Every finding on record at Glenwood Village Care Center

Based on interview and document review the facility failed to ensure the resident representative was notified of new bruising for 1 of 3 residents (R3) reviewed.Findings include: R3's quarterly Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included dementia and hemiplegia (one-sided weakness or loss of function to the face, arm, and/or leg). R3 needed total assistance with transfers and personal hygiene. R2's progress note dated 10/30/25 at 12:51 p.m., written by licensed practical nurse (LPN)-A, indicated R3 had 2 new bruises found on R3's left outer elbow. During an interview on 11/5/2025 at 11:56 a.m., family member (FM)-A R3's responsible party stated he was unaware of bruising on R3's left elbow. FM-A stated he had told the facility he wanted to be called with any changes R3 had and the facility never called him. He was upset as this was not the first time he had not been called when a change had occurred for R3. On 11/5/2025 at 12:13 p.m., LPN-A stated on 10/30/25, she found two dark purple bruises on R3's left elbow, LPN-A did not update R3's son on the new bruises, but she should have. On 11/5/2025 at 3:25 p.m., the director of nursing (DON) stated when a new injury or change is found on a resident that the family should be updated. R3's son should have been updated but was not. Review of facility policy titled Change In a Resident's Condition of Status dated 12/10/24, indicated the facility would promptly notify the residents representative of any change to the resident's status.

Based on observation, interview, and document review, the facility failed to implement immediate interventions to prevent re-occurrence following a fall from a full body (EZ Way) mechanical lift for 1 of 1 residents reviewed (R4) who sustained two brain bleeds and a fracture. This resulted in an immediate jeopardy (IJ). In addition to the resident in immediate jeopardy, the facility failed to implement person centered fall interventions and complete a fall analysis for 1 of 3 residents reviewed (R1) who had multiple falls and fractures identified which resulted in actual harm.The immediate jeopardy began on 10/16/25, when R4 returned to the facility from a hospital stay related to her injuries that were sustained after she fell from the fully body mechanical lift during a transfer and upon returning from the hospital there were no immediate interventions implemented to prevent re-occurrence, and was identified on 10/20/25. The administrator, director of nursing (DON), and assistant director of nursing (ADON) were notified of the immediate jeopardy at 6:15 p.m. on 10/20/25. The immediate jeopardy was removed on 10/22/25, but noncompliance remained at the lower scope and severity level 3, G scope and severity level, which indicated actual harm that is not immediate jeopardy.Findings include:R4's quarterly Minimal Data Set (MDS) dated [DATE], indicated R4 had diagnoses which included hereditary and idiopathic neuropathy, polyneuropathy, chronic kidney disease stage 3, anxiety disorder, and morbid obesity.R4's care plan dated 3/16/25, indicated R4 had actual impaired functional status related to impaired gait and mobility, neuropathy, osteoarthritis, depression, opioid use, antipsychotic use and required staff assistance with transfers using Hoyer (full body mechanical lift) assistance of two staff members and a large sling. R4's care plan was revised on 10/19/25, three days after R4 returned to the facility on [DATE], to include Hoyer sling to be removed from underneath resident after every transfer.R4's Fall-witnessed report dated 10/14/25 at 2:35 p.m., indicated writer was alerted to a resident fall that occurred in the resident's room during a transfer from a lift. A small amount of blood was noted on the floor, as well as on the resident's [R4] left ear and the left lower head just above the hairline. The resident was alert and oriented and verbalized just get me off the floor. Range of motion was limited but within normal limits per her usual restrictions. The resident reported mild pain to the left posterior shoulder and right knee. The resident refused to have vital signs obtained prior to being assisted from the floor. A lift sheet was properly positioned, and the resident was assisted from the floor using a Hoyer lift with assistance from four staff members. Resident and staff were interviewed following the incident. The care plan was followed at the time of the fall, and the staffs transfer technique was observed immediately after the fall with no concerns noted. The resident was able to answer questions appropriately and participate in the assessment. R4's progress notes revealed the following:-On 10/14/25 at 2:35 p.m., R4 was being transferred with assist of two staff members and R4 fell from the lift.-On 10/15/25, R4 was transferred to another hospital related to bleeding in the brain.-On 10/15/25, R4 was admitted to another hospital related to diagnosis of Traumatic subarachnoid and subdural hemorrhage. No tentative return date at this time. -On 10/16/25, R4 returned to the facility at approximately 2:15 p.m., from the hospital. R4 was admitted for intracranial bleeding due to fall. Transfers with Hoyer lift and assist of two staff with a medium sling.-On 10/19/25 at 12:43 p.m., a RN (registered nurse) Post Fall Follow-Up was completed. R4 continued to have pain in neck and right leg/knee. New intervention initiated was Hoyer sling to be removed from under resident after all transfers are completed and to be replaced behind resident for any further transfers. This would ensure sling is properly placed behind resident with every transfers. Root cause of resident's fall was determined to be the sling may not have been properly positioned behind resident while resident was being transferred resulting in resident not being secured.On 10/19/25 at 3:52 p.m., R4 transferred to the emergency room (ER) due to possible DVT (deep vein thrombosis).On 10/19/25 at 9:10 p.m., R4 returned to the facility by ambulance. R4 was diagnosed with peri-prosthetic distal transverse femur fracture. New orders to wear knee immobilizer whenever movement was occurring and Hydrocodone every 4-6 hours as needed for pain.On 10/16/25 at 9:14 a.m., family member (FM)-A stated they were notified following the fall from the lift and R4 was brought to the ER and then transferred to another hospital due to two brain bleeds. FM-A stated R4 was unsure what happened or what caused the fall.On 10/16/25 at 9:29 a.m., nursing assistant (NA)-A stated R4 required assist of two staff members and utilized a Hoyer lift for transfers. NA-A stated on 10/14/25 at approximately 2:30 p.m., R4 put on her call light and requested staff assistance with incontinence cares. NA-A stated she transferred R4 out of her electric wheelchair into R4's bed with assistance by NA-B, and there were no issues. NA-A stated staff then hooked R4 back up to the Hoyer lift and were going to transfer R4 from her bed back into her wheelchair, when R4 fell out of her sling and onto the floor. Further, NA-A stated the loops on the sling remained attached to the lift, the legs of the sling were crossed, ensured the sling was covering R4's body appropriately shoulder and below tailbone, and the sling was intact. NA-A stated R4 was complaining of pain on her ear and her knee following the incident and R4 was sent to the ER. In addition, NA-A stated since the incident there has been no interventions implemented to prevent re-occurrence or changes to R4's care plan as well as no training or education provided to staff.On 10/16/25 at 11:20 a.m., email was received from director of nursing (DON) stating she monitored all staff who were currently working during the transfer audits, answered questions, and provided education if needed. DON stated the facility would review the incident and educate all staff at the mandatory nursing department meeting that was scheduled for 10/29/25.On 10/16/25 at 11:49 a.m., NA-B stated R4 was dependent on staff for all activities of daily living (ADLs) and required assist of two staff and a Hoyer lift for transfers. NA-B stated on 10/14/25 at approximately 2:45 p.m., NA-B was assisting NA-A transferring R4 from her bed back into her wheelchair after assisting R4 with incontinence cares. NA-B stated staff hooked R4's sling back onto the lift, lifted resident off the bed and pulled the lift away from the bed when R4 began to giggle and went through the sling, her [R4] butt went through the opening of the legs which were crossed. NA-B stated R4's care plan identified R4 required the use of a size large sling for the Hoyer lift, but NA-B stated R4 should be switched to a size medium because the size large appeared to be too big. NA-B stated R4 fell through which resulted in R4 hitting her leg first on the ground then R4 hit her head on the Hoyer lift and R4 was sent to the ER. Further NA-B stated she reported to the DON following the incident NA-B's concern regarding R4's sling size and the large was too big for R4. In addition, NA-B stated there had