Every finding on record at Glenoaks Senior Living Campus

Based on interview, observation, and document review, the facility failed to maintain an effective infection prevention and control surveillance program to identify, track, and analyze potential infections, including signs and symptoms of infections that did not result in antibiotic treatment, which had the potential to affect all 40 residents who resided in the facility. In addition, the facility failed to ensure appropriate personal protective equipment (PPE) was properly utilized during care for 1 of 1 resident (R2) reviewed for enhanced barrier precautions (EBP). Findings include: The facility's infection surveillance tracking logs from 3/1/26 through 5/31/26, identified the facility had tracked infections when a resident received antibiotic treatment. However, the surveillance logs failed to include monitoring and tracking of resident signs and symptoms of potential infections, including infections or communicable illnesses that had not resulted in antibiotic use. The facility's infection surveillance system failed to ensure all suspected infections were identified, monitored, analyzed, and trended to assist with prevention, investigation, and control of infections within the facility. During an interview on 6/10/26 at 1:01 p.m., Infection Preventionist (IP)-A confirmed the facility had only tracked infections related to antibiotic use. IP-A stated the facility treated resident signs and symptoms of potential infections as they occurred, and symptoms were not documented on the infection surveillance tracking logs unless antibiotic treatment was initiated. IP-A stated concerns such as diarrhea were discussed during morning meetings, including whether other residents had similar symptoms, but the facility did not have a tracking process in place for those symptoms. During an interview on 6/10/26 at 1:37 p.m., Director of Nursing (DON)-A stated the expectation was the facility's infection prevention and control program included monitoring and tracking of all suspected and confirmed infections to identify trends and implement interventions to prevent the spread of infections. R2's quarterly Minimum Data Set (MDS), dated [DATE], indicated R2 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs), and diagnoses included gastrostomy status (artificial opening created directly into the stomach, typically for a feeding tube), acid reflux, quadriplegia, epilepsy and anemia. R2's care plan, revised 4/9/24, indicated R2 required EPB related to presence of an indwelling medical device, and staff would adhere to the use of EBP during completion of high-contact activities. During observation on 06/09/2026 at 5:20 p.m., a sign posted on R2's room door notified of EBP and directed staff to wear gown and gloves for feeding tube and wound care. During observation on 6/9/26 at 5:25 p.m., LPN-A entered R2's room, obtained water from the bathroom, and applied gloves. LPN-A left the room twice to obtain supplies, applied gloves, and administered R2's medications through the feeding tube. LPN-A then completed hand hygiene, applied new gloves, and completed wound care at feeding tube site. However, LPN-A failed to were a gown while feeding tube activities and wound care was completed. During interview on 6/9/26 at 5:43 p.m., LPN-A stated R2 was on EBP and gown and gloves should have been worn before the medications were administered and wound care was provided to reduce the spread of infection. LPN-A stated she was aware R2 was on EBP and EBP signs were on the door. During interview on 6/10/26 at 1:10 p.m., infection preventionist (IP) stated when a resident was placed on EBP, signs were placed on the door, bins with personal protective equipment (PPE) were placed by the door, and the information was indicated on the resident's care plan. IP stated staff were expected to wear gown and gloves with any high-contact care including dressing, bathing, grooming, feeding tube medication administration and feeding tube cares, to protect the staff and other residents from the spread of infection around the facility. IP stated agency staff received education before their first shift on facility EBP expectations. During interview on 6/10/26 at 2:27 p.m., director of nursing (DON) stated if there was EBP signage and bins outside of the room and the staff were going to touch the resident, staff were expected wear a gown and gloves. DON stated EBP compliance was important to reduce the chance of spreading infection and not putting residents and staff at risk. The facility's Infection Surveillance policy, dated 1/1/26, identified infection surveillance was an ongoing systematic collection, analysis, interpretation, and sharing of infection-related data. The policy identified the purpose of surveillance was to identify infections, monitor infection prevention practices, reduce infections, and prevent the spread of infections. The policy identified nursing staff participated in surveillance by assessing residents and reporting changes in condition, including when residents developed signs and symptoms of infection. The policy further identified the facility would collect data related to possible infections, including infection site, signs and symptoms, trends, patterns, and documentation of resident and staff reported signs and symptoms. The policy indicated all resident infections were to be tracked. The facility's Infection Prevention and Control Program policy, dated 1/1/26, identified the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections. The policy identified a surveillance system was utilized for prevention, identification, reporting, investigation, and control of infections and communicable diseases. The policy further identified the IP was responsible for surveillance activities, maintaining documentation of findings and corrective actions, and reporting surveillance findings to the Quality Assessment and Assurance Committee. The policy identified licensed nurses participated in surveillance through assessment of residents and reporting changes in condition. The facility's Enhanced Barrier Precautions policy, dated 2025, indicated PPE for EBP is only necessary when performing high-contact care activities which included wound care and device care or use of feeding tubes.

Based on interview and document review, the facility failed to ensure specialized rehabilitative services were provided as ordered when the facility failed to ensure a physician's order for occupational therapy (OT) evaluation and treatment was completed timely for 1 of 1 resident (R4) reviewed for specialized rehabilitative services.Findings include:R4's quarterly Minimum Data Set (MDS), dated [DATE], identified R4 had moderate cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included arthritis, paraplegia (loss of movement and/or sensation in the lower part of the body), dorsalgia (back pain), aphasia (difficulty understanding or expressing speech), and dysarthria and anarthria (difficulty speaking due to impaired muscle control). The MDS further identified R4 had impairment on both sides of the lower extremities, and a trunk restraint was used daily.R4's progress note, dated 5/29/26 at 3:00 p.m., identified R4 was seen during provider rounds, and the provider was informed of R4's concerns related to decreased range of motion (ROM) in the right hand. The provider wrote an order for occupational therapy (OT) to evaluate and treat R4's right hand contracture (shortening or tightening of muscles, tendons, or other tissue that limits movement) and decreased ROM as indicated. The progress note identified therapy was informed and the order was entered into the electronic health record (EHR).R4's EHR identified the OT order was entered on 5/29/26. However, the EHR lacked evidence an OT evaluation was completed, services were initiated, or R4's right hand contracture and decreased ROM were assessed and addressed per the provider order.During an interview on 6/10/26 at 11:58 a.m., director of therapy (DTR) stated therapy completed quarterly screens for residents. DTR stated R4 was last seen by OT for positioning needs, which ended on 4/29/25, and R4 received a custom wheelchair. DTR stated R4 received physical therapy (PT) services beginning on 11/5/25 and was later discharged . DTR stated R4's most recent quarterly screen was completed on 5/26/26, and therapy did not identify significant changes at that time. DTR stated he was not aware of any new therapy orders after the last quarterly screen. DTR stated if therapy identified a change in condition, therapy would request orders for PT/OT services. DTR stated R4's quarterly screen, dated 5/26/26, had been considered R4's baseline.During an interview on 6/10/26 at 1:30 p.m., DTR stated he had not received the 5/29/26 OT order. DTR reviewed emails dated 5/29/26 and identified three unopened emails. DTR opened the emails and the OT order summary dated 5/29/26 was contained in one of the three previously unopened emails. During an interview on 6/10/26 at 11:27 a.m., assistant director of nursing (ADON) stated R4's right hand contracture had remained the same, R4's grip was tighter than normal, and the provider wrote orders for OT and PT assessments. ADON stated when a provider wrote an order, the nurse on duty was responsible for entering the order and placing it in a designated location at the nurses' station for a second check. ADON stated staff were expected to document a progress note to update the interdisciplinary team and discuss new orders during morning meetings. ADON provided facility morning meeting minutes dated 6/1/26 which identified therapy staff were present and aware of R4's new OT/PT orders.During an interview on 6/10/26 at 12:40 p.m., director of nursing (DON) stated orders were processed by the nurse on duty and scanned. DON stated some orders, including orders processed by agency nurses, were provided to nursing leadership for follow up. DON stated therapy orders were either scanned directly to therapy staff or provided as a hard copy.The facility's Consulting Physician/Practitioner Orders policy, undated, identified physician/practitioner orders were to be followed according to facility procedures. The policy directed nursing staff to process orders timely, including documenting the order, entering the order, and following facility procedures to ensure the order was carried out.The facility's Therapy Screen policy, undated, identified the Rehabilitation Department would perform therapy screens to identify needed services for residents. The policy directed therapists to complete screens for clinical referrals timely as determined by the facility and document the screen in the resident's medical record.

Based on observation, interview, and document review, the facility failed to ensure resident care plans were revised for 1 of 1 resident (R28) reviewed for elopement. Findings include: R28's admission Record, dated 6/10/26, indicated diagnoses of Alzheimer's disease, major depression, anxiety disorder, hallucinations and muscle weakness. R28's quarterly Minimum Data Set (MDS), dated [DATE], indicated R28 was severely cognitively impaired, received substantial/maximal assistance assist with eating, and was dependent with all other activities of daily living (ADLs). R28 resided on the secured memory care unit and a keypad code was required to enter and exit the secured unit. During multiple observations on 6/8/26 through 6/10/26, when R28 was not in her room recliner watching TV or sleeping, R28 was propelled by staff to and from her room to dining room and to activities off the secured memory unit in the main dayroom of the facility. R28's last Elopement Risk Assessment, dated 11/10/25, R28 scored a 3, indicating a low risk for elopement. The assessment indicated a score of 5 or more is considered to be at risk for elopement. R28's care plan, revised 8/23/23, indicated R28 was at high risk for elopement with a score of 10 and wandered with no rational purpose and attempting to open doors. However, R28 was observed dependent with all transfers, mobility, cares, meals and activities. During an interview on 6/09/26 at 2:15 p.m., trained medication assistant (TMA)-A stated R28 was totally dependent on staff for all her cares but does feed self when food cut into finger foods. TMA-A stated she had not seen resident attempting to exit the unit, nor would be able to reach the keypads from her wheelchair. During an interview on 6/10/26 at 11:24 a.m., registered nurse (RN-A) and social service designee (SSD) stated resident was no longer actively exit seeking. SSD stated she had observed resident fiddling with doorknob going out to the enclosed courtyard but had not been able to open it. RN-A stated it had been a long time since R28 had been an elopement risk. During an interview on 6/10/26 at 11:33 a.m., the director of nursing (DON) stated the facility's expectation for care plan revision would be any changes noted during an assessment (quarterly/annual/significant change) or in review at a resident's care conference. The corporate nurse agreed R28 was no longer an elopement risk.The facility's Comprehensive Care Plan policy, dated 2025, indicated the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interview and document review, the facility failed to implement an effective antibiotic stewardship program when the facility failed to complete antibiotic time-outs to evaluate the effectiveness and continued need for antibiotic therapy for 2 of 2 residents (R5 and R23) reviewed for antibiotic use.Findings include:R5's quarterly Minimum Data Set (MDS),dated 5/13/26, identified R5 had severe cognitive impairment and diagnoses included Alzheimer's disease.R5's physician orders, 5/14/26, identified an order for Macrobid (an antibiotic) Oral Capsule 100 milligrams (mg) by mouth two times a day for urinary tract infection (UTI) suspicion related to increased agitation for five days. The order was initiated on 5/15/26, and discontinued on 5/20/26.R5's electronic health record (EHR) lacked evidence the facility had completed an antibiotic time-out (reviewed R5's response to the antibiotic, monitored for improvement or worsening symptoms, reviewed available laboratory results, evaluated if the antibiotic remained appropriate, or determined if any changes to the treatment plan were needed).R23's comprehensive MDS, dated [DATE], identified R23 had severe cognitive impairment and diagnoses included renal (kidney) failure and diabetes mellitus.R23's physician orders, dated 5/29/26, identified the following antibiotic orders:Bactrim 400-80 mg by mouth twice daily, initiated on 3/28/26 and discontinued on 4/9/26.Amoxicillin 875 mg by mouth twice daily, initiated on 3/31/26 and discontinued on 4/5/26.Ciprofloxacin HCl 250 mg by mouth twice daily, initiated on 4/4/26 and discontinued on 4/13/26.Cephalexin 500 mg by mouth three times daily, initiated on 4/19/26 and discontinued on 4/27/26.Cipro 500 mg by mouth twice daily, initiated on 6/8/26 and discontinued on 6/13/26.R23's EHR lacked evidence the facility had completed antibiotic time-outs for the five separate antibiotic courses prescribed between 3/28/26 and 6/13/26, to ensure the antibiotics remained appropriate and effective.During an interview on 6/10/26 at 1:01 p.m., Infection Preventionist (IP) stated the facility utilized Loeb or McGeer criteria to determine if residents met criteria for antibiotic treatment. IP-A stated if a resident met criteria, information was sent to the provider for review. IP-A stated when a resident was started on an antibiotic, a 72-hour antibiotic time-out was expected to be completed and documented in the EHR. IP-A stated the antibiotic time-out included reviewing the resident's symptoms, response to treatment, and determining if the antibiotic remained appropriate. IP-A antibiotic time-outs had not been consistently completed as expected. IP-A stated she reviewed residents receiving antibiotics, entered their symptoms into the EHR, and faxed providers to request laboratory orders when indicated. IP-A stated antibiotic time-outs were important to ensure residents receive the correct antibiotic and to determine if a different antibiotic was more appropriate. IP-A reviewed R5 and R23's medical records and confirmed antibiotic time-outs were not completed.During an interview on 6/10/26 at 1:37 p.m., Director of Nursing (DON) stated the expectation was for resident signs and symptoms to be monitored and trended to identify concerns, patterns, or potential outbreaks. DON-A stated she expected antibiotic use be monitored, and appropriate antibiotic time-outs completed, tracked, and trended. DON-A stated antibiotic time-outs were important to protect residents from antibiotic overuse, unnecessary antibiotic treatment, and to ensure appropriate antibiotic stewardship.The facility's Antibiotic Stewardship Program policy, dated 1/1/26, identified the purpose of the program was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The policy identified nursing staff were to assess residents suspected to have infections, notify the physician, and utilize antibiotic protocols including McGeer criteria and Loeb Minimum Criteria. The policy identified the facility would monitor antibiotic use by monitoring residents' response to antibiotics and laboratory results when available to determine if the antibiotic continued to be indicated or if adjustments were needed. The policy further identified nursing staff were to monitor the initiation of antibiotics, monitor the resident's response to the antibiotic, review laboratory results, and consult with the practitioner to determine if the antibiotic should continue or if adjustments were needed based on findings.

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included individualized interventions for the use of a seat belt while seated in a wheelchair for 1 of 1 resident (R4) reviewed for comprehensive care plans.Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R4's diagnoses included dementia, paraplegia (loss of movement and function in the lower body), and dysarthria and anarthria (difficulty or inability to speak clearly due to problems with muscle control). The MDS further identified R4 received antipsychotic and antidepressant medications, used a trunk restraint daily, and had no impairment of the upper extremities.During an observation on 6/8/26 at 1:15 p.m., R4 was observed seated in his wheelchair with a seat belt (trunk restraint) secured over R4's lap.R4's comprehensive care plan, dated 4/9/26, failed to identify the use of a wheelchair seat belt and individualized interventions related to the seat belt use, including the purpose of the device, level of required staff assistance, monitoring, safety considerations, and resident-specific needs related to the interventions.During an interview on 6/10/26 at 9:27 a.m., nursing assistant (NA)-A stated R4's seat belt was not indicated on the NA care sheet that direct R4's cares. NA-A stated staff attempted to apply R4's seat belt in the morning and R4 frequently refused use of the seat belt. NA-A further stated the seat belt should have been included on R4's care plan.During an interview on 6/10/26 at 9:54 a.m., NA-B stated R4 utilized a seat belt when seated in his wheelchair. NA-B stated staff attempted to apply the seat belt, and R4 frequently refused and yelled at staff. During an interview on 6/10/26 at 12:21 p.m., assistant director of nursing (ADON)-A stated the seat belt was assessed with a change in condition. ADON-A confirmed the seat belt was not identified in R4's care plan. ADON-A stated the seat belt should have been included on R4's care plan.During an interview on 6/10/26 at 12:40 p.m., director of nursing (DON)-A stated the seat belt should have been included in R4's care plan because the care plan directed staff on how to provide care for the resident.The facility's Comprehensive Care Plans policy, dated/revised 2025, identified the facility developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The policy indicated the comprehensive care plan included all services identified in the resident's comprehensive assessment and services met professional standards of quality, and the care plan included resident-specific interventions that reflected the resident's needs and preferences.

Based on interview and record review, the facility failed to provide written information regarding bed hold and return rights when a resident was transferred to the hospital for 1 of 1 resident (R6) reviewed for hospitalization.Findings include:R6's annual Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment and diagnoses included mild cognitive impairment, schizophrenia (a chronic mental health disorder affecting thoughts, perceptions, and behavior), bipolar disorder (a mood disorder characterized by episodes of depression and mania), and seizure disorder/epilepsy.R6's progress note, dated 12/5/25 at 5:55 a.m., indicated R6 was transferred to the hospital on [DATE] after being found on the floor experiencing active seizure activity with convulsions and unresponsiveness. However, R6's EHR lacked evidence the facility provided R6 and/or R6's resident representative with a written bed hold notice at the time of transfer to the hospital. During an interview on 6/09/26 at 2:50 p.m., Social Service Designee (SSD) stated nursing staff completed bed hold paperwork when residents were transferred to the hospital.During an interview on 6/10/26 at 10:05 a.m., registered nurse (RN)-C stated when a resident was sent to the hospital, the nurse obtained a verbal bed hold from the resident if they were able to provide one. If the resident was unable, the nurse contacted the resident's representative by telephone and obtained the information. RN-C stated the bed hold information was documented in the progress notes. During an interview on 6/10/26 at 11:27 a.m., Assistant Director of Nursing (ADON) stated the nurse on duty was responsible for asking about the bed hold. ADON stated a paper form was completed and, if needed, uploaded into the resident's electronic record.During an interview on 6/10/26 at 12:21 p.m., ADON confirmed R6's clinical record lacked bed hold documentation for R6's 12/5/25 hospitalization.During an interview on 6/10/26 at 12:40 p.m., Director of Nursing (DON) stated when a resident was transferred to the emergency room, nurses were expected to complete paperwork regarding the bed hold. DON stated if the resident was unable to complete the information, the resident representative should have been contacted to obtain verbal confirmation. DON stated the form included the date the resident was transferred and the hospital location. DON further stated completion of the bed hold process was important for billing, insurance, held the resident's placement, and ensured the correct disposition was documented.The facility's Bed Hold Notice policy, dated/revised 2025, identified the facility would provide written information to the resident and/or resident representative regarding bed hold practices both in advance and at the time of transfer for hospitalization or therapeutic leave. The policy identified the written information would include the duration of the state bed hold policy, reserve bed payment information, facility bed hold policies, and conditions related to the resident's return to the facility. The policy further identified that during an emergency transfer, the facility would provide written notice of bed hold policies to the resident and/or resident representative within 24 hours and would maintain a signed and dated copy of the bed hold notice in the resident's file and/or medical record.

Based on interview and record review, the facility failed to ensure psychotropic medications were managed appropriately, including failure to complete monitoring for potential adverse effects related to antipsychotic medication use, and failure to ensure a PRN (as needed) psychotropic medication order included a required stop date/duration, for 2 of 5 residents (R6 and R26) reviewed for unnecessary medications.Findings include:R6's annual Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment, received antipsychotic medication, and diagnoses included anxiety disorder, bipolar disorder (a mental health condition that caused changes in mood, energy, and activity levels), schizophrenia (a mental health condition that affected a person's thoughts, emotions, and behaviors), and obsessive-compulsive disorder. R6's physician orders, dated 6/10/26, identified an order for risperidone (an antipsychotic) 2 milligrams (mg) by mouth two times a day for schizotypal disorder related to schizophrenia, initiated 3/3/26. R6's physician orders further identified an order for monthly orthostatic blood pressure (to monitor for drop in blood pressure with position changes) while receiving antipsychotic medications, initiated 3/25/26. R6's electronic health record (EHR) from January 2026 through June 2026 identified orthostatic blood pressure monitoring was completed for April 2026. However, the EHR lacked documentation staff completed required monthly orthostatic blood pressure assessments for January, February, March, May and June 2026.R26's significant change MDS, dated [DATE], identified R26 had moderate cognitive impairment, and diagnoses included bipolar II disorder (a mental health condition that caused changes in mood and episodes of depression and elevated mood), anxiety disorder, and hallucinations (seeing or hearing things that were not present).R26's physician orders, dated 6/10/26, identified an order for lorazepam (an anti-anxiety psychotropic medication) 0.5 mg by mouth every four hours PRN for anxiety, initiated 5/14/26. However, R26's PRN lorazepam order did not include a stop date, specific duration, or documented prescriber rationale for extending the PRN psychotropic medication beyond 14 days, as required.During an interview on 6/10/26 at 10:05 a.m., registered nurse (RN)-C reviewed R26's order in the EHR and confirmed the lorazepam order did have an ordered end date.During an interview on 6/10/26 at 11:27 a.m., assistant director of nursing (ADON) stated staff attempted other coping mechanisms prior to administering a PRN medication. However, when interventions were ineffective, staff administered the PRN medication. ADON confirmed R26's PRN lorazepam order was initiated on 5/14/26 and did not have a specified stop date. ADON stated PRN psychotropic medications required a 14-day stop date unless the provider documented rationale for continued use beyond 14 days. ADON stated the PRN lorazepam order should have included an end date.During an interview on 6/10/26 at 12:21 p.m., ADON reviewed R6's clinical record and confirmed the orthostatic blood pressure monitoring was only completed in April 2026 and the remaining five monthly assessments from January 2026 through June 2026 were missing. ADON stated the orthostatic blood pressure monitoring was related to the resident's psychotropic medication use and was used to monitor for adverse effects.During an interview on 6/10/26 at 12:40 p.m., director of nursing (DON) stated PRN psychotropic medications required a 14-day end date and, if the medication continued to be needed, the provider should have been contacted for a new order or rationale for continued use. DON stated this was important to ensure the medication continued to be necessary and to discontinue medications residents no longer needed. Additionally, DON stated orthostatic blood pressure monitoring was placed on the medication administration record (MAR) and the shift nurse was responsible for completing the monitoring. DON stated if the monitoring was not completed, it should have been communicated during report. DON stated orthostatic blood pressure monitoring was important because changes in blood pressure could cause the resident to become more unstable on their feet, which increased the risk for falls and other concerns.The facility's Use of Psychotropic Medication(s) policy, dated 2026, indicated psychotropic medications included antipsychotic and anti-anxiety medications. Residents receiving psychotropic medications were to be monitored for effectiveness and adverse effects, and the resident's response to the medication was to be documented in the medical record. Additionally, PRN psychotropic medications, excluding antipsychotics, were limited to 14 days unless the provider documented a rationale for continued use beyond 14 days and included a specific duration.

Based on interview, observation, and document review, the facility failed to ensure dialysis-related care needs were coordinated and implemented, including failure to clarify and implement fluid restriction interventions, for a resident at risk for fluid overload for 1 of 1 resident (R11) reviewed for dialysis services.Findings included:R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had intact cognition, required assistance with activities of daily living (ADLs), and received dialysis services. R11's diagnoses included hypertension (high blood pressure), peripheral vascular disease (PVD; a condition causing decreased blood flow through the blood vessels), renal insufficiency (reduced kidney function), diabetes mellitus, schizophrenia (a mental health disorder affecting thoughts, emotions, and behaviors), and polyneuropathy (damage to multiple nerves causing weakness, numbness, or pain). R11's care plan, initiated 1/29/26, identified R11 had a diagnosis of end stage renal disease (permanent kidney failure requiring dialysis or transplant), received dialysis, and was at risk for fluid overload, and interventions directed staff to monitor for signs and symptoms of hypovolemia (low fluid volume) and hypervolemia (excess fluid volume). The care plan further directed staff to monitor, document, and report edema, unexplained weight gain, neck vein distention, difficulty breathing, increased heart rate, elevated blood pressure, changes in level of consciousness, and abnormal breath sounds. Additional interventions included obtaining lab reports, completing before and after dialysis assessments per dialysis protocol, and obtaining weights per facility protocol. However, the care plan failed to identify the amount of fluid R11 was allowed to receive daily and to direct staff to monitor fluid intake.R11's electronic health record (EHR) identified R11 received dialysis services. However, the EHR failed to identify a physician order or dialysis recommendation specifying the amount of fluid R11 was allowed to receive daily. Additionally, the EHR failed to identify documentation the facility communicated with the dialysis provider to clarify R11's fluid restriction recommendations, obtain necessary orders, and implement interventions to guide staff in monitoring fluid intake. On 6/9/26 at 11:50 a.m., R11 entered the dining room in his wheelchair. R11 was provided a cup of coffee and a glass of ice water. R11 then requested a large pitcher of water from the dining aide.On 6/9/26 at 12:09 p.m., R11 was observed in his room with three water pitchers on his bedside table, along with a bottle of water and a plastic cup that was half full of water.On 6/10/26 at 9:08 a.m., R11 was observed with one water pitcher, two plastic cups, and a bottle of water on his bedside table. R11 stated he was supposed to limit his water intake but did not know how much fluid he was allowed.During an interview on 6/9/26 at 5:45 p.m., nursing assistant (NA)-C stated R11 was on a renal diet but did not have any restrictions regarding fluids. NA-C reviewed R11's care sheet and stated it did not identify a fluid restriction.During an interview on 6/10/26 at 8:10 a.m., Fresenius Kidney Care registered nurse (RN)-D stated R11 should have been on fluid restrictions, as most residents receiving dialysis required fluid restrictions. RN-D stated R11's fluid restriction was 1800 milliliters (mL) daily. During an interview on 6/10/26 at 9:27 a.m., NA-A stated R11 was not on a fluid restriction. NA-A reviewed R11's care sheet and stated it identified a dialysis diet but did not include a fluid restriction. NA-A stated if a resident had a fluid restriction, it would have been listed on the care sheet and provided an example of another resident whose fluid restriction was listed.During an interview on 6/10/26 at 9:54 a.m., NA-B stated fluid restrictions were listed on the care sheet. NA-B reviewed R11's care sheet and stated R11 was not identified as having a fluid restriction.During an interview on 6/10/26 at 9:57 a.m., trained medication aide (TMA)-B stated fluid restrictions were listed on the resident medication administration record (MAR) orders. TMA-B reviewed R11's MAR and stated it did not indicate R11 was on a fluid restriction.During an interview on 6/10/26 at 11:27 a.m., assistant director of nursing (ADON) stated dialysis residents were monitored using a dialysis communication sheet completed prior to appointments. The ADON stated R11 was on a fluid restriction. After reviewing R11's record, the ADON stated fluid restrictions were usually listed under the diet order but stated, I am not seeing it typed in for him. I don't see an active fluid restriction in place for him. The ADON stated fluid restrictions were important because excess fluids could be disruptive to the dialysis process and impact the resident's blood and medications.During an interview on 6/10/26 at 12:37 p.m., the director of nursing (DON) stated not all dialysis residents were on fluid restrictions and restrictions depended on provider orders. The DON stated staff were expected to educate residents regarding risks and benefits, update dialysis and the physician as needed, and communicate with dialysis regarding fluid restriction orders. The DON stated communication and formal conversations regarding dialysis-related needs should have been documented. The facility's Fluid Restriction policy, undated, identified fluid restrictions would be followed according to physician orders. The policy identified fluid restrictions may be needed for residents with medical conditions including end stage renal disease (ESRD). The policy directed nurses to obtain and verify physician orders for fluid restrictions, including the amount of fluid allowed in a 24-hour period. The policy further directed staff to communicate fluid restrictions to appropriate departments, document the restriction according to facility protocol, and ensure bedside water was included in the resident's daily fluid allowance.

