order was answered 24 hours a day 7 days a week. RN-B requested to follow up. During a follow up conversation, RN-C stated she was able to figure out R3's catheter size was 18F. RN-C stated she had called the clinic number listed to obtain that information, but they were unable to tell her any additional information in regard to ongoing care/changes for the SP catheter so she had a call to the urologist. No additional information was provided.During an interview on 5/6/26 at 11:06 a.m., clinic registered nurse (RN)-D stated concerns with R3's catheter would be addressed through the urologist. RN-D stated this clinic could assist with tube changes after receiving orders from the urologist, but they were typically done at the urologist office. During an interview on 5/6/26 at 12:51 p.m., director of nursing (DON) stated resident orders should include size of catheter for suprapubic catheters. DON stated orders should also be clear on who (if not the facility) would be responsible for changing the catheter in case of an emergency. DON stated this information was expected for coordination of care. A facility policy titled Indwelling Catheter Use and Removal, dated 1/6/25, was provided. The policy did not address suprapubic catheters.

Based on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions for 1 of 1 (R6) resident identified at risk for falls to prevent further falls. Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 with severe cognitive impairment, delusions, and behaviors directed at others. In addition, R6 had no impairment of upper and lower extremities, required partial to moderate assistance with personal care and dressing. R6's diagnoses include dementia with behavioral disturbances, anxiety, affective disorder (psychiatric condition that affects emotional state), diabetes, and hearing loss.R6's care plan (CP) with date initiated of 9/1/25, identified R6 as Risk for Falls. CP Intervention with date initiated of 1/23/2024 indicated, TRANSFER: The resident is independent for transferring. Also, a CP Intervention with date initiated on 6/30/24, indicated, IF RESIDENT requires a Hoyer Transfer: SLING SIZE IS YELLOW/MEDIUM.R6's Kardex (care guide) state, TRANSFER: The resident is independent for transferring. and IF RESIDENT requires a Hoyer Transfer: SLING SIZE IS YELLOW/MEDIUM.During observation on 5/5/26 at 1:08 p.m., R6 was in a wheelchair and wheeled from hallway into shared bathroom by nursing assistant (NA)-A. NA-A then used a transfer belt to assist transferring R6 onto the toilet. After several minutes, NA-A attempted to assist R6 from toilet to wheelchair but R6 did not follow requests or commands. NA-A then asked NA-B to assist with transferring R6 to wheelchair. After this was done, both NA-A and NA-B wheeled R6 to bed which was two twin mattresses on the floor of bedroom. There was no bed frame. Both NA-A and NA-B used a transfer belt to assist R6 from wheelchair to stand and then pivoted him to sit down on mattress. During the transfer, NA-A stepped on and also kneeled onto the mattresses to assist R6 to lay down.During interview with NA-A and NA-B on 5/5/26 at 1:17 p.m., NA-A stated, we use a Hoyer (patient lift) to lift him up from mattresses and We use transfer belt to transfer him from the chair to mattress though. Need two of us. Both NA-A and NA-B stated expectation of staff to review resident Kardex's prior to providing any type of care or assistance. Both verified R6's Kardex did not identify that R6 had mattresses on the floor instead of a bed with bed frame. In addition, both stated the R6's Kardex failed to reflect his ability to transfer independently and did not clarify when to use the Hoyer for safely lifting R6 from wheelchair to the mattresses on the floor and from the mattresses on the floor to the wheelchair.During interview with licensed practical nurse (LPN)-A on 5/5/26 at 1:26 p.m., LPN-A stated R6 was a high fall risk and facility implemented the mattresses on the floor a couple weeks ago. LPN-A stated R6's Kardex failed to identify his current transfer abilities, and it failed to indicate when a Hoyer lift should be used. LPN-A stated R6 was not independent with transfers and required at least one to two staff when transferring from wheelchair to toilet and back. LPN-A stated R6 required a Hoyer lift with two staff members for all transfers from the mattresses on the floor to wheelchair and vice versa.During interview with Registered Nurse (RN)-A on 5/5/26 at 1:44 p.m., RN-A verified he was nurse manager of R6's unit. RN-A stated R6 was high risk for falls and facility decided to remove bed with bed frame and place two twin size mattresses on the floor for R6 instead. RN-A verified R6 required two staff to utilize a Hoyer when transferring R6 from wheelchair to mattresses on the floor and vice versa. RN-A also verified that R6 was not independent with transfers and required one to two staff using a transfer belt for safe transfers from wheelchair to toilet and vice versa. RN-A reviewed R6's CP and Kardex and verified both were not revised to reflect R6's current transfer ability.During interview with RN-A on 5/6/26 at 8:27 a.m., RN-A stated, [R6] could have fallen with the two aides transferring him from chair to bed without the Hoyer. And the two aides could have been hurt. We do not want that.During observation and interview on 5/6/26 at 9:47 a.m., NA-E and NA-D entered R6's room and woke R6 up for breakfast. NA-D picked up two fall mats that surrounded R6s mattresses and then placed wheelchair to side of mattresses and locked the wheels. NA-D then stepped onto top of R6's mattresses with her shoes on and knelt down to assist NA-E with positioning the Hoyer sling under R6. Hoyer sling had green piping on it. NA-D lifted up entire bottom of one of the twin mattresses on the floor, that R6 was lying on, and NA-E rolled the Hoyer lift forward with one leg of the Hoyer under the mattress. NA-D stood up on top of the mattresses again and both aides assisted R6 with arms inside the sling. NA-D lifted R6 up off the mattresses using the Hoyer while NA-E walked around to the wheelchair and positioned R6 into wheelchair as he was being lowered by the Hoyer. During this time R6 was calm and only his legs from the knees down were visible since his torso, arms, and head were inside the sling during the lift. Both NA's stated expectation of staff to review the resident care plan and Kardex to identify what cares need to be done, including the size of the Hoyer sling for residents requiring a Hoyer lift. NA-D stated R6 required a yellow sling but it was dirty so we used this green one. NA-E and NA-D stated importance of using the ordered sling for appropriate size for safety of the resident during transfers.During interview with RN-A on 5/6/26 at 9:26 a.m., RN-A stated he was responsible for ensuring every resident on the unit was assessed for correct Hoyer sling size by using their weight. RN-A stated facility utilized the Joerns Healthcare Hoyer Loop and Clip Style Sling for all Hoyer lifts in the facility and the Joerns Healthcare Patient Lift Hoyer HPL500. Also, RN-A verified the Model name for R6's sling was the Deluxe Transport and Stand-Aid Slings. RN-A pulled up the manufacturers' recommended weight range chart. According to the Color/Size Chart there were three sizes to use according to weight:Red for 75-150 pounds,Yellow for 125-275 pounds,Green for 175-440 pounds,RN-A verified R6's weight as of 5/1/26 was 155 pounds and required a Yellow sling per the manufacturer. RN-A stated the [NAME] sling is too big for [R6]. RN-A stated it was important to use the correct sling size when using a Hoyer lift for safety.User Instruction Manual for the Hoyer HPL500 by Joerns, Always check the sling is suitable for the particular patient and is of the correct size and capacity.During interview with the director of nursing (DON) on 5/6/26 at 9:33 a.m., the DON stated expectations of staff, to use the correct [Hoyer] sling size. If they do not, then there could be a fall.During interview with Physical Therapist (PT)-A on 5/6/26 at 9:46 a.m., PT-A stated, it does not make sense to use the Hoyer for one kind of transfer from [mattresses on the floor] to the wheelchair and [not] from the wheelchair to the mattresses on the floor.Facility policy titled Lifting Machine, Using a Mechanical, revised May 2024 state, Measure the resident for proper sling size and purpose, according to manufacturer's instructions.

Based on observation, interview, and document review, the facility failed to develop and/or implement a process to ensure coordination with hospice and ensure skin was accurately evaluated/monitored to promote healing and reduce the risk of complications (i.e., worsening) for 1 of 1 resident (R12) reviewed for skin alterations. In addition, the facility failed to ensure comprehensive monitoring was developed and completed for 1 of 1 residents (R9) reviewed with extensive, unilateral knee swelling.Findings include:Hospice Collaboration/Skin MonitoringR12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment and was diagnosed with arthritis, heart failure, and malnutrition. The MDS indicated R12 was receiving hospice services and was dependent/required maximal assistance from staff for activities of daily living (ADLs).R12's care plan dated 2/25/26, indicated R12 had potential for/actual impairment to skin integrity related to an open area on her coccyx, a skin tear on her left lower extremity, and a bruise to her left shin. The care plan did not include a reference to R12's right second toe wound. The care plan indicated that staff should assess and record the presence of skin breakdown. The care plan indicated that staff were to monitor and document the location, size, and treatment of skin injury. The care plan indicated that weekly treatment documentation was to include measurement of each area of skin breakdown, exudate (drainage), and any other notable changes.R12's progress note dated 3/20/26 at 2:07 p.m., indicated the hospice nurse had reported redness on R12's second toe on his right foot to facility staff, and they were waiting for an order for wound care from the hospice doctor.R12's skin check documentation dated 3/29/26, 3/30/26, 4/5/26, 4/12/26 (was refused), 4/19/26, 4/26/26 (was refused), and 5/3/26 were reviewed and did not note the wound on R12's right second toe. R12's electronic health record (EHR) progress notes and skin assessments completed by non-hospice staff dated 3/20/26 to 5/4/26 were reviewed, and a comprehensive assessment of R12's toe wound was not found.R12's hospice Communication Notes dated 3/20/26 to 5/5/26 were reviewed and did not include comprehensive assessments of R12's wound on her right second toe.R12's medication and treatment administration record dated 4/1/26 to 4/30/26, included an order dated 3/22/26 for wound care three times a week to R12's second toe on her right foot that was discontinued on 4/8/26. A new order for wound care to R12's second toe on her right foot started on 4/11/26, which was documented as completed all days but one, which was documented as 9 meaning other/ see progress notes.R12's order summary dated 4/8/26, included an order for wound care for R12's second toe on her right foot, which was to be completed on Monday, Wednesday, and Friday. The order summary included an order dated 2/15/26 for the nurse to complete a head-to-toe skin check and document this in the resident record every evening shift on Sunday.R12's hard chart was reviewed, and R12's Hospice, Interdisciplinary Group Meeting note dated 4/14/26 to 7/12/26 was found with the last staff signature dated 4/27/26. This included assessments of R12's second right toe wound on 3/20/26, 3/25/26, 3/27/26, 3/31/26, 4/2/26, 4/8/26, 4/13/26, and 4/21/26, including things such as measurements, drainage description, odor, wound bed and wound edge, and peri-wound description. An assessment for the day of 5/5/26 or 4/28/26 was not found.During an observation on 5/6/26 at 8:57 a.m., R12 was observed sitting in her wheelchair in her room. R12's right second toe was observed with a bandage dated 5/5 that appeared clean, dry, and intact.During an interview on 5/6/26 at 10:34 a.m., licensed practical nurse (LPN)-A stated she was unsure if R12 had a wound on her right second toe or if it was resolved. LPN-A stated that to know if the resident still had a wound in her toe and its status, she would check the resident's last skin check in the EHR, but did not see the wound included.During an interview and observation on 5/6/26 at 10:36 a.m., R12 was observed sitting in her wheelchair in her room. LPN-A was observed to enter the room with the director of nursing (DON). The DON was observed to remove R12's dressing, and a red open wound about the size of the eraser end of a pencil was present on R12's second toe on her right foot. The wound was observed with a small amount of pink/white/yellow drainage with wound edges that appeared elevated and shiny, as if the skin were tight. At 10:48 a.m. Registered nurse (RN)-A, a nurse manager, was observed to enter the room. RN-A was observed to assess the wound and stated he thought the wound was infected. RN-A and the DON were observed to work together to completed R12's dressing change. RN-A stated that usually wounds like this would be seen during wound rounds by himself, the DON, and the wound care provider. RN-A stated that this wound was not being seen during wound rounds as they had not been notified by hospice. RN-A stated he thought the wound required a different dressing and would need to reach out to R12's provider to obtain this.During an interview on 5/6/26 at 11:23 a.m. with the DON and RN-A, when asked if the facility had any documentation of assessments of R12's wound to her second toe on her right foot, RN-A was observed reviewing R12's EHR record and confirmed that he was unable to find documentation of R12's wound. RN-A stated that usually this would go under a skin issues evaluation, but he did not see that the staff had been completing this for R12. RN-A stated he would expect hospice to tell them directly about the wound so they could ensure assessments and necessary treatments were being completed. When asked if hospice completed wound assessments and where these could be found, RN-A stated that hospice completes a Communication Note when they visit that might include comments regarding her wound, but he was unsure if these notes discussed the wound. RN-A did not reference hospice interdisciplinary team notes. The DON stated that facility nursing staff should also indicate in the weekly head-to-toe skin assessment that R12 has a wound on her right second toe.During an interview on 5/6/26 at 2:11 p.m., RN-E, the hospice nurse, stated she completed weekly wound assessments on R12's right foot second toe wound but was unsure if the facility could see these assessments. RN-E stated in the IDT notes in the resident's hard chart at the facility should be able to see her wound assessments, but these were not given to the facility every week. RN-E stated she would include updates in her hospice communication notes but did not include comprehensive assessments of wounds.Knee SwellingR9's quarterly MDS dated [DATE], indicated R9 had intact cognition, and required supervision or touching assistance with toileting and was otherwise independent with most ADLs.R9's Medical Diagnosis listing dated 5/6/25, indicated R9 had a diagnosis of heart failure and asthma.R9's provider note dated 2/25/26, indicated R9 had increased pain and swelling in her left knee, and she was scheduled for imaging. The note indicated that on 2/2/26, 40 milliliters (mL) of fluid had been removed from her knee, and she was receiving recurrent steroid injections.R9's provider note dated 3/4/26, indicated R9 had increased pain and swelling in her left knee, and staff should monitor for recurrent swelling given her anticoagulation use.R9's provider note dated 4/16/26, indicated R9 had a biopsy confirmed hemangioma (a noncancerous, tumor- like growth that forms when blood vessels grow incorrectly) of the left knee with a surgery planned for May of 2026 to remove it.R9's order summary dated 5/7/26, included an order dated 5/7/26 to monitor R9's left knee for increase in size or pain, discoloration, or other changes. The order also indicated staff should update the provider with changes and if pain medication was not effective.R9's medical record was reviewed, including R9's care plan, last reviewed on 3/17/26, and did not include monitoring/order for monitoring of R9's left knee for increase in size, discoloration, or other changes that was in place before survey entrance.During an observation and interview on 5/4/26 at 1:59 p.m., R9 was observed lying on her bed with her left knee, notably larger than her right knee. R9 stated she had occasional pain in her knee related to a knee bleed. R9 stated her knee had been swollen for a while and she even had to get it drained.During an interview on 5/6/26 at 1:17 p.m., licensed practical nurse (LPN)-A stated she thought R9's left knee swelling was related to a tumor in her leg and related bleeding. LPN-A stated she monitored R9 for pain regularly but was unsure what else she needed to monitor the knee for.During an interview on 5/6/26 at 2:05 p.m., registered nurse (RN)-C, R9's nurse manager, when asked about R9's left knee enlargement, stated that R9 has cancer that was causing the knee swelling. RN-C stated she would expect nursing staff to complete monitoring of the knee and thought monitoring had been ordered in the past but it must have dropped off.The facility Resident Examination and Assessment policy dated 2/2024, indicated staff should review the resident's care plan and or admission assessment to assess for any special situations regarding the resident's care. The policy indicated that resident assessments should be documented in the resident's electronic health record.