been no changes to R4's care plan since the incident and no education or training was completed following the incident.On 10/16/25 at 12:51 p.m., NA-C stated R4 required assist of two staff for transfers utilizing a Hoyer lift and a large sling. NA-C stated R4's size large sling is too big for R4. The top of the sling went over her head and the bottom of the sling was above the butt area or lower back. NA-C stated an appropriate size sling would included the top of the sling at the resident's shoulder and the bottom of the sling would be around their butt. Further, NA-C stated she did not report the concerns of R4's sling size to management but knew another staff had. NA-C stated she had heard R4 had laughed which made her fall through the sling. In addition, NA-C stated there had been no education, training or new interventions since the incident. On 10/16/25 at 1:18 p.m., NA-D stated R4 required assist of two staff and a Hoyer lift for transfers. NA-D stated she heard R4 had fallen from the lift during a transfer and hit her head, and staff were stating R4's sling did not fit her appropriately and the large sling was too big for her. NA-D stated R4 slid through the bottom of the sling and NA-D stated the actual cause of the fall was the improper use of the sling and staff did not have it underneath her the right way. Further, NA-D stated she had transferred R4 many times utilizing a large sling and NA-D did not have any concerns regarding the sling size and stated the large was appropriate and sometimes staff needed to readjust the sling under her to fit appropriately before transferring R4. In addition, NA-D stated a sling is an appropriate fit when the top of the sling was at the resident's shoulders and the bottom of the sling was a little below the butt.On 10/16/25 at 2:02 p.m., NA-E stated R4 required assist of two utilizing a Hoyer lift and size large sling for transfers. Further, NA-E stated a size large sling was appropriate for R4 and the medium was too small. NA-E state sling size was determined by the resident's weight and the top of the sling should be at the resident's shoulders and the bottom should be at the middle of their butt.On 10/16/25 at 3:12 p.m., NA-A stated she had no concerns with R4's sling size large and the sizing was appropriate as the top of the sling was at her shoulders and the bottom was at the middle of her butt.On 10/16/25 at 3:42 p.m., registered nurse (RN)-A stated R4 required assist of two staff utilizing a Hoyer lift and a large sling for transfers. RN-A stated she had transferred R4 using the large sling and did not have concerns regarding sling size, and RN-A stated she was not aware of any staff concerns regarding R4's sling size. RN-A stated she heard R4 had fallen from the lift during a transfer and was sent to the hospital due to a brain bleed. RN-A stated R4 returned to the facility on this day (10/16/25) and staff were going to try to use a medium sling instead of a large sling for R4. Further, RN-A stated sling size was determined by reviewing the manufacturers guidelines for weight and R4's weight allows her to use a medium or a large sling according to the guidelines.On 10/16/25 at 4:49 p.m., DON stated she was made aware of R4's incident immediately and began investigating what had happened. DON stated she inspected the sling R4 had been using at the time of the incident and the sling was the appropriate size and there were no defects noted. DON observed NA-A and NA-B assist R4 off the floor and back into her wheelchair and there were no concerns with the transfer. Further, DON stated she had determined the root cause of R4's fall from the lift was R4's clothing selection. DON stated R4 was wearing a night gown style clothing, a large baggy sweater over top, and due to R4's weight and material of the sling, this had caused R4 to fall through the lift. DON stated following the incident, audits were completed on all residents residing in the facility who utilized a Hoyer lift which included reviewing the care plans to ensure care plan matched appropriate sling size as well as observing staff transfer the resident. In addition, DON stated there was no other interventions implemented for R4's transfers and all staff education would be completed at the all-staff meeting.On 10/16/25 at 5:09 p.m., EZ-Way (Hoyer lift company) sales representative (SR)-A stated they were made aware of R4's incident and reviewed R4's face sheet and determined a size large sling would have been an appropriate size for R4. Further, SR-A stated if nothing during the transfer malfunctioned and the sling remained intact and the loops attached during the transfer, the concern would have been the positioning of the sling under the resident and for the resident to fall through the sling with the leg straps crossed would have been the sling was positioned too high and above the tailbone, which would had resulted in the resident's bottom sticking through the bottom of the sling.On 10/17/25 at 9:48 a.m., DON stated the nurse manager of each unit would be expected to assess each resident for appropriate sling size which would be based on the resident's weight. Further, DON stated an appropriate sling would be positioned at the top of the resident's shoulders and to the middle of their buttocks. In addition, DON stated staff do measure a resident for appropriate sling size, it was based off the resident's weight.On 10/17/25 at 11:58 a.m., R4 was observed laying in her bed. DON used a soft tape measure and measured from R4's base of neck to two inches below her tailbone and stated it was 26 inches. DON stated staff had not switched R4 to a medium sling yet as indicated in R4's progress notes and R4 continued to utilize a size large. DON and NA-D attach the sling loops to the Hoyer lift and DON operated the machine while NA-D guided R4. R4 appeared to be positioned well in the sling as the top of the sling was at R4's shoulders and the bottom was below the tailbone.On 10/21/25 at 1:52 p.m., R4 was in the hallway on her electric scooter and there was no sling under her.On 10/21/25 at 1:58 p.m., trained medication aide (TMA)-A stated as of 10/19/25, staff were directed to remove R4's sling after transfers to ensure staff are double checking sling placement and the sling was intact.On 10/21/25 at 2:00 p.m., licensed practical nurse (LPN)-A stated this was her first day on R4's unit since the incident and LPN-A was notified through report, staff were to remove the sling from under R4 following each transfer.On 10/21/25 at 2:28 p.m., surveyor requested education provided to staff related to R4's care plan revision and new intervention as well as any other education that was completed.On 10/21/25 at 3:20 p.m., R4 was in her room in her wheelchair and stated as of 10/20/25, staff now remove the sling from under her after each transfer.On 10/21/25 at 3:23 p.m., NA-F stated she often will start her shift and check on R4 and noticed R4's sling is under her and the top part of the sling is above her head and not at her shoulders like it's supposed to be. NA-F stated she would report her concerns of sling positioning to the floor nurse but did not report to management.On 10/21/25 at 4:53 p.m., surveyor again requested evidence of staff education related to R4's intervention and DON stated she was waiting on the nurse manager to give her the copies. Facility failed to provide a copy of education. On 10/22/25 at 1:13 p.m., medical director (MD) stated he was made aware of R4's fall and R4 was sent to the ER and then admitted to the hospital related to a head injury. MD stated after R4 returned to the facility R4 continued to complain of pain in the lower right extremity and was sent to the ER where she was diagnosed with right distal fracture of the femur.Review of Sling Sizing Chart provided by EZ Way, undated, indicated the size/weight designations were merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit would involve the judgement of the caregiver. Further, it was important that the base of the sling be positioned two inches below the tailbone and the top of the sling was parallel with the top of the shoulder line (base of neck).Review of facility policy titled EZ Way Smart Lifts revised 1/14/25, directed staff to ensure all hooks are securely fastened before lifting resident, assist of two caregivers to assist with transfers for resident safety, and check the condition of the sling before every use by checking entire sling for damage or wear. When the lift was completed, disconnect the straps from the lift bar and remove sling by raising leg and pulling along the sides. However, facility policy lacked staff direction on proper sling placement prior to transfer and during transfer.The immediate jeopardy that began on 10/16/25, was removed on 10/22/25, when the facility completed the following: audited R4's lift equipment to ensure the sling was the appropriate size and in good condition, DON observed a transfer with the staff and R4 to verify the resident was positioned safely and securely in the sling, R4's care plan was revised and directed