Based on interview, observation, and document review, the facility failed to ensure a restorative device was implemented and monitored to maintain a resident's highest practicable level of function when staff failed to ensure a right hand splint used for contracture management had a current order, and failed to document application attempts or refusals of the splint for 1 of 3 residents (R4) reviewed for range of motion.Findings include:R4's quarterly Minimum Data Set (MDS), dated [DATE], identified R4 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R4's diagnoses included arthritis, paraplegia (loss of movement and/or sensation in the lower part of the body), and dysarthria and anarthria (conditions that affected a person's ability to speak clearly). On 6/8/26 at 11:28 a.m., R4 was observed with his right hand completely contracted with his thumb positioned inside his curled hand. R4 stated he thought he had a splint or something to put in his hand but was unsure.R4's care plan, dated 4/9/26, identified R4 had a self-care deficit related to requiring assistance with ADLs and impaired mobility. The care plan directed staff to apply R4's right hand splint as ordered and as R4 allowed, use a rolled washcloth if the splint was unavailable, check skin integrity with application and removal, and notify the primary care provider (PCP) of any abnormalities.Nursing assistant care sheet, undated, identified R4 required a hand splint to the right hand. R4's electronic health record (EHR) identified a splint order had been discontinued in February 2026. However, R4's EHR lacked a current physician order for the right hand splint. Additionally, the EHR lacked instructions identifying when the splint was to be applied, the length of time the splint was to be worn, removal instructions, and monitoring requirements. The EHR further lacked documentation to determine if staff attempted to apply the splint, used the care-planned alternative intervention of a rolled washcloth, monitored skin integrity, or if R4 refused the intervention.During an interview on 6/10/26 at 9:27 a.m., nursing assistant (NA)-A confirmed R4's right hand splint was listed on the nursing assistant care sheet. NA-A stated staff attempted to apply the splint in the mornings and R4 would frequently refuse.During an interview on 6/10/26 at 9:54 a.m., NA-B stated staff attempted to apply R4's splint, and R4 would frequently yell at staff and refuse application.During an interview on 6/10/26 at 11:27 a.m., the assistant director of nursing (ADON) stated R4 had a splint in his room and frequently refused the splint when staff attempted application. The ADON reviewed R4's medical record and confirmed there was no current order for the splint and no documentation to show staff attempted to apply the splint or that R4 refused the splint. The ADON stated the splint order had been discontinued in error in February 2026 and should have remained active.During an interview on 6/10/26 at 12:40 p.m., the Director of Nursing (DON) stated when a resident was evaluated by therapy and a splint was recommended, the recommendation should have been processed as an order. The DON stated the splint order should have been placed on the medication administration record (MAR) for staff to document application of the splint or resident refusal. The DON further stated residents were screened quarterly and with a change in condition to determine continued need for the splint and to identify any decline in function.The facility's Use of Assistive Devices policy, undated, indicated assistive devices were provided to residents requiring equipment to maintain or improve function and quality of life. The policy indicated assistive devices would be based on the resident's assessment and plan of care. The policy further indicated staff would monitor for consistent use of the device, and refusals or problems with the device would be documented in the medical record.The facility's Prevention of Decline in Range of Motion policy, undated, indicated the facility would provide interventions and/or therapy to maintain or improve range of motion, including appropriate equipment such as braces or splints. The policy indicated care plan interventions would include the type of treatment, frequency and duration of treatments, and resident goals. The policy further indicated the nurse responsible for the resident would monitor for consistent implementation of interventions, and refusals or problems associated with range of motion interventions would be documented in the medical record.

Based on observation, interview and document review the facility failed to follow manufacturer's safety guidelines for operating a wheelchair lift for 1 of 1 resident (R1). The facilities failures resulted in actual harm when R1 fell to the ground and sustained a head laceration that required transfer to the hospital emergency department for treatment. Findings include:Facility reported incident (FRI) #361588 submitted on 8/28/25, identified on 8/28/25, R1 experienced a fall from the facility transport bus while being transferred via the wheelchair lift. The incident occurred at approximately 11:30 a.m. during a scheduled clinic visit. R1 was being loaded onto the bus by trained staff (scheduler (SCH)-A).R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment, had diagnoses of fractured hip, chronic obstructive pulmonary disease (COPD), R1 was dependent on staff for activities of daily living (ADLs), had a history of falls, and used oxygen. R1 had verbal behaviors and rejected cares. R1 was dependent on staff for self-care and indoor mobility, used manual wheelchair, and had impairment on one lower extremity.R1's mobility and transfer care plan dated 7/9/25, indicated R1 had a self-care deficit as evidenced by R1 requiring assistance with ADLs, impaired balance during transfers and/or walking. The following interventions were included:-R1 used a wheelchair and required staff to propel it-R1 requires assist of 1 with bed mobility-R1 required assist of two staff for toileting-R1 requires assist of two staff for transfersR1's mood and behavior care plans dated 7/9/25, did not identify target behaviors that R1 had displayed and/or had a history of. The care plan included focus for behavior which identified alteration and at risk for negative statements, repetitive questions, verbalizations, persistent anger with staff or others, self-depreciation, expressions of unrealistic fears, sadness, crying, repetitive movements, withdrawn/reduced socialization related to diagnoses of depression. The care plan also had the focus of R1 had a potential for psycho-social well-being deficit and is at risk for changes in appetite, sleep patterns, ADL's, mood, socialization and increased sensitivity to environment, An additional focus included R1 had the potential for episodes of alteration in mood as evidenced by restlessness, easily fatigued, being irritable, having headaches/stomachaches, excessive worrying or difficulty controlling feelings of worry and having trouble falling asleep and/or staying asleep related to diagnosis of anxiety. R1's progress note dated 8/28/25 at 3:33 p.m., indicated R1 went to the emergency department after a fall while be loaded into the facility bus. R1 returned to Glen Oaks with no changes to medications.R1's progress note dated 8/29/25 at 8:31 p.m., described the fall incident that occurred on 8/28/25 at 11:20 a.m. The note identified, R1 was taken to a doctor appointment by staff trained to operate the facility bus and passed driver assessment. They arrived at clinic at 10:25 a.m. and were taken to exam room. Medical doctor (MD)-A and R1 had a heated discussion over her antianxiety and opioid medications. MD-A ended the appointment with the mention of R1 returning to hospice to help manager her anxiety and pain. SCH-A took R1 to the bus and was loading R1 backwards onto the ramp, locked the brakes, was standing on the ramp and holding R1's wheelchair while raising the ramp. Ramp stopped moving about six inches from the ground. SCH-A was looking for what stopped the ramp and stepped off ramp. SCH-A first checked right brake to make sure was on. SCH-A stepped off the ramp and R1 fell forward off her wheelchair hitting her head on the ground first. Staff went to get help, then attended to R1's bleeding head. Front wheels of wheelchair were off the yellow foot stop by three inches, brakes on all the way both sides. R1 obtained a four-centimeter laceration to right forehead as well as a hematoma directly right of eye in temporal area. R1 reported throbbing pain to head and denied pain anywhere else.R1's Medical and Transport/Emergency Documentation Form dated 8/28/25, that was handwritten included, 11:20 fell in parking lot out of w/c [wheelchair] to pavement. Right forehead laceration. R1's hospital emergency department after visit summary (AVS) dated 8/28/25 identified R1 was evaluated for a fall with injury; laceration to forehead. The AVS identified R1 had stiches that were to come out in 10-14 days with directions for wound care. There was no other information on the summary pertaining to the fall and/or R1's head injury. The facility investigation dated 8/28/25, included the aforementioned information pertaining to the fall. The form Skilled Nursing Facility-Fall investigation Form identified the time of the fall as 11:20 a.m. R1 was wearing slippers and also sustained a right shoulder abrasion in addition to the forehead laceration that was bleeding. R1's baseline behavior of the day was anxious. This document also included a handwritten statement by scheduler (SCH)-A. The statement included SCH-A had wheeled R1 backwards onto the ramp, locked the breaks, was standing on the ramp with R1 holding onto the wheelchair and the remote, started to raise the ramp. The ramp stopped moving about six inches from the ground. SCH-A was looking for whatever stopped the ramp and stepped off the ramp, first checking right brake to make sure was on. When she stepped off the ramp, R1 began to roll forward and fell forward off her wheelchair, R1's head hit the ground first, writer ran to get help then attended to R1's bleeding head. Front wheels of the wheelchair were off the yellow foot stop by 3 inches, brakes off all the way on both sides. R1 landed about four feet from ramp.During an interview on 9/11/25 at 11:37 a.m. R1 stated she remembered being upset with PCP when SCH-A was assisting her onto the wheelchair lift. SCH-A was raising the lift when it suddenly stopped about 6 inches from the ground. When the lift stopped R1 remembered the wheelchair rolling forward on the lift and being propelled out of the chair onto the ground. R1 could not remember if SCH-A was standing on the lift with her or not. R1 reported increased pain and was bleeding from her head.During an interview on 9/10/25 at 1:40 p.m., SCH-A stated R1 had been in a clinic appointment with her primary care provider (PCP) and was angry with her provider. SCH-A explained as she was taking R1 out of the clinic to the van, R1 told SCH-A she was not going to her appointment with orthopedics the next day. SCH-A backed R1's wheelchair onto the lift platform so that she was facing away from the van. SCH-A walked to R1's left side (standing on the ground not on the lift as identified in the facility's written statement) and used the remote to raise the lift off the ground. SCH-A stated as she pushed R1 to the van and when she was loading R1 onto the lift, R1 was in a horrible mood and was talking loudly. When the lift was approximately 6 inches from the ground, the lift suddenly stopped. SCH-A explained while one hand was on R1's wheelchair handle and the other hand on the lift remote, she leaned back and looked away from R1 so she could check to see if the oxygen tank or wheelchair wheels were properly positioned such that they were not touching the back plate of the lift which needed to be clear of any objects. Before SCH-A could see why the lift had stopped R1 fell forward out of wheelchair landing on the ground with the front wheels of wheelchair hanging about three inches from the ground. SCH-A remembers R1 stating Oh no here I go. During a subsequent interview on 9/11/25 at 12:30 p.m., SCH-A indicated the lift did not come equipped with a seatbelt or torso restraint to use with wheelchairs and was unaware if R1 would required one; she did not have either on her wheelchair. SCH-A further stated R1 was not holding onto the yellow lift handrails, and she had not provided instruction for R1 to hang on. SCH-A stated although the clinic staff thought R1 threw herself off the lift because she was angry, she had known R1 for many years and did not believe R1 would intentionally throw herself out of her chair onto the ground. SCH-A stated she was trained on how to run the bus and wheelchair lift by maintenance man (MM)-A and had previous history of driving a facility bus/van and use of wheelchair lifts. SCH-A further stated had not received any re-education since the incident on 8/28/25.During an interview on 9/11/25 at 2:38 p.m., clinic manager (CM)-A stated when she arrived at the bus after the incident, the front wheels of the wheelchair were hanging off the front of the lift about 6 inches from the ground. R1 was on the ground in a fetal position in distress; she had a large laceration on her head and complaining of head pain. CM-A also stated there was no restraint on the wheelchair, just a mechanical lift sheet that had slid down in the chair.During an interview on 9/11/25 at 2:29 p.m., maintenance (MM)-A stated he was made aware of R1's incident involving the lift on the bus on 8/28/25, by the administrator. Administrator had asked him to perform a post-incident inspection of the bus and wheelchair lift. MM-A stated MM-B and himself checked and re-checked the lift with a weight test, with each other in a wheelchair and moving around in the wheelchair; they could not find anything wrong with the lift. MM-A stated the facility did not have owner's manual for the lift, he had found the manual online before the previous Administrator signed him off on 2/8/25. MM-A explained even though he had inspected the lift, he had not documented the post incident inspection so there was no written documentation the lift had been inspected after the incident.Review of SCH-A employee file revealed a Drivers Skills Validation checklist, with the instructions to check item the driver performs satisfactorily, mark with an X where further training is recommended. Leave any items not evaluated blank. Signed by MM-A on 7/2/25, identifying SCH-A as qualified driver, even though there were no check marks or X s located on the checklist.Review of MM-A employee file revealed a Drivers Skills Validation checklist, with the instructions to check item the driver performs satisfactorily, mark with an X where further training is recommended. Leave any items not evaluated blank. Signed by previous Administrator on 2/8/25, identifying MM-A as qualified driver, even though there were no check marks or X s located on the checklist. During and interview on 9/12/25 at 12:43 p.m., MM-A stated he did not read the directions on how to fill out the Drivers Skills Validation checklist, just remembers signing SCH-A's sheet and marking her as qualified.Review of manufacturer's owner's manual for [NAME] Century 2 wheelchair lift, dated 3/2010, for lift model number NCL917FIB-2 and serial number: EA-03856 included:Lift terminology:-the inner roll stop, and outer barrier sense weight to prohibit lift operation. The lift will not function if the inner rolls stop, or outer barrier are occupied.-The inner roll stop features a locking mechanism that prohibits the platform from lowering if the lock does not engage. The lift platform cannot be raised more than three inches above the ground level unless the outer barrier is in the vertical position.Lift Operation Safety:-read manual and supplements before operating lift. Read and become familiar with all safety precautions, pre-lift operation notes and details, operating instructions and manual operating instructions before operating the lift.-whenever a wheelchair passenger (or standee) is on the platform, the passenger must be positioned fully inside yellow boundaries, wheelchair brakes must be locked, inner roll stop and outer barrier must be up (vertical), outer barrier latches must be fully engaged, and passenger should grip both handrail (if able).-lift attendants must ensure that lift occupants keep hands, arms and all other body part within the lift occupant area and clear of moving parts-accidental activation of control switch(es) may cause unintended operation(s)-observe the passenger during lift operations.-do not use outer barrier as a brake-always keep owner's (operator's) manual in lift-mounted manual storage pouch-failure to follow these safety precautions may result in serious bodily injury and/or property damage.Review of facility policy entitled Fleet Safety dated 5/2025, included the following:Wheelchair securement- loading and unloading:-employees must be trained on how to use the proper equipment to board wheelchairs in passenger vans. This includes understanding how the lift works, operation of the lift and how to position wheelchair on the lift.-employees should make sure that lift gate is level with the ground before loading a wheelchair onto the lift. Employees should ensure that any stops are utilized to prevent rolling issues.Occupant Restraints:-the occupant must be secured in the wheelchair in case of an accident. A seat belt will prevent the occupant from being ejected from the chair, protecting them from additional injury.

Based on interview and record review the facility failed to ensure performance evaluations for 4 of 4 nursing assistants (NA-P, NA-D, NA-S, and NA-L) were provided within the past 12 months.Findings include:Review of nursing assistant (NA)-P employee record identified a hire date of 10/25/23 and did not include a performance evaluation since NA-P's hire date. During interview on 9/12/25, nursing assistant (NA)-P could not remember receiving a performance evaluation since she was hired. Review of (NA)-D's employee record identified a hire date of 11/10/22 and included a performance evaluation dated 3/13/23; there were no subsequent performance evaluations included in her record.Review of NA-S employee record identified a hire date of 4/15/22 and included a performance review dated 3/13/23; there were no subsequent performance evaluations included her the record. During interview on 9/12/25 at 8:27 a.m., NA-S could not remember receiving a performance evaluation since 2023. Review of NA-L's employee file identified a hire date of 2/18/20, a performance evaluation for 2022 was found but no other performance evaluation were located in her file.During an interview on 9/12/25 at 7:40 a.m., director of nursing (DON) indicated she had not done any performance evaluations for nursing assistants in her three years as DON at the facility.During an interview on 9/12/25 at 12:30 p.m., Administrator indicated there was no policy for annual evaluations of nursing assistants but was an expectation they were completed.

Based on interview and document review the facility failed to ensure a thorough investigation was completed and protect residents after 2 of 2 allegations which included rushed and harsh cares in addition to physical abuse were reported by unknown residents which effected (R1, R4, R6, and R7) who reported on going inappropriate behavior and treatment by nursing assistant (NA)-P. Findings include:Review of NA-P's employee record included a written warning dated 8/1/25, that was authored by assistant director of nursing (ADON)-A. The ADON wrote- residents complained of nursing assistant (NA)-P being harsh and rushed, staff have complained about tone and verbiage coming from NA-P that is demeaning and lacked appropriate bedside manner. NA-P's employee record nor did the disciplinary action document identify which residents were involved that led to NA-P's written warning. Further, there were no recorded grievances and/or documentation of the concerns voiced by residents, there was no indication of an investigation into the concerns, or evident that follow-up with the effected residents was completed. During an interview on 9/11/25 at 3:32 a.m. ADON-A described NA-P's demeanor as lacking a bed side manner but was meeting the needs of the residents. ADON reviewed the written warning and explained she would not consider the description of rushed and harsh as rough cares, however, did not investigate the allegations because she did not think NA-P's rushed and harsh demeanor would be considered abuse. R1's significant Minimum Data Set (MDS) dated [DATE], R1 did not have cognitive impairment. R1 had history of falls, and diagnoses of fractured hip, chronic obstructive pulmonary disease (COPD), dependent on oxygen and dependent on staff to perform activities of daily living (ADLs) and used a wheelchair. R1 had verbal behaviors and rejection of cares.R1's 7/7/25 did not identify R1's vulnerabilities to abuse, was dependent on staff for activities of daily living involving transfers and toileting and had the risk for or had the potential of altered mood and behaviors. During an interview on 9/11/25 at 11:37 a.m., R1 stated she was very familiar with NA-P. R1 explained NA-P was very rough during cares. When NA-P rolled her in bed she would push really hard on her broken hip and move too fast which caused her increased pain. When R1 would tell NA-P she was hurting her by the way she was moving her, it seemed like NA-P would just push harder. R1 stated when she thinks about NA-P and when NA-P helps her with cares, her anxiety increased and caused her to act out. R1 had reported to ADON-A how NA-P treats her however, nothing changed. During a subsequent interview on 9/11/25 at 2:07 p.m., R1 stated the way NA-P treats her made her feel worthless and would prefer NA-P not come into her room.During an interview on 9/10/25 at 1:40 p.m., scheduler (SCH)-A stated she was with R1 at the clinic appointment on 8/28/25 when R1 made an accusation about staff was abusing her, by throwing R1 around. R1 did not tell SCH-A who that staff person was. When SCH-A got back to the facility she reported R1's allegations to the administrator.A facility five-day investigation of R1's fall from a wheelchair van lift submitted by the administrator to the State Agency (SA) on 9/3/25 indicated on 8/28/25, R1 had clinic appointment and had become upset with the physician. The report included a statement R1 made to the physician then we should talk about Glen Oaks and the staff that is beating me up. In review of investigatory file and facility reported incidents to the State Agency there was no indication any allegations of abuse were investigated after R1 made her statement.A handwritten grievance dated 9/5/25, authored by the director of nursing (DON) on behalf of R1 indicated NA-P was too fast during cares and did not want NA-P to assist her if possible. Facility records did not include any documentation of investigation activities such as interviewing other residents or staff members.During an interview on 9/11/25, at 10:17 a.m., Administrator confirmed she submitted the five-day report to the State Agency that included the allegation of abuse R1 had made. On 8/28/25, she was told by the facility scheduler (SCH)-A who heard R1 make the allegation to the physician during her appointment on 8/28/25. The Administrator indicated when she had talked with R1 she was not able to provide specific details of the incident including who the staff member involved and was not willing to further discuss the incident and therefor did not consider the incident reportable. Furthermore, Administer denied knowledge of NA-P's written warning 8/1/25, or grievance of 9/5/25.During an interview on 9/12/25 at 7:40 a.m., director of nursing (DON) stated she was made aware of incident on 9/5/25, while she was talking with R1. R1 stated NA-P was too fast with cares and asked DON to file a grievance against NA-P. DON filled out the grievance form and talked with NA-P on 9/5/25. DON did not complete an investigation and not talk to other residents about the care NA-P provided. However, DON provided education to NA-P to slow down during cares, every resident has different needs, and residents deserved quality of care. R4's social services data collection tool dated 8/5/25, R1 had no cognitive deficit and had no behaviors or rejection of cares noted. R4's face sheet dated 9/12/25, indicated diagnoses of cerebral infarction (stroke), bipolar disorder, and rheumatoid arthritis. R4 needed assistance with personal care.R4's care plan did not address the vulnerabilities to abuse.During an interview on 9/11/25 at 2:37 p.m., R4 did not know names of staff, however, gave a detailed description that was consistent with NA-P. R4 stated when NA-P gave her a shower she felt like she was rushed. NA-P would scrub with a washcloth really hard in her vaginal area and back which caused her to hurt after the shower. R4 stated she did not want NA-P to bath her because she did not want to have that discomfort and would refuse her shower if NA-P was working. R6's face sheet date 9/12/25, included diagnoses of cerebral aneurysm, adjustment disorder with depressed mood, and history of cerebral infarct (stroke).R6's social service data collection tool dated 8/26/25, indicated intact cognition, had no behaviors or rejection of cares notedR6's care plan did not address the vulnerabilities to abuse.During an interview on 9/11/25 at 3:00 p.m., R6 stated if NA-P was working on her hall and she had a request or need, she would wait until the next shift. During a subsequent interview on 9/12/25 at 12:30 p.m., R6 stated NA-P frustrated and made her very angry because of the way she treated residents. NA-P would make condescending remarks and say inappropriate things but then laugh about it like it was OK or to try to make up for saying them. R6 could not remember specific examples, however it made her feel angry enough she wanted to punch her or punch something. R7's face sheet dated 9/12/25, indicated diagnoses of chronic obstructive pulmonary disease (COPD), generalized anxiety, and rheumatoid arthritis.R7's social services MDS data collection tool dated 7/17/25, indicated moderate impaired cognition, and had no behaviors or rejection of cares.R7's care plan did not address the vulnerabilities to abuse.During an interview on 9/11/25 at 2:27 p.m., R7 did not know staff names, however, gave a detailed description that was consistent with NA-P. R7 stated NA-P was rough with cares and this upset her but what was she to do? She needed two staff for cares and didn't have a choice in the matter. During a subsequent interview on 9/12/25 at 12:35 p.m., R7 stated she did not want NA-P to come back to work with her room and did not give any other information. During an interview on 9/11/25 at 1:03 p.m., NA-G stated NA-P liked to rile up. When R1 would put on her call light she would taunt R1 by standing in her doorway and say to R1 you don't want me in there so you have to wait. NA-G stated she had reported these interactions and her concerns to the DON. To her awareness the DON had directed NA-P not to go into R1's room to assist her. Review of facility schedule 8/1/25 through 9/11/25, identified NA-P remained working with all residents of facility till state agency brought allegations to the attention of the administrator on 9/11/25 at 10:17 a.m.Facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 indicated the following:Should an incident or suspected incident or resident abuse be reported or observed, the Administrator must be notified immediately.The administrator will complete documentation of allegation of resident abuse and collect any supporting documents relative to the alleged incident.-Review documentation in resident record.-Assess the resident for injury if the allegation involves physical or sexual abuse.-provide proper notification of primary care provider, responsible party, etc.-attempt to obtain witness statements (oral and/or written) form all known witnesses.-If there is physical evidence that can be preserved, attempt to do so, maintain in a safe location to minimize risk of evidence being tampered with.Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this allegation of abuse is by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following process or a combination of the following, if practicable:1) suspending the employee; 2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility.