Based on interview and record review, the facility failed to update the care plan with identified and personalized nonpharmacological pain interventions for 1 of 1 residents (R3) reviewed for pain, failed to update fall interventions for 1 of 2 residents (R5) reviewed for accidents, and failed to update transfer ability for 1 of 1 residents (R6) reviewed who was identified as high risk for falls. Findings include: R3 R3's admission MDS assessment dated [DATE], identified R3 had intact cognition with no hallucinations or delusions. Furthermore, the assessment identified R3 received scheduled pain medication, did not receive as needed pain medication and did not receive any non-medication interventions for pain. During an observation and interview on 5/4/26 at 12:19 p.m., R3 stated he suffered from a lot of pain. R3 stated he was seen by a pain doctor and took as needed (PRN) pain medication. R3 stated he wasn't sure if any nonpharmacological interventions were helpful for his pain. R3's care plan, printed 5/6/26, indicated the following: -R3 has quadriplegia related to spinal injury with an intervention of pain management as needed. See MD orders. Provide alternative comfort measures as needed. -Potential alteration in comfort related to positioning with the following interventions: -administer analgesia as per orders -anticipate the resident's need for pain relief and respond immediately to any complaint of pain -monitor/document for probable cause of east pain episode. Remove/limit causes where possible -pain assessment and administer pain medication as order -monitor for side effects of pain medication The care plan lacked identification of R3's preferences for nonpharmacological interventions. Furthermore, lacked identification if any nonpharmacological interventions have been attempted, effective, not effective or preferred. R3's April's MAR/TAR included the following orders: -oxycodone (narcotic pain medication) 5 milligram tablet – give half tablet by mouth every 24 hours as needed for pain with a start date of 4/29/26 and had not been administered. R3's May Medication Administration Record (MAR/TAR) for 5/1/26-5/5/26 included the following orders: -oxycodone (narcotic pain medication) 5 milligram tablet – give half tablet by mouth every 24 hours as needed for pain with a start date of 4/29/26 which had been administered one time on 5/1/26. R3's April and May's MAR/TAR lacked identification of any nonpharmacological interventions. R3's progress notes for 4/1/26 to 5/5/26 were reviewed and lacked identification of nonpharmacological intervention preferences being identified. During an interview on 5/6/26 at 8:25 a.m., licensed practical nurse (LPN)-B stated nursing offered nonpharmacological interventions prior to administering as needed pain medications which ranged from: relaxation, toileting, reportion, comfort TLC, music, reposition and would be identified on a residents MAR/TAR. On 5/6/26 at 10:03 a.m., registered nurse manager (RN)-C stated any nonpharmacological interventions would be documented on a MAR/TAR or in a progress note. RN-C verified R3 did not have any identified nonpharmacological interventions and was going to add nonpharmacological interventions to R3's MAR/TAR. RN-C was going to review R3's care plan and follow up if able to locate any nonpharmacological interventions on the care plan. No follow up was provided. During an interview on 5/6/26 at 12:51 p.m., director of nursing (DON) stated a residents preferred nonpharmacological interventions should be listed on their care plan. DON stated keeping care plans updated was important for coordination of care. R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderately impaired cognition and had two or more falls with no injury and one fall with nonmajor injury since the prior MDS assessment. R5's care plan dated 3/25/26, indicated R5 was at risk for falls related to gait/balance problems and psychoactive drug use. The care plan included interventions such as frequent safety checks, ensuring the call light was within reach, a low bed with a floor mat, non-slip footwear, etc. The care plan/medical record did not include the use of a motion sensor with automated auditory reminders for the resident to remain in bed, when this motion sensor should be used, and what (if any) adverse effects of this motion sensor should be monitored for. R5's provider note dated 4/8/26, indicated R5 had a history of multiple falls with associated bruising and a hematoma (a closed wound where blood collects and fills a space inside your body). The note indicated R5 was an unreliable historian with advanced dementia, and staff should continue R5's ongoing fall precautions. During an observation on 5/5/26 at 11:00 a.m., nursing assistant (NA)-B was observed jogging down the hallway and entering R5's room. The surveyor was a distance from the room and unable to hear if the motion sensor was giving auditory reminders to R5. When the surveyor arrived at R5's room, R5 was observed lying diagonally on the bed with her feet off the right side of the bed. The director of nursing (DON) was observed entering the room and reminded NA-B to put the motion sensor on a long pause. NA-B was observed to press a button on a small rectangular remote with buttons such as short pause, long pause, bed mode, and chair mode. R5 was observed with no signs of obvious distress such as frowning, a frightened expression, calling out, a tense posture, etc. During an interview on 5/5/26 at 2:29 p.m., NA-B stated R5 had a history of falls, so they used interventions such as putting the bed down, placing fall mats next to the bed, and utilizing a motion sensor. NA-B stated she had observed the motion sensor giving R5 auditory reminders to wait for assistance, and R5 had not shown any signs of agitation or fear with the reminder. NA-B stated she thought the facility started using the motion sensor with R5 sometime at the end of last year. During an interview on 5/5/26 at 2:41 p.m., licensed practical nurse (LPN)-A stated R5 had a history of falls, so staff completed frequent safety checks, encouraged the resident to remain in the common area, ensured the resident was wearing non-slip footwear, utilized a low bed with a fall mat and a motion sensor with an alarm. LPN-A stated the motion sensor alerted staff if the resident attempted to get out of bed and reminded the resident to please wait for assistance. During an interview on 5/6/26 at 1:57 p.m., registered nurse (RN)-C, R5's nurse manager confirmed she had reviewed R5's care plan and stated she did not see that R5's use of a motion sensor was in the care plan. RN-C stated the motion sensor was put in place after R5 had fallen in November of 2025, and she would expect the motion sensor to be added to the care plan at that time. During an interview on 5/7/26 at 8:54 a.m., the DON stated that if a motion sensor was being used as a fall intervention for a resident, she would expect this to be added to the resident's care plan. R6 R6's quarterly Minimum Data Set (MDS) dated [DATE] identified R6 with severe cognitive impairment, delusions, and behaviors directed at others. In addition, R6 identified with no impairment of upper and lower extremities, required partial to moderate assistance with personal care and dressing. Also, R6's diagnoses include dementia with behavioral disturbances, anxiety, affective disorder (psychiatric condition that affects emotional state), diabetes, and hearing loss. R6's care plan (CP) with date initiated of 9/1/25 identified R6 as Risk for Falls. CP Intervention with date initiated of 1/23/2024 indicated, TRANSFER: The resident is independent for transferring. Also, CP Intervention with date initiated on 6/30/24 indicated, IF RESIDENT requires a Hoyer Transfer: SLING SIZE IS YELLOW/MEDIUM. R6's Kardex (care guide) indicated, TRANSFER: The resident is independent for transferring. and IF RESIDENT requires a Hoyer Transfer: SLING SIZE IS YELLOW/MEDIUM. During observation on 5/5/26 at 1:08 p.m., R6 was in a wheelchair and wheeled from hallway into shared bathroom by nursing assistant (NA)-A. NA-A then used a transfer belt to assist transferring R6 onto the toilet. After several minutes, NA-A attempted to assist R6 from toilet to wheelchair but R6 did not follow requests or commands. NA-A then asked NA-B to assist with transferring R6 to wheelchair. After this was done, both NA-A and NA-B wheeled R6 to bed which was two twin mattresses on the floor of bedroom. There was no bed frame. Both NA-A and NA-B used transfer belt to assist R6 from wheelchair to stand and then pivoted him to sit down on mattress. During the transfer, NA-A stepped on and also kneeled onto the mattresses to assist R6 to lay down. During interview with NA-A and NA-B on 5/5/26 at 1:17 p.m., NA-A stated, we use a Hoyer (patient lift) to lift him up from mattresses and We use transfer belt to transfer him from the chair to mattress though. Need two of us. Both NA-A and NA-B stated expectation of staff to review resident Kardex's prior to providing any type of care or assistance. Both verified R6's Kardex did not identify that R6 had mattresses on the floor in place of a bed with bed frame. In addition, both stated the R6's Kardex failed to reflect his ability to transfer independently and that it also did not clarify when to use the Hoyer for safely lifting R6 from wheelchair to the mattresses on the floor and from the mattresses on the floor to the wheelchair. During interview with licensed practical nurse (LPN)-A on 5/5/26 at 1:26 p.m., LPN-A stated R6 was a high fall risk and facility implemented the mattresses on the floor a couple weeks ago. LPN-A stated R6 was not independent with transfers and required at least one to two assist when transferring from wheelchair to toilet and back. Also, LPN-A stated R6's CP and Kardex were not updated or revised to accurately describe his transferring needs. LPN-A stated R6 required a Hoyer lift with two staff members for all transfers from the mattresses on the floor to wheelchair and vice versa. During interview with Registered Nurse (RN)-A on 5/5/26 at 1:44 p.m., RN-A verified he was nurse manager of R6's unit. RN-A stated R6 was high risk for falls and the facility decided to remove the bed and bed frame and place two Twin size mattresses on the floor for R6 instead. RN-A verified R6 required two staff to utilize a Hoyer when transferring R6 from wheelchair to mattresses on the floor and vice versa. RN-A also verified that R6 was not independent with transfers and required one to two staff using a transfer belt for safe transfers from wheelchair to toilet and vice versa. RN-A reviewed R6's CP and Kardex's and verified both were not revised to reflect R6's current transfer ability. RN-A stated expectation of staff to review both the CP and Kardex's of all residents prior to providing any type of care and assistance. During interview with RN-A on 5/6/26 at 8:27 a.m., RN-A stated R6's CP should have transfer status for all transfers. A facility policy titled Comprehensive Care plan revised 9/6/22, identified the following: The comprehensive, person-centered care plans are revised as information about the residents and the residents' conditions change, and will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; m. Identify the professional services that are responsible for each element of care;

Based on interview and document review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for BiPAP machine (noninvasive ventilatory device that helps patients breath by delivering two levels of air pressure: higher pressure during inhalation and lower pressure during exhalation).Findings include:R59's quarterly MDS assessment dated [DATE], identified R5 had intact cognition with no hallucinations or delusions. In Section O- Special Treatment, Procedures and Programs, in section G1 Non-invasive mechanical ventilator (to include BiPAP and CPAP in section G2 and G3 below) was not marked with a check mark to indicate use. Under section Z1: none of the above: was marked with a check.During an observation on 5/4/26 at 4:41 p.m., a BiPAP machine was observed sitting on R59's side table by her bed. There was a gallon of water next to the machine. R59 indicated staff assist with her with the machine at night.During a follow up interview on 5/6/26 at 8:16 a.m., R59 stated she previously had a CPAP (a machine that provides continuous positive pressure via mask to help with conditions like obstructive sleep apnea) and was changed to a BiPAP machine. R59 stated she was unsure when the change was made but it was a long while ago. F59's May Medication Administration Record, printed 5/6/26, included the following order:- ok to resume CPAP with home settings every night shift with a start date of 2/5/26 R59's after visit summary, dated 3/10/26, included the following order:-BiPAP machine for home use with pressure: IPAP (inspiratory positive airway pressure) 20 centimeter(cm)H20(water column), EPAP (expiratory positive airway pressure) 16smH20 for obstructive sleep apnea. See qualify BIPAP titration study from 8/4/25. During an interview on 5/6/26 at 8:33 a.m., licensed practical nurse (LPN)-B stated R59 had a CPAP machine that staff assisted her with. LPN-B stated R59 had the machine for a long time but did not give a specific time frame. During an interview on 5/6/26 at 1:17 p.m., director of nursing (DON) stated accuracy of MDS assessments is important to ensure accurate billing and reflection of resident needs.During an interview on 5/6/26 at 1:25 p.m., registered nurse MDS coordinator (RN)-B stated they completed MDS assessments for the facility. RN-B verified R59's quarterly MDS on 3/3/26 was coded as R59 did not have a BiPAP machine. After review of R59's medical record, RB-B verified the MDS was corded incorrectly and R59 did use a non-invasive ventilatory device. RN-B stated they were going to correct the MDS and resubmit it correctly. A facility policy related to MDS assessments was requested but not received.