staff to now remove the lift sheet immediately following each transfer, R4 would have a lift assessment conducted quarterly to ensure type of lift and sling remain appropriate, all staff educated on concerns regarding transfers and R4's intervention, and all staff have been re-educated per manufacturer's guidelines regarding proper sling application, loop selection, lift safety, and escalation procedures if concerns arrive, but the noncompliance remained at the lower scope and severity level 3.R1's quarterly MDS dated [DATE], indicated R1's diagnoses included supraventricular tachycardia, abnormalities of gait and mobility, anxiety disorder and Alzheimer's disease. Further, MDS revealed R1 had one fall with no injury since previous assessment.R1's care plan initiated 6/5/25, identified R1 was at high risk for falls related to diagnosis of anemia, impaired range of motion, anxiety, depression, poor communication/comprehension, dizziness with standing related to supraventricular tachycardia, unaware of safety needs, vision/hearing problems as exhibited by the need for a walker to stabilize, history of falls with major injury, difficulty with sitting balance and transitions, confusion, gait/balance problems and incontinence. R1's goal was to be free of falls through the review date and R1's interventions included: not to be left alone in dining room after meals, assist to toilet after meals and offer resident to join an activity, assist resident with p.m. cares and transfer to bed between 9-10 p.m., toileting schedule upon waking, before and after meals, and at hour of sleep and 2:00 a.m., staff assist of one with gait belt and 4-wheeled walker for all transfers/ambulation, assist R1 into her pajamas earlier in the evening to prevent her from doing this herself, call light within reach and encourage her to use it, appropriate non-slip footwear when ambulating, sign attached to walker reminding R1 to utilize, and medications as ordered for her diagnosis of supraventricular tachycardia. Further, R1's care plan identified R1 had exit seeking behaviors and will go from door-to-door looking to leave the facility and directed staff to redirect, offer an activity and reapproach with a different staff member.R1's Fall Incident Report dated 9/26/25, indicated R1 was observed to have lost her footing with her right leg and fell sideways onto her left side of body but did not hit her head, witnessed by nurse and dietary aid. Approximately 30 minutes prior, R1 was assisted to the floor by the nurse when R1 lost her footing by the exit door, R1 was exit seeking. R1 was assessed and checked for injury, and none were noted at the time, and R1 did not allow staff to visually assess her and take vital signs as R1 was very angry. R1 was utilizing her walker at the time of the incident. Further, R1 was angry and wanted to go home so R1 walked fast with walker and her right foot seemed to give way when she was walking fast and was not paying attention because R1 was angry and would not redirect. Staff attempted to assist R1 to her recliner after the first incident and R1 refused any care offered. In addition, the incident report lacked evidence of a root cause analysis review completed by the interdisciplinary team (IDT) and lacked evidence of a new person-centered intervention to prevent future falls.R1's Fall Incident Report dated 10/5/25, Resident was found sitting on floor with her legs extended and back was resting on side of her bed. R1 was unable to state what had happened and continued to state she wanted to go home. R1 was assessed for injury and non were noted at the time of the incident. R1 was assisted off the floor with a mechanical device and R1 had a pre-existing left arm fracture. R1's bed was noted to be in low position and R1 had transferred without assistance. Further, R1 tended to sundown and start exit seeking and R1 had been noted to be very confused that evening, refused meals, medications and care. In addition, the incident report lacked evidence of a root cause analysis review completed by the interdisciplinary team (IDT) and lacked evidence of a new person-centered intervention to prevent future falls.R1's Progress Notes revealed the following:-On 9/23/25, R1 complained of right side back pain near their ribs. No bruises or marks were observed in the area. R1 was offered pain medications and R1 declined.-On 9/24/25, R1 was seen by her primary doctor and R1 denied having any questions or concerns.-On 9/26/25, R1 has had an increase in reporting and signs of lower back/rib pain. R1 had been given as needed Tylenol more frequently as well due to right lower back/rib pain. Family requested that R1 have an x-ray completed. May we have orders for portable x-ray services to come to facility and do 2 views of the right side of the ribs and lower back, to rule out any possible fractures. Please advise.-On 9/26/25, R1 had a fall in the hallway. R1 was very angry and agitated, the hall was calm, area clean. R1 had landed on her left side and did not hit her head. No apparent injuries were noted and R1 denied pain. R1 had a near fall 30 minutes prior to this fall and the nurse had to lower R1 to the floor. R1 walks very fast when she was angry and her right left noted to give way and fell to the left. R1 would not allow for nurse to observe her skin or obtain vital signs. R1 was assisted to sit in her recliner then later assisted to recliner in commons area to keep resident within view.-On 9/27/25, portable x-ray services called to come to facility and x-ray R1's lumbar spine and right ribs.-On 9/29/25, family meeting R1 at the clinic for an appointment-On 9/29/25, call placed to radiology department, no results yet from imaging performed to resident's arm today.-On 9/30/25, family called to report she had set up an appointment for 9/30/25 for a follow up orthopedics appointment related to R1's x-ray results.-On 9/30/25, R1 had x-ray done to the left elbow and shoulder. Results will be faxed over from radiology.-On 10/1/25, spoke with clinic and orthopedic specialist and appointment scheduled to apply splint to left arm.-On 10/2/25, physician visit note revealed assessed pain in left upper extremity, noted left elbow skin tear and left elbow radial head fracture.-On 10/3/25, R1 complained of hurting all over and an ice pack was applied to left arm.-On 10/4/25, R1 was agitated and wanting to go home, complained of pain. R1 observed by staff member attempt to stand without assistance, because she wanted to go home, R1 was assisted to wheelchair due to weakness and previous fall with fracture to left arm.-On 10/5/25, R1had a fall in resident's room. R1 was observed to be sitting on the floor next to her bed and her back was resting on the bed. R1 had an existing left arm fracture, and no other injury was noted. R1 had been agitated all evening wanting to go home. R1's bed was in lowest position, frequent checks were performed, and one to one staff was implemented.-On 10/5/25, R1 was transferred to the ER and admitted to the hospital.R1's progress notes lacked evidence of IDT root cause analysis following two falls on 9/26/25 and the one fall on 10/5/25. In addition, there also was not evidence of new interventions implemented to prevent future falls and injuries. R1's Patient Report, from portable x-ray company, dated 9/28/25, indicated R1 had pain after fall and findings included right lateral 8th and 9th rib fractures.R1's Office Visit note dated 10/2/25, indicated R1 had multiple falls recently last week. R1 had an x-ray of her left elbow that showed a radial head fracture, which was nondisplaced. R1 was referred to our office for definitive management of the fracture. The patient right now states there was no pain over the elbow and denied range of motion deficits of that elbow. However, there was a skin tear of the left elbow. On 10/15/25 at 1:06 p.m., family member (FM)-A stated R1 would have frequent falls and R1 would not always report her falls to the staff at the facility. FM-A stated she was not aware of interventions the facility staff were attempting to prevent falls other than there was a sign on R1's walker. Further, FM-A stated R1 had three falls in a short period of time and R1 did sustain fractures of the ribs and elbow from the falls.On 10/15/25 at 2:51 p.m., LPN-B stated R1 had impaired cognition and would often become agitated and attempt to leave and exit seek in the evenings. When R1 would exhibit these behaviors, LPN-B stated R1 would often lose her gait and had falls. LPN-B stated R1 was at risk for falls and R1 had reported falls to her granddaughter that R1 had not reported to staff before. LPN-B stated she was working when R1 had the two falls on 9/26/25, and following the falls LPN-B stated staff were watching her closely as an intervention but was not aware of any care plan changes for long term interventions following those two falls. Further, LPN-B stated she was also working on the 10/5/25 fall and R1 did not complain of pain at the time but had a pre existing left arm fracture, and staff were completing frequent checks through