Based on interview the facility failed to ensure 4 of 4 (R1, R5, R6 and R7) residents were treated with dignity and respect when care was provided to them by nursing assistant (NA)-PFindings include:Review of facility grievances identified a grievance dated 9/5/25, against NA-P made by R1, filled out by the director of nursing (DON). The grievance stated while DON was checking in on R1, R1 reported a nursing assistant for doing cares too fast. R1 identified NA-P. R1 further stated NA-P needed to slow down and I don't want her to help if that was even possible. DON reassured R1 she would speak to NA-P and R1 changed the topic.R1's significant Minimum Data Set (MDS) dated [DATE], identified no cognition deficits. R1 had history of falls, and diagnoses of fractured hip, chronic obstructive pulmonary disease (COPD), dependent on oxygen and dependent on staff to perform activities of daily living (ADLs) and used a wheelchair. R1 had verbal behaviors and rejection of cares.During an interview on 9/11/25 at 11:37 a.m., R1 identified NA-P to surveyor and stated when she knew NA-P was to assist her with cares, it increased her anxiety and caused her to act out. R1 further stated R1 made her feel worthless, during a subsequent interview on 9/11/25 at 2:07 p.m.R5's social service data collection tool dated 7/29/25, identified no cognitive deficits. R5 did not have any behaviors or rejection of cares.During an interview on 9/12/25 at 9:30 a.m., R5 stated NA-P could be rough during cares. Would prefer NA-P not work with her. During a subsequent interview on 9/12/25 at 1:45 p.m., R5 stated NA-P made her feel on edge, more anxious.R6's social service data collection tool dated 8/26/25, identified no cognition deficits, had no behaviors or rejection of cares.R6's face sheet date 9/12/25, indicated diagnoses of cerebral aneurysm, adjustment disorder with depressed mood, and history of cerebral infarct (stroke).During an interview on 9/11/25 at 3:00 p.m., R6 stated if NA-P was working on her hall and she had a request or need, she would wait until the next shift. During a subsequent interview on 9/12/25 at 12:30 p.m., R6 stated NA-P would say totally inappropriate things and then laugh trying to make up for whatever NA-P had said, increasing R6's frustration. R6 further described NA-P as being loud and obnoxious. R65 stated she had reported NA-P but to management, but nothing ever gets done. R7's social services MDS data collection tool dated 7/17/25, identified moderately impaired cognition, and had no behaviors or rejection of cares.R7's face sheet dated 9/12/25, indicated diagnoses of chronic obstructive pulmonary disease (COPD), generalized anxiety, and rheumatoid arthritis.During an interview on 9/11/25 at 2:27 p.m., R7 did not know staff names, however, gave a detailed description was consistent with NA-P. R7 stated NA-P was rough with cares and this upset her but what was she to do, she needed two staff for cares. R7 further stated during a subsequent interview on 9/12/25 at 12:35 p.m., stated she did not want NA-P to come back to work with her and just described her cares as rough.During an interview on 9/11/25 at 1:03 p.m., NA-G stated she had witnessed NA-P on different dates talking back to R1. NA-P seemed to enjoy upsetting R1 and other resident to see if NA-P could get a reaction from them. NA-G had reported this to the DON. NA-G had not noticed a change with NA-P's behavior with residents.During an interview on 9/11/25 at 3:32 p.m., assistant director of nursing (ADON)-A described NA-P demure as lacking a bed side manner but was meeting the needs of the residents appropriately. Further stated NA-P had not had any rough cares. When the NA-P's written warning was brought up ADON-A would not count rushed and harsh as rough cares.During an interview on 9/12/25 at 7:40 a.m., DON stated she had gone over the grievance form with NA-P on 9/5/25, and asked NA-P slowed down and encouraged NA-P to treat residents as individuals and had individual care needs and to provide quality care to all residents.Review of NA-P employee files included:-a coaching/teachable moment dated 7/18/25, for her tone of voice and disrespectful and condescending to coworkers.- a written warning dated 8/1/25, NA-P being harsh and rushed, staff have complained about tone and verbiage coming from NA-P that was demeaning and lacked appropriate bedside manner.- a grievance 9/5/25, DON wrote for R1, where R1 identified NA-P by name and reported NA-P was too fast during cares and that it was possible would not like NA-P to assist with cares if possible. Review of facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 indicated the following: -Personal degradation of a dependent adult, means a will act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person.-Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes agitating a resident to solicit a response, derogatory statement directed to the resident.

Based on interview and document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 1 resident (R1) who reported staff to resident physical abuse. Findings include:A facility five-day investigation submitted by the administrator to the State Agency on9/3/25 indicated on 8/28/25, R1 had clinic appointment and had become upset with the physician. The report included a statement R1 made to the physician then we should talk about Glen Oaks and the staff that is beating me up. In review of facility reported incidents to the State Agency there was no indication R1's allegations of abuse were reported to the State Agency. R1's significant Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment. R1 had verbal behaviors and rejection of cares.During an interview on 9/11/25, at 10:17 a.m., Administrator confirmed she submitted the five-day report to the State Agency that included the allegation of abuse R1 had made. On 8/28/25, she was told by the facility scheduler (SCH)-A who heard R1 make the allegation to the physician during her appointment on 8/28/25. The Administrator indicated when she had talked with R1 she was not able to provide specific details of the incident including who the staff member involved and was not willing to further discuss the incident and therefor did not consider the incident reportable.During an interview on 9/12/25 at 7:40 a.m., director of nursing (DON) stated was made aware of incident on 9/5/25 when R1 made a grievance towards NA-P. DON filled out the grievance form and talked with NA-P. DON did not make a report to the SA, regarding the allegation of rough cares as she did not consider rough cares as a reportable event. Review of facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 indicated the following:Reporting:-All allegation of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of property should be reported immediately to the administrator.-All allegations of resident abuse shall be reported to the appropriate state entity not later than two hours after the allegation is made.

Based on observation, interview, and document review, the facility failed to have a current, ongoing system of infection control (IC) surveillance to identify potential outbreaks of infectious disease, analyze data, and track infections through to resolution or identify the need to alter treatment. The facility also failed to ensure employee illnesses were tracked to identify when staff last worked and the criteria for when they would be allowed to return to work. The facility also failed to ensure staff appropriately wore a gown (personal protective equipment (PPE)) and/or bagged soiled linen during transport. This had the potential to affect all 29 residents in the facility. In addition, the facility failed to appropriately disinfect 1 of 1 resident's (R7) glucometer prior to returning it to the medication cart, Findings include: RESIDENT INFECTION SURVEILLANCE Review of the infection surveillance logs from January 2025 through March 2025 identified the columns for name, room #, infection date, site of infection, culture taken, causative agent, antibiotic treatment, isolation precautions and center acquired (obtained while in the facility). In January 2025, three residents (R100, R101, and R18) were listed with active infections as follows: 1) R100 was listed twice with two separate infections, COVID and a urinary tract infection (UTI). An antibiotic was given for each infection. COVID (a virus) was treated with amoxicillin (an antibiotic) 500 milligrams (mg) x three days. Isolation was marked yes. R100 second infection, identified to start the same day, was a UTI. No culture was marked as having been taken, but R100 was prescribed amoxicillin clavulanate potassium (a combination antibiotic) 875/125 mg, x six days, given twice per day. There was no date identified when R100 was put on precautions, what type of precautions were implemented, what their symptoms were, if an antibiotic time out (ATO) was performed (done to ensure the resident is on the correct antibiotic or if the antibiotic should be discontinued) or if there was a need to alter therapy during treatment or upon completion. It is also unknown why R100 was prescribed an antibiotic for the COVID viral infection, or why two antibiotics were listed as having been given. 2) R101 had a skin infection dated 1/31/25. No culture was marked as taken. Zesorb antifungal medication 2% powder was ordered for 14 days, twice daily. It is unknown where the infection was located, or if it resolved after therapy. 3) R18 was noted to have pneumonia. A culture was marked as obtained, and amoxicillin clavulanate potassium, 875/125 mg was given for five days. There was no evidence an ATO was completed. In February 2025, four residents (R30, R18, R23, and R13) were listed with active infections as follows: 1) R30's infection date listed was 2/11/25. R30 was diagnosed with a UTI. A culture marked as taken, and the organism from the culture listed was E-Coli (bacteria). R30 was started on Septra DS (antibiotic) twice daily x three days. There was no indication an ATO was performed. 2) R18 was diagnosed with a UTI on 2/11/25. A culture was noted to be taken; however, it was not noted what the organism was. R18 was given Keflex (antibiotic) 500 mg every 12 hours for seven days. No ATO was noted. 3) R23's UTI was listed as beginning on 2/17/25, A culture was reported as being taken, however, the causative agent (organism) was also blank. R23's corresponding progress notes indicated she was sent to the hospital and noted to have a UTI and given an oral antibiotic. R23's after visit summary made no mention of oral antibiotic. There was no further documentation as part of infection control surveillance to support staff had called the hospital to inquire about a culture result, nor had asked why R23 was not given an order for her oral antibiotic as indicated in the progress note to identify if the oral antibiotic was perhaps no longer needed. There was no indication any of the above-mentioned residents' symptoms were, or if there was a need to alter therapy during treatment or if symptoms resoled upon completion of the antibiotic. 4) R13 was noted to have an infection to a neck surgical incision dated 2/29/25. R13 was given an IV antibiotic. No isolation precautions were noted. R13's progress notes identified R13 had cervical (neck) surgery on 2/6/25 and began showing signs of potential infection on 2/17/25, with surgical site swelling and a non-productive cough was noted. On 2/19/25, R13 had a temperature of 100.4 and complained of vomiting. R13 was sent to the physician's office, who then admitted him to the hospital for treatment. R13 returned to the facility again on 2/24/25 and had a peripherally inserted central catheter (PICC) line (catheter placed into a vein to administer medication directly into the bloodstream for serious infections). There was no indication R13 was placed on enhanced barrier precautions (EBP) upon his return. In March 2025, four residents were identified with infections (R15, R16, R5, and R101) as follows: 1) R15 was noted to have an infection on 3/4/25. The site of the infection was old peg tube site/skin. No culture was taken. R15 was placed on augmentin (antibiotic). No isolation precautions were noted as having been placed. There was no indication R15 was on enhanced barrier precautions (EBP) prior to the infection to reduce the risk of infection before it had occurred. There was no indication an ATO had occurred. 2) R16 was noted to have an infection on 3/1/25 to their bilateral lower legs. No culture was obtained, R16 was placed on augmentin. No isolation precautions were implemented. There was no evidence an ATO was completed. 3) R5 was noted to have a urinary tract infection on 3/6/25. A culture was obtained. The organism causing the infection was a bacteria known as citrobacter freundii. There was no indication an ATO occurred. Review of the National Library of Medicine October- December 2013 article, located at https://pmc.ncbi.nlm.nih.gov/articles/PMC3836000/ identified that bacteria was known to be emerging as a multi- resistant pathogen (MDRO). There was no indication R5 was placed on EBP or if the infection preventionist had provided appropriate oversight to ensure the potential to spread the infection was limited or if R5's strain of bacteria was resistant to the antibiotic ordered or if the antibiotic was appropriate. 4) R101 was noted to have pneumonia on 3/11/25 and was treated with doxycycline. No isolation was noted to be implemented and no culture was noted. There was no indication during any of the above-mentioned surveillance as to whether the infection date was the date when the resident had been diagnosed or if it indicated the onset of symptoms. There was no mention what symptoms each resident had, when transmission based precautions (TBP) were placed or what type of precautions were implemented. Furthermore, there was no evidence of a medication start and stop date. In addition, there was no evidence an ATO was performed nor was there evidence the facility had followed any criteria for an ATO. There was also no indication when symptoms had improved, resolved, or if there was a need to alter treatment. Review of the 10/1/22, Infection Prevention and Control Program policy identified the infection control (IC) program was to consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The IC program was to be overseen by the infection preventionist (IP). Surveillance data was to include documented IC incidents and corrective actions taken, identify if physician management of infections is optimal, whether antibiotic usage patterns need to be changed because of resistant strains of bacteria, whether culture results or antibiotic resistance is transmitted accurately and in a timely manner, and ensure there would be appropriate follow-up of infections. The policy was to be reviewed annually and was to include updating or supplementing existing policies, assessing staff compliance with policies and regulation, and identifying trends or significant problems. The information obtained from surveillance was to be compared with data from other facilities with use of acknowledged standards and used to assess effectiveness of IC practices. Antibiotic Stewardship was to include culture reports, sensitivity data and usage reviews using medical criteria and standardized definitions, and be evaluated with feedback from physicians. There was no mention of having staff perform an antibiotic time out or what specific criteria was used to determine appropriateness of medication. EMPLOYEE SURVEILLANCE Review of the employee surveillance from January 2025 through March 2025 identified the social services designee (SSD) called in sick on 2/17/25 and was noted to have a a diagnosis of Strep (bacterial throat infection) with a fever of 102 degrees Fahrenheit (F) . There was no last day of work noted, if and/when the SSD returned to work, or if she received any antibiotic therapy. Review of the Centers for Disease Control (CDC) article, Clinical Guidance for Group A Streptococcal Pharyngitis, located at https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html, identified Strep is spread through close contact with another person. Crowded settings can increase the risk for spreading the bacteria. Treatment with an appropriate antibiotic for 12 hours or longer limits the person's ability to transmit Strep. Persons infected should stay home from work until both conditions are met: 1) They are without fever. 2) At least 12-24 hours after starting an appropriate antibiotic. The SSD's time card for 2/17/25 identified she had worked 5 hours on 2/17/25, and returned for a full day (8 hours) on 2/18/25. Review of the 10/1/22, Infection Prevention and Control Program policy identified the infection control (IC) program was to consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The facility was to have established policies and procedures for infection control among employees where staff should report their infections or avoid the facility. There was no indication a policy was developed to include when staff would be excluded from work, or if they met criteria to return to work. It is also not indicated the IC policy had been reviewed or updated since 2022 to ensure it met current standards of practice. PPE/SOILED LINEN Observation on 4/21/25 at 4:45 p.m., of medication aid (TMA)-B walking down the hallway carrying a ball of rolled up sheets, a reusable pad (used as an additional barrier on residents' beds), and a pair of pants. The clothing and linens were touching her clothing, she dropped the pad on the floor and bent over and picked it back up and continued down the hall to the soiled utility room. Interview on 4/21/25 at 5:20 p.m., with TMA-B confirmed she was carrying the linens and clothing down the hall, the items were touching her clothing, and she had dropped some of them on the floor. She confirmed they were not bagged, and she reported they were soiled with urine. She identified she was aware she was supposed to bag soiled linens before taking them out of the room due to risk for cross contamination. She identified she normally bags soiled linens but was in a hurry. Interview on 4/23/25 at 1:14 p.m., with the IP identified she was the assistant director of nursing. She works about 20 to 30 hours per week. Her responsibilities included order supplies for the nursing department weekly, complete wound rounds with assessments and physician updates weekly, complete infection preventionist tasks, she occasionally picked up nursing floor shifts, and she was the assistant director of nursing (ADON) which came with several other tasks. Nursing staff document infection in the electronic medical record program (PCC). If the infection lasts one day, she reported she wouldn't add that to the surveillance log. She agreed she was missing information on the surveillance log to be sure a thorough analysis was being completed and had not performed any antibiotic time outs and had no documentation to support she followed and professional criteria for antibiotic appropriateness. She also only documented infections that had been treated with a medication. She noted she received all IC data from the corporate office. She had competed her previous training in 2023 but did not receive any competencies related to her oversight abilities of the infection control program. The corporate office reviews her logs. She felt she wasn't able to provide appropriate oversight as she was responsible for so many other tasks and noted she did not have enough time to complete her duties. I'm not just gathering information, I am working on the floor, updating physicians, writing orders, ordering supplies, doing wound care, and picking up floor shifts. The DON was to oversee the ICP when she was not working. Interview on 4/24/25 at 5:15 p.m., with the registered nurse consultant (RNC) identified staff are required to bag soiled linens prior to transporting them to another area. Staff received training online and were expected to adhere to those processes. The RNC provided documentation of the infection control training completed by TMA-B. She also noted her expectation for the role of the IP was to be deemed competent to provide the oversight and understanding with respect to all that entails, including antibiotic stewardship. The IP should be monitoring all infections, not just those treated with medication. Review of the 10/1/22, Infection Prevention and Control Program policy identified the infection control (IC) program was to consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The facility was to educate staff and ensure they adhered to proper IC techniques and procedures. There was no indication a policy was developed to include when staff would be excluded from work, or if they met criteria to return to work. It is also not indicated the IC policy had been reviewed or updated since 2022 to ensure it met current standards of practice. Interview on 4/22/25 at 1:50 p.m., with the director of nursing identified she was not the infection preventionist (IP) but she was certified in infection control. She was unaware of what an antibiotic time out was and did not know the facility was supposed to complete one. She reports they have an IP that works about 16 hours per week. Her responsibilities are wound care, ordering supplies, and infection control. 35992 Glucometer cleaning R7's significant change Minimum Data Set assessment of 1/28/25, indicated R7 had moderate cognitive impairment. R7 was identified as receiving help with activities of daily living. R7's medical diagnoses included diabetes (a group of diseases that affect how the body uses blood sugar (glucose), as well as endocrine (the system which released hormones into your blood while continuously monitoring the levels), nutritional, and metabolic diseases (any of the diseases or disorders that disrupt normal metabolism, the process of converting food to energy on a cellular level). On 4/22/25 at 4:30 p.m., licensed practical nurse (LPN)-A was observed during routine medication pass. At this time, R7 was due for blood sugar monitoring (checking the level of blood sugar in the blood to help determine if medication or additional interventions are needed). LPN-A performed hand hygiene and set up equipment to complete blood sugar check, using R7's monitor. LPN-A brought gloves to room along with equipment, and donned gloves before starting the procedure. R7's finger was cleansed with an alcohol prep, blood was drawn with the use of a disposable lancet (needle used for blood sugar checks), and blood sugar was checked with glucometer (a machine used to check blood sugars). LPN-A gathered supplies and exited room. The lancet was disposed of appropriately, machine was placed on cart, gloves removed and hand hygiene performed. LPN-A then applied gloves and wiped the machine with an alcohol wipe to clean/sanitize the machine. LPN-A stated this was the process she was trained in when she started at the facility. LPN-A proceeded to return the machine to the med cart in the area designated for R7's machine. LPN-A then removed gloves and performed hand hygiene before proceeding to the next task. On 4/22/25, at 4:35 p.m., an interview was held with the director of nursing (DON) to inquire of the process for sanitizing glucometers following performing a blood glucose test. DON stated the glucometer should be cleaned with the use of a disinfectant wipes, wrapping the glucometer in the wipe and allowing to dry to complete the sanitation process. Nurse Consultant (NC) was also present at this time, and verified EPA (Environmental Protection Agency) approved wipes should be used for sanitation. The facility policy, Blood Glucose Monitoring Policy and Protocol, undated, identified All glucometers will be cleaned per manufacturer recommendations prior to performing bedside test. The policy then later identified The glucometer will be cleaned prior to each use and after after each use per manufacturer recommendation. The policy lacked indication as to what product was to be used with cleaning, aside from identifying per manufacturers recommendations. The manufacturer's policy for the glucometer, with the recommendations for cleaning, was requested and not received.

Based on interview and record review, the facility failed to provide a Quality Assurance and Performance Improvement (QAPI) plan that identified necessary policies and procedures describing how the facility will identify and correct quality deficiencies. This had the potential to affect all 29 residents residing in the facility. Findings include: When interviewed on 4/23/25 at 1:29 p.m. the administrator indicated there was no formalized QAPI plan in place to track and measure performance, no goals established to measure performance, and no development or implementation of corrective action or performance improvement activities. The administrator stated although there were attendance rosters available for quarterly QAPI meetings from the past year, the facility lacked any documentation to reflect the QAPI process. The administrator stated awareness of the need for and importance of the QAPI process, however, was new to the facility and this had not yet been implemented. During follow up interview on 4/24/25 at 4:54 p.m., the administrator stated she had again reviewed all documentation in place for QAPI and had not located any information for the past QAPI program. The administrator reported information was present for 2023, however, there was not documentation for 2024 to present. During an interview on 4/24/25 at 3:51 p.m., the director of nursing (DON) stated the facility held quality assurance meetings quarterly, which she had attended. The DON stated during these meetings, she presented updates regarding infection control, and current status within the facility. The DON lacked any documentation related to QAPI presentation of information, or of any previous, or current QAPI programs in place. The facility policy and procedure, titled Quality Assurance Performance Improvement (QAPI), Quality Assessment Assurance (QAA) Plan, updated on 1/2/25, was provided for review. The policy identified facility specific QAPI goals were to implement the QAPI process successfully as evidenced by the formulation of effective Performance Improvement Plans. In addition, the policy identified specific QAPI goals were to be found within the QAPI committee documentation and Performance Improvement Committee(s) documentation.

Based on interview and document review the facility failed to ensure the quality assurance (QA) team developed, and revised, a quality improvement program to correct infection control concerns identified through tracking and trending and the infection control process as presented by the director of nursing (DON) during routine QAPI meetings. This had the potential to affect all 28 residents residing in the facility. Findings include: On 4/23/25, at 8:28 a.m., the administrator provided information for review related to the Quality Insurance Performance Improvement (QAPI) meeting attendance rosters, and meeting minutes for the current QAPI program. A review of the attendance roster and meeting minutes lacked indication as to what the overall program focused on, as well as what the Performance Improvement Plan (PIP) focus was. The information following the attendance roster of 1/17/24 included hand written notes, however, these notes provided no context as to what the QAPI program was focusing on, benchmarks and goals, or information regarding the current PIP programs. The minutes did reference infection control, and identified no patterns of infection. The meeting minutes referenced 22 staff days lost [related to illness], and also identified 11 Covid in December. A review of the remainder of the meeting attendance sheets lacked further agendas, meeting minutes, or documentation until 3/19/25. Upon review of the final document provided by the facility, the meeting minutes identified the PIP review as Anti-psychotic will begin 3/20/25 in weekly meeting. Upon further review, it was noted under the area titled Infection Control, there was no Covid, four infections, no trends. The document identified the following under the area titled action plan/follow up : auditing TB (tuberculosis), PPE (personal protective equipment), Peri-Care audits performed. During follow up interview on 4/23/25 at 4:54 p.m., the administrator stated she was unable to locate any program specific information regarding the QAPI program, or PIP initiatives, prior to her arrival as the administrator approximately one month ago. The administrator stated at this time, the facility is in the beginning stages of formalizing the QAPI program, and development of the PIP. The administrator stated they were planning to utilize the current survey results to identify focus areas for the PIP. The administrator stated upon receipt of the survey results, the QAPI team would review, and further their process at this time. The facility policy and procedure, titled Quality Assurance Performance Improvement (QAPI), Quality Assessment Assurance (QAA) Plan, updated on 1/2/25, was provided for review. The purpose statement indicated the purpose of QAPI was to develop a culture of proactive leadership and identify plans for improvement leading to systematic changes. The policy identified under guiding principles the following; QAPI program will be ongoing and comprehensive, dealing with the full range of services that we provide, including all departments; and, the organization expects areas for improvement to be identified.