Based on observation, interview and document review, the facility failed to ensure hand hygiene was performed for 1 of 3 residents (R24) observed during personal cares and 1 of 1 residents (R24) observed during wound cares. Furthermore, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 residents (R24) observed for EBP. Findings include: R24's quarterly Minimum Data Set, dated dated [DATE], indicated he had intact cognition and required partial to moderate assistance with personal hygiene. The MDS reported diagnoses of kidney failure, high blood pressure, depression and chronic pain. The MDS also reported his use of an indwelling urinary catheter and identified he had one venous ulcer. R24's care plan identified his catheter use and need for EBP. The care plan also indicated he had an activities of daily living (ADL) self-care performance deficit related to his left leg amputation and limited mobility. The care plan directed staff to provide extensive assistance with personal hygiene. Furthermore, the care plan reported a venous/stasis ulcer to his left shin and identified a goal to be free from signs and/or symptoms of infection. R24's treatment administration record (TAR) dated 3/27/25, indicated the following wound care order: - wound on right lower leg, cleanse with wound cleanser. Leave on bed 1 - 5 min. [sic, minutes] Apply skin prep to peri wound skin. Allow to dry completely (not tacky). Then apply thin layer, Xeroform over open leg wound. Only apply on wound bed. Cover with ABD Pad. Hold in place with Kerlix. Apply a white wound sock over Kerlix before applying low stretch wrap to his foot to help with edema two times a day. Hand Hygiene and Personal Cares During observation on 3/26/25 at 11:35 a.m., R24 was lying in bed and nursing assistant (NA)-D and NA-E were performing personal cares with gowns and gloves on. NA-E set up a basin with water and washcloths at the bedside. The NAs helped R24 remove his hospital gown over his head and then pulled down his incontinence brief. NA-E used one hand to secure the catheter tubing while using the other hand to wash his peri-area. NA-E used a new corner of a folded washcloth to wipe his groin and then each thigh/inner leg. Next, NA-E used a new washcloth to wipe down each of R24's legs, starting at his hip level and wiping down. NA-E did not change gloves or perform hand hygiene. NA-D assisted him onto his left, and he grabbed the grab bar with his hands and pulled himself over. R24 had a tan-colored foam dressing covering his coccyx and the bottom portion of the dressing was not intact. Continuing with the same gloves, NA-E used a new washcloth to wipe his back, then cleansed his buttocks. NA-E rolled the briefs and linen under his body and using the same gloved hands, applied cream to his bottom and around the foam dressing. Next, R24 was assisted to turn over the pile of rolled briefs and linen onto his other side and NA-D pulled the linen and briefs through so he could lay flat on his back again. NA-D fastened the tabs on the brief and NA-E doffed the gloves before donning new gloves without performing hand hygiene. Together, the NAs helped guide his arms into his t-shirt and pulled it over his head and pulled it down in the back. The NAs assist him onto his back per his comfort and NA-E gave him a washcloth for him to wash his hands. Per interview on 3/26/25 at 11:52 a.m., NA-E stated to prevent the spread of infection, staff should perform hand hygiene before entering a resident's room, during resident cares, and with any glove change. NA-E also stated staff should wear appropriate personal protective equipment (PPE). NA-E verified staff should wash in a clean to dirty manner or change gloves between dirty and clean during personal hygiene cares. NA-E confirmed a missed opportunity for hand hygiene during cares when going from dirty to clean and not changing gloves. Hand Hygiene, EBP and Wound Care During observation of wound care on 3/27/25 at 10:32 a.m., registered nurse (RN)-C knocked and entered R24's room without a gown or gloves on and asked him if wound cares could be performed. He was agreeable and RN-C donned clean gloves but not a gown. RN-C placed an absorbent pad underneath his right leg and began removing the tape and wrapped gauze from his wound. R24 asked RN-C if he could have pain medication and RN-C offered to bring him his medication before starting the dressing change. He stated he would prefer to have his pain medication first. RN-C finished removing the wrapped gauze, leaving the padded dressing to cover his leg wound, doffed the gloves the doorway and exited the room. At 10:41 a.m., RN-C knocked and entered the room with a paper medication cup. RN-C assessed his pain and gave him the cup before going to the bathroom and performing hand washing. RN-C donned clean gloves but did not don a gown. At his bedside, RN-C sprayed wound cleanser over the padded dressing to remove it, then removed the yellowed-colored petroleum dressing from the wound beds. RN-C asked R24 how he was feeling and, with the same gloved hands, began to spray the wound with the wound cleanser before patting it dry with clean, dry gauze. RN-C repeated the spray and patting dry with gauze three times. Next, RN-C doffed the gloves, performed handwashing at the bathroom sink, and donned clean gloves. RN-C then applied liquid from a blue bottle labeled Vashe to a clean gauze and dabbed it onto each wound bed on R24's right shin. With gloved hands, RN-C walked over to his dresser and opened the top drawer, then closed the drawer and came back to his bedside and began applying more of the Vashe to the gauze, then dabbing it onto his wound beds. RN-C explained the Vashe had to dry for 5 minutes before it could be covered with the padded dressing. R24 asked for a drink of water, and RN-C assisted him lifting his water pitcher to his mouth with the same gloved hands. RN-C conversed with him about the TV program he was watching and doffed the gloves, did not perform hand hygiene and donned new gloves. RN-C cut new pieces of the petroleum gauze and laid them overtop the wound beds on his right shin. Next, RN-C applied the padded dressing, then wrapped his right lower leg with the rolled gauze. As RN-C was about to tear a piece of tape off the roll, the petroleum gauze fell on to the floor and with gloved hands, RN-C picked up the dressing from the floor and threw it away in the garbage. Without changing gloves, RN-C tore two pieces of tape from the roll and applied them to the wrapped gauze on R24's leg. RN-C then doffed gloves and performed hand washing at the sink. Per interview on 3/27/25 at 10:59 a.m. with RN-C, hand hygiene should be performed before starting resident cares, between glove changes, if gloves are soiled, and when finished with cares. RN-C verified R24 was on EBP and stated staff were expected to wear gown and gloves when performing wound care and catheter care. RN-C stated it was important to perform hand hygiene and follow EBP to prevent the spread of infection and for resident safety. RN-C stated I should have worn a gown during wound cares. RN-C indicated changing gloves during wound care but acknowledged missed hand hygiene opportunities. Per interview at 3/27/25 at 1:09 p.m. with RN-D, a nurse lead, and the infection preventionist (IP), staff were expected to perform hand hygiene, or foam in and out, when going in and out of resident rooms and when changing gloves. RN-D and IP expected staff to perform peri-cares in a clean-to-dirty manner or, if gloves become dirty or soiled, to change gloves and perform hand hygiene. RN-D and IP stated PPE for EBP should be worn during wound care and expected staff to perform hand hygiene after going from a dirty dressing or area to a clean dressing or area and with glove changes. Per interview on 3/27/25 at 3:19 p.m. with licensed practical nurse (LPN)-A, staff were expected to perform hand hygiene during personal cares and wound cares in addition to wearing appropriate PPE for a resident on EBP. Per facility policy titled Handwashing/Hand Hygiene revised 8/19, the facility considered hand hygiene the primary means to prevent the spread of infection and directed staff to perform handwashing when hands were visibly soiled and after contact with a resident with infectious diarrhea. The policy directed staff to use an alcohol-based hand rub (ABHR) or soap and water before and after direct contact with residents, before performing any non-surgical invasive procedures, before and after handling an invasive device (for example, urinary catheters), before handling clean or soiled dressings or gauze pads, before moving from a contaminated body site to a clean body site during reside care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after contact with objects (medical equipment) in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings, and remove and disposing of PPE. Per facility policy titled Enhanced Barrier Precautions revised 4/5/24, EBP would be implemented for residents with chronic wounds, including pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers. The policy indicated all team members would wear appropriate PPE (gown and gloves) for high-contact resident care, including wound care.