out the night and again LPN-B could not recall any new interventions implemented following that fall as R1 was admitted to the hospital and returned to the facility on Hospice services.On 10/15/25 at 3:21 p.m., NA-A stated R1 was at risk for falls and NA-A stated I don't think we really had many to be honest when asked what interventions staff would implement to prevent R1 from falling. NA-A stated R1's door to her room would be kept open and staff would check on her and assist with cares as needed. NA-A stated she was working the overnight on 10/5/25, and at approximately 1:00 a.m. NA-A found R1 on the floor and R1 was last seen at 11:30 p.m. sleeping in her bed.On 10/16/25 at 11:49 a.m., NA-B stated R1 exhibited behaviors of wandering and attempted to escape out of the doors. NA-B stated R1 was identified as a fall risk and stated, she didn't have many interventions for falls, and staff were directed to keep R1 close to the nursing station, bring her to activities, and R1 had a toileting schedule. Further, NA-B stated fall interventions were in the resident's care plan for staff to reference.On 10/16/25 at 12:51 p.m., NA-C stated R1 appeared to be more confused in the afternoon into the evenings and R1 often would express wanting to go home. NA-C stated staff would attempt to redirect her, offer activities, assist with walking, or provide a one-to-one staff to de-escalate behaviors. NA-C stated R1 was at risk for falls and staff were directed to leave walker within reach, keep room door open, and had a toileting program. Further, NA-C stated R1 has sustained rib fractures and an arm fracture from recent falls.On10/16/25 at 3:42 p.m., RN-A stated R1 appeared to be confused and would attempt to exit seek and self-transfer. RN-A stated R1 was at risk for falls and interventions included assist R1 with nighttime care, transfer to her bed between 9-10 p.m., toileting schedule, walker with a sign attached, appropriate footwear while ambulating and keep her call light within reach even though she would not utilize her call light. RN-A stated R1 had two falls that occurred on 9/26/25, the first fall was due to weakness and the second fall was R1 lost her footing. RN-A stated she reviewed both falls and the long-term intervention was to have R1 out in the recliner in the commons area within view, however RN-A could not give further detail on when staff would be directed to implement this intervention, and the intervention was not communicated to staff and R1's care plan was not revised. Further, RN-A stated the root cause for R1's fall on 10/5/25 was R1 was agitated all evening and refusing care, and RN-A stated there was no long-term intervention implemented due to R1 being transferred to the hospital and returning to the facility on hospice. In addition, RN-A stated facility process for falls included RN-A reviewing each fall and determining a root cause, and reviewing the immediate intervention staff implemented for appropriateness and adjusting intervention if not appropriate. RN-A confirmed a RN follow up note which would include the root cause analysis of the fall, IDT input, and a new intervention was not completed for R1's three falls per facility protocol.On 10/16/25 at 4:49 p.m., DON stated R1 had a fall at the end of September in the hallway and R1 did not have any injuries at the time. DON stated R1 had self-reported a fall to staff and she was having pain, however there were no reports of R1 having a fall and DON was questioning if R1 had fallen into something. R1 obtained x-rays which revealed rib fractures and an elbow fracture. DON stated R1 had another fall from her bed and was sent to the hospital and returned on palliative care. Further, DON stated the nurse manager on the unit would be responsible for reviewing each fall and completing a follow up note with an intervention. DON stated the floor staff would be expected to implement an immediate intervention until the nurse manager reviewed the fall and determines an appropriate intervention and then updates the resident's care plan and communicates revisions in the nurses' report.On 10/16/25 at 5:29 p.m., surveyor receive email from DON which revealed: After reviewing the fall that occurred on 9/26, it was noted that the nurse on duty implemented an intervention to keep the resident within view in the common area. However, upon further review with the nurse manager responsible for the resident at the time, it was identified that an RN fall follow-up was not completed. We will be proceeding with progressive counseling for the RN regarding this incident and will provide education to all staff on appropriate fall interventions during our next team meeting on 10/29. On 10/17/25 at 9:48 a.m., DON stated prior to R1's fall on 9/26/25, R1 had been reporting she fell but there was no bruising noted to the area. On 9/26/25, there was a progress note regarding increased rib pain. DON stated she was made aware of R1's rib fractures on 9/29/25, and DON stated she was assuming R1 had fallen against something because there was no evidence of other falls. DON stated she interviewed a couple of the nurses who were not aware of any additional falls, and DON stated she should have investigated the fractures more following that. Further, DON confirmed R1's two falls on 9/26/25, did not have evidence of a RN follow-up note or new interventions implemented to prevent future falls. DON stated R1 had an x-ray of her arm following the fall on 9/26/25, and DON reviewed the radiology report and interpreted as not being a definite fracture but more than likely the fracture would have been associated with R1's fall. DON confirmed R1's fall that occurred on 10/5/25, did not have an RN follow-up completed either with a root cause analysis or new intervention. On 10/16/25 at 11;06 a.m., LPN-C stated R1 would exhibit sundowning behaviors and want to leave the facility and R1 would be challenging to redirect. LPN-C recalls R1 reporting she had fallen but there was no documentation by staff of any other falls because no staff had found her, R1 just kept reporting she fell. On 10/16/25 at 11:19 a.m., NA-G stated R1 had impaired cognition and was at risk for falls. NA-G stated staff were assuming R1 was falling and not reporting the falls to staff. NA-G stated she had heard noises coming from R1's room but upon arrival R1 was not on the floor and R1 would deny a fall. On 10/21/25 at 10:42 a.m., attempted interview with R1's physician unsuccessful. Review of facility policy titled Fall Prevention and Management revised 6/11/25, defined an intercepted fall as when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another p

Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 63 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date. Findings include: During the initial tour of the main kitchen and kitchenettes on 5/19/25 at 11:22 a.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A: kitchen refrigerator: -Thirteen sandwiches were covered with plastic on a try, undated. -one bag cabbage wrapped, undated. Ruby Ridge kitchenette refrigerator: -tray with six small dishes of sherbet, uncovered and undated in freezer. -seven pasteurized eggs in bag undated. -cocktail sauce opened dated 1/31/25. -french dressing opened dated 4/3/25. -soy sauce opened, undated. -sweet and sour sauce, initialed, undated. -ranch dressing opened, undated. -barbeque sauce opened, undated. -ketchup opened, undated. -mustard opened, undated. Golden Meadow kitchenette refrigerator: -cocktail sauce opened dated 1/31/25. -ketchup opened, undated. Sunrise Cove kitchenette refrigerator: -cocktail sauce opened, dated 1/31/25. -french dressing opened, dated 1/13/25. -ranch dressing opened, dated 2/11/25. -soy sauce opened, undated. -ketchup opened, undated. Sunrise Cove resident refrigerator: -Chinese dish of food, not labeled, undated. -small cardboard container, initialed, undated. During an interview and initial tour on 5/19/25 from 11:22 a.m. to 11:55 a.m., DM-A confirmed the above findings and confirmed expectations of all foods to be covered, labeled and dated. DM-A stated the dietary aides were responsible for dating items and removing items out of date. DM-A indicated was unsure how long dressings and sauces should have been kept in the refrigerator once opened, and then disposed of dressings and sauces identified and listed above. Review of facility policy titled Food Storage, revised 5/20/25, identified purpose to store food in it's appropriate place and within it's appropriate expiration date to ensure foods were consumed by the safe used by date or discarded. Foods would be stored to prevent contamination and cross contamination. All food containers would be legible and accurately labeled. Review of facility policy titled Food Brought In By Family/Visitors Policy revised 2/18/24, identified food brought into the facility by visitors and family was permitted. The policy identified family was instructed that any food kept in facility coolers was to have resident name and date on the container. Any food not labeled or dated was to be discarded.