Based on observation, interview, and document review, the facility failed to ensure the infection preventionist had the appropriate time allotted to have oversight of the facility infection control program and was deemed competent in providing that oversight. This had the potential to affect all 29 residents. Findings include: RESIDENT INFECTION SURVEILLANCE Review of the infection surveillance logs from January 2025 through March 2025 identified the columns for name, room #, infection date, site of infection, culture taken, causative agent, antibiotic treatment, isolation precautions and center acquired (obtained while in the facility). In January 2025, three residents (R100, R101, and R18) were listed with active infections as follows: 1) R100 was listed twice with two separate infections, COVID and a urinary tract infection (UTI). An antibiotic was given for each infection. COVID (a virus) was treated with amoxicillin (an antibiotic) 500 milligrams (mg) x three days. Isolation was marked yes. R100 second infection, identified to start the same day, was a UTI. No culture was marked as having been taken, but R100 was prescribed amoxicillin clavulanate potassium (a combination antibiotic) 875/125 mg, x six days, given twice per day. There was no date identified when R100 was put on precautions, what type of precautions were implemented, what their symptoms were, if an antibiotic time out (ATO) was performed (done to ensure the resident is on the correct antibiotic or if the antibiotic should be discontinued) or if there was a need to alter therapy during treatment or upon completion. It is also unknown why R100 was prescribed an antibiotic for the COVID viral infection, or why two antibiotics were listed as having been given. 2) R101 had a skin infection dated 1/31/25. No culture was marked as taken. Zesorb antifungal medication 2% powder was ordered for 14 days, twice daily. It is unknown where the infection was located, or if it resolved after therapy. 3) R18 was noted to have pneumonia. A culture was marked as obtained, and amoxicillin clavulanate potassium, 875/125 mg was given for five days. There was no evidence an ATO was completed. In February 2025, four residents (R30, R18, R23, and R13) were listed with active infections as follows: 1) R30's infection date listed was 2/11/25. R30 was diagnosed with a UTI. A culture marked as taken, and the organism from the culture listed was E-Coli (bacteria). R30 was started on Septra DS (antibiotic) twice daily x three days. There was no indication an ATO was performed. 2) R18 was diagnosed with a UTI on 2/11/25. A culture was noted to be taken; however, it was not noted what the organism was. R18 was given Keflex (antibiotic) 500 mg every 12 hours for seven days. No ATO was noted. 3) R23's UTI was listed as beginning on 2/17/25, A culture was reported as being taken, however, the causative agent (organism) was also blank. R23's corresponding progress notes indicated she was sent to the hospital and noted to have a UTI and given an oral antibiotic. R23's after visit summary made no mention of oral antibiotic. There was no further documentation as part of infection control surveillance to support staff had called the hospital to inquire about a culture result, nor had asked why R23 was not given an order for her oral antibiotic as indicated in the progress note to identify if the oral antibiotic was perhaps no longer needed. There was no indication any of the above-mentioned residents' symptoms were, or if there was a need to alter therapy during treatment or if symptoms resoled upon completion of the antibiotic. 4) R13 was noted to have an infection to a neck surgical incision dated 2/29/25. R13 was given an IV antibiotic. No isolation precautions were noted. R13's progress notes identified R13 had cervical (neck) surgery on 2/6/25 and began showing signs of potential infection on 2/17/25, with surgical site swelling and a non-productive cough was noted. On 2/19/25, R13 had a temperature of 100.4 and complained of vomiting. R13 was sent to the physician's office, who then admitted him to the hospital for treatment. R13 returned to the facility again on 2/24/25 and had a peripherally inserted central catheter (PICC) line (catheter placed into a vein to administer medication directly into the bloodstream for serious infections). There was no indication R13 was placed on enhanced barrier precautions (EBP) upon his return. In March 2025, four residents were identified with infections (R15, R16, R5, and R101) as follows: 1) R15 was noted to have an infection on 3/4/25. The site of the infection was old peg tube site/skin. No culture was taken. R15 was placed on augmentin (antibiotic). No isolation precautions were noted as having been placed. There was no indication R15 was on enhanced barrier precautions (EBP) prior to the infection to reduce the risk of infection before it had occurred. There was no indication an ATO had occurred. 2) R16 was noted to have an infection on 3/1/25 to their bilateral lower legs. No culture was obtained, R16 was placed on augmentin. No isolation precautions were implemented. There was no evidence an ATO was completed. 3) R5 was noted to have a urinary tract infection on 3/6/25. A culture was obtained. The organism causing the infection was a bacteria known as citrobacter freundii. There was no indication an ATO occurred. Review of the National Library of Medicine October- December 2013 article, located at https://pmc.ncbi.nlm.nih.gov/articles/PMC3836000/ identified that bacteria was known to be emerging as a multi- resistant pathogen (MDRO). There was no indication R5 was placed on EBP or if the infection preventionist had provided appropriate oversight to ensure the potential to spread the infection was limited or if R5's strain of bacteria was resistant to the antibiotic ordered or if the antibiotic was appropriate. 4) R101 was noted to have pneumonia on 3/11/25 and was treated with doxycycline. No isolation was noted to be implemented and no culture was noted. There was no indication during any of the above-mentioned surveillance as to whether the infection date was the date when the resident had been diagnosed or if it indicated the onset of symptoms. There was no mention what symptoms each resident had, when transmission based precautions (TBP) were placed or what type of precautions were implemented. Furthermore, there was no evidence of a medication start and stop date. In addition, there was no evidence an ATO was performed nor was there evidence the facility had followed any criteria for an ATO. There was also no indication when symptoms had improved, resolved, or if there was a need to alter treatment. R1's 3/4/25, quarterly Minimum Data Set (MDS) assessment identified her cognition was moderately impaired and she was dependent on staff for activities of daily living (ADL)'s. R1 had diagnoses of dementia, heart failure, diabetes, multiple sclerosis, anxiety, and depression, and had been taking an antibiotic. R1's 4/9/25, physician order with lab results that identified her urine was positive for Aerococcus (a bacterium associated with urinary tract infections). The lab result included an order for R1 to start taking Macrobid 100 milligrams (MG) twice a day for 7 days. The order noted a susceptibility lab (test to identify what antibiotic the bacterium is susceptible to) was not completed. R1's April 2025, medication administration record identified she was administered 14 doses of macrobid 100 mg by mouth from 4/11/25 through 4/18/25. Review of the undated, Antibiotic Stewardship policy identified the facility would monitor the use of antibiotics by residents, staff would receive education that will include inappropriate use of antibiotics and how they affect residents. The policy did not identify a process of how the infection preventionist should monitor and communicate with the prescribing provider of the effectiveness or appropriateness of the antibiotic prescribed. EMPLOYEE SURVEILLANCE Review of the employee surveillance from January 2025 through March 2025 identified the social services designee (SSD) called in sick on 2/17/25 and was noted to have a a diagnosis of Strep (bacterial throat infection) with a fever of 102 degrees Fahrenheit (F) . There was no last day of work noted, if and/when the SSD returned to work, or if she received any antibiotic therapy. Review of the Centers for Disease Control (CDC) article, Clinical Guidance for Group A Streptococcal Pharyngitis, located at https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html, identified Strep is spread through close contact with another person. Crowded settings can increase the risk for spreading the bacteria. Treatment with an appropriate antibiotic for 12 hours or longer limits the person's ability to transmit Strep. Persons infected should stay home from work until both conditions are met: 1) They are without fever. 2) At least 12-24 hours after starting an appropriate antibiotic. The SSD's time card for 2/17/25 identified she had worked 5 hours on 2/17/25, and returned for a full day (8 hours) on 2/18/25. Review of the 10/1/22, Infection Prevention and Control Program policy identified the infection control (IC) program was to consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The facility was to have established policies and procedures for infection control among employees where staff should report their infections or avoid the facility. There was no indication a policy was developed to include when staff would be excluded from work, or if they met criteria to return to work. It is also not indicated the IC policy had been reviewed or updated since 2022 to ensure it met current standards of practice. PPE/SOILED LINEN Observation on 4/21/25 at 4:45 p.m., of medication aid (TMA)-B walking down the hallway carrying a ball of rolled up sheets, a reusable pad (used as an additional barrier on residents' beds), and a pair of pants. The clothing and linens were touching her clothing, she dropped the pad on the floor and bent over and picked it back up and continued down the hall to the soiled utility room. Interview on 4/21/25 at 5:20 p.m., with TMA-B confirmed she was carrying the linens and clothing down the hall, the items were touching her clothing, and she had dropped some of them on the floor. She confirmed they were not bagged, and she reported they were soiled with urine. She identified she was aware she was supposed to bag soiled linens before taking them out of the room due to risk for cross contamination. She identified she normally bags soiled linens but was in a hurry. Interview on 4/22/25 at 1:50 p.m., with the director of nursing identified she was not the infection preventionist (IP) but she was certified in infection control. She was unaware of what an antibiotic time out was and did not know the facility was supposed to complete one. She reports they have an IP that works about 16 hours per week. Her responsibilities are wound care, ordering supplies, and infection control. Interview on 4/23/25 at 1:14 p.m., with the IP identified she was the assistant director of nursing. She works about 20 to 30 hours per week. Her responsibilities included order supplies for the nursing department weekly, complete wound rounds with assessments and physician updates weekly, complete infection preventionist tasks, she occasionally picked up nursing floor shifts, and she was the assistant director of nursing (ADON) which came with several other tasks. Nursing staff document infection in the electronic medical record program (PCC). If the infection lasts one day, she reported she wouldn't add that to the surveillance log. She agreed she was missing information on the surveillance log to be sure a thorough analysis was being completed and had not performed any antibiotic time outs and had no documentation to support she followed and professional criteria for antibiotic appropriateness. She also only documented infections that had been treated with a medication. She noted she received all IC data from the corporate office. She had competed her previous training in 2023 but did not receive any competencies related to her oversight abilities of the infection control program. The corporate office reviews her logs. She felt she wasn't able to provide appropriate oversight as she was responsible for so many other tasks and noted she did not have enough time to complete her duties. I'm not just gathering information, I am working on the floor, updating physicians, writing orders, ordering supplies, doing wound care, and picking up floor shifts. The DON was to oversee the ICP when she was not working. Interview on 4/24/25 at 5:15 p.m., with the registered nurse consultant (RNC) identified staff are required to bag soiled linens prior to transporting them to another area. Staff received training online and were expected to adhere to those processes. The RNC provided documentation of the infection control training completed by TMA-B. She also noted her expectation for the role of the IP was to be deemed competent to provide the oversight and understanding with respect to all that entails, including antibiotic stewardship. The IP should be monitoring all infections, not just those treated with medication. Review of the 10/1/22, Infection Prevention and Control Program policy identified the infection control (IC) program was to consist of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The IC program was to be overseen by the infection preventionist (IP). Surveillance data was to include documented IC incidents and corrective actions taken, identify if physician management of infections is optimal, whether antibiotic usage patterns need to be changed because of resistant strains of bacteria, whether culture results or antibiotic resistance is transmitted accurately and in a timely manner, and ensure there would be appropriate follow-up of infections. The policy was to be reviewed annually and was to include updating or supplementing existing policies, assessing staff compliance with policies and regulation, and identifying trends or significant problems. Antibiotic Stewardship was to include culture reports, sensitivity data and usage reviews using medical criteria and standardized definitions, and be evaluated with feedback from physicians. The facility was to educate staff and ensure they adhered to proper IC techniques and procedures. There was no indication a policy was developed to include when staff would be excluded from work, or if they met criteria to return to work. There was no mention of having staff perform an antibiotic time out or what specific criteria was used to determine appropriateness of medication. It is also not indicated the IC policy had been reviewed or updated since 2022 to ensure it met current standards of practice.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physicians orders and manufacturers guidelines for 2 of 7 (R24 and R30) residents observed to receive medications. A total of seven (7) errors out of 26 errors were identified, resulting in a 26.9% (percent) facility error rate. Findings include: On 4/22/25 at 3:56 p.m., licensed practical nurse (LPN-A) was observed to prepare medications at a mobile medication cart in the hallway of the unit. R24 was in the hallway and approached the medication cart for medication administration. LPN-A proceeded to set up medications, including topical medication Voltaren External Gel 1 % (Diclofenac Sodium). The label for this prescription cream directed staff to apply two gm (grams). LPN-A stated she did not have the dispensing film to measure out the two grams as ordered, however, R24 only wished to receive a pea sized amount. LPN-A was unsure how much this was comparative to the two grams amount ordered. LPN-A stated the order on the med sheet, as well as on the label was to be administered, however, R24 preferred only a smaller amount. Immediately following observation of administration of medications, a review was completed of R24's electronic medical record, and Medication Administration Record. A review of the electronic Medication Administration Record indicated the following order: Voltaren External Gel 1 % Diclofenac Sodium (Topical); Apply to knees topically three times a day for knee pain. Apply 2 grams to affected joints. The start date for this order was 10/11/24. Upon review of the Voltaren gel information on https://www.drugs.com/dosage/voltaren-gel, it was identified the 2-gram line is 2.25 inches long. R30's Order Summary Report, dated 4/24/25, identified R30's current physician-ordered medications and treatments. These orders included the orders for Aspirin Delayed Release 325 mg by mouth in the morning for pain with order date of 1/15/25. The orders also included Colace (Docusate sodium) 100 mg by mouth twice a day for stool softener, effective 1/15/25. R30 had orders also noted for Furosemide 20 mg by mouth every morning for tachy-[NAME] syndrome and edema (swelling) effective 3/12/25. R30 had orders in place for Gabapentin 100 mg capsule ordered twice daily by mouth for pain effective 1/22/25. Additional orders were in place for Metoprolol 25 mg twice daily by for essential hypertension, effective 1/21/25. The orders directed staff to give with food. R30 also had orders in place, effective 1/22/25, for Tylenol (acetaminophen) 500 mg two tablets three times a day for pain management. The orders also included Vitamin D3/cholecalciferol (2000 IU)/50 mcg (a unit of measurement) one tablet daily for Vitamin D deficiency, effective 3/6/25. The orders also identified orders for Potassium Chloride Crystals ER (Extended Release) (K-Cl ER) 20 mEq by mouth in the morning for mineral balance. R30's EMAR, printed 4/24/25, identified the above listed medications. The instructions outlined on the EMAR lacked any additional instructions for administration of medications. The EMAR lacked direction to the staff to crush medications and mix with applesauce prior to administration. On 4/23/25, at 7:29 a.m. TMA-B prepared R30's medication at a mobile cart in the hallway near the nurses station. TMA-B proceeded to set up medications for R30 upon review of the EMAR. TMA-B informed surveyor medications were crushed for R30. The following medications were removed from the med cart, compared to the EMAR for accuracy, and set up by TMA-B: Aspirin (ASA) 325 mg one tablet daily by mouth; Colace (Docusate Sodium) 100 mg one tablet twice daily by mouth; Furosemide 20 mg one tablet daily in the morning by mouth; Metoprolol 25 mg one tablet twice daily by mouth; Acetaminophen 500 mg two tablets three times a day; and Vitamin D3/cholecalciferol (2000 IU)50 mcg one. Upon preparation of the Gabapentin 100 mg one capsule twice daily by mouth, the capsule was opened and contents placed into applesauce. TMA-B prepared the K-Cl ER 20 mEq one tablet every morning by mixing this with a small amount of water to prepare a slurry (dissolving the medication in water to give in a suspension). Upon setting up all medications as outlined, with the exception of the Gabapentin and K-Cl ER, the medications were subsequently crushed and placed into applesauce. The medications were then administered to R30. On 4/23/25, at 12:50 p.m. TMA-B was interviewed in follow up regarding the process to determine whether or not to crush meds. TMA-B stated she knew orders to crush medications came from therapy (speech therapy). TMA-B stated the staff would perform a trial to see what worked best for the resident, then a crush order would be obtained if indicated. TMA-B stated she was unsure where the order was found on the electronic medical records (EMR). TMA-B stated this information was relayed to the oncoming staff at shift reports. The information was also displayed on the resident banner within the EMR, and was generally noted in red. Upon review of the banner for R30, TMA-B stated the order crush meds was not observed in the banner. On 4/23/25, at 1:50 p.m. inquired of TMA-B if there have been any problems to date with administration of crushed meds for R30. TMA-B stated R30 had no problems with crushed meds. On 4/24/25, at 3:45 p.m. the assistant director of nursing (ADON) stated the provider must provide the order allowing crushed meds before this would be initiated. The ADON went on to say medications would then be crushed unless it was contraindicated to do so. The ADON stated this order would be placed on the order sheet, and would be found under Other orders. If the orders were entered correctly, it would also be displayed on the resident banner in the EMR. A review of the R30's EMR lacked indication of orders by the provider, as well as information in the banner regarding authorization to crush medications. During interview on 4/24/25, at 3:51 p.m., the director of nursing (DON) stated orders must have been obtained from the provider before medications were given crushed. The assistant director of nursing (ADON) was in the office during this discussion, and upon review of the concerns regarding crushing of meds for R30, verified there were no orders in place in the EMR. In regards to R24, DON stated medications were to be given as prescribed. DON stated if a lesser dose was requested, as in the Diclofenac amount for R24, the provider was to be contacted in update and an alternate order was to be obtained. On 4/23/25, at 4:17 p.m. the consulting pharmacist (CP) was provided an overview of the medications being given without a provider order to crush medications. CP stated a provider order was needed before medications were crushed and given to the resident, and medications were not to be given crushed without first consulting the provider. CP stated prior to authorization to crush the medication, the provider reviewed the residents medication and a determination would need to be made as to if the medications were acceptable to crush. If the provider deemed it was not appropriate to crush medications, an alternate method of administration/or alternate medication with a different delivery source would need to be considered. A review was completed with the medications which were given crushed. CP stated upon review of the medications, CP stated ASA was a medication which was not to be crushed. When asked if this was considered a significant medication error, CP stated she did not wish to give things a label. A facility policy, noted to have been revised April 2018, indicated The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify the appropriate indications and procedures for crushing medications. The policy identified the order to crush medications must come from the physician. The policy identified the MAR or other documentation must indicate why it was necessary to crush the medication. A facility policy, titled Administering Medications, last revised December 2012. identified: If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation and interview the facility failed to ensure hazardous chemicals were appropriately secured in 1 of 2 unlocked soiled utility rooms located in hall A. This had the potential to affect 16 of 29 residents residing in that hall. Findings include: Observation on 4/21/25 at 1:49 p.m., of the unlocked soiled utility room a bottle of Lysol toilet bowl cleaner was sitting on the counter next to the sink. Some of the cleaner was spilled on the countertop. Interview on 4/21/25 at 1:54 p.m., with the maintenance director confirmed the above findings. He does walk through the building but was unable to recall the last time he had checked the utility rooms. He identified they have a locked closet off the nursing floor that is supposed to be used to store cleaning supplies and other hazardous chemicals. He was not certain who had left the toilet bowl cleaner in the unlocked utility room. Interview on 4/24/25 at 4:58 p.m., with the nurse consultant and administrator identified they would expect staff to ensure all hazardous chemicals are always kept in a locked closet away from the resident areas to ensure there was no risk of injury. Review of the 2017 Hazardous Areas, Devices and Equipment policy identified the facility will be assessed for hazards on an on-going basis. When a hazard is identified the safety committee will give recommendations for measures to ensure that vulnerable residents cannot access hazardous areas in the facility with locks, alarms, supervision, etc.