Based on observation, interview, and document review, the facility failed to ensure wounds were accurately assessed and reported appropriately when thought to be deteriorating for 1 of 3 residents reviewed for wound assessment and monitoring. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had severe cognitive impairment, required substantial/maximal assistance with personal cares and mobility, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers but did not have any at the time of the assessment. The MDS further indicated R32 did not exhibit physical or verbal behaviors towards others and did not reject cares. R32's diagnoses included dementia, type 2 diabetes, congestive heart failure, and kidney disease. R32's care plan revised 12/31/24, indicated R32 had potential for pressure ulcer development related to immobility, incontinence, and diabetes. The care plan instructed staff to monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size [length x width x depth], stage. R32's Kardex printed 3/27/25, indicated, Follow facility policies/protocols for the prevention/treatment of skin breakdown. R32's BRADEN (assessment for predicting skin breakdown risk) dated 2/24/25, indicated R32 was at moderate risk for developing a pressure ulcer. R32's skin check dated 2/26/25, indicated R32 had four skin issues: - bruising on left outer forearm, in-house acquired, wound is new - skin tear on left outer forearm, in-house acquired, wound is new - skin tear on left outer forearm, in-house acquired - abrasion on left gluteal fold, in-house acquired R32's skin check dated 3/5/25, indicated R32 had seven skin issues: -bruising on left outer forearm, stable, in-house acquired, unknown how long wound present - skin tear on left outer forearm, in-house acquired, wound is new - skin tear on left outer forearm, in-house acquired - abrasion on left gluteal fold, in-house acquired - skin tear on left outer wrist, in-house acquired, wound is new - scab, in-house acquired, unknown how long wound present, length 1cm, width 1cm - stage 2 pressure ulcer (partial-thickness skin loss involving the epidermis and/or dermis, presents as a shallow open ulcer, blister, or abrasion) on buttocks, increased exudate (fluid that leaks out of blood vessels into surrounding tissue), in-house acquired, unknown how long wound present, wound not measured due to resident being combative. R32's skin check dated 3/12/25, indicated three previous skin tear issues and one scab resolved. The other four skin issues indicated: - stage 2 pressure ulcer-progress deteriorating on buttocks 3.4cm x 3cm x 0.1cm - bruising on left outer forearm - abrasion on left gluteal fold-progress stalled R32's skin check dated 3/19/25, indicated three skin issues: - stage 2 pressure ulcer on buttocks-partial thickness skin loss with exposed dermis (no measurements) - bruising on left outer forearm - abrasion on left gluteal fold R32's March 2025, treatment administration record (TAR) indicated, Left gluteal fold treatment: Cleanse with wound cleaner, pat dry and cover with Mepilex Border until healed every evening shift. Update provider with any concerns. Start date 2/15/25 (still active) and signed off as being completed every evening shift 3/1/25 through 3/26/25. R32's TAR further indicated left forearm skin tear wound care orders start date 2/4/25 and discontinued date 3/7/25. R32's TAR lacked evidence of any further active or discontinued wound treatment orders. R32's electronic medical record (EMR) lacked evidence of any wound care team weekly rounding notes for any current skin issues. During observation and interview on 3/25/25 at 2:55 at p.m., nursing assistant (NA)-A was overheard requesting a new patch for R32 from a nurse. When interviewed, NA-A stated (R32) had a pressure wound on his backside and the patch was to keep it covered and protected. During observation and interview on 3/27/25 at 9:52 a.m., NA-B and NA-C into R32's room for a brief check and transfer. R32's wet and bm soiled brief removed and personal care completed. An uncovered nickel-sized open area (top layer of skin removed) was observed on R32's left gluteal fold. NA-C stated there should be Mepilex dressing covering the open area and could not explain why it was missing. NA-B stated thinking R32's wound had been open like this for 1-2 weeks. During interview on 3/27/25 at 11:05 a.m., licensed practical nurse (LPN)-A stated R32's wound on his buttock and on the left gluteal fold were actually the same wound and had probably been labeled wrong in documentation. LPN-A stated thinking the wound was from friction-sliding off his wheelchair-and not a pressure ulcer. LPN-A stated could not remember the last time she laid eyes on R32's bottom and was not aware of any open areas. LPN-A stated R32 was not receiving weekly wound rounds and only getting weekly skin checks by the assigned nurse. LPN-A stated expectation for staff to report any changes or new skin areas. LPN-A stated skin status changes could result in new orders for treatment and weekly wound round monitoring for wound pictures and measurements. During interview on 3/27/25 at 11:27 a.m., director of nursing (DON) stated was not aware of any open areas on R32's buttock. DON stated all newly identified skin issues should have been reported to LPN-A. DON stated if a new stage 2 pressure ulcer had been identified and reported, the provider would be updated and new orders for treatment and wound round inclusion would potentially be initiated. DON stated all wounds should be rounded on and tracked for status changes with a goal for the wound to heal or at minimum not to deteriorate. During observation and interview on 3/27/25 at 11:44 a.m., LPN-A, registered nurse (RN)-D and DON entered R32's room to evaluate his wound status. LPN-A stated there was one wound on R32's bottom and it appeared superficial with granulation. LPN-A stated the wound bed and surrounding tissue were blanchable and did not feel it was a stage 2 pressure ulcer. RN-A and DON agreed with LPN-A's assessment. R32 appeared cooperative while wound pictures and measurements were taken. During interview on 3/27/25 at 12:15 p.m., LPN-C stated had just placed new dressing on R32's bottom this morning after NAs reported it missing. LPN-C stated had not worked with R32 in a while and could not identify the type of wound or how long it had been open. During interview on 3/27/25 at 3:32 p.m., nurse practitioner (NP) stated was initially informed of a friction abrasion on R32's bottom and had provided treatment orders. NP stated had not received any notification that the wound had changed or deteriorated or that there were any new pressure ulcers. NP stated had she been notified of any changes; she would have potentially provided new treatment orders and would expect R32 to be included on weekly wound care team rounds. Facility policy Change in a Resident's Condition of Status dated 2/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Facility policy Wound Care dated 4/1/22, indicated the facility would utilize evidence-based clinical practices to provide pressure injury and wound treatments in our skilled nursing and rehabilitation health centers.

Based on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were completed, including shaving for 1 of 1 resident (R22) reviewed for grooming. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R22 had severe cognitive impairment, required partial to moderate assistance with personal hygiene including shaving, and did not exhibit rejection of care. R22's diagnoses included Alzheimer's, dementia, lack of coordination, and need for assistance with personal cares. R22's care plan dated 2/25/25, indicated R22 had an ADL self-care deficit related to diagnoses and impaired balance. The care plan instructed staff to assist R22 with personal hygiene and cares. R22's Kardex printed 3/25/25, indicated R22 required assistance with cares and instructed staff to keep his routine as consistent as possible. R22's shaving task dated 2/24/25 through 3/24/25 indicated, Resident *MUST* be shaved. A check mark was documented once each day under the Yes column. R22's March 2025, treatment administration record (TAR) indicated, Document if resident was shaved . A check mark and yes or Y was documented twice a day each day in March through day shift on 3/25/25. During observation and interview on 3/24/25 at 1:38 p.m., R22 stated he preferred to be clean shaven and usually shaved every day. R22 had several day's growth of facial hair. During observation on 3/25/25 at 1:05 p.m., R22 was sitting in the dining room eating lunch. R22 was not shaved and had a several day's growth of facial hair. During interview on 3/25/25 at 2:36 p.m., nursing assistant (NA)-A stated NAs were responsible to assist residents with shaving per their preferences. If a resident preferred to shave daily, the NAs would assist the resident as needed. NA-A stated R22 could shave himself but needed assistance with set up and he did like to shave every day. NA-A stated the NAs had a task sheet on their iPad that they would sign off when specific tasks were completed. NA-A stated tasks should not be signed off as completed if not actually done. During interview on 3/25/25 at 2:58 p.m., registered nurse (RN)-A stated NAs were responsible to complete showers and other personal cares such as shaving with the residents, and they should be signing the task off when completed. RN-A confirmed there was a task in R22's TAR for the nurse to sign off to ensure R22 was shaved and could not explain why it was signed off when R22 had not been shaved. RN-A stated occasional residents would refuse some cares and that refusals should be documented as such in the TAR. During interview on 3/25/25 at 3:07 p.m., director of nursing (DON) stated expectation tasks should only be signed off as completed if actually done otherwise refusals or other reasons not completed should be documented. DON further stated expectation R22 would be clean shaven per his preference, but thought there might have been an issue with his shaver. Facility policy Activities of Daily Living (ADLs), Supporting dated March, 2018, indicated residents will be provided with care and services appropriate to maintain their ability to perform ADLs. Those residents who were unable to perform ADLs independently would receive services necessary to maintain good grooming and personal hygiene.

Based on interview and document review, the facility failed to inform in advance and obtain consent for psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R22 had severe cognitive impairment, felt down, depressed or hopeless 2-6 days of the 14 day look back period, required moderate to substantial assistance with most activities of daily living (ADLs) and was taking antipsychotic and antidepressant medication. R22's diagnoses included Alzheimer's, dementia, depression and hallucinations. R22's care plan dated 2/25/25, indicated R22 used antipsychotic and antidepressant medications and was at risk for behaviors related to hallucinations. R22's March, 2025 medication administration record (MAR) indicated: Escitalopram Oxalate Oral Tablet 5 MG (Lexapro). Give 1 tablet by mouth one time a day for anxiety AEB (as evidenced by) reports of anxiety, restless physical movements, repetitive questions about going to work or home, reports of visual hallucinations. R22's physician order indicated Lexapro original start date was 7/4/24. R22's electronic medical record lacked evidence of an informed consent for Lexapro. During interview on 3/27/25 at 10:09 a.m., licensed practical nurse (LPN)-A stated any resident on a psychotropic medication should have been informed of risks and benefits and have a signed informed consent by self or representative. During interview on 3/27/25 at 11:16 a.m., director of nursing (DON) stated expectation R22, or representative should have been provided informed consent for any psychotropic prior to starting the medication and that signed consent should be in the resident chart. During interview on 3/27/25 at 1:54 p.m., consultant pharmacist (CP) stated R22 should have a signed consent for each of the psychotropic medications currently taking. During interview on 3/27/25 at 3:21 p.m., SS-A stated unable to locate a consent for Lexapro in R22's chart. Facility policy Antipsychotic Medication Use dated July 2022, indicated, Residents [and/or resident representatives] will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use.

Based on observation, interview and document review, the facility failed to thoroughly investigate injuries of unknown origin for 4 of 4 residents (R46, R18, R57, and 30) who had bruises where the injury was not witnessed, the resident could not explain the injury and the bruises were suspicious. The facility's pattern of failure to investigate injuries of unknown origin constituted an immediate jeopardy (IJ) situation. The IJ began on 3/26/24, when R46 was identified with a 2.4 centimeter (cm) x 2.6 cm inner thigh bruise and continued 3/27/24 when R18 was identified with a 7 cm x 5 cm facial bruise, 4/2/24 when R30 was identified with a 10 cm calf bruise, and 4/11/24 when R57 was identified with a 5.5 cm x 4 cm wrist bruise. The facility's system failure to identify suspicious injuries and thoroughly investigate injuries of unknown origin resulted in unverified rationale and lacked implementation of corrective action to protect resident from further sustaining injuries. The administrator, director of nursing (DON), executive director (ED) and administrative intern were notified of the IJ on 5/2/24 at 10:20 a.m. The facility implemented corrective action and the IJ was removed on 5/2/24 at 6:50 p.m. However, non-compliance remained at the lower scope and severity of E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R46 R46's annual Minimum Data Set (MDS) dated [DATE], identified R46 had mild cognitive impairment and diagnoses which included non-traumatic brain dysfunction and dementia. On 4/30/24, review of health status note dated 3/26/24 at 8:08 a.m. revealed R46 was found sitting on the floor at 6:15 a.m. but was unable to recall what caused the fall. Licensed practical nurse (LPN)-E completed head to toe skin check and no injuries noted. During a telephone interview on 5/2/24 at 6:00 a.m., LPN-E explained he observed R46's head, neck, back, chest and all extremities on 3/26/24 at 8:08 a.m. and no bruises were noted at that time. Further review of the skin only evaluation dated 3/26/24 at 1:31 p.m., revealed registered nurse (RN)-D documented four new bruises noted on right forearm (4.5 cm x 4 cm), right lower arm (3.8 cm x 3.5 cm), right anterior elbow (3.8 cm x 3 cm) and right medial (inner) thigh (2.4 cm x 2.6 cm). It was unknown whether these bruises were the result of the fall in the morning on 3/26/24. Interview of RN-D on 4/20/24 at 4:15 p.m. revealed a nursing assistant asked her to look into the above bruises on 3/26/24 after R46 received a shower. RN-D did not know the cause of the right inner thigh bruise. On 5/1/24 at 2:30 p.m., interview of LPN-A, who completed an incident report related to a fall on 3/26/24, revealed she did not document the four new bruises were noted on 3/26/24 after a fall in the morning. When asked, LPN-A suspected R46 hit the grab bar or siderail during the fall from bed to floor causing the bruise on the right medial (inner) thigh. However, there was no evidence an investigation was done to rule out the root cause. On 5/1/24 at 2:40 p.m., interview of the director of nursing (DON) revealed she suspected the bruise on the right inner thigh was due to the use of Hoyer (full body mechanical lift) sling on 3/26/24 when lifting the resident up from the floor, however, there was no evidence an investigation was done to rule out the root cause. When asked, the DON did not know who operated the Hoyer lift on 3/26/24 to lift up R46. On 5/1/24 at 2:50 p.m., interview of the administrator revealed she was not aware of R46's inner thigh bruise. There was no evidence that the