Based on interview and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of. This deficient practice had the potential to adversely affect all 63 residents which resided in the facility. Findings include: During an interview on 5/21/25 at 3:29 p.m., director of nursing (DON) indicated she was in charge of the facility's quality assurance and performance improvement (QAPI) program. DON stated the facility did not have any care related citations last year so the facility did not have any projects related to the standard survey completed in 2024. Reviewed 2024's standard survey with DON and discussed potential projects. DON stated yes we could use that the kitchen as a project. DON explained the facility had a huge turnover in the kitchen recently. DON indicated the facility only used citations from care areas as projects rather than any other citations. Review of CASPER Report 0003D Provider History Profile Report Selection Criteria dated 4/15/25, revealed the following repeat deficiencies: - residents provided assistance with activities of daily living. - nutritive value/appear, palatable/prefer temperature. - sanitary kitchen/dining services. Review of facility QAPI minutes dated 2/21/25 to 5/21/25, revealed the current QAPI projects included: hand hygiene, personal protective equipment (PPE), falls, and enhanced barrier precautions (EBP). QAPI plan minutes lacked documentation on activities of daily living (ADLs), concerns with the kitchen, and meal palatable/prefer temperature and other quality of life concerns. Review of the facility form titled, quality assurance/assessment an performance plan (QAPI) revised 10/21/2022 , revealed the QAPI Program was to utilize an on-going, data driven, pro-active approach to advance the quality of life and quality of care for all residents of [NAME] Village Care Center (GVCC) Quality Assurance and Performance Improvement principles would drive our decision making to promote excellence in all resident and staff related areas. All facility staff, families and residents would be encouraged to identify opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. GVCC would review the designated sources of data; identify areas where gaps in performance may negatively affect resident or staff outcomes. Where opportunities for improvement were detected, the QAPI Committee, with input from the leadership team would prioritize focus areas for performance improvement project (PIP) development. In prioritizing activities, the team would consider: high-risk to residents and/or staff, high-volume or problem-prone areas, health outcomes, resident safety and resident autonomy. The team would be interdisciplinary with staff representing each job role affected by the project and may include resident and/or family representation when appropriate. A project lead would be selected and would be responsible for coordinating, organizing and directing the activities of that specific project PIP team. The PIP team would identify the information needed to evaluate the problem at hand, supplies required, staff participation, and any equipment needs. The project lead would communicate any identified resource needs to the QAPI Quality Manager. The team would utilize root cause analysis to identify the cause of the problem and any contributing factors.

Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 residents (R34) reviewed for urinary tract infection (UTI) as part of their antibiotic stewardship program. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics such as UTI prophylaxis and implement specific interventions to improve use. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and had an indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal to remain free from urostomy related trauma. R34 would show no signs or symptoms of UTIs. R34's intervention was to monitor/record/report to primary provider for signs and symptoms of UTI: pain, burning, blood tinged urine,cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. R34's care plan lacked a focus area for extended antibiotic use. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxine Laetrile Oral Tablet 500 milligrams (MG) (Cefuroxine Laetrile). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs, when to reevaluate prophylaxis antibiotic usage, and duration. R34's provider visit notes dated 1/23/25, 3/27/25, and 5/1/25, lacked documentation for continued use rationale and duration of extended antibiotic use. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's electronic treatment administration records (ETAR) from 3/1/25 through 5/21/25, lacked documentation of monitoring R34 for signs and symptoms of a UTI or extended antibiotic use. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed there had been no reevaluation of duration and continued antibiotic use for R34. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to has R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have have reevaluated the use of this antibiotic. On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD). During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 had a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documention if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) who was also known to be the infection preventionist of the facility, confirmed the above findings and stated she was unaware R34 was taking the antibiotic. DON stated her expectations were all medications had proper diagnosis, duration and rationales with supporting documentation when receiving antibiotics. DON stated antibiotic use would have been discussed at QAPI meetings. During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use. Review of facility QAPI minutes dated 2/21/25 to 5/21/25 revealed the current QAPI projects included: hand hygiene, personal protective equipment (PPE), falls, and enhanced barrier precautions (EP). QAPI plan minutes lacked documentation of the antibiotic stewardship program. Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 5 residents (R 22 and R62) who resided on the Blue Horizon and [NAME] Ridge units reviewed for food. This deficient practice had the potential to affect all 23 residents residing on these units. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 had intact cognition and was able to feed herself after staff set up her tray. R 62's admission MDS dated [DATE], indicated R62 had intact cognition and was independent with eating. During an interview on 5/19/25 at 1:35 p.m., R22 stated she usually ate her meals in the dining room and the hot food was usually lukewarm or cold. During an interview on 5/19/25 at 1:47 p.m., R62 stated the staff in the kitchen needed some training because the food was not very good. R62 indicated the hot food was not always hot and the cold food was not always cold. Review of resident council meeting minutes dated 1/15/25 and 2/19/25, identified residents had concerns with the food not being served hot. During an observation on 5/19/25 at 11:50 a.m., a tray was brought to the dining room which contained three metal containers which were placed in the steam table. The metal containers were placed a few inches above the hot water on the steam table. A container which contained potato salad was placed in a large plastic bin about two inches above the ice. .- at 12:46 p.m., as the last tray was being dished up a test tray was requested. The meal consisted of potato salad, mashed potatoes, au gratin potatoes. DA-A tested the food temperatures and the temps were as follows: -au gratin potatoes were 109 degrees Fahrenheit (F). -mashed potatoes were 110 106 degrees Fahrenheit (F). -Ribs were 95 degrees Fahrenheit (F). - potato salad was 51.9 106 degrees Fahrenheit (F). After temping the meal, the surveyor and dietary manager (DM) tasted the food from the test tray. The ribs were lukewarm, potatoes were cold and the potato salad was lukewarm. During a resident council meeting on 5/20/25 at 1:00 p.m., R22 stated she had brought up concerns about the food being cold at resident council meeting however, nothing had ever been done about it. During an interview on 5/19/25 at 1:05 p.m., DM stated the holding temperature for hot food should be at least 135 degrees Fahrenheit (F). and the temperature of cold food should be at 41 degrees Fahrenheit (F).or lower. DM stated her expectation was that all food would have been at the proper holding temperatures. During an interview on 5/19/25 at 1:39 p.m., R62 stated the meat and potatoes were cold and the potato salad was lukewarm. Review of a facility policy titled Food Service Policy revised 5/20/25 identified hot foods were to be served hot and cold food was served cold. Identified hot food must reach a holding temperature of 135 degrees Fahrenheit (F).and cold foods must be maintained at 41 degrees Fahrenheit (F).or below until served.