Based on interview and document review, the facility failed to ensure medications to prevent blood clotting were administered, and associated blood testing was performed, in accordance with physician orders for 1 of 1 residents (R3) reviewed who was at increased risk for recurrent stroke, clots, and/or decreased blood supply to tissues/organs causing a shortage of oxygen, after an ordered blood test was not performed resulting in missed subsequent anticoagulation orders and anticoagulation therapy for a 14 day period. These findings resulted in an immediate jeopardy (IJ) situation, for R3 when the facility failed to take adequate, systemic action(s) to analyze R3's missed blood testing, missed and/or incorrectly administered anticoagulants, failed to update R3's medical provider related to the surrounding anticoagulants and/or blood test concerns, and failed to provide staff education to potential factors which contributed to the error thus causing the potential for similar reoccurrences and potential harm for R3. In addition to the resident in immediate jeopardy, the facility failed to ensure insulin (blood sugar regulator) medication was administered in accordance with physician orders for 1 of 1 residents (R6) who was provided insulin outside of ordered parameters during a medication pass observation. This resulted in potential harm that is not immediate jeopardy. The immediate jeopardy began on 8/28/23, when the facility failed to perform a physician ordered INR (international normalized ratio - blood clotting rate) blood test which led to a lack of subsequently provided anticoagulant order(s). As a result, R3 was not administered anticoagulants from 8/28/23 through 9/10/23. In addition, after the anticoagulation clinic updated the facility on 9/11/23, related to R3's 8/28/23 missed INR and resultant anticoagulant therapy, R3 missed two additional doses on 9/15/23 and 9/17/23, and received one dose higher then ordered on 9/16/23. This resulted in immediate risk of serious harm for R3. The facility administrator, the clinical nurse consultant (NC)-A, and licensed practical nurse (LPN)-E were notified of the immediate jeopardy at 2:26 p.m. on 9/20/23. The immediate jeopardy was removed on 9/21/23 at 12:35 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R3's admission Minimum Data Set (MDS), dated [DATE], identified R3 was moderately cognitively impaired with a diagnosis of vascular dementia (lack of blood carrying oxygen/nutrients to the brain). In addition, R3 was diagnosed with peripheral vascular disease (abnormal narrowing of arteries), aortic valve stenosis (narrowing), thoracic aortic ectasia (dilation), cerebrovascular disease (impacted blood flow in the brain), hypertension, cardiomyopathy (disease of heart muscles), and intestinal infarct (blocked arteries in intestines. The MDS identified R3 was administered anticoagulant medication for the four days following his facility admission. R3's face sheet listed diagnoses of prior stroke, atherosclerotic heart disease (buildup of plaque in artery walls), and below the knee amputation. A nursing progress note, dated 8/11/23, identified R3's facility tested INR value was 1.4. Results were faxed to the Anticoagulation Clinic (ACC). An Anticoagulation Monitoring Pharmacy Clinic (ACC) progress note, dated 8/11/23, indicated R3's facility tested INR value continued to be far low of goal range. Goal range of 2.5-3.5 with indicators for anticoagulant use of embolic stroke, aortic valve replacement, and long term (current) use of anticoagulants. The note indicated R3 was at high thrombotic risk due to history of stroke and valve replacement. Due to continued low INR, and prior history of R3 requiring approximately 10 mg (milligrams) weekly dose of warfarin (anticoagulant), the ACC wanted to be aggressive over the weekend with dosing and ordered the following: -Start enoxaparin (anticoagulant) 120 mg subcutaneous (SQ) daily (QD). -Warfarin two (2) mg QD on 8/11/23 through 8/13/23. -INR check 8/14/23. -Give morning (am) dose of enoxaparin on 8/14/23 and await warfarin instructions. An ACC progress note, dated 8/14/23, indicated R3's INR value was 2.3 and considered subtherapeutic. The following orders were provided: -Administer warfarin three (3) mg today 8/14/23 and then return to weekly dosing. -Discontinue enoxaparin. -INR check on 8/18/23. R3's August Medication Administration Record (MAR) identified warfarin 3 mg was scheduled during the evening (pm) shift on 8/14/23; however, the code 9 (other-see progress notes) was charted A nursing progress note, dated 8/14/23 at 9:31 p.m., indicated R3 felt unwell and refused his pm medications; however, took them when offered at bedtime. Once administered, he immediately vomited and his medication was expelled. He declined to attempt the medications again. In review of R3's record, it was not evident the ACC or physician were notified of the expelled medications or R3 not feeling well. R3's progress note, dated 8/15/23 at 4:16 a.m., identified R3 was sent to the emergency department (ED) for stroke symptoms identified as unable to speak clear, speech mumble[d]/slurred, unable to follow direction, cold, clammy, diaphoretic, unable to grasp or follow finger with eyes. R3's blood pressure was 124/70 and his pulse was 125. 911 was called. A medical provider hospital Summary of hospitalization note, dated 8/18/23, identified R3's assessment was consistent with recurrent cardiac thromboembolism. R3 was diagnosed new a splenic infarction, multiple acute appearing left-sided cerebral infarctions (strokes), and acute myocardial injury. R3's hospital laboratory report indicated the following hospital INRs: -8/15/23: 2.5. -8/19/23: 3.0. R3's hospital Discharge Summary, dated 8/20/23, indicated he was stable and ready to return to the facility. An ACC progress note, dated 8/24/23, indicated R3's INR was 2.3 and identified as near low. The following orders were provided: -Warfarin 2 mg on 8/24/23, 8/25/23, 8/26/23. -Warfarin 1 mg on 8/27/23. No additional warfarin orders were provided past 8/27/23. -INR check on 8/28/23. R3's medical record lacked evidence R3's ordered 8/28/23 INR check was entered into R3's orders for completion and/or completed by facility staff. R3's August and September MARs, date range 8/28/23 through 9/10/23, lacked evidence R3 was administered anticoagulant medication(s). An ACC progress note, dated 9/11/23, indicated the ACC contacted the facility and spoke to licensed practical nurse (LPN)-E to follow up on R3's anticoagulant therapy. The ACC directed the facility to check R3's INR. The INR value was 1.2 (subtherapeutic). The note indicated R3 lacked warfarin administration since 8/27/23. Due to hospitalization in August for splenic infarction, R3 required bridging with enoxaparin until his INR was within 10% of his goal range (2.2). Updated warfarin orders were provided with an INR check ordered for 9/15/23. An ACC progress note, dated 9/15/23, indicated R3's INR was 2.0 and continued to be subtherapeutic (not within his 10% goal range). The following orders were provided: -Enoxaparin 100 mg SQ QD. -Warfarin 2 mg on 9/15/23. -Warfarin 1 mg on 9/16/23 and 9/17/23. -INR check on 9/18/23. R3's September MAR, date range 9/15/23 through 9/17/23, identified the following: -9/15/23: lack of evidence R3 was provided 2 mg of warfarin as ordered. -9/16/23: R3 was provided 3 mg total of warfarin (2 more mg than ordered) (two separate warfarin orders signed off: one for 1 mg and one for 2 mg). -9/17/23: The enoxaparin was not administered and indicated a chart code of 9 (other-see progress notes). Corresponding nursing notes did not identify why the doses of enoxaparin was not administered. An ACC progress note, dated 9/18/23, indicated R3's INR was 1.4 (subtherapeutic). The note identified the following information: -R3 missed the 9/15/23 warfarin. -R3 was administered 3 mg of warfarin on 9/16/23. -R3 was not administered the 9/17/23 enoxaparin. -Updated warfarin and enoxaparin orders were provided. -INR check on 9/22/23. On 9/18/23, facility medication error reports were requested. One of the reports, dated 9/18/23, indicated R3 missed the 9/15/23 ordered warfarin. The report identified the ACC clinic was updated; however, the report did not include and/or identify an analysis of causal factors that led to the error or corrective action plan to prevent or reduce the risk of future errors. No error reports were provided for the missed doses of anticoagulation on 8/28/23 through 9/10/23, 9/16/23, and 9/17/23. When interviewed on 9/18/23 at 1:26 p.m., R3 denied medication administration concerns and stated he took Coumadin (warfarin) to thin his blood as his heart did not beat as it should, he suffered a past heart attack, and only was at 30 percent heart pumping capacity. He felt all his INR values were within range and he was provided his medications as ordered. He expected his medications to be administered as ordered and expected the provider to be updated if concerns were identified. On 9/18/23 at 3:56 p.m., the ACC registered nurse (RN)-C was interviewed via telephone and indicated the clinic currently managed R3's anticoagulation therapy in which over the past couple weeks R3's INR readings were far low . which indicate[d] no warfarin was given. She explained an INR reading of 0.9 or 1.1 would be an expected value for a person not taking anticoagulant medication. It took approximately five to seven days of missed anticoagulant medication to show a value of 1.1 or lower and then another five to seven days, possibly up to 10 days, to return to the anticoagulation goal range. The only reason an INR reading would value at 1.1 or lower for someone who took anticoagulants was missed medication. The facility was responsible to check the INRs as ordered and update the ACC with the results. RN-C reported the ACC was not updated on 8/28/23 on R3's INR value. ACC staff realized this on 9/11/23 and contacted the facility to inquire. Facility staff denied R3 missed any anticoagulant medication and were unsure as to why the INR was low. RN-C explained R3's low INR values were concerning as R3 had multiple comorbidities and a heart valve which increased his risk for blood clots and associated death. When interviewed via telephone on 9/19/23, at 2:07 p.m., R3's nurse practitioner (NP)-A stated R3 required daily warfarin due to his blood clotting risk in relation to his blood clotting history and multiple comorbidities. If one dose of warfarin was missed it would be concerning; however, would not be a matter of life or death. If 14 days of warfarin were missed, R3 would be at huge risk for recurrent stroke, clots, and it could lead to his death. She stated, after she reviewed R3's clinic chart, the chart lacked information the facility updated her, or the physician, related to R3's medication errors 8/27/23 through 9/10/23, 9/15/23, 9/16/23, and 9/17/23. She explained she expected the facility to update the clinic when medication errors occurred as she and the physician were overall responsible for R3's medical care and may have insight into potential concerns. She reviewed the ACC notes she was able to access and stated she was concerned there appeared to be a lack of facility follow-up to determine why R3's INRs were so subtherapeutic after the ACC clinic updated the facility of their concerns. During an interview on 9/19/23 at 5:49 p.m., LPN-A denied knowledge of anticoagulant concerns with R3 or that staff brought concerns to her while she was in a charge role. In addition, she denied management staff questioned her on any potential concerns related to R3 and she denied recent education related to anticoagulant therapy and/or associated processes was provided to her. When interviewed on 9/19/23 at 6:20 p.m., trained medication aide (TMA)-A denied knowledge of anticoagulant concerns with R3; however, on 9/15/23 R3's warfarin was not found in the facility, and they awaited it from pharmacy. She explained registered nurse (RN)-B took over around 6:00 p.m., thus, she was unsure if it was administered. She was unsure if she updated RN-B that evening; however, she updated LPN-E before she left. She denied management staff questioned her on any potential concerns related to R3 or that she was provided recent education related to anticoagulant therapy and/or associated processes. A Thrifty [NAME] Pharmacy packing slip report, dated 9/15/23, identified four 1 mg warfarin tablets were brought to the facility for R3 which would have covered the 9/15/23 order. During interview on 9/19/23 at 6:43 p.m., management LPN-E explained after an order was initially processed another nurse, typically the night nurse, was expected to double check the order to decrease any potential processing errors. She reviewed R3's anticoagulant therapy orders and the MARs from 8/14/23 through 9/18/23. She stated the 8/28/23 INR lab order was not processed into R3's MAR and thus was not completed as ordered, no anticoagulants were administered from 8/28/23 through 9/10/23 and on 9/15/23, R3 received two more milligrams of warfarin on 9/16/23 than ordered, and enoxaparin was not administered on 9/17/23 as ordered. She was unable to explain the reason the 8/24/23, 9/11/23, and 9/15/23 orders were not double checked by a second nurse. In addition, she was unable to explain the reason for the errors other than processing concerns and a system failure related to the double check process. She was unaware of R3's missed INR lab on 8/28/23 and the missed associated warfarin orders, or of ACC's communicated concerns; however, she was aware of the three medication errors that started on 9/15/23. She explained the facility had not started an investigation or staff education into any of R3's medication errors and had yet to complete medication error reports for the 9/16/23 and 9/17/23 incidents. LPN-E stated if a medication was missed, the medical provider was expected to be updated. She was unsure if R3's provider was updated; however, she explained being he was followed by the ACC they updated the ACC instead of the provider. In addition, she explained if a resident who required anticoagulation therapy valued an INR around 1.1, that resident was at a very high risk for clots and she would have expected monitoring above and beyond the typical monitoring the facility provided for signs and symptoms of anticoagulant therapy bleeding risk, such as monitoring for blood pooling, extremity pain, and stroke like symptoms. When interviewed on 9/20/23 at 10:15 a.m., RN-B, who was the assistant director of nursing, stated order double checks were an expected part of order processing. This was to be completed within a day or two after the order was initially processed and was completed by management or floor nurses if they noticed orders in the double check file. Typically, the night charge nurse completed the double checks; however, that staff member was no longer employed. An INR value of 1.1 for a resident requiring anticoagulant was a concern as that meant the blood was too thick and they were at risk for clotting. She expected the charge nurse to investigate a low INR value as they were responsible for the medications and orders that day. In addition, when INR values were low and/or subtherapeutic, she expected the charge nurse to contact the ACC and discuss a plan of action. Furthermore, she expected an assessment to be completed if a resident missed anticoagulation medication to ensure resident stability, and to update the medical provider for additional orders, especially since the risk of missed anticoagulation therapy was higher and could increase other medical complications related to clotting. It was not a facility practice to set up missed medication assessment monitoring: We probably should. When a medication error was identified, staff were expected to complete an incident report by the end of the shift to help rule out any potential concerns, to determine required education if applicable, and to ensure the facility's processes were completed for when errors occurred. RN-B was unaware of the concern severity related to R3's anticoagulation therapy and thus she was unsure as to what occurred or what was investigated/implemented; however, she was aware of his 9/17/23 missed enoxaparin. She explained this error occurred as the medication was not in the facility. She stated staff should have followed the on-call pharmacy processes to request the medication on 9/17/23 instead of waiting until the next day (Monday). In addition, she stated staff should have contacted the ACC or the provider to update for additional instructions as R3 was at a definite risk for clotting and another infarction with possible death. RN-B stated missed anticoagulants were a significant medication error in which R3's anticoagulation medication errors certainly could have been harm [for R3]. During interview on 9/20/23 at 12:10 p.m., the administrator stated he was not aware of any systemic medication concerns prior to being updated on R3's anticoagulant and INR concerns after the abbreviated survey started. He expected orders to be processed as directed and was unaware of what nursing did to ensure process accuracy. If an INR value was reported to be low, he expected staff to verify the result and verify the resident was provided the ordered medication(s). In addition, he expected a root cause analysis and for the provider to be updated. He expected the nurse managers (RN-B, LPN-E) to also follow-up and fully investigate any sort of medication and/or order concern. When interviewed via telephone on 9/21/23 at 8:45 a.m., the medical director (MD)-A stated an INR value of 1.1 for an anticoagulated resident would be suspicious as it indicated they were not provided the ordered medication, especially if there were not orders in place to decrease the anticoagulation for procedures or surgery. R3's INR values, missed 8/28/23 INR, and missed/incorrect anticoagulation therapy was discussed. A one-time missed dose would not be a significant concern; however, there was a concern for R3 due to the multiple missed medication and lower INR values. He stated the facility required an order entry process change and expected the facility to be more hypervigilant with warfarin residents. He explained at a minimum a nurse should be in charge every day for quite a while to review all warfarin residents to ensure they were provided ordered medication(s) and INRs were completed as ordered. In addition, he expected these residents to be monitored and the provider to at least receive an FYI (for your information) fax to update on anticoagulation concerns such as a missed anticoagulant dose(s). The immediate jeopardy that began on 8/28/23, was removed on 9/21/23, after the facility reconciled all anticoagulation orders for residents who received warfarin, which included R3, and reviewed INR orders to ensure they were properly scheduled. In addition, R3's provider was updated with no new orders provided. The medical director was updated. Incident reports on identified medication errors were completed with root cause analysis and reviewed by the QAA (quality assurance) committee. Staff education was provided to all licensed nurses and TMAs on the importance of anticoagulation medication administration and INR lab draw order compliance as well as the process for medication administration, provider notification, order processing, and completion of ordered labs draws with communication of results. For staff not in attendance, required recorded education was to be completed before their next working shift. Furthermore, an INR Tracking Log was added to the facility anticoagulation system with daily audits initiated by nursing leadership along with weekly warfarin administration audits. Policy and procedure reviews were conducted with plan for facility QAA committee to review progress of the abatement plan weekly until further notice. Despite this removal plan and actions taken, noncompliance remained at the lower scope and severity level 2 D as the facility failed to ensure insulin (blood sugar regulator) medication was administered in accordance with physician orders for 1 of 1 residents (R6) who was provided insulin outside of ordered parameters during a medication pass observation. _____________________________________________________________________________________ R6's quarterly MDS, dated [DATE], indicated R6 was cognitively intact and was diagnosed with diabetes and utilized insulin seven days a week. A Endocrinology Diabetes Program progress note, dated 5/30/23, identified R6 was educated on the importance of maintaining good glycemic control due to potential complications of uncontrolled diabetes. R6 was diagnosed with type 2 diabetes mellitus with stage 3 chronic kidney disease and diabetic neuropathy requiring insulin use. The note's Plan section indicated adjusted insulin orders with NovoLog orders directing NovoLog to be given before each of R6's meals. A NovoLog, NovoLog FlexPen Prescribing Information PDF, dated 2/23, indicated a section labeled Dosage and Administration. This directed administration within 5 - 10 minutes before a meal . R6's Order Summary Report identified R6 was ordered the following: -Blood sugar (BS) checks four times a day (QID). -NovoLog FlexPen 100 unit/ml (milliliters) seven (7) units subcutaneously (SQ) three times a day (TID). Give prior to meals. -NovoLog FlexPen 100 unit/ml per sliding scale TID (0-149 = 0; 150-200 = 2; 201-251 = -4; 252-302 = 6; 303- 353 = 8; 354-404 = 10; greater than 400 call on call provider. R6's September Medication Administration Record (MAR) identified the NovoLog was scheduled for 7:30 a.m., 11:30 a.m., and 4:30 p.m. (half hour prior to mealtimes). During a medication pass observation on 9/18/23 at 12:56 p.m. (one and a half hours after scheduled), LPN-D stated R6's BS check around 11:50 a.m. was 206 and he had yet to receive his lunch time insulin. She reviewed R6's electronic MAR (eMAR) orders and calculated he required 11 units of NovoLog based on his scheduled and sliding scale instructions. She prepped the FlexPen and administered the 11 units of NovoLog insulin to R6. She exited R6's room and documented the administration in the eMAR. Immediately following, LPN-D was interviewed. She stated she provided insulin to residents after they ate as being provided insulin if they did not eat too good would not be good as their blood sugar could drop too low. LPN-D explained she was expected to read the entire order prior to medication administration and follow the directions as ordered; however, after she reviewed R6's orders, she stated she did not read the entire order as expected and did not follow the administration directions. In addition, she stated she was not aware of the direction to provide the insulin a half hour before meals, and if she had, she would have questioned this direction and would have investigated the order to ensure a transcription error was not made as in her history of nursing it was general nursing practice to administer insulin after meals. She denied there were risks to residents, including R6, if insulin was administered after meals versus prior to as directed. A review of R6's September MAR identified the following scheduled NovoLog insulin administration documented by LPN-D: -9/5/23 7:30 a.m. dosing: BS 127. Time stamped 9:43 a.m. -9/5/23 11:30 a.m. dosing: BS 189. Time stamped 1:15 p.m. -9/6/23 7:30 a.m. dosing: BS 149. Time stamped 10:07 a.m. -9/13/23 7:30 a.m. dosing: BS 147. Time stamped 9:24 a.m. -9/13/23 11:30 a.m. dosing: BS 152. Time stamped 1:05 p.m. -9/18/23 7:30 a.m. dosing: BS 166. Time stamped 10:15 a.m. -9/18/23 11:30 a.m. dosing: BS 206. Time stamped 1:05 p.m. R6's nursing progress notes, dated 9/5/23 through 9/18/23, lacked rationalization(s) for insulin administration not being provided as ordered i.e., poor intake, illness, R6 preferences and/or refusals prior to meals. On 9/20/23 at 10:15 a.m. RN-B was interviewed. She expected staff to follow the five rights of medication administration which included ensuring the order directions were followed. If a medication was directed to be provided before meals, she expected the medication to be given prior to meals. If there were concerns related to order directions, she expected staff to communicate with the provider and/or the pharmacy for clarification. She would be concerned if R6 was provided his NovoLog after meals as he required this before meals to prevent blood sugar spikes. When interviewed via telephone on 9/21/23 at 8:45 a.m. R6's medical provider MD-A stated the diabetic center managed R6's insulin and he would defer directions to them as they may have specific reasons why the insulin was scheduled as it was; however, he explained the typical timing of NovoLog would be five to ten minutes before meals. He explained if given prior to meals, a half hour in R6's case, the insulin would have time to peak and cover blood sugars during the meal, thus making the insulin more effective for improved blood sugar control. MD-A was concerned when updated on the medication pass observation as R6's A1C (glycosylated hemoglobin) lab was 8.1 which indicated R6's diabetes was slightly uncontrolled. On 9/21/23 at 4:40 p.m. the diabetic NP-B was interviewed via telephone. She stated NovoLog rapid acting was typically dosed prior to meals which was a long-standing practice. She explained the general rule was to administer the insulin 15 to 30 minutes prior to meals to decrease pre-meal blood sugars, thus, assisting in blood glucose control maintenance surrounding mealtimes when the blood sugar again would rise. If the insulin was provided after meals, the rising blood sugar acquired during the meal, on top of the blood sugar prior to the meal, would then have to be chased which led to decreased blood glucose control. An Administering Medication policy, dated 12/2012, identified medications were to be administered in a safe and timely manner, and as prescribed. It directed medications must be administered in accordance with the orders within one hour of their prescribed time, unless otherwise specified i.e., before and after meal orders. The administering staff must check the label THREE (3) times to verify the right resident .right dosage, right time .before giving the medication. An Adverse Consequences and Medication Errors policy, dated 4/2014, defined a medication error as the preparation or administration of medications which were not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples included, but not limited to, a medication omission, wrong dose, or wrong time. The policy directed that any resident who received any medication with potential for adverse consequence would be monitored to ensure any such consequences were promptly identified and reported and if a medication error was identified the resident would be monitored for possible medication-related adverse consequences. In the event of a significant medication-related error, immediate action was to be taken to protect the resident's safety and welfare. Examples of significant were defined as requiring medication discontinuation or dose modification and/or life threatening. Any significant medication error was to be promptly reported to the attending provider and the error information documented in an incident report and the resident's chart. A Medication Order policy, dated 11/2014, identified the purpose of the policy was to establish uniform guidelines in the receiving and recording of medication orders. The policy lacked information related to any established guidelines for medication and/or procedural order processing. A policy related to order processing was requested. None was provided. An Anticoagulation - Clinical Protocol policy, dated 11/2018, directed staff and the physician would collaborate in ensuring anticoagulants were assessed for risk, properly prescribed, and monitored for possible complications related to supratherapeutic INR values. The policy lacked information related to ACC collaboration and their role in resident anticoagulation needs. In addition, the policy lacked information related to resident monitoring when subtherapeutic INR values are present.

Based on observation, interview and document review the facility failed to investigate and respond to a Hoyer lift incident before placing the Hoyer lift back into care service for 1 of 2 (R2) residents. Additionally, the facility failed to have a system to perform regular maintenance on resident ceiling lift and failed to respond to voiced concerns by nursing staff related to ceiling lift malfunction and safety related to care planned two person Hoyer lift for 1 of 2 (R1) resident viewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R2 and R1. The IJ began on 7/30/23 at 8:22 a.m., when a Hoyer lift being used to transfer R2 would not stop and a different Hoyer lift had to be used to complete the transfer. The Hoyer lift was placed out of service for a short period but returned to service before the facility completed an internal investigation or contacted the manufacturer for direction. Additionally, the facility failed to have a system for routine maintenance related to a ceiling lift used to transfer R1 which had ongoing staff reports of malfunction over the last six months and failed to reassess R1's safe transfer in a Hoyer lift, both potentially causing R1 discomfort and pain. The DON and administrator were notified of the IJ on 9/14/23, at 5:35 p.m. The IJ was removed on 9/15/23, at 5:35 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R2's annual MDS dated [DATE], indicated R2 was cognitively intact, required extensive assist of two with bed mobility, transfers, impairment on upper extremities and used a wheelchair for mobility. R2's Care Plan dated 8/29/23, indicated R2 had spinal Stenosis (narrowing of the spinal canal in the lower part of back), osteoporosis, edema, and lower back pain. Care plan further indicated R2 transferred with assist of two and mechanical lift. 9/12/23-9/15/23, R1 was in the hospital and unable to be observed or interviewed. Incident Report dated 7/30/23 at 8:22 a.m., indicated R2 was being transferred by two staff and Hoyer lift out of bed. Resident was being lowered down and Hoyer lift would not stop. R2 ended up sitting in sling about a foot off the ground; the Hoyer would not stop when stop button was pushed, needed another Hoyer to complete transfer. The report indicated staff assisted resident with another Hoyer lift and four staff to place resident in her wheelchair. Hoyer machine was taken off the floor and a repair slip completed for maintenance. Report indicated no injuries occurred to R2. During interview on 9/13/23 at 7:00 p.m., NA- B stated on 7/30/23, she was transferring R2 with the Hoyer lift out of bed when the lift automatically just started to lower to the ground, NA-B stated R2 had jerking movements with her body and maybe that caused the lift to lower on its own. NA-B also stated with R1 they have had issues with the ceiling lift battery not charging and she had told the MND several times and he just told us to make sure we have the battery on the charger correctly. NA-B stated we tried that, and it doesn't charge the battery. During interview on 9/14/23 at 8:07 a.m., MND stated he was aware of the incident with R2 and looked over the Hoyer lift but was unable to find anything wrong with the lift, so he put the lift back on the floor for staff to use. The MND confirmed he never called the manufacturer to see if it was safe to put back on the floor despite the manufacturer primarily working with the lifts, completing the maintenance on a routine basis and all the lifts having just been checked two weeks prior to the incident. The MND did state he had never called the manufacture for a concern since they come out every 6 months to do their safety checks and maintenance on them. During interview on 9/14/23 at 8:30 a.m., director of nursing (DON) stated she was aware of the incident with R2 and the lift lowering R2 to the floor. DON added, since MND looked at the lift and was unable to find anything wrong, she felt there was no reason to complete an investigation on the incident. During interview on 9/14/23 at 9:14 a.m., EZ Way Service and Sales Support staff stated the EZ Way Hoyer lift should have been removed from the floor and not been put back onto the floor until calling EZ Way, due to the possibility of brake failure of the machine and needing to complete two checks over the phone and if that did not work a technician might need to come out to look over the machine. During interview on 9/14/23 at 10:00 a.m. EZ Way representative (R)-A stated the facility had preventive maintenance done on the EZ Way lifts and stands on 9/20/22 and then on 7/17/23 and 7/18/23. The R-A stated the facility should have had preventative maintenance done in March 2023 but was not scheduled. EZ Way, INC. Service Manual revised 7/11/22, indicated the manufacturer suggests that the following components and operating points be scheduled for inspection at intervals not greater than six months. Any detected deficiency must be rectified before the lift is put back into service. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, required extensive assist of two with bed mobility and total assist of two with transfers. The MDS indicated R1 had limited mobility in upper and lower extremity and used a wheelchair for mobility. R1's care plan dated 8/17/23, identified R1 was bariatric and had peripheral vascular disease, inflammation of lower extremity, lack of coordination, abnormal posture, significant pain management needs and was on hospice care. The care plan indicated a two person assist with activity of daily living care and mechanical lift for transfers. On 9/12/23 at 12:43 p.m., during observation and interview R1 was observed being transferred from wheelchair to bed using a ceiling lift by nursing assistant (NA)-C, NA-D and trained medical aide (TMA)-B. R1 was several inches off her wheelchair when the ceiling lift stopped, staff were observed working with the remote to get the lift working. R1 was observed to be jerked up and down by the lift during this time and yelling out, ouch and was crying. Staff stopped and put her back in chair. Staff reported they told leadership the ceiling lift was not working, again. Per interviews with (NA)-C, NA-D and (TMA)-B the ceiling lift had not been functioning correctly for over six months. Staff expressed they believed R1 preferred the ceiling lift, and it was safer and more comfortable for her to use than the EZ Way Hoyer Lift. The staff stated when they have used the Hoyer lift in the past some of them have had to stand on the legs of the lift to prevent it from tipping over. Additional concerns the staff expressed included the ceiling lift stopping and jerking R1, causing her unnecessary pain during transfers. They expressed this was something that had been ongoing despite complaints they had made to leadership and requests for repairs to maintenance. When they put maintenance request in, MND would instruct them to put the battery on the charger tilted or crooked to get it to charge, which was not a sustainable solution. During same observation surveyor attempted to interview R1 but she was not interviewable. A second observation and interview on 9/12/23 at 1:10 p.m., during transfer from the wheelchair to her bed using the EZ Way Hoyer Lift. The MND was asked by facility leadership to demonstrate how to use the EZ Way Hoyer Lift safely with R1. MND and NA-C, NA-D and TMA-B were observed hooking R1 up to the EZ Way Hoyer Lift from her wheelchair, bed was in low position, MND was running the EZ Way Hoyer Lift while the aids were guiding R1. When R1 was in the air, the EZ Way Hoyer Lift wheel was observed to lift off the ground two inches and the transfer had to be halted due to the bed being in the wrong placement position for transfer (bed in low position), which caused R1 to yell out in pain. Interview with DON confirmed the transfer with R1 was not completed the way she would have transferred R1. According to manufacturer during an interview on 9/14/23 at 3:30 p.m., the EZ Way Hoyer Lift is not safe or stable to use if the wheels are not all on the ground during transfers and if the wheels are lifting off the ground, this could be because of a bent frame or broken bolt(s). After observation of resident transfer on 9/12/23, at 1:10 p.m. Hoyer was not removed from resident care and staff were not immediately retrained. A Physical Therapy Treatment Encounter Note indicated an evaluation was completed on 9/13/23 with R1 which indicated, .Physical Therapy recommends a minimum of three staff for Hoyer transfers and that staff move Hoyer lift slowly for resident comfort and safety. During interview on 9/13/23 at 11:52 a.m., DON stated the MND does the training with the staff on the Hoyer lifts and assumed he received training from the EZ Way. The DON stated the MND was not a NA or trained in patient care and should not have had him transfer R1. During interview on 9/13/23 at 2:34 p.m., MND stated he encouraged staff to scan the QR code on the lifts and watch the video for training on the lifts. The MND stated he had not received training from EZ Way to transfer residents in the Hoyer lifts. During interview on 9/15/23 at 9:00 a.m., MND stated the ceiling lifts were purchased from Direct Supply company but he was told by corporate they were no longer working with Direct Supply for the ceiling lift (for approximately a year and a half) so he was not able to purchase replacement batteries for the lift. MND stated he was not aware of any contracted routine maintenance for the ceiling lift and confirmed he had not completed any routine maintenance on the lift himself but had directed staff to put the battery on the charger different ways to get it to charge better. During interview 9/20/23 at 6:20 p.m., the facility nurse consultant stated she had been the consultant with the facility for the past year and was not aware the ceiling lift was being used for resident care. The IJ that started on 7/30/23 was removed on 9/15/23, when it was verified through observation, interview and document review the facility removed the Hoyer lift and ceiling lift from resident care pending inspection/routine maintenance check, retrained staff on safe transfers with the EZ Way Hoyer lifts and reviewed policies and procedures to ensure alignment with regulatory standards. All staff were educated on the procedures.

Based on interview and document review, the facility failed to ensure residents were free from allegations of physical and verbal abuse by staff for 2 of 2 residents (R1, R4) reviewed for abuse. This resulted in an Immediate Jeopardy (IJ) when R1 reported nursing assistant (NA)-A pulled the door shut while his arm was in the the doorway, resulting in R1 sustaining a substantial skin tear in the process. In addition, R4 was verbally abused by NA-A, when NA-A called R4 a bitch. The IJ began on 5/17/23, when the facility failed to prevent and protect R1 from physical abuse when nursing assistant (NA)-A was forceful with R1 during cares. This resulted in a skin tear to R1's right forearm. The administrator and the director of nursing (DON) were notified of the IJ on 5/24/23, at 5:32 p.m. The facility had implemented actions to prevent recurrence by 5/24/23, so F600 was issued at past non-compliance. Findings include: A facility 5 day report submitted to the State Agency (SA) on 5/22/23, indicated NA-A had requested a bandage for R1 on 5/17/23 at approximately 7:30 p.m. Licensed practical nurse (LPN)-A went into R1's room, and observed a fresh skin tear to R1's right forearm. The area was still actively bleeding. When LPN-A asked NA-A what happened, NA-A stated, He was being a complete jerk and fighting me while I was putting him to bed. NA-A stated R1 receied the skin tear from his wheelchair. NA-A stated she did not ask for help with R1's cares, or give R1 a chance to calm down. R1 was interviewed immediately and stated, She pulled the door shut very hard, she did not slam it but pulled it shut hard and continued to pull it shut while my arm was still in the door. R1's Admission Record dated 3/13/23, indicated R1's diagnoses included dementia without behavioral disturbance, anxiety, depression, and generalized muscle weakness. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, required assist of two staff and a mechanical lift for transfers, was non-ambulatory, and required limited assistance with activities of daily living (ADLs). R1's care plan dated 3/13/23, indicated R1 had impaired cognitive function. Staff intervention included to use simple words, and approach in calm manner. The care plan further indicated R1 was non-ambulatory, and required extensive assistance of two staff and and EZ lift (mechanical lift) with transfers. R1's progress note dated 5/17/23 at 8: 43 p.m., indicated family member (FM)-A was informed R1 was physically abused as evidenced by a 5 centimeter (cm) x 2.5 cm skin tear on the right arm. The note indicated the staff member was suspended immediately. The note further indicated R1 was in his room sleeping and safe. R1's progress note dated 5/17/23 at 9:21 p.m., indicated R1's primary physician was notified about the abuse allegation. The progress note further indicated the DON assessed R1 head to toe, and no other injuries were noted. A report was made to the State Agency (SA). The DON immediately suspended NA-A who was escorted out of the facility pending the outcome of the investigation. R1's progress note dated 5/18/23 at 11:41 a.m., indicated R1 was able to sleep overnight and felt safe in his environment. On 5/23/23 at 1:38 p.m., R1 was interviewed and stated, I don't remember what really happened and acknowledged doing good and stated he felt safe. On 5/23/23 at 2:47 p.m., LPN-A was interviewed and stated NA-A requested a bandage for R1 who had sustained a large skin tear. Upon assessment, LPN-A stated she tried to clean the wound and was unsuccessful. LPN-A stated she called the DON for assistance, who came with the social worker (SW)-A to assess and put a dressing on the wound. LPN-A stated NA-A denied any physical abuse towards R1, instead NA-A stated R1 scratched his arm on the wheelchair, but no blood was found on the wheelchair. LPN-A stated NA-A had a poor attitude at work, and that had been brought forward to the DON on multiple occasions. On 5/23/23 at 3:40 p.m., registered nurse (RN)-A stated the DON informed her of the alleged physical abuse of R1. RN-A stated NA-A had a negative attitude toward staff. RN-A stated she had heard NA-A called a resident a bitch, but believed it was an isolated incident. RN-A stated she was not sure about any follow-up regarding the incident. On 5/23/23 at 3:54 p.m., RN-B stated the DON alerted her of R1's alleged physical abuse. RN-B stated some allegations were made against NA-A, and stated she felt like the DON took care of it. RN-B also stated NA-A's poor attitude could affect how she provided care to the residents. On 5/24/23 at 9:23 a.m., NA-A was interviewed. NA-A denied physical abuse with R1. NA-A stated while she was caring for R1, he refused to take his shirt off. NA-A stated R1 became agitated, pinched, and scratched the back of her arm, but he did not leave any marks. NA-A stated she was able to put the EZ lift sling around R1, and she transferred him into bed. NA-A acknowledged when R1 became agitated, she should have reapproached R1 and called for help. R4's Admission Record dated 10/14/22, indicated R4's diagnoses included severe dementia with agitation, delirium, and major depressive disorder. R4's admission MDS dated [DATE], indicated R4 had severe cognitive impairment, required extensive assistance with transfers, was non-ambulatory, and required limited assistance with ADLs. R4's care plan dated 5/3/23, indicated R4 had severe cognitive impairment, hard of hearing, and at risk for harm from others and to self. Staff intervention included adjust tone of voice, anticipate any non-verbal needs, use terms, gestures she can understand, approach in calm manner, call by name, and remove unwanted stimuli. On 5/24/23 11:23 a.m., the DON stated she became aware of the allegations of NA-A calling R4 a bitch. The DON stated she did not recall when this was, but thought it had been within the last couple of weeks. The DON stated she had interviewed some staff and residents, and did not determine anything had occurred. The DON stated she did not report the allegation of verbal abuse to the SA. The DON stated she did complete a verbal teachable moment with NA-A, but did not document it. The DON further stated she was working at the time of the allegation of physical abuse towards R1, and was aware. The DON stated she sent NA-A home immediately after the allegation was made. The DON stated she started providing education to all staff. On 5/24/23 at 1:10 p.m., NA-C was interviewed and stated sometime in April, NA-A called R4 a bitch after R4 pinched her in the arm. NA-C stated she thought that was verbal abuse; however, NA-C did not immediately report the incident, but reported it to LPN-A a couple days later. On 5/24/23, at 2:55 p.m., LPN-A stated a month and half ago, probably around March 14th, on the p.m. shift, she was in the dining room when NA-C came to her. LPN-A stated NA-C told her NA-A called R4 a bitch a couple days ago. LPN-A stated she directed NA-C to talk to the DON. LPN-A stated she did not document the allegation, nor did the DON talk to her about the allegation. R4's progress notes reviewed from 3/1/23, through 5/24/23, lacked documentation of the allegation of verbal abuse. The facility Vulnerable Adult policy revised 2/6/23, directed the facility to provide a supportive and safe environment for all residents to the extent possible through the deployment of trained and qualified staff to meet residents' needs as identified in both the individual resident care plan and the facility assessment. The IJ was removed on 5/24/23, when it was determined NA-A was suspended pending further investigations with a follow-up plan to either terminate or provide education with ongoing monitoring for compliance. The facility Vulnerable Adult policy was reviewed with no changes. Residents and staff were interviewed to determine if any other residents sustained either verbal or physical abuse, and no further incidents were reported. The facility completed re-education of all staff on abuse procedures including reporting of allegations of abuse and how to care for residents with difficult behaviors. Staff were interviewed on 5/24/23, and verified re-education had occurred. F600 was issued at past non-compliance.