facility conducted a thorough investigation related to right inner thigh bruise, which was identified on 3/26/24. R18 During observation on 4/10/24, at approximately 8:30 a.m., R18 was observed seated in a Broda (reclining wheelchair) in the activity room. R18 had a fading purple bruise approximately two inches in diameter on the left side of R18's chin and neck area. R18 was unable to respond when questioned about the bruise. During interview on 4/10/24 at 12:11 p.m., family member (FM)-A stated R18 had sustained a large bruise on the left side of their chin/neck area; however, the facility was unable to explain to FM-A how the bruise occurred. R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 as requiring substantial assistance with all activities of daily living. R18's Progress Note (nurses note) dated 3/27/24 at 6:00 a.m., indicated a night nursing assistant had reported a big bruise on the left side of chin. R18 was questioned if she had fallen or hit her face and reported no. R18's Progress Note dated 3/27/24 at 8:05 a.m., indicated LPN-A met with R18 to evaluate the bruising to the left jaw/chin area. LPN-A noted some hardened swelling to jaw. R18 denied pain and did not allow an oral examination. LPN-A assessed R18 who was able to currently report the place and month to the staff. R18 denied intentional harm and reported they felt safe. R18's initial Incident Report dated 3/27/24, identified the bruise with no witnesses to an event which resulted in bruising. The completed investigation dated 4/2/24, identified the bruise as 7 cm by 5 cm on the left chin. The investigation indicated the nurse practitioner would assess the area and determine if the bruise could be dental in origin. The report further indicated the bruise may have also been due to R18's chin pressing against clavicle or shoulder as R18 had a history of resting their head in a dependent position. R18 was not displaying concerns with meal intake or pain at the time of the assessment. The conclusion of the investigation indicated Intentional harm is not suspected. R18's Geriatrics for Follow Up Nursing Home (nurse practitioner examination) dated 3/28/24, indicated R18 was seen due to possible dental issues resulting in a bruise to the left side of chin. R18 had a history of sleeping in a bent position leaning toward the left side with her head and chin nearly touching her shoulder. R18 denied pain and no pain was observed as she ate all her lunch. The nurse practitioner assessment identified the facial bruising of the left distal (lower) chin as of unknown etiology (cause) and differential (list of possible conditions that share the same symptoms) included trauma to jaw or dental concern of broken tooth, cavity, or abscess. The nurse practitioner indicated an abscess was unlikely due to no reports of pain or other infectious symptoms. During continuous observations on 4/11/24 from 8:05 a.m. to 9:00 a.m., R18 ate her breakfast meal without expressing any type of facial or dental pain. During interview on 4/11/24 at 9:54 a.m., LPN-B stated R18 had sustained a bruise from something in her mouth. LPN-B could not recall what had caused the bruise. During interview on 4/11/24 at 1:45 p.m., LPN-A stated injuries of unknown origin included physical injuries which were not witnessed, and the resident was not able to explain how the injury was obtained. LPN-A indicated she had been notified of R18's facial bruise on 3/28/24, and due to the location, LPN-A had determined the bruise was consistent with a dental issue. LPN-A verified R18 had last been evaluated by a dentist in January of 2024 and had not expressed any type of dental concerns from the time of the evaluation to 4/11/24. LPN-A stated due to the location of the bruise, LPN-A determined the cause would be dental. When asked if LPN-A had interviewed any staff or completed any type of investigation to rule out alternative possibilities such as abuse, LPN-A confirmed the facility had not interviewed any of the direct care staff or investigated the bruise as a potential abuse or as an injury sustained during the provision of care. During interview of 4/11/24 at 2:31 p.m. RN-A confirmed a facial bruise which was 7 cm x 5 cm of unknown origin would be considered suspicious. The staff should have reported the bruise and investigated the origin to decide if the bruise was sustained due to abuse or inappropriate provision of care. RN-A confirmed the bruise was not investigated. During interview on 4/11/24 at 2:57 p.m., the administrator stated the bruise had been discussed as a dental concern and none of the staff identified the bruise as a possible injury of unknown origin or abuse. Upon review of the bruise, the administrator confirmed the facial bruise should have been investigated to ensure abuse had not occurred. During telephone interview on 4/19/24 at 9:53 a.m., LPN-A stated R18 frequently bent her neck and had her chin positioned next to her left side of the body. LPN-A had interviewed R18 on 3/27/24, and R18 was orientated to self, place (the name of the facility) and the month only. R18 denied being fearful of any staff members thus LPN-A had documented, no intentional harm and reported that [R18] felt safe. LPN-A had not performed any investigation to rule out potential abuse, or inappropriate care causing the bruising. During telephone interview on 4/19/24 at 10:08 a.m., the DON stated the facility felt the bruise was due to a dental concern and the facility had not completed any type of investigation to determine the origin of the bruise. During telephone interview on 4/19/24 at 10:40 a.m., LPN-A stated they had completed an abnormal involuntary movement scale (AIMS) on 3/26/24, (the day before the bruise was identified) which included observation of R18's face. At that time R18 did not have any type of facial bruising at the time of the assessment. In addition, LPN-A stated R18 was to be transferred by one staff and a gait belt. During telephone interview on 4/19/24 at 11:15 a.m., RN-C stated NA-E reported R18 had facial bruising on 3/27/26 at 6:00 a.m. and RN-C assessed R18 by looking into her mouth, R18 denied pain but did wince when the area was touched. R18 denied any type of maltreatment. RN-C completed the facility incident report. During telephone interview on 4/19/24 at 11:22 a.m., NA-F stated R18 transferred with two staff members and did not require any type of additional assistive devices. According to NA-F, R18 was not resistive to cares and NA-F was unaware of how R18 had sustained the bruise. During telephone interview on 4/19/24 at 11:36 a.m., NA-G stated R18 required assistance with transfers which included one staff member. NA-G stated they frequently would assist R18 by placing one arm under R18's shoulder/neck area and one under R18's buttocks/thighs. NA-G would then pick up R18 from the reclining chair and place them into bed or vice versa. NA-G stated they did not have any type of problems with the transfer as R18 was small in stature and did not weigh very much. R18 was not resistive during the transfers and R18's body did not touch NA-G's body during the transfer. NA-G stated they were not aware any other staff members transferring R18 like this, but it worked well for them. NA-G denied any instance in which they had difficulties transferring R18 such as near miss falls or quick sudden adjustments while positioned in their arms. During telephone interview on 4/19/24 at 2:36 p.m., NA-H stated R18 transferred with assistance of two staff members. R18 was not resistive to transfers and was able to stand, pivot and sit on the bed or chair without difficulties. NA-H denied R18 having difficulties or resistive behaviors during transfers. During telephone interview on 4/19/24 at 2:46 p.m., NA-E stated R18 required two staff for transfers. R18 was not resistive to cares. NA-E had reported the facial bruising to the nursing staff the morning of 3/27/24. During the night, the staff did not turn the overhead lights on until R18 was ready to get out of bed. During the night, R18 received incontinence cares via light from the bathroom or hallway. The main overhead light was not turned on until 3:00 - 5:00 a.m. At that time R18 was noted to have facial bruising which was reported to the nursing staff. NA-E unaware of how R18 would have sustained facial bruising. On 4/19/24 at 3:00 p.m. the DON, administrator and LPN-A were interviewed. The DON stated the cares for each resident were communicated to the staff members via a Kardex system (written notes), on the Tasks section of the electronic medical record and on the resident care plans. The staff members were to transfer R18 with assistance of two staff as directed by the care plan. The nursing staff supervised the direct care staff to ensure they were following the resident care plans. The DON, administrator and LPN-A were informed of the discrepancies between the transfers styles utilized by the staff: one person transfer, two-person transfer and full body lift without a mechanical lift with arm under neck/shoulder and other under buttocks. The DON confirmed a potential for personal injury for a resident transferred being picked up. The DON stated if the facility had been aware of the discrepancies of transfer styles, they may have approached the facial bruising that R18 sustained differently. The DON verified the facility had not completed any type of investigation of R18's bruise of unknown origin since the SA interviewed staff members on 4/11/24. During a follow-up interview on May 1, 2024, at 12:40 pm, LPN-A explained that if the IDT (Interdisciplinary Team) found the extent and location of bruises suspicious in cases of unknown origin injuries, they were considered reportable. LPN-A conducted an investigation into the left facial bruising of R18 on 3/27/24 and completed a summary on 4/2/24. However, LPN-A stated that she had not interviewed any staff and added, There is no other documentation of investigations prior to my summary on 4/2/24, in the incident report. Whatever I have in the progress notes, is all I have. When asked what actions the facility took in response to R18's injury of unknown origin, LPN-A said, I notified the Nurse Practitioner to assess the resident for dental issues. LPN-A explained that the extent and location of a bruise determined if it should be considered an injury of unknown origin as reportable and that no formal tool was utilized to investigate the root causes of incidents that included bruises and injuries of unknown origin. During a follow-up interview on 5/1/24 at 1:44 p.m., the DON clarified LPN-A was responsible for collecting information and not assessing a resident. The DON expected LPN-A to promptly complete her investigation of R18's left chin bruise within the five-day window and document all investigations in the progress notes and facility incident report. The DON expected LPN-A to interview the staff that worked at the time of R18's incident on 3/27/24 and prior to 3/27/24. The DON stated, I was notified of the incident via text message on 3/27/24 at 7:41 a.m., and I did not see or assess R18. The DON also indicated that no formal tool was utilized to thoroughly investigate the root causes of incidents. When asked what actions were taken to protect R18 from further incurring a bruise, the DON stated, I do not know. Further, the DON indicated that there was no abuse and neglect training conducted between when the incident occurred on 3/26/24 until the date of the interview on 5/1/24. During a follow-up interview on 5/1/24 at 2:53 p.m., the administrator stated LPN-A had collected and summarized all the information regarding R18's left facial bruising on 3/27/24 in the facility's internal incident report. When asked who was responsible for investigating allegations of abuse and/or injuries of unknown origin, the administrator replied that it depended on who and that she primarily served as a contact person. The administrator also acknowledged R18's left facial bruising could have been considered suspicious due to its location, but it was not deemed reportable [by the facility]. Furthermore, the administrator revealed that no formal tool was utilized to investigate the root causes of incidents, and it was based on their practical knowledge. Finally, when asked if R18's left facial bruising was suspicious, the administrator responded, I was not worried. R57 R57's significant change MDS dated [DATE], identified R57 was severely cognitively impaired and had diagnoses which included Alzheimer's disease and dementia. R57's progress note (PN) dated 4/11/24, authored by LPN-B, identified LPN-B was notified by aide of a bruise to R57's wrist. LPN-B assessed the bruise and noted a 5.5 x 4 cm bruise around R57's left wrist. LPN-B notified LPN-A. R57 was unable to state how she obtained the bruise. R57's PN dated 4/11/24, authored by LPN-A, identified LPN-A interviewed R57 regarding the bruise. R57 stated she did not know how she obtained the bruise, did not know it was there, and might have bumped it on something. R57's incident report dated 4/11/24, included the information from LPN-B and LPN-A's progress notes in the nursing description of the incident. Predisposing environmental factors were identified as none. Predisposing physiological factors were identified as confused, fragile skin, history of falls and impaired memory. There were no predisposing situation factors identified. The report identified no witnesses found. The report included the text of R57's PN dated 4/19/24 which identified the investigation of the incident. R57 was noted to have bruising to left wrist. R57 was interviewed regarding bruising and denied intentional harm and reported she felt safe. R57 was happy/laughing during interview, mood pleasant and outgoing. R57 was unsure how bruise occurred but stated that she might have bumped it on something. R57 used a Broda chair (a tilt in space positioning chair) when out of bed and frequently was seated at tables in common area, occasionally attempted to exit chair/stand independently. The report indicated bruise likely occurred due to unintentional contact between extremity and furniture or fixture, such as table. During interview on 4/30/24 at 1:56 p.m., LPN-B reviewed R57's electronic medical record and stated she thought the bruise to R57's wrist wrapped around part of the wrist but was not sure if it was the inner or outer portion of the wrist. The bruise curved but did not go around the entire wrist. It did not look like anyone had grabbed her but with any bruises to the wrist she liked to be sure to update the manager so they could look at it. She did not identify the bruise to be suspicious. During interview on 4/30/24 at 2:14 p.m., NA-A stated she had worked with R57 on 4/10/24 and had not noticed any bruising on that day. She worked with R57 again on 4/11/24 and in the morning noticed black/purple bruises on the top of both of R57's wrists that were approximately the size of a walnut. They almost looked like thumb marks. She notified LPN-B of the bruises. During follow-up interview on 4/30/24 at 2:44 p.m., LPN-B stated she didn't recall bruises on both of R57's wrists. She had only looked at one bruise. During interview on 5/1/24 at 12:40 p.m., LPN-A stated in general if someone had a skin injury or bruise, she would evaluate the bruise, interview the resident, and interview the team. She checked for resident pain, looked at the injury and looked for potential causes of the bruise such as use of blood thinner, combative behaviors or resident known health issues. She looked at the extent, location, resident statements about the injury, and team member voiced concerns to help determine if an injury was suspicious. Injuries of unknown cause would be suspicious if the injury was in an area such as a breast or if it was like a handprint for example. The investigation was documented in the incident report and progress notes, however she did not keep details of the investigation such as interviews, unless the incident was determined to be reportable to