Based on observation and interview, the facility failed to disinfect a multi-use glucometer (a machine that is used for blood glucose monitoring) after use for 1 of 2 residents (R51) reviewed for blood glucose monitoring. This deficient practice had the ability to affect all 5 residents who required blood glucose monitoring. Findings include: The Centers for disease Control and Prevention (CDC) Infection Prevention for Blood Glucose Monitoring and Insulin Administration dated 2/6/2013, identified due to the risk of transmitting infectious diseases during assisted blood glucose (blood sugar) monitoring whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. R51's quarterly Minimum Data Set (MDS) dated [DATE] identified R51 had intact cognition and diagnoses which included asthma, heart failure and and diabetes mellitus (DM). R51's current physician orders signed 4/11/25, identified R51 required blood glucose monitoring checks two times weekly. During an observation on 5/20/25 at 8:45 a.m., licensed practical nurse (LPN)-B sanitized hands, applied gloves and removed a glucometer, strip and a lancet (small device with a needle used to get blood for blood glucose monitoring) from the top drawer of the medication cart. RN-A used the lancet to poke R11's finger and obtained a small drop of blood onto the glucometer strip. LPN-B removed gloves, sanitized hands and placed the glucometer in the top drawer of the medication cart. LPN-B did not sanitize the glucometer prior to placing it in the medication cart. During an interview on 5/20/25 at 9:00 a.m., LPN-B verified she had not disinfected the glucometer which was used for multiple residents prior to placing it in the medication cart. LPN-B stated she should have disinfected the glucometer per manufacturer's guidelines prior to placing it into the drawer of the medication cart to prevent the spread of blood-borne infections. During a joint interview on 5/21/25 at 9:19 a.m., infections preventionist (IP) and director of nursing (DON) verified the glucometer in the top drawer of the medication cart was used for multiple residents. IP and DON stated their expectation was that the glucometer would have been disinfected between residents using a Sani-wipe or per manufacturer's guidelines to prevent blood- borne infections. Review of Manufactures guidelines for Assure Prism multi Blood Glucose Monitoring System (BGMS) revised 9/24, identified disinfecting the glucometer was to be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe, after every resident use. Identified ,what would happen when a blood glucose meter was not cleaned and disinfected after use. Per the CMS F-Tag 880 guideline, surveyors may issue a citation if they observed no cleaning and disinfecting of meters after a blood glucose test as they would not be in compliance with CMS F-Tag 880. Review of a facility policy titled Cleaning of Blood Glucose Meter revised 1/24, identified blood glucose monitors that are shared among residents must be cleaned and disinfected between each use per manufactures guidelines to prevent carry-over of blood and infectious agents.

Based on interview, and document review, the facility failed to ensure an allegation of employee to resident abuse was immediately reported no later than two hours, to the State agency (SA) for 1 of 1 residents (R15) reviewed for abuse. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included: dementia, anxiety and depression. Identified R15 was dependent on staff for transfers, dressing and personal hygiene. R15's Care Area Assessment (CAA) dated 10/25/24, identified R15 was cognitively intact and was able to follow a conversation and answer appropriately. Indicated R15 was at risk for falls and cognitive impairment due to diagnosis. R15's care plan dated 10/20/23, identified R15 had an activities of daily living (ADL) self-care performance deficit and limited physical mobility with interventions which included: assistance for bathing/showering, dressing, personal hygiene toilet use, and transfers with two staff and a sit to stand non-mechanical lift. Indicated R15 was a vulnerable resident related to nursing home placement, physical limitations and sensory impairments. R15 was to be safe and comfortable in R15's environment, free from abuse, neglect, exploitations, and maltreatment. During a telephone interview on 5/21/25 at 11:15 a.m.,complainant (C)-A indicated R15 made a complaint on 11/7/24, stating a nursing assistant (NA), unknown name, turned R15 in bed roughly on 11/5/24, and R15 received a bruise as a result. R15 asked C-A to speak with the administrator about the incident. C-A stated R15 was going to talk to the Care Transition Coordinator (CTC) about the incident. C-A further stated C-A spoke with the administrator on 11/26/24, and the administrator indicated she would follow-up on the information provided. C-A indicated C-A never heard back from the administrator. On 5/21/25 at 1:30 p.m., R15 declined an interview. During an interview on 5/21/25 at 2:27 p.m., CTC confirmed R15 had talked to the CTC about the incident that took place on 11/5/24. CTC did not remember the exact date and time R15 talked with the CTC. CTC stated R15 did not appear to have any bruising and a full investigation was completed. CTC further stated CTC did not feel it needed to be reported to the SA. During an interview on 5/21/25 at 2:34 p.m., administrator indicated if a resident had any abuse allegations the administrator would work with the director of nursing (DON) and social services to complete a through investigation. Administrator stated the staff member would be placed on a leave while the investigation was being completed. Administrator further stated she did not remember receiving a call from C-A and she would look for any information regarding this incident. Administrator indicated if abuse was suspected there should have been a report sent to the SA within two hours of the allegations being discovered. During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to look into R15's allegations and attempt to find documentation regarding the allegations. Requested a copy of the investigation report, however one was not provided. Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, the plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, has been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. If the events did not result in serious bodily injury, the individual should report the suspicion immediately.