Based on observation, interview and document review, the facility failed to provide routine resident condition monitoring after the facility was notified by the pharmacy of an albuterol nebulizer medication national shortage and communicate this shortage, and missed inhaler medications, to the provider for alternative medication utilization for 1 of 3 residents (R1) to prevent acute respiratory changes and hospitalization . This resulted in an immediate jeopardy for R1. In addition, the facility failed to provide the same condition monitoring and provider updating for 2 of 2 residents (R2, R3) who were ordered ipratropium-albuterol (DuoNeb) nebulizer treatment and/or demonstrated acute respiratory symptoms at the same time they were not provided ordered medication due to the shortage. The immediate jeopardy began on [DATE], when the facility failed to routinely monitor and update R1's provider when the pharmacy notified the facility of an albuterol nebulizer medication national shortage and were unable to dispense R1's ordered albuterol. In addition, R1 missed 11 doses of Advair inhaler. This resulted in hospitalization for R1. Administrator, director of nursing (DON), assistant directors of nursing (ADON)-A and ADON-B, and director of clinical services (DCS)-A were notified of the immediate jeopardy at 7:00 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Admission Record face sheet identified R1's primary admission diagnosis was chronic obstructive pulmonary disease (COPD). R1's COPD care plan, initiated on [DATE], identified R1 was at risk for SOB (shortness of breath) and respiratory infections with a goal R1 would remain free of signs/symptoms (s/s) of respiratory distress and maintain optimal functioning within limitations of the disease process. The care plan directed staff with the following interventions: administer medications/puffers as ordered, observe for effectiveness and side effects, monitor for signs of respiratory infection/distress, adventitious (not per R1's normal) lung sounds, SOB, coughing, elevated temperature, increased respiratory rate, report as necessary to the physician. R1's physician orders indicated R1 was prescribed on [DATE], albuterol sulfate (treats wheezing and shortness of breath caused by breathing problems such as asthma, chronic obstructive pulmonary disease) nebulizer solution inhaled orally three times a day (TID) for diagnosis of acute respiratory failure with hypoxia and every four hours as needed (PRN) for SOB and wheezing. In addition, R1 was prescribed on [DATE], Advair Diskus (fluticasone-salmeterol, steroid and bronchodilator combination medicine that is used to prevent asthma attacks) inhaler which directed one puff inhaled orally two times (BID) a day related to diagnosis of acute respiratory failure with hypoxia. The facility's pharmacy fax binder identified pharmacy Reorder Forms and Packaging Slips with the following information: -[DATE], R1's albuterol was requested. The binder lacked evidence the albuterol was dispensed and lacked a follow-up notation related to dispensing concern. -[DATE], R1's Advair and albuterol were requested. The binder lacked evidence the Advair or the albuterol were dispensed and lacked follow-up notation related to dispensing concerns. -[DATE], R1's albuterol was requested. The Reorder Form identified a handwritten Back order next to the request. -Three other Reorder forms, undated, identify staff requested R1's Advair and albuterol. The binder lacked evidence of a follow-up notation related to Advair dispensing concerns; however, the other two forms identified handwritten notations the albuterol was on back order and was unable to be dispensed, and the other one indicated the albuterol was out. R1's Medication Administration Record (MAR) identified R1 missed 11 of 20 doses of the Advair from [DATE] through [DATE], and 15 of 18 doses of the albuterol from [DATE] through [DATE]. Indications for the missed doses identified med not available. R1's MAR, and associated Treatment Administration Record (TAR) [DATE] through [DATE], lacked documented evidence R1's respiratory status was monitored in relation to the missed doses of Advair and albuterol. R1's progress notes identified the following entries: -[DATE], 7:50 a.m. Advair was not located in the cart or found in his room. -[DATE], 8:25 p.m. Advair was not available. -[DATE], Advair was out waiting on pharmacy. -[DATE], Advair request was faxed to pharmacy. -[DATE], 11:48 p.m. R1 was weak and seemed a bit off. He had been coughing, his pulse was elevated at 109, and he was assessed to have slight expiratory wheezes in his upper left lobe. -[DATE], 11:42 a.m. Advair request was faxed to the pharmacy. -[DATE], 11:43 a.m. albuterol was not administered due to a shortage. -[DATE], 12:37 p.m. albuterol was not administered due to a shortage. -[DATE], 4:38 p.m. entered by ADON-B, R1 had an order for albuterol nebulizers; however, the pharmacy reached out and stated, There is a shortage and that they are unable to get albuterol at this time. -[DATE], 4:28 p.m. R1 complained of chest pain. Vitals were assessed without identified concerns and his lung sounds were clear. -[DATE], 8:49 p.m. R1 was provided cough syrup in response to a bad cough in which he was losing [his] voice. -[DATE], 5:59 a.m. R1 reported a stuffy nose. -[DATE], 10:27 p.m. albuterol was not administered due to a national shortage. -[DATE], 10:27 p.m. Advair will be ordered. -[DATE], 12:48 p.m. albuterol was not administered due to a national shortage. -[DATE], 11:07 p.m. R1 coughed all PM [evening] shift in which his cough was loose and productive. R1 was administered PRN cough syrup. -[DATE], 12:44 p.m. albuterol was not administered due to a national shortage. -[DATE], 10:20 p.m. R1 was provided emergency room (ER) transport orders due to wheezing, chest congestion and mild chest tightness and discomfort. -[DATE], 10:30 p.m. R1 was sent to the ER as he complained of chest pain, coughing, audible wheeze and chest congestion. R1's progress notes dated [DATE] through [DATE], lacked documented evidence R1's provider was updated related to missed medications, the albuterol national shortage, and/or his change in respiratory condition prior to [DATE], order to send R1 to the ER. R1's ED provider note dated [DATE], identified R1 presented with chest pain and SOB. R1 reported the nursing home did not have any nebs for him and he usually receive[d] one. Note indicated, R1 had diffuse wheezing and bibasilar crackles and R1 complained of a lot of chest pain. He received three doses of DuoNeb and one dose of an intravenous (IV) steroid. On [DATE], at 1:35 a.m. R1 required 2 liters of oxygen for oxygen saturations of 81% and diagnosed with a COPD exacerbation. R1's hospital History and Physical dated [DATE], identified R1 reported ,d+[DATE] days worth of cough, runny nose, congestion leading up to ER visit. Additionally, the facility apparently failed to provide R1 with his normal albuterol treatments for two weeks prior to this episode. R1 wheezed and demonstrated course upper airway sounds, wet cough. R1's Discharge Summary dated [DATE], identified the discharge diagnosis was Acute hypoxic respiratory failure - COPD exacerbation - resolved. He was medically stable, and his lungs were clear to auscultation bilaterally on room air. On [DATE], at 9:58 a.m.: R3 was observed sitting in his room. No obvious signs of respiratory distress noted, appeared comfortable. When interviewed on [DATE], at 10:13 a.m. R1's hospital medical provider (MD)-B stated if R1 were provided his ordered inhaler [Advair] and albuterol he would not have had that flair [exacerbation] and thus R1 would not have required hospitalization . R1 likely had a viral illness which could have been managed in the facility if he were administered the inhaler and nebulizer, with a possible clinic visit for follow-up of symptoms and adjusted treatment at most. MD-B indicated she based her thoughts on his hospital symptoms and how well he responded to the nebulizer medication he received at the hospital. During an interview on [DATE], at 12:57 p.m. pharmacy tech (PT)-A stated albuterol sulfate shortages have occurred for at least two months. This shortage included DuoNeb and did not include Advair, adding the medications were last supplied to the pharmacy the beginning of February and a restock time frame was unknown. She expected the facility to update the providers for alternative orders if the pharmacy was unable to dispense medications. R1's albuterol was last dispensed on [DATE], for an equivalent of 30 doses (10 days based on the TID order) and the Advair was last dispensed on [DATE]. When interviewed on [DATE], at 1:29 p.m. registered nurse (RN)-A explained R1 missed albuterol doses due to the shortage. She was unsure why R1 missed Advair doses and was unaware of any Advair dispensing concerns, indicating she just hoped [the Advair] was in the room but it was not there. RN-A confirmed R1's provider was not updated on the missed Advair and albuterol, which were missed for maybe a couple weeks despite managements knowledge of the shortage. Additionally, RN-A stated it had been a while since these medications were last dispensed for any resident, a few residents continued to have scheduled and/or PRN albuterol/DuoNeb orders. RN-A stated R1's acute respiratory status changes and reported chest pain should have been reported to the provider when first noted in order to get a hold of the concerns and keep on top of it to prevent hospitalization especially due to R1's increased risk for respiratory concerns related to his diagnosis, decreased mobility, and time of year. RN-A stated the facility lacked a protocol for respiratory monitoring when acute changes or medication concerns were present; however, monitoring was important to keep tabs on the resident to update the provider with more specific details, and if monitoring was not completed, the resident could get worse, could be detrimental, and could lead to hospitalization . RN-A added, We saw it with [R1]. When interviewed on [DATE], at 2:32 p.m. trained medication aide (TMA)-A stated she would be significantly concerned if R1 complained of chest pain as this was not a complaint he reported, and potentially indicated something was going on with his health. R1's complaints of chest pain, especially with his lung issues, was a change in R1's condition and she expected the nurses to update providers when residents presented with changes in condition for follow-up orders to manage the change. During an interview on [DATE], at 2:54 p.m. licensed practical nurse (LPN)-A stated she assessed R1's complaints of chest pain on [DATE], which was not a reoccurring complaint for him. She was aware of the albuterol shortage; however, not aware of the DuoNeb shortage. On [DATE], R1 was free of any immediate signs of distress. She did not doubt he had chest pain but felt the pain was food related; however, chest pain potentially indicated a change in condition which required the provider to be updated. She passed this information on to the night shift and asked them to keep an eye on R1; however, she denied she initiated respiratory and/or cardiac monitoring for R1 or contacted the provider. She denied it was facility practice to set up monitoring for acute changes. During an interview on [DATE], at 3:31 p.m. R1 stated he had a terrible cold, in which everything is congested, he had increased phlegm and terrible chest pain because he did not get this machine. As R1 pointed to his nebulizer machine he stated, This thing helps me a lot .if I do not get it, [NAME] and performed a thumbs down movement with his hand. Additionally, he stated there was a pharmacy issue for why he was not provided the nebulizer and if staff would have figured it out, he would have avoided hospitalization . He also required the inhaler (as he made a motion as if to self-administer an inhaler) to help manage his respiratory condition, which he was not often administered before the hospitalization . The symptoms started about a week before he went to the hospital when he experienced chest pain like a [NAME] kicking [him]. This chest pain scared him. He updated staff about the chest pain and his not feeling well; however, they did not do anything for me .they should have called [his provider] sooner. R1 added that he was much worse on [DATE], but now he continued to have periods of chest pain which comes and goes; however, this no longer scared him as he overall felt better. When interviewed on [DATE], at 4:09 p.m. ADON-B stated when a resident experienced condition changes she expected them to assess the resident, update the provider, and initiate monitoring each shift for approximately a week related to the signs and symptoms presented to prevent any progressive sickness that could occur and to assist with updating the provider with comprehensive assessed details on the status changes. She was aware of R1's missed albuterol due to the shortage; however, was unaware he missed inhaler doses. It was important to monitor and update the provider with changes to prevent adverse impacts to the resident, such as R1's hospitalization . When interviewed on [DATE], at 12:53 p.m. MD-C stated she first learned of R1's hospitalization after the fact .through the grapevine and was first updated on the shortage when she visited for rounds on [DATE]. She reviewed R1's clinic record during the interview and indicated there were no records the facility contacted the clinic related to R1's missed medications and/or his acute respiratory changes. She expected the facility to contact her right away after they were unable to procure medications and after changes in resident status, especially a sign or symptom change not improved with ordered and/or standing order medications, for alternative medication and/or treatment orders to be provided. R1's Advair was ordered as a preventative medicine after he experienced several ER visits, and because R1 was not administered the inhaler as ordered, he was hospitalized . If the facility had updated her as expected, she would have adjusted R1's Advair and/or albuterol orders and potentially kept him from being hospitalized . During an interview on [DATE], at 2:28 p.m. RN-C stated there were a couple residents having respiratory issues who were sent to the hospital because the facility did not have any nebs to treat them, adding R1 was one of them. RN-C indicated she was unaware of a systemic process to ensure all the residents were reviewed for the impacted medication shortage or if all the providers were updated. It was important to update providers for alternative orders, especially if the residents were ordered PRN nebulizers and required this for acute respiratory distress. Residents were at risk of increased respiratory concerns with ceased breathing if they were not administered ordered respiratory medications timely. She explained the facility did not utilize standing orders and if a resident were unable to be provided an ordered as needed nebulizer, staff contacted the provider for stat (immediate) orders which had the potential to delay treatment. In addition, it was not standard practice to implement respiratory monitoring when respiratory symptoms were identified and thus, she did not set up monitoring for R1. She denied she updated R1's provider after she assessed his condition changes during two of the five days prior to his hospitalization , nor updated the provider related to R1's missed medications; however, she was expected to update the provider with such assessed changes, for example., productive cough, expiratory wheezes, and lack of ordered medication supply. When interviewed on [DATE], at 3:15 p.m. the DON stated she was updated on the albuterol shortage on [DATE], after she contacted the pharmacy about R1's missed albuterol. She denied knowledge of the DuoNeb shortage or that R1 missed multiple doses of his Advair. She instructed the floor nurses to notify providers of the shortage; however, did not follow up to ensure this was completed, did not conduct any audits to determine the scope of the albuterol shortage in the facility, did not reach out to additional pharmacies or to the consulting pharmacist to inquire about the shortage, and did not contact the medical director. She expected staff to notify the providers right away when there was a medication concern or a change in resident condition, especially if there was chest pain to avoid further changes and/or hospitalization . She confirmed the facility currently worked on initiating facility standing orders and she expected staff to routinely check the pharmacy book to ensure requested medications were brought by the pharmacy. If not, a pharmacy inquiry was expected: This is not happening as expected. The DON stated R1's provider should have been updated on [DATE], and staff should have initiated respiratory monitoring due to his risk of further condition changes and respiratory distress, along with pneumonia. During a follow-up interview on [DATE], at 12:20 p.m. ADON-B stated she personally spoke to the pharmacy on or around [DATE] (Friday) about their inability to dispense R1's albuterol due to shortage. She updated the floor nurses after the conversation; however, did not perform any additional actions related to the shortage for R1 or any other residents with albuterol or DuoNeb orders. On [DATE] (Monday), management discussed the shortage in the morning meeting and in response R1's provider was to be updated during [DATE], provider rounds. She denied an all-house audit was completed to look for other impacted residents after the meeting. The immediate jeopardy that began on [DATE], was removed on [DATE], after the facility obtained alternative nebulizer orders for those residents who were prescribed albuterol and/or DuoNeb, audited 72-hours of all resident progress notes for changes in condition and updated providers and families with identified changes, and audited 72-hours of all medications charted as unavailable and obtained alternative provider orders. In addition, the facility communicated with the dispensing pharmacy and the medical director related to processes for medication dispensing concerns, implemented a process for resident assessments and monitoring in the event of dispensing concerns, educated nursing staff related to provider notification with status changes and medication dispensing concerns, and educated nursing leadership related to system management and expectations related to identification of missed medications and follow-up, but the noncompliance remained at the lower scope and severity level D. R2's Admission Record face sheet identified R2 was diagnosed with COPD, obstructive sleep apnea (OSA), chronic oxygen dependence, nicotine dependence, and morbid obesity with alveolar hypoventilation (rare disorder in which a person does not take enough breaths per minute). R2's COPD care plan, initiated [DATE], identified R2 was at risk for SOB, impaired breathing, and respiratory infections with a goal R2 would remain free of complaints and/or s/s of SOB. The care plan directed staff with the following interventions: administer medications/puffers as ordered, observe for effectiveness and side effects, monitor for signs of respiratory infection/distress, adventitious lung sounds, SOB, coughing, elevated temperature, increased respiratory rate, report as necessary to the physician. R2's MAR, dated ,d+[DATE], directed staff to administer DuoNeb four times (QID) to R2 for chronic respiratory failure with hypoxia. The MAR identified R2 missed 5 of 15 doses of the DuoNeb from [DATE] through [DATE]. Indications for the missed doses identified med not available. R2's MAR, and associated treatment administration record (TAR), [DATE] through [DATE], lacked documented evidence R2's respiratory status was monitored in relation to the missed doses. R2's progress notes identified the following entries: -[DATE], DuoNeb was not administered due to out of stock. -[DATE], 1:19 p.m. DuoNeb was not administered due to national shortage. -[DATE], 2:35 a.m. R2 was congested with audible wheezes and SOB. PRN albuterol nebulizer was administered. Follow up at 5:41 a.m. identified the PRN nebulizer was Ineffective. -[DATE], 7:58 a.m. R2 coughed and wheezed. PRN albuterol was administered. -[DATE], 9:43 a.m. DuoNeb was not administered due to faxed pharm shortage. -[DATE], 12:43 p.m. DuoNeb was not administered due to shortage. -[DATE], 7:40 p.m. an unidentified TMA requested LPN-B to assess R2's lung sounds. R2 was wheezing with short rapid breathing. TMA was instructed to administer a nebulizer. R2 declined provider/ED follow-up. The progress notes lacked R2's provider or the on-call provider was updated. In addition, R2's progress note lacked a follow-up assessment or evidence of routine monitoring related to her changes in condition. -[DATE], 5:46 a.m. At 2:18 p.m. R2 left for the ER after staff found her pale purple lips. Her breathing was very deep and rapid with expiratory and inspiratory wheezes. Oxygen saturation was 83% on 4 liters of oxygen, and her pulse was 110. R2 initially did not want to present to the ER; however, after about 10 minutes of staff encouragement she agreed to ER transport. R2's ER Provider Note, dated [DATE], indicated R2 was provided a DuoNeb enroute to the hospital and she required 10 liters of oxygen per mask. R2 was unable to give additional history on arrival due to increased work of breathing. Later, R2's oxygen was decreased to 5 liters per a mask and was able to maintain oxygen saturation level of 94%; however, she continued with diffuse wheezing, increased work of breathing, and productive cough. She was initially diagnosed with pneumonia and COPD exacerbation. R2's hospital Discharge Summary, dated [DATE], identified R2 passed away on [DATE]. She was admitted for cough, exertional dyspnea, and hypoxemia and subsequently diagnosed with acute on chronic hypoxic and hypercapnic respiratory failure, healthcare associated pneumonia, acute exacerbation of end-stage COPD. R2 was treated with antibiotics and required intermittent noninvasive positive pressure ventilation (ventilation provided by a mask). She held her own' for the first two days but on [DATE] began to deteriorate. That evening, after she removed her mask briefly she died rather quickly. R3's Admission Record face sheet identified R3 was diagnosed with obstructive sleep apnea. The face sheet was free of additional respiratory diagnoses. R3's COPD care plan, initiated [DATE], identified R3 was at risk for medical complications and/or discomfort related to OSA. Interventions directed staff to observe for and report to the provider s/s of sleep apnea which included excessive daytime sleepiness and cognitive decline related to fatigue R3's hospital Discharge Summary, dated [DATE], indicated R3 was hospitalized for systemic inflammatory response syndrome (SIRS - exaggerated defense response) due to viral gastroenteritis. His discharge examination identified he was alert, and his lungs were clear without any signs or symptoms of respiratory illness. His condition was stable. R3's progress notes identified the following entries: -[DATE], 9:54 p.m. R3 was lethargic, not responding and not wanting to bear weight and stand up. The DON checked the [R3] and [he] was deemed to be 'OK.' R3 declined to go to the Dr again. Staff attempted to contact family; however, the note lacked evidence facility contacted the provider. -[DATE], 10:41 a.m. R3 fell asleep twice during the meal and was observed to be SOB at rest. -[DATE], 4:25 p.m. R3 presented with heavy breathing, and he was assessed to have expiratory wheezes in the upper and lower left lobes. -[DATE], 5:50 a.m. R3 presented with wheezing. He was lethargic and hard to arouse. -[DATE], 8:05 a.m. R3's provider was updated via fax at 8:00 a.m. R3 was assessed to have course lung sounds with crackles and expiratory wheezes and 3+ bilateral feet pitting edema. He was very lethargic and was unable to stay awake. His respiratory rate was 25. -[DATE], 12:52 p.m. R3 was transported to the ER. The progress notes lacked evidence R3's provider or the on-call provider were updated prior to [DATE]. In addition, R3's progress note lacked evidence of routine monitoring in response to his condition changes. R3's MAR, dated ,d+[DATE], directed staff to administer DuoNeb QID PRN for SOB, cough or with exercise, ordered [DATE] and discontinued [DATE]. Budesonide one vial inhaled PRN for prophylaxis for one day was ordered on [DATE]. The MAR lacked evidence R3 was administered the PRN DuoNeb from [DATE] through [DATE] or the Budesonide on [DATE] in response to his respiratory s/s. The facility's pharmacy fax binder identified pharmacy Reorder Forms and Packaging Slips with the following information: -[DATE], R2's DuoNeb was requested. -One Reorder Form, undated, identified R2's DuoNeb was requested, and the form identified a handwritten out under the request. -The binder lacked documented evidence staff requested R3's DuoNeb and/or a rationalization as to why it was not dispensed. On [DATE], at 2:15 p.m. R3 was observed sitting up in wheelchair in day room. No s/s of respiratory distress or ancillary muscles to breath. Surveyor attempted to interview R3 but he appeared to be sleeping. During a follow-up interview on [DATE], at 12:13 p.m. PT-A stated R2's DuoNeb was last dispensed to the facility on [DATE] (30-day equivalent). R3's DuoNeb was never dispensed. When interviewed on [DATE], at 12:53 p.m. MD-C reviewed R3's clinic record, and current pile of faxes, and indicated there were no records the facility contacted the clinic related to R3's acute respiratory changes and/or a request for an alternative PRN nebulizer. She explained at R3's baseline he was very with-it and can talk to you. After she was updated on R3's [DATE] to [DATE] progress note entries, she stated she expected R3 would be administered his PRN DuoNeb and if the facility was unable to obtain it, they should have requested an alternative right away. In addition, she expected staff would have updated her on [DATE] related to his status changes especially as he did not have respiratory concerns during his recent hospital stay and newly presented onset of wheezing and altered cognitive level; adding, he was at risk for developing heart failure as he experienced an MI (myocardial infarction) during his hospital stay so his respiratory s/s potentially were cardiac in nature. During interview on [DATE], at 1:42 p.m. MD-C reviewed R2's clinic record and indicated there was no evidence the facility contacted the clinic related to R2's acute respiratory changes and/or an update related to her missed DuoNeb medication. MD-C also denied the facility contacted him related to any of his other residents adding, he found out about R2's status and passing when he received a request for the death certificate. MD-C indicated he was unaware of an albuterol or DuoNeb shortage and he expected the facility to contact him with changes in resident statuses, especially as respiratory concerns cannot wait long to be addressed and if there were issues obtaining medications stating, if the facility would have updated him on her progress when the symptoms started, he most likely would have ordered steroid medication as he would have presumed she was having an exacerbation of her respiratory diagnoses. However, he did not feel her exacerbation was attributed to five missed DuoNeb doses as R2 also received a long-acting nebulizer medication, was a smoker, lacked good underlying health, had terrible lung disease, and had a higher mortality rate, thus her being sent to the ER was unavoidable. In addition, R2 was finding a way to exit this mortal coil, and he was unsurprised by her death. On [DATE], at 2:15 p.m. R3 was approached, and an interview attempted. He was free of s/s of observed respiratory distress. His eyes were closed, his head slightly bent (appeared asleep) and did not arouse to his name being called and/or physical touch. When interviewed on [DATE], at 1:29 p.m. RN-A stated R3 was very tired and slow to wait up earlier that morning; however, he was not feeling good. R3 lacked any outward s/s of respiratory distress; however, she did not listen to his lungs or assess his respiratory status as shift report lacked indicated of any respiratory concerns. RN-A stated R4 was slowly declining and coughed more with eating. R4 was free of s/s of respiratory concerns earlier that morning. She stated neither R3 nor R4 had a DuoNeb supply in the med cart. Based on this, if R3 required a PRN DuoNeb, she would call MD-C, or the on-call provider, and request alternative treatment. She explained this was a difficult process as their pharmacy was in Willmar and she questioned how she was supposed to get the adjusted PRN medication other than sending [the resident] to the ER. RN-A stated residents lacked the ability to just bounce back. As residents required ordered medications, it was not going to be good if the medications were not administered as ordered. During interview on [DATE], at 2:28 p.m. RN-C stated R2's assessed cough, congestion, short rapid breathing, and audible wheezes on [DATE] were new; however, the SOB was normal for her. RN-C was unable to remember if she updated the provider after she assessed R2 and/or a reason as to why R2's provider was not updated. RN-C stated R3 experienced a status decline recently where he was off, and staff did not think he was breathing well, the first night after a hospital return. Due to this, the DON was asked if she would assess R3. RN-C denied she went back to reassess R2 after the DON stated R2 was okay or set up any routine respiratory monitoring. RN-C stated R4 has been okay and lacked evidence of any distress on the overnights. When interviewed on [DATE], at 3:15 p.m. the DON stated she expected staff would have updated R2, R3, and R4's providers, or an on-call provider, related to their status changes and related to the shortage to obtain additional orders. She denied she reviewed R2's medical record once the facility was updated on R2's death to audit the record for any concerns or to see if R2 was potentially impacted by the shortage. The DON stated she expected R3 would have received a PRN nebulizer treatment when he presented with respiratory s/s. She denied R4 displayed any changes in his respiratory status; however, she was frustrated as him of all people need [the nebulizer medication] related to his diagnoses. The DON explained residents were at a risk for changes in condition and increased risk of hospitalization , or even worse, if staff failed to perform as expected. A policy Resident Examination and Assessment, dated ,d+[DATE], directed staff to notify the physician if any of the following abnormalities were identified: abnormal vital signs, labored breathing, breath sounds that are not clear, productive or nonproductive cough, worsening pain, and other information in accordance with professional standards of practice. A policy Acute Condition Changes - Clinical Protocol, dated ,d+[DATE], directed staff to monitor and document acute condition changes until the problem or condition has resolved or stabilized. In addition, the policy directed staff to contact the physician based on the urgency of the situation in which the provider was expected to respond in a timely manner to notifications of problems or changes in condition and status. A policy Pharmacy Services Overview, dated ,d+[DATE], identified residents were to have a sufficient supply of their prescribed medications and receive those medications in a timely [NAME][TRUNCATED]