the SA. She gathered information and brought the incidents to leadership for a decision as to what needed to occur going forward such as a report to the SA, further investigation etc. Incidents were also discussed at the interdisciplinary team (IDT) meetings which occurred twice daily. The meetings were informal, and no notes were taken. She did not utilize a formal tool such as root-cause analysis to conduct the investigation or analyze the incidents. During interview on 5/1/24 at 1:44 p.m., the DON verified the facility did not use a formal tool for the investigation of incidents. However, stated if an incident was determined to be reportable to the SA, they did use some rudimentary tools to help document the investigation that were not required for use with non-reportable incidents. The facility did not record why an incident was determined not to be reportable. A bruise would be reported related to the circumstances around the bruise such as location, suspicion such as sexual assault or a handprint. The size the bruise would be a factor as well. She would expect LPN-A to gather information related to devices used, knowledge of the resident and to interview staff working at the time. The facility had recently changed their process related to incidents from their previous use of written witness statements to their electronic medical record system which was paperless. She stated they probably have some work to do on their process. During interview on 5/1/24 at 2:52 p.m. the administrator stated they were the contact person for all abuse and neglect reportable concerns, and she reviewed all incidents in the electronic medical record. If an incident was reportable, they would interview all other residents to ensure residents were safe. They would also assess the affected resident and take into consideration predisposing factors and risk factors. If any of these factors were off they would report the incident. She would at times expect the investigation of incidents to include interviews of staff. During interview on 5/1/24 at 4:04 p.m., RN-E recalled seeing a purple/reddish bruise on the inner side of R57's wrist. She was not sure how R57 obtained the bruise and noted it was reported by the day shift nurse. During interview on 5/2/24 at 7:51 a.m., LPN-A identified she investigated R57's bruise. She stated although the progress note indicated the bruise was around R57's wrist, the bruise curved around the inner left wrist but did not encircle the wrist. R57 believed she may have bumped it on something. She sat in a Broda chair at the table most of her day and would push herself from the armrests to move the chair and try to stand/transfer. It looked like more of an edge of table bump. LPN-A stated she had spoken extensively with LPN-B regarding the bruise but could not specifically remember if she had spoken with NA-A. She had no further documentation of her investigation such as interviews and she had not considered the bruise suspicious. LPN-A stated NA-A's description of bruises that looked like thumb marks would have prompted a full investigation, however LPN-A stated It didn't, I saw it. R57's record lacked documentation regarding the right wrist. During interview on 5/2/24 at approximately 8:00 a.m., the DON indicated she was aware of R57's bruise and had signed off on the incident report. There was no report of the area looking like a thumb mark, but such a report should have initiated an investigation and report to the SA. R30 R30's quarterly MDS dated [DATE], identified R30 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia, and anemia. The MDS also identified R30 had no hallucinations or delusions and did not exhibit any physical, verbal or other behavioral symptoms during the look back period. Interview and observation of R30 on 4/30/24 at 3:50 p.m., revealed the resident was alert but oriented to person only. The resident reported leaving the facility and planning to move back to the United States. On 4/30/24, review of a nursing progress note dated 4/30/2024 at 10:05 p.m., revealed R30's family reported to RN-C a bruise was noted on resident's left lower extremity. RN-C assessed and documented that a bruise of 4 inches (10 cm) was noted from the resident's left middle calf to left foot. When asked, R30 was unable to recall. RN-C and the family member believed R30 bumped the left foot on something. On 5/1/24, review of the facility incident report dated 4/11/24, revealed LPN-A documented R30 self-propels in a wheelchair around the unit and receives anticoagulant therapy. At times, the resident kicks out or strikes out at caregivers. LPN-A documented Bruising likely occurred due to resident striking left foot on, unintentionally or while attempting to kick out. There was no incident on 4/2/24 which might contribute to the bruise on left calf and left foot. On 5/1/24 at 2:30 p.m., interview of LPN-A revealed he/she reported the bruise to the administrator and DON on their routine interdisciplinary team (IDT) meetings. The IDT meetings ran twice a day. LPN-A stated no further action was taken after the meeting. However, LPN-A did not recall the date of the meeting. Further review of Respond History related to Behavior Monitoring and Intervention dated on 4/2/24 and the nursing progress note dated 4/2/24, revealed R30 did not have any behavior issue which might contribute to the bruise as a result of kicking or bumping. It is unknown how R30 might kick or bump at the front causing a bruise on the left middle calf and foot and which object might pose a risk to R30 causing future bruising. There was no thorough investigation completed to rule out the root cause. Interview of RN-C on 5/1/24 at 4 p.m., revealed a purple bruise was first noted on the top of left foot and left shin on 4/2/24 in the evening, which is inconsistent with the skin assessment he/she documented on 4/2/24. See F684. The Facility Responsibilities for Reporting Allegations policy dated 9/2022, directed an injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of: o The extent of the injury, or o The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or o The number of injuries observed at one particular point in time, or o The incidence of injuries over time The Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating policy dated 9/2022 directed upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The policy also directs the individual conducting the investigation at minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. The immediate jeopardy that began on 3/26/24, was removed on 5/2/24, at 6:50 p.m., when the facility conducted interviews with all interviewable residents regarding their perception of safety in the facility and completed a physical assessment of all residents to identify any injuries of unknown origin. Nursing leadership, including the facility unit managers, DON and administrator were educated on investigating injuries of unknown origin by the facility's regional director of health services. The facility's policy regarding injuries of unknown source was reviewed and all staff were educated on identification of injuries of unknown source. The administrator will monitor compliance daily to ensure complete investigation practices are followed and will complete an audit of incidents of unknown source or bruising for four weeks. Any identified concerns will be addressed immediately and if trends or patterns are identified, the facility will conduct an ad-hoc Quality Assurance and Performance Improvement meeting to address any additional interventions needed to ensure compliance. However, non-compliance remained at the lower scope and severity of an E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. 38053 33562 18987

Based on interview and document review, the facility's Administration failed to take appropriate action in a timely manner to address injuries of unknown origin and bruises for 4 of 4 residents (R18, R30, R46, & R57) reviewed for Administration. Findings include: 1. Review of the facility's internal incident report regarding R18's facial bruise, dated 3/27/24, revealed that R18 suffered a big bruise on the left side of the chin. Nursing assistant (NA)-E reported the incident to registered nurse (RN)-C and confirmed that R18's bruise was about the size of a small ball. The unit manager, licensed practical nurse (LPN)-A was informed by RN-C about R18's left facial bruising at 6:17 a.m. on 3/27/24. A summary of the investigation was completed on 4/2/24. During an interview on 4/30/24 at 12:36 p.m., the director of nursing (DON) stated LPN-A had informed her about R18's left facial bruising on 3/27/24, at around 8:00 am. The incident was also discussed in an interdisciplinary team (IDT) stand-up meeting. The DON mentioned that LPN-A's initial assessment was that it [R18's facial bruise] could be related to dental issues, and the DON had informed their Nurse Practitioner about it. When asked, the DON confirmed that the administrator was the investigator for the facility and was aware of the left facial bruising. The DON also verified that the facility had determined the bruising to be an injury of unknown origin. Furthermore, when informed by LPN-A, the DON did not see or assess R18. On 4/30/24 at 1:00 p.m., the DON presented a screenshot of LPN-A's text message to the DON and the administrator regarding R18's left facial bruise on 3/27/24 at 7:41 a.m., indicating that the administrator and the DON were aware of R18's facial bruise. Despite the DON and administrator being aware of R18's facial bruise with unknown origin, survey investigations from 4/10/24 to 5/1/24. revealed the facility failed to report the injury of unknown origin to the state agency, conduct thorough investigation, and implement appropriate action to prevent incurring further bruises and/or injuries. In a follow-up interview on 5/1/24 at 1:44 p.m., the DON indicated that no formal tool was utilized by the facility to investigate the root causes of incidents thoroughly. When asked what actions were taken to protect R18 from further incurring a bruise, the DON stated, I do not know. In an interview on 5/1/24 at 2:53 p.m., the administrator stated LPN-A had collected and summarized all the information regarding R18's left facial bruising on 3/27/24 in the facility's internal incident report. When asked who was responsible for investigating allegations of abuse and/or injuries of unknown origin, the administrator replied that it depended on who [which facility staff discovers an injury of unknown origin?] and that she [the administrator] primarily served as a contact person. The administrator also acknowledged that R18's left facial bruising could have been considered suspicious due to its location, but it was not deemed reportable by the facility. The administrator also indicated that no formal tool was utilized by the facility to investigate the root causes of incidents thoroughly, and stated, We learn through practice. 2. Review of R30's progress notes revealed 4/2/24 10:05 pm .The resident [sic] daughter called the attention of the writer regarding a bruise she found on her mother, from the middle calf to her left foot. The nurse confirmed it after looking at the leg and assessing it, which is about four inches in length. The writer asked how she got the bruise; she said she didn't remember. The writer and her daughter believe she bumped her foot into something . A review of the [Electronic Medical Record, EMR] Risk Management notes revealed that the DON and administrator were notified of R30's left calf and foot bruise on 4/11/24, indicating that the DON and administrator were aware of R30's bruise of unknown origin. However, despite the DON and administrator being aware of R30's left calf/foot bruise with unknown origin, survey investigations from 4/30/24 to 5/1/24 revealed the facility failed to report the injury of unknown origin to the state agency, conduct thorough investigation, and implement appropriate action to prevent incurring further bruises and/or injuries. 3. Review of R46's progress notes revealed, 3/26/24 8:08 am .Resident [R46] was found on the floor at 0615 by CNA after she was heard calling out she was sitting on the floor . 3/26/24 1:31pm .new, Issue Type: bruising. Location: Right forearm. Length (cm - [centimeter]) 4.5 Width (cm) 4; New. Issue type: Bruising. Location: Right lower arm. Length (cm) 3.8 Width (cm) 3.5; New. Issue type: Bruising. Location: Right medial thigh. Length (cm) 2.4 Width (cm) 2.6; New. Issue type: Bruising. Location: Right anterior elbow. Length (cm): 3.8 Width (cm): 3 . A review of the [EMR] Risk Management notes revealed that the DON and administrator were notified regarding R46 being found on the floor with bruising on 4/1/24, indicating that the DON and administrator were aware of R46's incident. However, despite the DON and administrator being aware of R46's bruises on right forearm, right lower arm, right anterior (upper) elbow, and right medial (inner) thigh with unknown origin, survey investigations from 4/30/24 to 5/1/24 revealed the facility failed to report the injury of unknown origin to the state agency, conduct thorough investigation, and implement appropriate action to prevent incurring further bruises and/or injuries. 4. Review of R57's progress notes revealed, 4/11/24 3:41 pm .Writer was told by [nurses'] aide that she seen [sic] a bruise on resident's wrist. Writer assessed bruise and noted a 5.5 cm x 4 cm bruise around resident's [R57] left wrist. Writer notified [name of LPN-A] nurse manager . Review of the facility's internal incident report dated 4/11/24 revealed R57 had sustained a 5.5 cm x 4 cm bruise around her left wrist area. LPN-A completed a summary of the investigation on 4/19/24. A review of the [EMR] Risk Management notes revealed that the DON and administrator were notified of R57's wrist bruise with unknown origin on 4/22/24, indicating that the administrator and DON were aware of R57's incident. However, despite the DON and administrator being aware of R57's bruise around her left wrist with unknown origin, survey investigations from 4/30/24 to 5/3/24 revealed the facility failed to report the injury of unknown origin to the state agency, conduct thorough investigation, and implement appropriate action to prevent incurring further bruises and/or injuries. During an interview on 5/1/24 at 1:44 p.m., the DON was asked about the facility's process for identifying, reporting, and investigating injuries of unknown origin and/or bruises and actions implemented to prevent further occurrence of bruises. The DON explained that the unit managers were responsible for collecting information about such incidents, which was then discussed during the facility's interdisciplinary team stand-up meetings held twice a day. During these meetings, the DON and/or the administrator would determine whether an incident was reportable to the state agency. Additionally, the unit managers would investigate these incidents and provide a summary of their findings in the facility's internal incident report system within five days. During an interview on 5/1/24 at 2:53 p.m., the administrator was asked about the facility's process for identifying, reporting, and investigating injuries or bruises of unknown origin and actions implemented to prevent further occurrence of bruises. In response, the administrator stated LPN-A (unit manager) was responsible for gathering information and summarizing the investigation. The administrator indicated the DON and LPN-A worked together to investigate concerns, she also acknowledged there was no formal process in place. She mentioned she held IDT stand-up meetings twice daily to review and discuss all incidents and noted her role as the Contact Person. When asked about who the facility's investigator was, the administrator stated she was not the investigator herself and it depended on whose responsibility it was. The administrator went on to state the facility's unit managers were responsible for sending reports to the state agency.