Based on interview and document review, the facility failed to submit to the State Agency (SA) the results of the investigation within 5 working days for 1 of 1 residents (R15) reviewed for abuse, for 1 of 1 allegations of abuse reviewed. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included: dementia, anxiety and depression. Identified R15 was dependent on staff for transfers, dressing and personal hygiene. R15's Care Area Assessment (CAA) dated 10/25/24, identified R15 was cognitively intact and was able to follow a conversation and answer appropriately. Indicated R15 was at risk for falls and cognitive impairment due to diagnosis. R15's care plan dated 10/20/23, identified R15 had an activities of daily living (ADL) self-care performance deficit and limited physical mobility with interventions which included: assistance for bathing/showering, dressing, personal hygiene toilet use, and transfers with two staff and a sit to stand non-mechanical lift. Indicated R15 was a vulnerable resident related to nursing home placement, physical limitations and sensory impairments. R15 was to be safe and comfortable in R15's environment, free from abuse, neglect, exploitations, and maltreatment. During a telephone interview on 5/21/25 at 11:15 a.m., complainant (C)-A indicated R15 made a complaint on 11/7/24, stating a nursing assistant (NA), unknown name, turned R15 in bed roughly on 11/5/24, and R15 received a bruise as a result. R15 asked C-A to speak with the administrator about the incident. C-A stated R15 was going to talk to the Care Transition Coordinator (CTC) about the incident. C-A further stated C-A spoke with the administrator on 11/26/24, and the administrator indicated she would follow-up on the information provided. C-A indicated C-A never heard back from the administrator. On 5/21/25 at 1:30 p.m., R15 declined an interview. During an interview on 5/21/25 at 2:27 p.m., CTC confirmed R15 had talked to the CTC about the incident that took place on 11/7/24. CTC did not remember the exact date and time R15 talked with the CTC. CTC stated R15 did not appear to have any bruising. During an interview on 5/21/25 at 2:34 p.m., administrator indicated if a resident had any abuse allegations the administrator would work with the director of nursing (DON) and social services to complete a through investigation. Administrator stated the staff member would be placed on a leave while the investigation was being completed. Administrator further stated she did not remember receiving a call from C-A and she would look for any information regarding this incident. During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to look into R15's allegations and attempt to find documentation regarding the allegation. Requested a copy of the investigation report, however one was not provided. Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, The plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, had been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. The notice to the SA should include the occurrence of such incident, type of abuse that was committed, date/time the alleged incident occurred, name (s) of all persons involved in the alleged incident and what immediate action was taken by the facility. The administrator, or a designee, would provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident.

Based on interview and document review, the facility failed to ensure the resident or legal representatives had been provided a written notice of transfer for 2 of 2 residents (R22, R64), and failed to be informed of bed hold rights for 1 of 2 residents (R22) reviewed for discharges. In addition, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 2 of 2 residents (R22, R64) reviewed for hospitalization s. Findings Include: R22 R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 was cognitively intact and had diagnoses which included: arthritis, hemiplegia (partial or total paralysis on one side of the body)affecting left side, and peripheral vascular disease (disease of the circulatory system outside of the brain and heart). R22 required substantial/maximal assistance for dressing, shower/bathe self, and transfers and was dependent for personal hygiene. Review of R22's progress notes from 3/5/25 to 5/21/25, identified the following: -3/5/25 at 4:57 p.m., R22 admitted to hospital due to back pain associated with urinary tract infection (UTI). -3/6/25 at 7:44 a.m., writer spoke with daughter, who informed writer R22 was going to be in hospital a few days due to multiple infections. -3/9/25 at 9:40 a.m., hospital nurse stated R22 diagnosed with UTI, pyelonephritis (kidney infection), and refractory back pain (chronic pain that persists despite treatment), and will re-evaluate on Monday regarding discharge. -3/18/25 at 12:15 p.m., R22 was treated for pyelonephritis, acute back pain now improved. R22 will return today at 1:30 p.m. R22's medical record lacked documentation the notification of the emergency transfer was sent to the LTC ombudsman and lacked documentation that a transfer notification and bed hold was provided to the resident and/or resident's representative. During an interview on 5/21/25 at 8:18 a.m., social service designee (SSD)-A reviewed R22's medical record and confirmed it lacked documentation of a bed hold, written notice for transfer or notification of transfer to ombudsman. SSD-A indicated the facility expectation was the forms be completed when a resident was transferred. During an interview on 5/21/25 at 9:21 a.m., licensed practical nurse (LPN)-B indicated R22 was hospitalized for back pain and a UTI. LPN-B stated when a resident was transferred to the hospital, they printed a transfer/discharge record from the medical record and provided a verbal report to the hospital nurse. LPN-B stated they completed a bed hold and a written notice of transfer on the facility Transfer Discharge form and provide it to the resident or family and a copy is placed in their medical record. During a follow up interview on 5/21/25 at 9:42 a.m., SSD-A indicated R22 went independently to the walk in clinic on 3/5/25, and was then sent to the emergency room , where R22 was admitted and as a result, the bed hold was missed. SSD-A stated the facility expectation was to follow up and complete the bed hold. SSD-A indicated the facility did not complete written notice of reason for transfers, but after shown the facility Transfer Discharge form indicated often they were only notified verbally. SSD-A indicated the expectation was the Transfer Discharge forms were signed and sent to the ombudsman. During an interview on 5/21/25 at 12:13 p.m., director of nursing (DON) confirmed R22's medical record lacked a bed hold, written notification for transfer and ombudsman notification. DON stated the notifications were important for continuity of care and to update the correct people. R64 R64's admission MDS dated [DATE], identified R64 had moderate cognitive impairment and diagnoses which included: heart failure, diabetes mellitus and dementia. Indicated R64 required supervision/touching assistance with transferring, and partial assistance with lower body dressing, hygiene and to shower/bathe self. Review of R64's progress notes from 3/6/25 to 3/7/25, identified the following: -3/7/25 at 4:33 a.m., R64 transferred to hospital, for low blood sugar with seizure like activity. Bed hold verbal by daughter and daughter updated. R64's Bed Hold And Readmissions Policy dated 3/7/25, documented verbal from daughter on 3/7/25 at 4:15 a.m. R64's medical record lacked documentation the notification of the emergency transfer was sent to the LTC ombudsman and lacked documentation that a transfer notification was provided to the resident and/or resident's representative. During an interview on 5/21/25 at 8:18 a.m., social service designee (SSD)-A reviewed R22's medical record and confirmed it lacked documentation of a bed hold, written notice for transfer or notification of transfer to ombudsman. SSD-A indicated the facility expectation was the forms be completed when a resident was transferred. SSD-A stated R64 was discharged from the facility after he went to the hospital related to family dynamics. SSD-A stated the case manager completed all paper work for transfers and notified the ombudsman of transfers. SSD-A indicated the facility had not been notifying the ombudsman of transfers and discharges, and as a result, they put a new system in place beginning in April 2025. During a follow up interview on 5/21/25 at 9:42 a.m., SSD-A indicated R22 went independently to the walk in clinic on 3/5/25, and was then sent to the emergency room , where R22 was admitted and as a result, the bed hold was missed. SSD-A stated the facility expectation was to follow up and complete the bed hold in those situations. SSD-A indicated the facility did not complete written notice of reason for transfers, but after shown the facility Transfer Discharge form indicated often they were only notified verbally. SSD-A indicated the expectation was the Transfer Discharge forms were signed and sent to the ombudsman. At 9:49 a.m. SSD-A confirmed a written notice for transfer form had not been completed and the ombudsman had not been notified of R64's transfer. During an interview on 5/21/25 at 12:13 p.m., director of nursing (DON) confirmed R22's medical record lacked a bed hold, written notification for transfer and ombudsman notification. DON stated the notifications were important for continuity of care and to update the correct people. During a follow-up interview on 5/21/25 at 12:17 p.m., DON confirmed a written notice for transfer or ombudsman notification of transfer had not completed for R64's transfer as was the expectation. Review of facility policy titled Transfer/Discharge Policy revised 1/15/24, identified the resident and representative were notified in writing, which included: the specific reason for the transfer, effective date of the transfer, specific location and explanation of the resident rights, notice of facility bed-hold policies, and name and address and telephone number of the LTC Ombudsman. A copy of the notice was sent to the LTC Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. When a resident was sent emergently to an acute care setting the notice would be provided as soon as was practicable. Bed-Hold policy would be provided to the resident and resident representative within 24 hours of emergency transfer. Documentation would include basis for transfer, that an appropriate notice was provided to the resident and/or legal representative, date and time of the transfer, new location of the resident, mode of transportation, summary of resident's condition and other as appropriate.