Based on observation, interview and document review, the facility failed to properly assess and implement interventions to prevent a hazard free environment for 1 of 3 residents (R1) reviewed for accidents after moving R1 to a new room, whose bed was historically positioned against the wall for safety, and then whose bed was placed against a radiator heater. This resulted in actual harm to R1 who required medical treatment at the emergency department when he obtained [MEDICAL CONDITION] the right thigh and calf and on both feet from a radiator heater while in bed. This failure resulted in an immediate jeopardy (IJ). The IJ began on 2/8/21, at 6:40 a.m. when R1 was discovered by staff to be laying on the radiator heater and found second and third [MEDICAL CONDITION] R1's right thigh, calf and two feet. R1 was sent to the emergency department for monitoring and treatment of [REDACTED]. Findings include: R1's current [DIAGNOSES REDACTED]. R1's significant change Minimum Data Set ((MDS) dated [DATE], included cognitive skills severely impaired, bed mobility was total dependence with a two person physical assist, always incontinent of urine and bowel. R1's Care Area Assessment (CAA) dated 12/30/20, indicated cognitive impairment, confusion, dementia and Parkinson disease, difficulty making self-understood, difficult understanding others, totally incontinent of urine requiring staff to continue with check and change every 2 hours and monitor for changes in condition, total dependent of staff for all mobility uses a ceiling lift/Hoyer lift for all transfers, history of falls mostly related to rolling out of bed. R1's care plan dated 8/6/20, identified, FALL RISK: high risk for falls; history of falls; is no longer ambulatory; Hoyer lift/ceiling lift for all transfers and totally dependent of staff for all mobility. Also identified, at risk for falls related to progressive [MEDICAL CONDITION] along with [DIAGNOSES REDACTED]; bowel and bladder incontinence; medications; chronic pain related [MEDICAL CONDITION] of knee and impaired functional range of motion lower extremities related to [MEDICAL CONDITION]. R1 does not communicate needs and has history of rolling out of bed. R1's goal was to be free from falls with no major injuries. Interventions included auto lock brakes on resident's bed, toileting per elimination plan of care, total assist of two with full body lift for all transfers and to turn and reposition in bed. Added on 2/9/21, was When positioning on side avoid over position to prevent him from rolling over. Added on 2/17/21, Keep bed in lowest position. Bed must not be positioned against walls or against wall heater at any time. Headboard of bed should be positioned with the headboard of the bed in line with the light fixture on the wall. Added on 2/17/21, Place fall mats on floor on both sides of bed when resident is lying in bed. Keep bed in lowest position while resident is lying in his bed to ensure safety. R1's incident report dated 2/8/21, at 6:40 a.m. included, Resident was sleeping in bed in low position. Bed was in proximity to heat register on the wall. Between nursing rounds, resident rolled self close to heat register. During the next nurse round, the nurse noticed this and moved resident and bed immediately away from heat register. Nurse evaluated and found resident to [MEDICAL CONDITION] right leg and both feet. Resident's call light was not on and did not call out for staff that they were in pain. Resident sent to ER for further evaluation. R1's progress note dated 2/8/21, at 6:40 a.m. included R1 to be sent to emergency room in Willmar. Ambulance called and resident left the facility at 6:07 a.m. to Rice Hospital ER to evaluate R1's burns. R1's Emergency Department Provider Notes from Rice Memorial Hospital dated 2/8/21, included, Pt (patient) comes from(NAME)Oaks NH by ambulance. Staff is not sure how long pt laid by the register by they had checked him 2 hours prior and he was still in bed. Pt is disoriented at baseline and unable to offer any information.[MEDICAL CONDITION] right lateral lower extremities (LE) and medial left foot. Pt reports pain to both ankles when he does speak but this was inconsistent. R1's Wound Ostomy Continence (WOC) Outpatient Clinic, Carris Health-Rice Memorial Hospital dated 2/8/21, exam included, His right lower extremity is assessed. To the right lateral thigh and right lower leg is an area of partial thickness burn which measures 61 x 8 cm (centimeter) over the lateral thigh most proximal is a serous blister measuring 5.5 x 4.5 cm. There is a serous blister distal to this measuring 1.5 x 2 cm. Most distal and lateral is a serous filled blister measuring 0.8 x 1.4 cm. Over the fifth metatarsal head is a full thickness burn measuring 0.5 x 1 cm. There is surrounding irritation measuring 1.5 x 1.5 cm. Over the lateral leg distal to knee is an area of full thickness burn measuring 3.5 x 2 cm. The left lower extremity is assessed. There is a full thickness burn to the great metatarsal head measuring 4 x 4.2 cm. To the left great toe distal is an area of [DIAGNOSES REDACTED] measuring 1.1 cm. Over the mid foot is a burn measuring 1.2 x 1.1 cm. There is a faint [DIAGNOSES REDACTED] of the mid foot measuring 18 x 6 cm. The wounds are cleansed with saline. R1 was sent back to nursing home and not admitted to the hospital. When interviewed on 2/16/21, at 9:30 a.m. the administrator stated following the incident, the facility developed a plan of correction immediately on 2/8/21. The plan titled, Glenoaks Abatement Plan was dated, 2/8/21 was reviewed with the administrator and stated all the beds in the facility were audited for their location in the rooms and temperatures of the heaters, all nursing staff were educated on positioning beds safely away from the heaters and all residents care plans were audited. The administrator further explained the beds should be positioned center of the light fixture which is a safe distance from the heater and an ongoing audit of bed position would be conducted. Administrator stated the facility consulted an engineer on 2/8/21, which concluded due to extreme low temperatures the boiler could have over worked and raised the temperature levels. Administrator stated an ongoing temperature audit of the heaters of all the rooms were also initiated and will be conducted throughout winter months. It was observed on 2/16/21, at 12:09 p.m. R1 in bed resting, bed was low to the ground and was approximately two to three feet away from the radiator heater. A night stand was observed as a barrier between the bed and radiator heater. Mats on the floor were also observed. When interviewed on 2/16/21, at 12:19 p.m. health information coordinator (HIC)-A stated, previous to R1's recent injuries R1's bed was known to be right next to the heater to help with falls. HIC-A stated R1 could become wiggly and believed R1 moved toward that side and the mattress pushed him over to the heater. During observation and interview on 2/16/21, at 1:15 p.m. R1'[MEDICAL CONDITION](first to third degree on leg) were observed to be in varying stages of healing. R1's bilateral feet had dressings intact and were unable to be observed. While completing the dressing change, ADON stated R1 had a follow up appointment today with WOC. ADON stated R1 had noticeable pain when someone would mess with [MEDICAL CONDITION] the doctor had ordered [MEDICATION NAME] which had been effective. ADON stated she was not working when incident occurred but recalls R1's bed had always been against a wall to help keep him from rolling out of bed. ADON is not aware of any assessments completed regarding risks of R1's bed against the heater. ADON did not recall R1's care plan indicating the position of the bed to be against a wall. When interviewed on 2/16/21, at 1:24 p.m. nursing assistant (NA)-A stated R1's bed was always against a wall. NA-A stated R1 was in a different room previously and had his bed against a wall but not against the heater. NA-A stated when R1 moved to his current room R1's bed was moved to be against the wall where the heater was. NA-A stated she was not aware of an assessment completed when R1 changed rooms to look at the risks for his bed to be next to a heater. NA-A state R1's care plan instructed to have his bed at a low position but did not recall R1's bed to be against a wall. When interviewed on 2/16/21, at 1:34 p.m. administrator stated R1 previous room had his bed positioned against a wall, however it was an interior wall and the heaters were not located there. Administrator stated he was not sure why R1's current room had his bed against the wall where the heater was. Administrator stated he was not aware if there was an assessment completed addressing risks for the positioning of R1's bed. Administrator stated he was not aware if R1 or his family wanted his bed against the wall with the heater. When interviewed on 2/16/21, at 1:52 p.m. by phone, family member (F)-A stated R1 had a history of [REDACTED]. F-A stated she knew R1's bed was against a wall in his previous room but did not recall it being against a heater. F-A stated R1 moved rooms during a COVID outbreak and had not seen his room due to visitor limitations. F-A stated the family did not request his bed be against a wall and was not aware his current room had his bed positioned against a heater. F-A stated her understanding for R1 to be against a wall due to his history of rolling out of bed. F-A stated she feels the facility reacted competently and acted to get R1 the care he required once [MEDICAL CONDITION] discovered. When interviewed on 2/16/21, at 2:22 p.m. the environmental director (ED) stated the investigation started on 2/8/21, regarding R1'[MEDICAL CONDITION] if there was a malfunction with the heater. ED stated the administrator and ED checked the temperature of R1's heater and positioned his bed away from the heater. ED stated the heater is approximately six feet long located on the exterior wall. ED stated the head of the bed that was parallel to the heater recorded a temperature of 80-90 degrees Fahrenheit. When the middle of the 6-foot heater was checked is recorded a temperature of 122 degrees Fahrenheit. ED stated the facility consulted with an engineer for potential remedies for the radiator running inconsistently. The engineer reported the heaters in the facility are designed to be safe to touch and a temperature of 115 degrees Fahrenheit and under will not burn skin. ED stated the natural cold weather was also a factor, temperatures that morning on 2/8/21, were below 20 degree Fahrenheit and the boiler was working overtime. ED stated R1's heater has dampers and upon investigation the dampers were positioned in the wrong direction, blowing the heat all to the top of the heater on the metal. ED stated R1's bed was against the heater and in his previous room his bed was positioned against a wall. ED stated when R1 moved to his current room it was overlooked, the heater piece, because R1 bed was positioned against the wall in his prior room. When interviewed on 2/16/21, at 2:44 p.m. NA-B stated R1's bed is positioned at the lowest level when he is in bed and the bed is put up against the wall. NA-B stated R1 does wiggle a lot in bed and was not surprised he could do this himself. NA-B stated his bed was known to be against the heater. NA-B stated she thought the heaters did not get that hot to burn so bad. NA-A stated R1 is repositioned every two hours even during sleeping hours due to R1 being incontinent. When interviewed on 2/16/21, at 3:31 p.m. phone call with NA-C stated she discovered R1 burns. R1 is a check and change every two hours, even during sleeping hours. NA-C stated she checked on R1 at 11:30 p.m., 1:30 a.m., and at 3:30 a.m. NA-C stated he was positioned on his right side. NA-C stated between 4 a.m. or 5 a.m. that is when they discovered R1's right leg was on the heater and his left leg was over his right leg and both feet were touching the heater. NA-C added, R1 would usually yell out if he was in pain or needed help, but he never did that on 2/8/21. NA-A stated the nurse was called immediately to assist. NA-C stated she touched the heater and it was hot and had to remove her hand in less than a minute. NA-C stated R1's bed had been up against the wall in his previous room. NA-C state R1's care plan did not state to have his bed against the wall. When interviewed on 2/17/21, at 5:56 a.m. phone call with licensed practical nurse (LPN)-A stated she was the nurse who discovered R1'[MEDICAL CONDITION] with nursing assistants. LPN-A stated she checked on R1 at 4:15 a.m. and R1's leg was not against the heater. LPN-A stated it was around 5 a.m. when the nursing assistants were doing their last rounds. LPN-A stated when R1 was found to [MEDICAL CONDITION] bed was positioned farther away from the heater immediately. LPN-A assessed R1's skin and discovered the burns. LPN-A stated R1 did not appear to be in pain when found. LPN-A did touch the heater and stated it was too hot and had to pull away her hand. LPN-A stated she called facility administration, family and R1's doctor and the plan of care was to send R1 to hospital by ambulance. When interviewed on 2/17/21, at 10:08 a.m. director of nursing (DON) stated R1's bed was positioned against the heater during this incident and she was unsure why his bed was positioned by the heater. DON stated there was no assessment completed when R1 changed room. DON stated R1's previous room the bed was positioned against an interior wall and the heater was not located on that wall. DON stated she was not aware R1's care plan stating his bed should be against the wall especially against the heater. DON stated when R1 moved it is not known why is bed was placed by the heater, no assessment was completed or intervention for R1's safety to have his bed positioned against the heater. On 2/17/21, at 9:20 a.m. the administrator provided two new policies dated 2/16/21, titled: Heat Register Safety and Resident Bed Placement policy. Heat Register Safety stated the purpose was to ensure heat registers are kept at a safe temperature to prevent potential harm to residents, staff, or visitors. Resident Bed Placement Policy stated the purpose was to ensure residents are free from unnecessary restraints or any other hazards regarding the placement of their bed within their living space. Interviews on 2/17/20, were completed with various staff positions which all verified education was received the day of the incident about where to position beds, away from the heater. On 2/17/21, it was observed at 2:10 p.m. R1 in bed approximately two to three feet away from the heater, bed was in low position with mats on both sides of R1's bed. On 2/17/21, all resident rooms were observed between 2:15 p.m. and 3:00 p.m. to confirm bed placement was positioned safely away from heater and per policy. No concerns were identified. The past non-compliance IJ which began on 2/8/21, was removed prior to the abbreviated survey due to multiple action(s) taken by the facility to correct the identified non-compliance. These actions included a review and revision of the facility's policy and procedure related to environmental safety, heater temperatures, bed positioning in resident rooms and care plan audits. Additionally, R1 and all resident served had bed placement and heat elements audited for safety and ongoing audits were put into place and all staff were verified to be trained on new policies. As a result, the IJ was removed and the identified non-compliance was corrected as of 2/8/21.