Based on observation, interview and document review, the facility failed to recognize and report injuries of unknown origin to the administrator and/or the State Agency (SA) for 4 of 4 residents (R18, R57, R30, and R46) with suspicious bruises. Findings include: R18 During observation on 4/10/24, at 8:30 a.m., R18 was observed seated in a Broda (reclining wheelchair) in the activity room. R18 had a fading purple bruise approximately two inches in diameter on the left side of R18's chin and neck area. R18 was unable to respond when questioned about the bruise. During interview on 4/10/24 at 12:11 p.m., family member (FM)-A stated R18 had sustained a large bruise on the left side of their chin/neck area; however, the facility was unable to explain to FM-A how the bruise occurred. R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 as requiring substantial assistance with all activities of daily living. R18's Progress Note (PN) dated 3/27/24 at 6:00 a.m., indicated a night nursing assistant had reported a big bruise on the left side of chin. R18 was questioned if she had fallen or hit her face and reported no. R18's initial Incident Report dated 3/27/24, identified the bruise with no witnesses to an event which resulted in bruising. The completed investigation dated 4/2/24, identified the bruise as 7 centimeters (cm) by 5 cm on the left chin. The investigation indicated the nurse practitioner would assess the area and determine if the bruise could be dental in origin. The report further indicated the bruise may have also been due to R18's chin pressing against clavicle or shoulder as R18 had a history of resting their head in a dependent position. R18 was not displaying concerns with meal intake or pain at the time of the assessment. The conclusion of the investigation indicated Intentional harm is not suspected. R18's Geriatrics for Follow Up Nursing Home (nurse practitioner examination) dated 3/28/24, indicated R18 was seen due to possible dental issues resulting in a bruise to the left side of chin. R18 had a history of sleeping in a bent position leaning toward the left side with her head and chin nearly touching her shoulder. R18 denied pain and no pain was observed as she ate all her lunch. The nurse practitioner assessment identified the facial bruising to the left distal chin as of unknown etiology differential included trauma to jaw or dental concern of broken tooth, cavity, or abscess. The nurse practitioner indicated an abscess was unlikely due to no reports of pain or other infectious symptoms. During interview on 4/11/24 at 9:54 a.m., licensed practical nurse (LPN)-B stated R18 had sustained a bruise from something in her mouth. LPN-B could not recall what had caused the bruise. During interview on 4/11/24 at 1:45 p.m., LPN-A stated injuries of unknown origin included physical injuries which were not witnessed, and the resident was not able to explain how the injury was obtained. LPN-A indicated she had been notified of R18's facial bruise on 3/28/24, and due to the location, LPN-A had determined the bruise was consistent with a dental issue. LPN-A verified R18 had last been evaluated by a dentist in January of 2024 and had not expressed any type of dental concerns from the time of the evaluation to 4/11/24. LPN-A stated due to the location of the bruise, LPN-A determined the cause would be dental. LPN-A confirmed the facility had not reported the bruise to the SA. During interview on 4/11/24 at 2:31 p.m., registered nurse (RN)-A confirmed a facial bruise which was 7 cm x 5 cm of unknown origin would be considered suspicious and stated staff should have reported the bruise to the SA. During interview on 4/11/24 at 2:57 p.m. the administrator stated the bruise had been discussed as a dental concern and none of the staff identified the bruise as a possible injury of unknown origin or abuse. Upon review of the bruise, the administrator confirmed the facial bruise should have been reported to the SA. During telephone interview on 4/19/24 at 9:53 a.m., LPN-A stated R18 frequently bent her neck and had her chin positioned next to her left side of the body. LPN-A had interviewed R18 on 3/27/24, and R18 was orientated to self, place (the name of the facility) and the month only. R18 denied being fearful of any staff members thus LPN-A documented no intentional harm and reported that [R18] felt safe. During telephone interview on 4/19/24 at 10:08 a.m., the director of nurses (DON) stated the facility felt the bruise was due to dental concerns and the facility had not reported the bruise to the SA. During telephone interview on 4/19/24 at 10:40 a.m., LPN-A stated they had completed an abnormal involuntary movement scale (AIMS) on 3/26/24, (the day before the bruise was identified) which included observation of R18's face. At that time R18 did not have any type of facial bruising. In addition, LPN-A stated R18 was to be transferred by one staff and a gait belt. During telephone interview on 4/19/24 at 11:15 a.m., RN-C stated NA-E reported R18 had facial bruising on 3/27/26 at 6:00 a.m. RN-C assessed R18 by looking into her mouth, R18 denied pain but did wince when the area was touched. R18 denied any type of maltreatment. RN-C completed the facility incident report. RN-C did not report the bruise to the SA. During telephone interview on 4/19/24 at 11:36 a.m., NA-G stated R18 required assistance with transfers which included one staff member. NA-G stated they frequently would assist R18 by placing one arm under R18's shoulder/neck area and one under R18's buttocks/thighs. NA-G would then pick up R18 from the reclining chair and place them into bed or vice versa. NA-G stated they did not have any type of problems with the transfer as R18 was small in stature and did not weigh very much. R18 was not resistive during the transfers and R18's body did not touch NA-G's body during the transfer. NA-G stated they were not aware any other staff members transferring R18 like this, but it worked well for them. NA-G denied any instance in which they had difficulties transferring R18 such as near miss falls or quick sudden adjustments while positioned in their arms. During telephone interview on 4/19/24 at 2:46 p.m., NA-E stated R18 required two staff for transfers. R18 was not resistive to cares. NA-E had reported the facial bruising to the nursing staff the morning of 3/27/24. During the night, the staff did not turn the overhead lights on until R18 was ready to get out of bed. During the night, R18 received incontinence cares via light from the bathroom or hallway. The main overhead light was not turned on until 3:00 - 5:00 a.m. At that time R18 was noted to have facial bruising which was reported to the nursing staff. NA-E unaware of how R18 would have sustained facial bruising. On 4/19/24 at 3:00 p.m. the DON, administrator and LPN-A were interviewed. The DON stated the cares for each resident were communicated to the staff members via a Kardex system (written notes), on the Tasks section of the electronic medical record and on the resident care plans. The staff members were to transfer R18 with assistance of two staff as directed by the care plan. The nursing staff supervised the direct care staff to ensure they were following the resident care plans. The DON, administrator and LPN-A were informed of the discrepancies between the transfers styles utilized by the staff: one person transfer, two-person transfer and full body lift without a mechanical lift, placing one arm under the shoulder/neck area and one under buttocks. The DON confirmed a potential for personal injury for a resident transferred this way. The DON stated if the facility had been aware of the discrepancies of transfer styles, they may have approached the facial bruising that R18 sustained differently. The DON confirmed the bruise was not reported to the SA. 38053 33562 R57 R57's significant change MDS dated [DATE], identified R57 was severely cognitively impaired and had diagnoses which included Alzheimer's disease and dementia. R57's PN dated 4/11/24, authored by LPN-B, identified LPN-B was notified by an aide of a bruise to R57's wrist. LPN-B assessed the bruise and noted a 5.5 x 4 centimeter (cm) bruise around R57's left wrist. LPN-B notified LPN-A. R57 was unable to state how she obtained the bruise. R57's PN dated 4/11/24, authored by LPN-A, identified LPN-A interviewed R57 regarding the bruise. R57 stated she did not know how she obtained the bruise, did not know it was there, and felt she might have bumped it on something. R57's incident report dated 4/11/24, included the information from LPN-B and LPN-A's progress notes in the nursing description of the incident. Predisposing environmental factors were identified as none. Predisposing physiological factors were identified as confused, fragile skin, history of falls and impaired memory. There were no predisposing situation factors identified. The report identified no witnesses found. The report included the text of R57's PN dated 4/19/24 which identified the investigation of the incident. R57 was noted to have bruising to left wrist. R57 was interviewed regarding bruising and denied intentional harm and reported she felt safe. R57 was happy and laughing during the interview, mood was pleasant and outgoing. R57 was unsure how the bruise occurred but stated she might have bumped it on something. R57 used a Broda chair (a tilt in space positioning chair) when out of bed and frequently was seated at tables in common area, occasionally attempted to exit chair/stand independently. Bruise likely occurred due to unintentional contact between extremity and furniture or fixture, such as table. During interview on 4/30/24 at 1:56 p.m., LPN-B reviewed R57's electronic medical record and stated she thought the bruise to R57's wrist wrapped around part of the wrist but was not sure if it was the inner or outer portion of the wrist. The bruise curved but did not go around the entire wrist. It did not look like anyone had grabbed her but with any bruises to the wrist she liked to be sure to update the manager so they could look at it. She did not identify the bruise to be suspicious. During interview on 4/30/24 at 2:14 p.m., NA-A stated she had worked with R57 on 4/10/24 and had not noticed any bruising on that day. She worked with R57 again on 4/11/24 and in the morning noticed black/purple bruises on the top of both of R57's wrists that were approximately the size of a walnut. They almost looked like thumb marks. She notified LPN-B of the bruises. During follow-up interview on 4/30/24 at 2:44 p.m., LPN-B stated she didn't recall bruises on both of R57's wrists. She had only looked at one bruise. During interview on 5/1/24 at 4:04 p.m., RN-E recalled seeing a purple/reddish bruise on the inner side of R57's wrist. She was not sure how R57 obtained the bruise and noted it was reported by the day shift nurse. She had not reported the bruise to the SA. During interview on 5/2/24 at 7:51 a.m., LPN-A identified she investigated R57's bruise. She stated although the progress note indicated the bruise was around R57's wrist, the bruise curved around the inner left wrist but did not encircle the wrist. R57 believed she may have bumped it on something. She sat in a Broda chair at the table most of her day and would push herself from the armrests to move the chair and try to stand/transfer. It looked like more of an edge of table bump. LPN-A stated she had spoken extensively with LPN-B regarding the bruise but could not specifically remember if she had spoken with NA-A. She had no further documentation of her investigation such as interviews and had not reported the bruise to the SA as she had not considered the bruise suspicious even though it wrapped around. LPN-A stated NA-A's description of bruises that looked like thumb marks would have prompted her to report to the SA, however, stated It didn't, I saw it. During interview on 5/2/24 at approximately 8:00 a.m., the DON indicated she was aware of R57's bruise and had signed off on the incident report. There was no report of the area looking like a thumb mark, but such a report should have initiated an investigation and report to the SA. R57's Highwood Park Incident Check List dated 4/11/24, identified a 5.5 x 4 cm bruise to R57's left wrist. The check list included an injury decision tree to identify concerns reportable to the state agency. The first question in the decision tree asked, Was the resident able to explain injury? The choice of No was circled. The second question asked Is the injury suspicious because of extent of injury, location of injury and/or pattern of numerous injuries to one location, or numerous injuries over a period of time. The choice of No was circled. The decision tree directed if the injury was not suspicious in any way listed, there was no need to file a report to the SA. The report did not identify the bruise to the right wrist. 18987 R30 R30's quarterly MDS dated [DATE], identified R30 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia, and anemia. The MDS also identified R30 had no hallucinations or delusions and did not exhibit any physical, verbal or other behavioral symptoms during the look back period. On 4/30/24, review of a nursing progress dated 4/2/24 at 10:05 p.m., revealed R30's family reported to RN-C that a bruise was noted on resident's left lower extremity. RN-C assessed and documented that a bruise of 4 inches (10 cm) was noted from the resident's left middle calf to left foot. When asked, R30 was unable to recall. RN-C and the family member believed R30 bumped the left foot on something. It is unknown how R30 may kick or bump the front causing a bruise on the left middle calf and foot. Interview of RN-C on 5/1/24 at 4:00 p.m., revealed she received a shift report that R30 was agitated and kicked on that day. Therefore, she believed the bruise was due to kicking or bumping. However, review of the Respond History related to Behavior Monitoring and Intervention dated 4/2/24, and the nursing progress note dated 4/2/24, revealed there was no incident reported that may contribute to the bruise on the left middle calf and left foot as a result of kicking or bumping. On 5/1/24, review of the facility incident report dated 4/11/24, revealed LPN-A documented R30 self-propels in a wheelchair around the unit and receives anticoagulant therapy. At times, the resident kicks out or strikes out at caregivers. LPN-A documented Bruising likely occurred due to resident striking left foot on, unintentionally or while attempting to kick out. There is no incident prior to 4/2/24 which may contribute to the bruise on left calf and left foot. On 5/1/24 at 2:30 p.m., interview of LPN-A revealed he/she reported the bruise to the administrator and the DON on their routine meetings. The routine meetings run twice a day. LPN-A stated no further action was taken after the meeting. However, LPN-A did not recall the date of the meeting. On 5/1/24 at 2:30 p.m., interview of DON revealed the facility did not report the alleged violation related to a bruise of unknown origin to the SA. R46 R46's annual MDS dated [DATE], identified R46 had mild cognitive impairment and diagnoses which included non-traumatic brain dysfunction and dementia. On 4/30/24, review of health status note dated 3/26/24 at 8:08 a.m., revealed R46 was found sitting on the floor at 6:15 a.m., but unable to recall what caused the fall. LPN-E completed a head to toe skin check and no injuries were noted. Telephone interview of LPN-E on 5/2/24 at 6:00 a.m., revealed LPN-E explained R46's head, neck, back, chest and all extremities were observed on 3/26/24 at 8:08 a.m. No bruise was noted at that time. Further review of the skin evaluation dated 3/26/24 at 1:31 p.m., revealed RN-D documented four new bruises were noted on right forearm (4.5 cm x 4 cm) , right lower arm (3.8 cm x 3.5 cm) , right anterior elbow (3.8 cm x 3 cm) and right medial (inner) thigh (2.4 cm x 2.6 cm). It is unknown whether these bruises were the result of the fall in the morning on 3/26/24. Interview of RN-D on 4/30/24 at 4:15 p.m., revealed a nursing assistant asked her to look into the above bruises on 3/26/24 after R46 received a shower. RN-C did not know the cause of the right inner thigh bruise. On 5/1/24 at 12:30 p.m., observation of R46's room revealed the grab bars were secured on the each side of the bed. No padding was noted. On 5/1/24 at 2:30 p.m., interview of LPN-A, who completed an incident report related to a fall on 3/26/24, revealed she did not document the four new bruises were noted on 3/26/24 after a fall in the morning. When asked, LPN-A suspected R46 hit the grab bar or siderail during the fall on 3/26/24 from bed to floor, which might cause the bruise on the right medial (inner) thigh. On 5/1/2424 at 2:40 p.m., interview of the DON revealed she suspected the bruise on the right inner thigh was due to the use of Hoyer's (full body mechanical lift) sling on 3/26/24 when lifting the resident up from the floor. On 5/1/24 at 2:50 p.m., interview of the administrator revealed he/she was not aware of R46's right inner thigh bruise. The cause of the bruise on the right inner thigh was unknown. There was no evidence that the facility reported this bruise of unknown origin to the SA. The Facility Responsibilities for Reporting Allegations policy dated 9/22, directed the staff to identify a injury of unknown source when all of the following criteria are met: - The source of the injury was not observed by any person; and - The source of the injury could not be explained by the resident: and - The injury is suspicious because of: the extent, location, number of injuries or incident of injuries over time. The Abuse, Neglect, Exploitation or Misappropriation- Reporting Investigating policy dated 9/22, directed the staff to report allegations of abuse, neglect, exploitation, misappropriation of resident property or injuries of unknown source immediately (within two hours) if the allegation involves bodily injury and within 24 hours if the allegation does not involve abuse or result in serious bodily injury to the administrator and other officials according to state law.