Based on observation, interview and document review, the facility failed to comprehensively assess, and implement behavior management interventions for 1 of 1 residents (R13) who exhibited escalating physical and verbal behaviors with frequent aggressions toward staff causing distress. This resulted in actual psychosocial harm for R13 who had repeated behaviors of hitting, kicking, grabbing, and use of vulgar language that required hospitalization and subsequent intramuscular (IM) medication to alleviate these unassessed, escalating behaviors. Findings include: R13's Resident Face Sheet dated 11/26/18, included [DIAGNOSES REDACTED]. R13's admission Minimum Data Set ((MDS) dated [DATE], indicated R13 was severely cognitively impaired, and had [DIAGNOSES REDACTED]. The MDS identified R13 had no depression, and further indicated R13 had no physical behaviors, such as hitting biting, or kicking; or verbal behaviors, such as threatening, screaming, or cursing; and no rejection of cares or wandering. R13's admission care area assessments (CAA) dated 8/29/18, for cognitive loss/dementia indicated severe impairment and R13 resided on secure unit for safety. Care area assessment for behavioral symptoms did not trigger. R13's CAA for urinary incontinence dated 8/30/18, indicated R13 was frequently incontinent of bladder since admission, was at risk for increased incontinence related to need for staff assist to find bathroom at times, and has significant cognitive impairment, diagnoses, medications. Staff assist with toileting routinely and monitor for change in continence. A(NAME)Oaks Pre Admission Assessment form dated 8/22/18, indicated in the section, Comments on behavior, Treatments, infections etc: coming from assisted living to secured memory care, wanders frequently, paranoid of new staff. Compliment her clothes, smile, direct eye contact, before cares. Needs q 2 hr (every two hours) toileting while awake. Can be aggressive when agitated. A type-written sheet, identified Tips for her caregivers caring for R13, undated, included a Behaviors heading and indicated: R13 does NOT like new care givers, especially younger staff, please follow to decrease behaviors: 1. When coming to assist her with anything, always get down to eye level and say hello and compliment her on how she looks or ask how she is doing first. SMILE. 1. Don't ask her if she wants to do something as this is too difficult for her to process and she will often refuse, Just lead her by the hand toward the task (bathroom) or say 'come with me' or say 'it's time to.' R13's care plan, revised 11/15/18, did not identify or address R13's behaviors or aggressions as a separate care area, but behaviors were addressed under toileting. The care plan directed if R13 refuses or becomes combative, as evidenced by seeking out other with intent to harm, ramming other with walker, striking out, kicking, pinching, scratching, grabbing at staff and raising fists with cares/activities, to leave R13 in a safe situation and re-approach after a few minutes. If unsuccessful, try alternate care giver, and then attempt to re-approach when resident appears to be approachable. If continues to be resistive or combative, change activity, and attempt to involve her in activity. If continues to refuse and be combative with staff, contact outside nursing staff or family for ideas on how to approach the situation. Under the care area of sensory/ cognition/ communication, R13's care plans directed staff to monitor for change in behavior related to agitation, aggression, refusals, depression and weepiness. The area identified in the care plan were generic and not individualized to help reduce or alleviate R13's aggressive behaviors. Even though the nursing home had a Tip Sheet for Caregiver from R13's previous facility which identified specific interventions for her behavior, these were not identified on her care plan. During observation on 11/26/18, at 5:01 p.m. R13 was seated in the dining room at the start of the evening meal, where nursing assistant (NA)-B asked R13 what she wanted to eat and drink. R13 was served a meat sandwich, bowl of vegetable soup,baked cinnamon apples and glass of cranberry juice to drink. R13 intermittently ate bites of her sandwich, and was reminded and encouraged to eat and drink, but took only bites. At 5:25 p.m. family member (FM)-E came onto the unit and sat near R13 and also encouraged R13 to eat. Following the meal R13 ambulated with a 4-wheeled walker (4WW) from the dining room and sat in a recliner in her room and visited with FM-E. During observation on 11/27/18, between 9:45 a.m. and 10:23 a.m., registered nurse (RN)-C was on the memory care unit assisting and supervising residents in the dining area. R13 was ambulating the hallways on both sides of the dining area. At 9:48 am RN-C asked R13 if she needed to use the bathroom to which R13 responded, I don't have to go. At 9:54 a.m. RN-C intercepted R13 in the hallway and questioned her again about toileting and R13 responded by saying, Why do I need to go in there? RN-C stated, Clean underwear. R13 paused her walking, then continued on down the short hallway on the unit. When R13 turned at hallway's end and came back RN-C suggested Let's go in the bathroom, where are you going? R13 replied,Where I want to and tells the staff to kiss my ass and R13 continued to ambulate. RN-C again asked R13 to toilet at 10:23 a.m. without success. During observation on 11/28/18, at 9:07 a.m. R13 was seated in a chair at the table with two other residents at breakfast. R13 was finished eating and was looking about the room and observing staff and other residents. At 9:11 a.m. R13 stood up without her walker and was walked around the dining room, touching the table tops as she navigated the area without her walker. NA-D got R13's walker and placed it in front of R13 and asked her is she needed to use the bathroom. R13 ignored NA-D's question, took the walker and ambulated out of the dining area, down the hall. A few minutes later R13 parked her walker next to her and sat on the small couch in the dining area. At 10:06 a.m. while seated in the couch, NA-D approached then asked R13, as she stood up, if she needed to use the bathroom, to which R13 responded kiss my ass and began ambulating down the main hallway on the unit. At 10:12 a.m. NA-B met R13 near her room door as she ambulated toward her room door. NA-D asked if she could see something in her room, and once inside R13's room, NA-D pointed R13 to the bathroom, asked if she needed to go, to which R13 responded yes and ambulated into the bathroom and subsequently toileted. Review of R13's progress notes from 8/29/18 to 11/28/18, identified the following: -9/24/18 Resident tried to kick AM (morning) staff while doing her cares (R13) was easily redirected. -9/27/18 (R13) was pacing in the hallways and tried to hit staff who were blocking the doors to get out. R13 later calmed down and has been sitting in her room watching TV -10/2/18 R13 was aggressive with aide and pulled on the aide's arm while aide attempted to help another resident into a w/c (wheel chair). -10/6/18 (R13) refused lunch d/t (due to) being agitated. R13 trying to run over staff with her walker and threatening to kick your ass! R13 did take her medications well. -10/6/18 At bedtime R13 was approached by writer to take teeth out, and was swung writer reapproached R13 later and was verbally assaulted. When other staff attempted helping, R13 chased staff around until with walker while swinging it close, kicked staff in chest with trying to help resident into bed; slapped another staff that attempted to help; when told Good night, I hope you sleep good, R13 replied I hope you get hit by a car. -10/7/18 Resident was hitting and punching staff, causing bruising to staff and refused personal cares when resident urinated on her bed and floor. -10/10/18 Resident refused HS (night time) medications X 1 (one time), R13 then took it after the second attempt/ PM. Only one attempt to hit staff tonight. -10/11/18 Resident was pleasant and allowed AM cares before breakfast. After breakfast resident became combative, refused toileting and blood pressure measurement. Res would not follow direction even after multiple approaches and staffs attempts. -10/12/18 Writer entered R13's room at 6:45 to administer morning med, R13's mood was per usual, writer bent down to offer the spoon with pill and applesauce when R13 grabbed writers's shirt and forcefully tugged and whipped writer's neck around. Writer tried to release R13's grip but was unable and R13 continued. R13 pulled so hard at writer's shirt that shirt spilt down the middle at which time R13 lost grip and writer able to back away. A progress note dated 10/12/18, indicated social service, director of nursing and nurse manager made a conference call to family member (FM)-C in regard to R13's behaviors. Nursing reviewed meds (medications) with Pharm D (pharmacist) prior to call. Medications and behaviors were discussed with FM-C. Facility is considering a behavioral health stay may be warranted with increased behaviors noted in the past few weeks, escalating today. Family came to facility to discuss option. The note indicated family member (FM)-D, FM-C and FM-E came to the facility to discuss option. Family agrees that behavioral stay may be the best solution for behaviors as no triggers were found and there was no correlation with time and/or staff. Referral faxed to behavior unit. A nursing progress note dated 10/15/18, indicated a fax (facsimile) was sent to R13's physician. Resident has been having escalated behaviors. Resident is refusing to toilet when soaked. Resident has been hitting, kicking, and grabbing at staff. Resident was noted to be constipated also during the past week. Family does toilet her and not let staff know. The behaviors have been escalating over the past month. Staff has questioned pain, migraines, and constipation. With family involvement, Nursing and Social Services feel the best route is to have a behavioral health stay at [MEDICAL CONDITION]. The next opening is around Tuesday. Resident has made comments about being scared at the facility to family. Resident has not made comments like this to staff. Staffs (sic) have been questioning migraines. Resident was noted to be holding her head. Staff does not know what to use to be done for migraines. Staff started her on Tylenol 650 mg (milligrams) PRN (as needed) at 12n (noon) and 5 p.m.; along with her scheduled Tylenol ER (extended release) BID (two times daily.) No documented behaviors this weekend. A progress note dated 10/15/18, indicated R13's physician was okay with a behavioral health stay for R13, as long as FM-C was okay with it. R13's physician thinks FM-C had a change of heart over the weekend regarding the in-patient stay, and the physician also discussed changing R13's medications. R13's physician decided it was a lot to start messing with (R13's medications) and would not be beneficial to resident. The physician does not feel (behaviors) migraine are related. A progress note (PN) dated 10/16/18, indicated the facility received orders for a behavioral health stay R13. FM-C contacted R13's physician and wanted to try switching medications, as FM-C did not want to move (R13) and cause unneeded stress on her. The PN indicated R13 will start [MEDICATION NAME] (antipsychotic medication) 12 mg BID (twice daily) for a week, and staff will update doctor in a week. A review of R13's Medication Administration Record [REDACTED]. A review of the progress notes, after the initiation of [MEDICATION NAME] on 10/16/18 through 10/23/18 indicated the following: -10/20/18 Resident was verbally abusive to staff at start of shift, medications were difficult to administer, reapproached x5. After administration resident call writer stupid.' At snack time an unrelated residents' spouse calmed down the resident after (R13) was yelling at both NA and RN. He said (R13) us Norwegians can't let others see that we get angry. This was the only intervention that calmed R13 down. After the evening meal, residents were sitting on the chairs in the hallway when R13 stood up, pushed her w/c aside to took steps to punch the NA twice. -10/21/18 Upon the start of the shift, resident appeared to be riled up. R13 was combative, swinging at nursing staff using vulgar language. R13 call a TMA (trained medication assistant) a '[***] ' and R13 was hesitant with cares. -10/21/18 Bedtime routine went per usual, many redirections were necessary to carry out the task. R13 did strike out at staff x1. -10/22/18 R13 was trying to ram her walker into staff while she was helping her with cares today-no further behaviors. A progress noted dated 10/23/18, indicated FM-C and FM-D were at the facility and made the decision to have R13 get an evaluation at Meeker Memorial behavioral health. A bed hold was signed and additional paper work sent with family to Meeker. The facility census record indicated R13 left the facility for an in-patient, behavioral-health hospitalization on [DATE], and returned to the facility on [DATE]. A Meeker Memorial Hospital physician's progress note dated 11/5/18, indicated R13 was at the hospital for behaviors in the context of her dementia, was doing well and was going back to the nursing home today. A Patient Continuing Care form dated 11/5/18, indicated the nursing summary of hospitalization : (R13) has showed a decrease in agitation. Takes medications with food (crushed) and has shown no signs of being physical. There has been no threatening of staff. UTI (urinary tract infection) was found and was treated with [MEDICATION NAME] (an antibiotic medication). R13's hospital discharge notes contained no behavioral assessment or interventions. R13's record lacked evidence the facility reassessed R13 upon return to the facility. Review of R13's progress notes from 11/6/18 to 11/28/18, identified the following: -11/6/18 (FM-C) here till lunch, after (FM-C) left resident refused to remain at the meal and got up and wandered the halls. Resident sat in different chairs and got back up again over and over. Staff attempted to toilet but resident started swinging at them and attempted to ram her walker into staff. -11/17/18 Resident very agitated this morning, going out of her way to grab and hit at staff, staff was able to pull away form her hitting but was unable to remove her arm from resident's grip. Resident hit staff five times, attempted to hit at staff another six times, and attempted to run staff over with her walker. -11/17/18 Resident not aggressive, let writer put dentures in and glasses on. Took medication easily. Nursing apprehensive about toileting, writer waited to re-approach. Family came in and toileted resident. -11/18/18 by RN-E identified, (R13)'s (FM-E) had visited at the top of the shift. Upon his departure, resident wandered hallway w/o (without) walker. Writer brought walker to resident and resident threw walker at writer. Resident had been friendly to other residents up until 4 p.m. Resident had been verbally abuse to staff all shift, and around 4, resident stood up and walked across the dining area to threaten CNA (certified nursing assistant). (R13) said, Get off your horse and get the hell out of here. There was a table between resident and CNA at the time. At that time all residents who were able to self transfer left the dining room and to go to their rooms. (R13) was asked by writer to go to the toilet, at that time resident showed her fist and yelled I pay for this place and I can do whatever the hell I want. Writer requested and received assistance of male CNA who is known to have good reputation with the resident to distract her while writer administered 1 ml (milliliter) of ordered PRN (as needed) [MEDICATION NAME] (an anti-[MEDICATION NAME] medication, indicated for itching, but may also be used short term to treat anxiety) IM (intra-muscularly). R13's (MONTH) (YEAR) [MEDICAL CONDITION] Drug Monitoring form, which tracked R13's behaviors. The form had space to record the target behaviors, interventions and outcomes for each shift, for each day of the month. The form identified three behaviors to monitor: Agitated, Spitting out, and Verbally abusive, and listed several, generic interventions including re-direct, 1 on 1, toilet, give food, fluids, (and others). The form identified the outcome to the interventions worsened R13's behavior or were left blank. The interventions identified were generic, and there was no indication an individualized non pharmacological interventions were developed to decrease or eliminate R13's behavioral aggression. During interview at 6:02 p.m. on 11/26/18, FM-E acknowledged R13 had some behaviors, but thought those behaviors were manageable. FM-E also stated he had questions about the use of the shot to control R13's behaviors. During the interview FM-E commented there were often new faces and staff giving care to residents on the unit and FM-E stated R13 usually did not respond well to that. When interviewed at 6:20 p.m. on 11/26/18, FM-C expressed numerous concerns about R13's ADLs not being done timely. FM-C said R13 did have some behaviors, and stated they occurred during toileting, and added R13 did not do well with new staff. FM-C questioned why the facility did not have the same staff on the unit, and she and other family members discussed numerous times with the facility about having consistent staff work with R13. They felt this would have eliminated many behaviors exhibited by R13. FM-C stated the facility response regarding consistent staff was their fear of staff burn out, to which I replied that is not an excuse! FM-C stated that should be an intervention, to have the same, consistent staff work with R13. FM-C said she did consent to having R13 evaluated at the behavioral unit, but was still frustrated upon R13's return to the nursing home. She started exhibiting the same behaviors, nothing really changed. FM-C stated she felt frustrated with the facility because there was no consistent approach to caring for R13, and added I cried when she learned staff used IM medication when R13 got aggressive. FM-C stated they had a care conference after R13 got back from the hospital, but nothing was said about the IM (intra muscular injection) as being an option for treatment. FM-C stated she was also upset having learned about the use of the injection a couple days after it happened. FM-C said (R13) took medications by mouth and questioned why the staff used the injection. FM-C stated the facility should please let me know what you are thinking! FM-C stated after learning (R13) got the injection, I cried, just knowing she got it, I cried. During interview at 2:39 p.m. on 11/28/18, RN-E acknowledged she utilized R13's order for as needed [MEDICATION NAME] and administered the medication after R13 became riled up on the unit. RN-E stated the incident happened on a Sunday, later in the afternoon. RN-E stated she did not know why R13 was agitated that day, and could not recall if during the incident if she was trying to administer medications to R13 or only talking to R13 to help calm her down. RN-E stated R13 was yelling and hollering and I just didn't know what else to do. RN-E stated R13 had an order to use the medication to help calm her, was administered via injection. RN-E identified the IM was not really effective, and she did not know if she would give the medication again. When interviewed at 12:51 p.m. on 11/28/18, licensed practical nurse (LPN)-C talked about R13's behavior and stated R13's negative behaviors occurred when staff tried to toilet R13 and stated maybe we didn't have a good behavior management plan for R13. LPN-C questioned the need for the in-patient hospital stay for R13, which other may have seen differently. LPN-C stated during his shifts R13's behaviors were manageable, with patience and a lot of re-direction. LPN-C added, I would not think to use IM medication to control behaviors. During interview at 1:37 p.m. on 11/28/18, RN-B summarized R13's nursing home stay. RN-B stated R13 had been in assisted living, was admitted in the locked memory care unit, began to have aggressions toward staff, especially during cares, had an adult behavior mental health stay at a hospital, then returned. RN-B stated prior to the in-patient stay, there was an attempt to change medications, but that was not successful. RN-B stated R13's behaviors center on incontinence and refusal to allow staff to assist her. RN-B acknowledged and stated in regard to R13's behaviors, there probably was not a comprehensive assessment completed upon admission. RN-B stated, (R13)'s current behavioral assessment for behavior was lacking. RN-B stated the care area assessments for cognitive loss/ dementia was lacking and acknowledged R13's CAA for falls and toileting contained more information addressing R13's behaviors. RN-B stated information for assessments was gathered from many sources including family, observations, and staff. RN-B showed the surveyor a Get to know me form where staff submitted their ideas and notes for R13's care. RN-B also referred to a type-written sheet (R13) Tips for her caregivers, which contained very specific approaches regarding R13's behaviors, wandering, and tips for giving medications and toileting. RN-B acknowledged they should have added these interventions and they had not completed a comprehensive assessment. RN-B stated there was no a specific behavior care plan for R13. The interview continued and RN-B stated there were no new formal assessments made regarding behaviors after R13 returned from the behavioral health stay. RN-B discussed the incident when R13 got an IM medications. RN-B stated upon return from the hospital, R13 had an order to use IM [MEDICATION NAME] for aggressive behaviors, and recalled communication with R13's doctor to clarify the orders. RN-B acknowledged the use of the IM medication given to R13 and stated since she was not present during the incident, was hard to comment on its use. RN-B stated the care plan did not specifically address use of the IM, or really detail what actions and interventions staff should take to addresses R13's behaviors. RN-B stated there was the doctor's order to use the IM for R13, but no protocol, steps or interventions to try first, only re-direction and re-approach. RN-B stated she realized the assessment is really not there. RN-B stated R13 was currently in a review period and those assessments is what I am working on. When interviewed at 1:06 p.m. on 11/29/18, the director of nursing (DON) stated at admission each resident was assessed, as was R13, to compile information, assess triggers and interventions of what is working, to build the resident care plan. The DON stated assessment information was gathered from the resident themselves, staff, from family, and in the case of R13, the DON stated the facility had a history with that resident. The DON stated staff were trying the care planned approaches for R13, but they were not working. The DON acknowledged R13's behaviors escalated, and the focus became making sure R13, other residents and staff were safe, and this ultimately lead to her behavioral health evaluation. Although from R13's prior placement history, and admission to the nursing home, R13 exhibited frequent and escalating aggressions toward staff. There was no indication a comprehensive assessment of R13's behaviors was completed to identify what the behaviors were, when they occurred, with whom, the frequency, antecedents, and discussion of why behaviors occurred. There was no indication of what interventions were consistently implemented and evaluated to determine if there were effective. Prior to her admission the(NAME)Oaks Pre Admission Assessment form dated 8/22/18, identified specific interventions to manage R13, which included utilizing consistent staff, complimenting R13 about her dress, making eye contact but there was no indication these were consistently implement nor was there any mention of these interventions on R13's care plan. As a result R13 behaviors continued to escalate to the point of R13 was hospitalized . Upon return from her hospitalization for behaviors, the facility did not re-assess and implement any behavior interventions. The lack of re-assessment, care plan and implementing interventions caused R13 behaviors to escalate, and caused harm when R13 had to be hospitalized for [REDACTED]. A facility policy, Dementia - Clinical Protocol, revised (MONTH) (YEAR), identified under Assessment and Recognition, the IDT (inter-disciplinary team) will review past and current physical, functional and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Under Cause Identification, the policy indicated, should psychiatric consult be needed to help manage behavioral issues, the IDT will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition and function, monitoring for complications related to treatment, and evaluating progress. And in the Monitoring and Follow-Up section, the policy directed: The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc.

Based on observation, interview, and document review, the facility failed to monitor, assess, and implement and/ or revise interventions to prevent pressure ulcers from developing, and to ensure healing of current pressure ulcers for 2 of 2 residents (R53, R14) reviewed for pressure ulcers. This resulted in actual harm for F53 who had recurring, multiple pressure ulcers. Findings include: R53 sustained harm when he developed two stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcers to the left and right heel, and a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer to the coccyx. The facility failed to monitor and comprehensively assess pressure ulcers as they developed; failed to notify the physician of the development of pressure ulcers to assure proper treatment; failed to obtain physician direction of treatments and to notify the physician when changes were made for treatment of [REDACTED]. R53's annual Minimum Data Set ((MDS) dated [DATE], indicated R53 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS also indicated R53 was at risk for developing pressure ulcers, but had no current pressure ulcers, and there were no pressures ulcers on the prior assessment. R53's pressure ulcer Care Area Assessment (CAA) dated 6/17/15, indicated R53 was, At risk for skin impairment and breakdown r/t (related to) s/p (status [REDACTED].(history) of PU (pressure ulcer) to heels. admitted (R53) to facility last year with (B) (bilateral) hamstring contractures which increases risk for pressure ulcers to heels/feet. R53's CAA also included, No current skin issues. Heels intact. The CAA included interventions including; staff to reposition R53 every two hours, have the resident wear heel protectors while in bed, use of an alternating pressure mattress and a cushion in the wheelchair, and skin monitoring with daily cares. R53's most recent quarterly MDS dated [DATE], indicated R53 continued to be at risk for pressure ulcers, and had one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) that was not present on the prior MDS assessment, dated 6/17/15. During an observation on 10/14/15, at 9:27 a.m., nursing assistant (NA)-B was assisting R53 with morning cares. R53 had a blue heel boot on the right heel, was wearing only a white sock on the left foot, and both heels were directly on the bed. R53's bottom sheet on the bed had numerous areas of drainage. NA-B removed the heel boot from the right heel, and there was a saturated dressing covering the lateral heel. NA-B then removed the sock from the left foot, which had a beefy red colored pressure ulcer approximately 2 cm, with 2 cm of surrounding tissue that had a pasty white color located on the medial left heel. NA-B stated she had never worked with R53, and she needed to find the nurse to have the pressure ulcer on the left heel covered. The blue heel boot for R53's left heel was observed laying in R53's recliner, and was not on his left heel. The blue heel boots were noted to be cloth foam boots which velcroed on the foot and leg, however, the heel was still touching the boot and pressure was not relieved from the heel (s)while wearing the blue boot. On 10/14/15, at 9:49 a.m. licensed practical nurse (LPN)-B entered R53's room per NA-B's request with dressings and a culturette. LPN-B removed the saturated dressing from the right heel and cultured the drainage on the right heel pressure ulcer. The right heel pressure ulcer was observed to be approximately 2-3 cm, beefy red, with surrounding tissue that had a pasty white color. LPN-B stated she worked with R53 daily, and knew about the pressure ulcer on the right heel however, she was not aware R53 had a pressure ulcer on the left heel also. LPN-B directed NA-C to summon registered nurse (RN)-C to assess R53's pressure ulcers on the heels. RN-C entered R53's room and stated she was aware R53 had a left heel pressure ulcer, but she was not aware it was open. RN-C observed R53's right heel pressure ulcer and identified it as a stage 3 pressure ulcer, and stated the right heel appeared Swollen however RN-C did not measure the right heel pressure ulcer. RN-C did measure the left heel pressure ulcer at that time and described it as, 4.5 centimeters (cm) in length with 2 cm open, and 3.7 (cm) width; with 1.2 c.m. actual open area. RN-C was unsure what stage the left heel pressure ulcer was. During interview on 10/14/15, at 10:29 a.m. LPN-B stated the nursing assistants should be informing the licensed staff if they note any resident skin concerns however, LPN-B was not aware of R53's left heel pressure ulcer until this morning and stated, No one had reported it.

Based on interview and document review, the facility failed to conduct assessment and implement interventions to prevent further potential for burns from coffee after 2 of 3 residents (R7 and R59) had sustained burns from spilled hot beverages, resulting in actual harm for R7 when burns were sustained a second time. In addition, Furthermore, the facility failed to ensure fall interventions were in place for 1 of 3 residents (R45) reviewed for falls. Findings include: R7 sustained second degree burns from spilled hot coffee on 11/23/13, the facility failed to implement interventions to prevent further burns for R7 and on 12/2/13, R7 sustained another second degree burns from spilled hot coffee, resulting in actual harm. R7's significant change Minimum Data Set ((MDS) dated [DATE], included [DIAGNOSES REDACTED]. The MDS indicated R7 had severe cognitive impairment and required extensive assistance with eating/drinking. The cognitive loss/dementia Care Area Assessment (CAA) dated 11/13/13, indicated R7's cognition varied considerably from being alert and oriented to extremely confused. The ADL (activities of daily living) functional/rehabilitation potential CAA dated 11/13/13, indicated R7 was declining in condition and started end of life hospice care. R7's care plan dated 1/21/14, identified R7 needed assistance with meals and encouragement with fluids. All hot liquids needed to be covered with lids related to resident's history of spilling hot liquids on self. When interviewed on 2/5/14, at 9:30 a.m. the assistant director of nursing (ADON) stated R7 could independently drink fluids, including hot beverages. R7's Resident Incident Report, dated 11/23/13, indicated R7 had spilled coffee on her lap on 11/22/13, in the facility dining room and sustained 0.5 c.m. (centimeter) blister on her right inner thigh. The blister was intact with no redness. According to the incident report, an ice pack was immediately applied to the burned area. No additional interventions were implemented after the resident burned her thigh. R7's Resident Incident Report, dated 12/2/13, at 3:00 p.m. included R7 was found in her recliner with her coffee cup in her lap. The resident stated, "I'm sorry, I fell asleep," then began crying a few minutes later. Blisters were found on her right inner thigh, measuring 0.7 cm X 1.8 cm, 0.2 cm X 4 cm and 0.5 cm X 2 cm. The blisters were open. An ice pack was applied. Additionally Mepiliex (a soft foam dressing that absorbs wound fluid) was applied to the area. The physician was contacted and ordered Silvadene ointment (a topical ointment used to treat and prevent bacterial infection in second and third degree burns) to be applied to the area daily. Staff were instructed to, "Cover all hot liquids-Required." A progress note from the hospice staff dated 12/3/14, indicated R7 was having pain from the burned area. R7's progress note dated 12/4/13, indicated the blister area to the right inner thigh measured a total of 10 cm X 3 cm and there were additional 2 smaller blisters that were intact on the outer edges. The large blister had opened and had beefy red area noted to the wound bed. Although R7 had two separate incidents of second degree burns from coffee, the facility had not assessed her to determine if she could safely handle hot beverages independently at the current temperature. R59 sustained redness to skin from spilling hot chocolate on himself on 10/9/13, the facility did not implement measures to prevent burns for R59 and on 10/10/13, R59 sustained another incident where hot chocolate was spilled which could have caused burns to skin. R59's quarterly MDS dated [DATE], included a [DIAGNOSES REDACTED]. R59's care plan dated 1/6/14, identified cover cups for all fluid especially hot fluids, set up tray and assist with meal as needed. R59's Resident Incident Report dated 10/9/13, at 5:30 p.m. included R59 had sustained a burn from hot chocolate while in the dining room. No interventions were placed to ensure R59 would not spill hot liquids on himself again and suffer additional burns. R59's progress notes dated 10/9/13, indicated R59 dropped his hot chocolate onto his upper thighs. He sustained slight redness to the area with no evidence of blistering. An ice pack was applied. R59's Resident Incident Report dated 10/10/13, at 5:15 p.m. indicated R59 again spilled hot chocolate onto his lap. An ice pack was placed on the, "burned area of his thighs." His thighs were red but the redness was, "gone by HS (bedtime)." As result of the second incident, staff recommended all liquids should have covers. Although R59 had two separate incidents of spilling hot chocolate, the facility had not assessed him to determine if she could safely handle hot beverages independently. When interviewed on 2/5/14, at 11:45 a.m. the director of nursing (DON) stated she was aware R7 and R59, had all sustained burns from hot liquids. The DON added that R7 and R59 were assessed to require covers on their hot beverage containers, but was not implemented until after the 2nd incidents. Temperatures of the hot beverages were tested with the DM on 2/5/14, at 11:51 a.m. The Cafitesse 3000 automatic coffee/hot liquid dispenser was found in the open main dining room, which served 43 residents of varying cognitive and mobility impairment levels. The DM estimated 40 of the residents were capable of drinking hot beverages independently. The DM checked the temperature of the hot beverages and the coffee was 161 degrees Fahrenheit (F), the decaffeinated coffee was 169 degrees F, hot water was 163 degrees F and hot cocoa was 147 degrees F. A facility policy dated 8/2013 Adaptive Feeding Equipment, identified, "Residents will be provided with adaptive feeding equipment upon assessment by the licensed nursing and therapy staff." The procedure includes, "Resident with limited and fine motor skills or tremoring of the hands/arms, at risk for spills, will be assessed for the appropriateness of covered cups for liquids to prevent spills..." R45 had sustained five falls while attempting to take herself to the toilet. The facility failed to ensure staff assisted her to the toilet, and used appropriate foot wear as directed by her care plan. R45's admission Minimum data set ((MDS) dated [DATE], identified the resident had no cognitive impairment, required extensive assistance with toileting, and had a history of [REDACTED]. During observation on 2/4/14 at 9:19 a.m. R45 was observed walking in the hallway wearing a transfer belt being assisted by an (unknown) nursing assistant (NA). The resident was walking quickly and had a slight shuffle when she walked. R45's care plan dated 12/30/13 identified the resident was at high risk for falls related on dependence on staff for transfers and toileting, impaired cognition, medications, and many falls at home. The care plan indicated the resident was independent with bed mobility, transfers and ambulation, locomotion in wheelchair in room and out of room "depending on residents condition," and resident was to wear grippy socks or shoes on at all times. R45's toileting plan included resident was frequently incontinent of urine, with most incontinence seen during the night. Toileting plan adjusted to include staff assist to toilet on routine night rounds. The care plan instructed staff to assist to the bathroom every two hours, on night rounds, and make sure to wake on 4:00 a.m. rounds and as needed per her request. Upon review of R45's falls on the Resident Incident Report indicated the following: 11/23/13 at 7:20 a.m.- "Resident found sitting on butt in bathroom. Resident stated she was going to bathroom and slowly slipped to floor... had regular socks on feet." The immediate intervention identified was to ensure "grippy socks" were on at night. The incident report indicated the resident had last been toileted during, "last rounds." During interview on 2/5/14, at 5:15 p.m. registered nurse (RN)-B stated R45 was on a toileting program of being toileted every two hours. RN-B stated there was no way to tell according when the resident had last been toileted, however, she had assumed it had been between 5:30 a.m. and 6:00 a.m., as that is when last rounds was, "Usually," completed. 12/20/13 at 2:20 p.m.- "Resident found sitting on her buttocks in bathroom floor and states she was backing up to the toilet and sat down too soon..." The resident was only wearing regular socks at the time. The immediate intervention at that time was to remind resident to ask for assistance if she, "feels she needs it," and to look back at the toilet before sitting down. There is no indication of when the resident had last been assisted with toileting. During interview on 2/5/14, at 5:15 p.m. RN-B stated R45 was reminded to ask for assistance at that time. RN-B verified there was no indication of when the resident had last been assisted to the bathroom with staff. 12/30/13, at 2:00 p.m.- "Found in bathroom. Sitting on her bottom on the floor in front of toilet in a sitting position... admits to hitting head... wearing socks at time of fall." Immediate intervention at this time was to wear gripper socks or shoes at all times. The incident report indicated, "self toileted at 1:00 p.m." A follow up Resident Progress Note dated 12/30/13, at 3:35 p.m. indicated, "Writer called to resident room approximately 3:15 p.m. with reports resident having emesis. Resident continued to have emesis with dry heaves. Resident noted to have fall approximately 2:00 p.m. where she hit her head on the toilet. Neuros started at 2:00 p.m. and it was noted her systolic blood pressure went from 118 to 160-170's. Also noted temperature went from 97-98.7 in a short amount of time. No injuries noted at time of fall and at 3:15 p.m. resident noted to have swelling to right side of back of head... send to emergency room (ER)..." Follow up Progress Note on 12/30/13 at 6:46 p.m. from the emergency room nurse indicated there were no findings at the ER and resident returned to the facility that evening. During interview on 2/5/14, at 5:15 p.m. RN-B stated R45 toileted herself and often did not ask for help. RN-B stated R45 should have been assisted by staff with toileting every 2 hours. 1/13/14, at 7:50 a.m.- "Resident alerted staff with call light at 7:50 a.m., when writer entered room resident was sitting on floor next to bed with walker in front of her, reported she had been tangled up in her bedding... assisted to bathroom." Resident had bare feet at the time of the fall. The incident report indicated the resident had last been toileted at 3:00 a.m. During interview on 2/5/14, at 5:15 p.m. RN-B stated R45 had been care planned to be toileted every two hours and have gripper socks on at all times. RN-B verified the report indicated R45 had not been toileted since 3:00 a.m., 4 hours and 50 minutes before the fall, and also the resident did not have any gripper socks on as care planned. RN-B stated she had no further information regarding why this had not been done. 1/26/14 at 7:20 a.m.- "Found sitting on floor in room between bathroom and hallway door...slipped onto bottom... wearing regular socks at the time of the fall." The incident report indicated the resident was last toileted and repositioned "per self" and "needed gripper socks on at all times or shoes." During interview on 2/5/14, at 5:15 p.m. RN-B stated she was unsure why the resident had not been toileted or did not have gripper socks on at the time of the fall. RN-B stated R45 had been assessed as needing toileting with staff assistance every two hours, however, she believed that staff may be just checking on the resident at the beginning of their shift to see if the resident is strong enough to toilet herself that day. During interview on 2/4/14, at 9:13 a.m. nursing assistant (NA)-B stated R45 can be independent with toileting and staff will ask her if she feels weak or not that day. If she is weak staff will assist her with toileting. During interview on 2/4/14 at 9:43 a.m. NA-A stated staff will check with resident about every two hours to see how she feels in regards to toileting herself. Although all of R45's falls were related to self toileting, the facility failed to ensure the fall interventions which were put in place were being followed or appropriate. A facility fall policy was requested but not provided.