Based on observation, interview and document review, the facility failed to ensure the resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 3 resident (R18) reviewed for behaviors. Findings include: The Center for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) manual Version 3.0 Manual dated October 20, 2023, directs facilities to assess residents' behavioral symptoms by: 1. Review the medical record for the seven-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who have close interactions with the resident during the seven day look back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the seven-day look-back period. R18's quarterly Minimum Data Set (MDS) dated [DATE], identified R18 with moderate cognitive impairment and diagnoses including dementia, Parkinson's disease and anxiety disorder. The assessments indicated R18 did not display behavior of any type. R18's physician orders dated 2/26/24, indicated R18 had received Lorazepam (Ativan- antianxiety medication) 0.5 milligram (mg) in the morning and 1 mg in the evening since 1/23/24. However, on 2/26/24, the order was decreased to 0.5 mg every two hours as needed for anxiety because R18 had displayed lethargy. R18's care plan dated 3/4/24, indicated R18 utilized psychotropic and antianxiety medications related to behaviors. The plan identified R18's behaviors as pulling at /our hair, biting nails and yelling out. The plan directed the staff to monitor R18's behaviors. R18's March 2024, MAR indicated R18 had received Lorazepam 0.5 mg on 3/23/24, at 12:28 p.m. and at 5:33 p.m. R18's Progress Notes (nurses notes) from 3/23/24 - 4/2/24 (seven day look back period for MDS completion) revealed the following information: -On 3/23/24 at 12:28 p.m., indicated R18 had received Lorazepam as R18 was very restless, repeatedly calling out: Please help me, I'm stuck. -On 3/23/24 at 1:16 p.m., the follow up documentation indicated the medication administration was effective. -On 3/23/24 at 5:33 p.m., R18 was received a second dose of Lorazepam 0.5 mg. The clinical record lacked documentation as to why the medication was given. -On 3/23/24 at 6:32 p.m., the follow up documentation indicated the medication was effective. R18's Behavior Monitoring and Intervention Reports from 3/26/24- 4/2/24 (MDS seven day look back period) , indicated R18 did not display any type of behavior. During interview on 4/10/24 at 12:05 p.m., family member (FM)-A stated R18 frequently called out repetitive phrases and questioned if the staff responded to R18's concerns. FM-A stated R18 had dementia and had recently lost their spouse after many years of marriage. During observations on 4/11/24, the following behaviors were identified: -At 9:20 a.m., R18 was seated in a Broda chair (reclining wheelchair) in the dining room and stated, Take me back to my room. -At 9:22 a.m., R18 stated, Get me out of here. -At 9:23 a.m., R18 stated please help me I am stuck nursing assistant (NA)-B directed R18 and informed R18 they were fine. R18 stated No I am not, I am stuck. Please help me. -At 9:26 a.m., NA-A wheeled R18 to their room NA-A left the room as R18 stated Please help me. -From 9:26 a.m. to 9:50 a.m. R18 repeated the phrases Help me, I am stuck. while seated in R18's room During interview on 4/11/24 at 9:50 a.m., licensed practical nurse (LPN)-B stated R18 called our repeatedly. On 4/11/24 at 10:00 a.m., NA-A assisted R18 from the private room to the activity room. On 4/11/24 at 10:02 a.m., R18 stated, I am stuck. activity aide (AA)-A spoke to R18 and reclined the Broda chair. On 4/11/24 at 11:02 a.m., NA-A was observed to assist R18 with cares as R18 stated, Please help me, I am stuck. NA-A stated R18 called out all the time. On 4/11/24 at 2:04 p.m., licensed practical nurse (LPN)-A stated R18 displayed daily behaviors of yelling out repeatedly. R18 utilized Lorazepam as needed for anxiety and the behaviors were to be monitored. The nursing staff documented what type of behavior R18 displayed at the time of the medication administration and one to two hours later would identify if the medication was effective. On 4/11/24 at 2:31 p.m., registered nurse (RN)-A stated R18 did not display behaviors, R18 simply yelled out phrases like I am stuck repeatedly throughout the day. RN-A stated when this happened, the staff were to offer comfort measures such as assisting R18 to the restroom, offering a drink of water, engage R18 in an activity or conversation. RN-A confirmed repetitive yelling was indicative of a behavior and staff responded to R18. RN-A verified R18's care plan identified yelling out as a behavior. On 4/11/24 at 3:33 p.m., the administrator verified the MDS was to be completed in accordance to the Centers for Medicare and Medicaid (CMS) instruction Resident Assessment Instrument (RAI) manual. On 4/11/24 at 3:34 p.m., RN-B (facility MDS coordinator) stated the mood and behavior sections of the MDS were completed by the licensed social workers (LSW). RN-B stated they did not visit R18 on a routine basis and were not familiar with R18's behaviors. On 4/11/24 at 4:00 p.m. the director of health center sales and services (DHCSS) (a licensed social worker) stated R18 had displayed repetitive calling out behaviors for a long time. DHCSS stated to complete the MDS, the LSW reviewed the Behavior Monitoring and Intervention Reports. The reports during the look back period indicated R18 had not displayed behaviors, however, confirmed the progress notes did identify behaviors. The director of health center sales and services confirmed the MDS did not accurately reflect R18's behaviors during the look back period.

Based on observation, interview and record review, the facility failed ensure transfer interventions were consistently implemented for 1 of 1 resident (R18) reviewed for injuries of unknown origin. Additionally, the facility failed to implement interventions for monitoring and documenting bruising for 2 of 2 residents (R30 and R46) reviewed for injuries of unknown origin. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], identified R18 had severe cognitive impairment and diagnoses which included dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 weighed less than 100 pounds and required substantial/maximal assistance with transfers. R18's care plan dated 10/23, directed staff to provide extensive assistance of two staff for transfers. During observation on 4/11/24 at 11:05 a.m., R18 was seated in a Broda chair (reclining wheelchair) next to R18's bed. Nursing assistant (NA)-A stood in between the chair and the bed, squatted in front of R18 and directed R18 to give me a big hug. R18 placed arms around NA-A's upper body as NA-A lifted R18 out of the chair, pivoted R18 and assisted R18 into bed. At no time was NA-A observed to utilize a gait belt or have assistance from another staff member during the transfer. During observation on 4/11/24 at 11:27 a.m., NA-A and registered nurse (RN)-A assisted R18 to sit on the edge of the bed. NA-A squatted down in front of R18 and directed R18 to give me a big hug. RN-A backed away from the resident as NA-A assisted R18 from the bed back into the Broda (reclining wheel) chair. At no time was NA-A observed to utilize a gait belt or request assistance from RN-A for the transfer. RN-A stood next to NA-A but did not attempt to assist with the transfer. During interview on 4/11/24 at 11:27 a.m., NA-A confirmed a gait belt was not utilized during the transfer as R18 was light enough to assist without a belt. During interview on 4/11/24 at 11:30 a.m., RN-A confirmed NA-A did not utilize a gait belt, or two staff members as directed by the care plan. During interview on 4/11/24 at 2:11 p.m., unit manager, licensed practical nurse (LPN)-A, confirmed the staff were to utilize gait belt for transfers and the number of staff as directed on the care plan. During interview on 4/11/24 at 3:33 p.m., the administrator indicated all residents were to receive care according to their individualized care plans. During a telephone interview on 4/19/24 at 8:30 a.m. the administrator gave permission for the State agency to complete telephone interviews with staff members. During telephone interview on 4/19/24 at 10:40 a.m., LPN-A stated R18 was to be transferred by one staff and a gait belt. During telephone interview on 4/19/24 at 11:36 a.m., NA-G stated R18 required assistance with transfers which included one staff member. NA-G stated they frequently would assist R18 by placing one arm under R18's shoulder/neck area and one under R18's buttocks/thighs. NA-G would then pick up R18 from the reclining chair and place them into bed or vice versa (like one would pick up a child). NA-G stated they did not have any type of problems with the transfer as R18 was small in stature and did not weigh very much. NA-G stated they were not aware any other staff members transferring R18 in this manner, but it worked well for them. On 4/19/24 at 3:00 p.m. the DON, administrator and LPN-A were interviewed. The DON stated the cares for each resident were communicated to the staff members via a Kardex system (written notes), on the Tasks section of the electronic medical record and on the resident care plans. The staff members were to transfer R18 with assistance of two staff as directed by the care plan. The nurses supervised the direct care staff to ensure they were following the resident care plans. The DON, administrator and LPN-A were informed of the discrepancies between the transfers styles utilized by the staff: one person transfer, two-person transfer and full body lift without a mechanical lift, like you would pick up a child. The DON confirmed a potential for personal injury to a resident transferred using the aforementioned, non-care planned method. 18987 R30 Interview of R30 on 4/30/24 at 3:50 p.m., revealed the resident was alert, but oriented to person only. The resident reported leaving the facility and planning to move back to the United States. On 4/30/24, review of R30's care plan related to anticoagulant therapy dated 5/24/23, revealed the facility intervention was to monitor/document bruising. Further review of R30's nursing progress note dated 4/2/24 at 10:05 p.m., revealed R30 was an [AGE] year old senior who has been residing in the facility over a year. R30's family reported to registered nurse (RN)-C that a bruise was noted on resident's left lower extremity. RN-C assessed and documented a bruise of four inches was noted from the resident's left of middle calf to left foot. However, there was no measurement of the width. The color of the bruise was unknown. See F684 for additional information. Further review of the skin only evaluation dated on 4/3/24 at 2:21 p.m., within 24 hours when the bruise was first identified by RN-C and R30's family member, revealed LPN-C documented skin warm & dry, skin color WNL (within normal limit) and turgor is normal. Resident does not have an external device. Interview of LPN-C on 5/1/24 at 12:00 p.m. revealed she could not recall R30's skin condition on 4/3/24, but she documented her observations on the electronic clinical record. There was no evidence the facility staff implemented the care plan to monitor and document the bruise after a bruise was identified on 4/2/24 until it was resolved. R46 On 4/30/24 at 11:30 a.m., observation of R46, who was sitting in a wheelchair in the hallway, revealed the resident is alert and oriented to person. A quarter size purple bruise was noted on the resident's right forearm, close to the right wrist. The resident reported having bruises all over her body by pointing to the body trunk. No sign or symptom of pain or fear was noted. Observation of R46 on 4/30/2424 at 4:00 p.m., during toileting, which was provided by NA-I, revealed no other bruises were noted on the resident's body trunk (chest, abdomen and back). On 4/30/24, review of the skin only evaluation dated 3/26/24 at 1:31 p.m., revealed RN-D documented four new bruises were noted on the right forearm (4.5 cm x 4 cm) , right lower arm (3.8 cm x 3.5 cm) , right anterior elbow (3.8 cm x 3 cm) and right medial thigh (2.4 cm x 2.6 cm), however, the color of each bruise was unknown. R46's care plan related to skin injury due to fragile skin dated 11/14/23, instructed licensed nurses and nursing assistants to monitor, document and report changes in skin status including appearance, color and wound healing, sign/symptom of infection, wound size and stage. The licensed nurses documented the measurements of these bruises on 3/26/24, 4/2/24, 4/9/24, 4/16/24, 4/23/24 and 4/30/24. The size of each bruise remained the same without resolving. However, the color of these bruises were unknown. There was no evidence the facility staff implemented the care plan to monitor and document the color of the four bruises since they were first identified on 3/26/24.