Based on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R34) whose care plan was reviewed. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with Urinary Incontinence and Indwelling Catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. Additionally, R34 triggered for physical restraints related to R34 utilizing a Velcro removable strap across R34's lap to remind R34 not to self-transfer. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 was at high risk for falls and R34 had a goal not to sustain serious injures. R34 had an intervention in place to use a front Velcro wheelchair seatbelt when in R34's wheelchair. Staff were to ensure the device was in placed every two hours or as needed (PRN). R34's had alterations of R34's urinary system with a goal R34 would remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to have R34's urostomy emptied every two hours. Review of R34's signed physicians orders dated 3/27/25, identified R34 was to have R34's urostomy emptied every two hours during the day. Orders further identified R34 would be monitored while in R34's wheelchair. Staff were to ensure R34's belt was loose around R34's waist every two hours. Review of [NAME] Village Care Center (GWVCC)-Alarm assessment dated [DATE], restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: -Unsteady Gait - Frequent falls - Sliding out of wheelchair/chair - Attempts to self-transfer - Other Interventions tried and failed. Describe events or failed interventions leading up to use of alarms. -Resident uses feet to propel wheelchair, and legs/ feet get caught up under wheelchair causing resident to fall forward out of wheelchair. Seatbelt will assist resident is staying seated in the event that resident falls out of wheelchair. What device is being used for the resident? - Resident is currently in a tilt and space wheelchair at its lowest position. along with the Velcro front wheelchair seatbelt Start Date of Alarm Use - 6/13/2024 Benefits of the resident using the alarm - Benefit is using Velcro front wheelchair seatbelt as resident is able to self-propel his wheelchair, without the danger of tripping/ catching his own feet and falling forward out of wheelchair. This includes independence to maneuver around facility. Resident is able to remove front Velcro seatbelt when desired. Education on identification of a medical symptom requiring the use of the device, the risks and/or benefits, the least restrictive interventions, and when/how long the device was going to be used for. - Resident received education on alarms - Resident Representee received education on alarms Who made the decision to implement the restraint? - Case Manager registered nurse (CMRN)/Case Manager licensed practical nurse (CMLPN) - Family Member/Guardian What family member/responsible party notified? - Family Member (FM)-D Date notification was given - 6/13/2024 Physicians order obtained with specific type of restraint, duration of application, reason for restraint and specify when it is to be used (i.e. seatbelt, while up in chair, for repeated attempts to rise unattended, release and ambulate for 10 minutes every two hours) - yes Ordering Physician R34's primary physician Review of Sunrise Cove/Golden Meadow resident report form undated, indicated staff were to monitor R34's urostomy every two hours. During a continuous observation on 5/21/25 at 7:10 a.m., to 9:46 a.m., R34 was in the hallway, dining room and personal room. R34's Velcro belt was not secured around R34's waist with one strap laying along side both R34's right and left outer legs. At 8:58 a.m., R34's FM-A returned R34 to R34's room, applied R34's jacket, turned R34's television on and sat next to R34 in personal room. During an interview on 5/21/25 at 9:38 a.m., trained medication aid (TMA) indicated R34 was to have R34's ostomy checked and changed whenever it comes bulging out. TMA identified all staff could check R34's ostomy and empty it when it was full. TMA stated nursing staff changed it a couple times a week. TMA identified R34 wore a seatbelt to remind him not to self-transfer. TMA indicated R34 could remove the belt and had several times before. TMA was unaware R34's ostomy was not checked, seatbelt was not fastened and no staff had checked either R34's ostomy or seatbelt. TMA confirmed both items were to be checked every couple of hours. Review of R34's belt, it remained unfastened and R34's ostomy needed to be emptied. TMA indicted TMA was going to finished passing morning medications and would get another staff person to check on R34's equipment. During an interview on 5/21/25 at 9:46 a.m., clinical manager (CM)-A confirmed R34's care plan and identified R34's urostomy and seatbelt were to be checked every two hours. CM-A stated R34 has taken the seatbelt off at times and staff were to place it back on him. Surveyor explained TMA had not checked on R34, CM-A called TMA and requested TMA to check on R34's ostomy and seatbelt at that time. TMA went into R34's room and checked ostomy and replaced seatbelt. Surveyor requested R34's restraint assessment, CM-A was going to locate it and provide it to surveyor. Follow-up interview on 5/21/25 at 12:23 p.m., CM-A identified R34's restraint assessment and stated it was called an alarm assessment that was created on 6/13/24. CM-A further stated the assessment included physician's orders and the seatbelt was to be reevaluated every two hours. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and indicated she was unaware R34's ostomy and seatbelt had not been checked for over two hours. DON stated her expectations were staff were to be following each residents care plan. Facility policy titled Comprehensive Care Plans revised 12/10/24, Each resident would have a person-centered comprehensive care plan developed and implemented to meet their other preferences and goals, and address the residents medical, physical, mental, and psychosocial needs. When developing the comprehensive care plan, facility staff must, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. Facility policy titled Restraints revised 7/1/24, It shall be the policy of the [NAME] Village Care Center that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

Based on observation , interview and document review, the facility failed to provide assistance with oral care for 1 of 7 residents (R34) and nail care for 1 of 7 residents (R40) reviewed for activities of daily living (ADL's). Findings include: R40 R40's annual Minimum Data Set (MDS) dated [DATE], identified R40 had moderate cognitive impairment and had diagnoses which included Alzheimer's, psychotic disorder, and hypertension (elevated blood pressure). Identified R40 required staff assistance with personal hygiene. R40's care plan dated 12/12/22, identified R40 had dementia and forgetfulness. Identified R40 required supervision and limited assistance with grooming. R40's annual comprehensive Care Area Assessment (CAA) dated 3/11/25, identified R40 required assistance with ADL's related to dementia and confusion. Identified R40 required partial to moderate assistance with hygiene. During an interview on 5/19/25, at 1:20 p.m., family member (FM)-A stated R40's fingernails were generally pretty long when he came to visit. FM-A stated R40 required staff assistance to cut his fingernails. During an observation, R40 was seated in a recliner in his room. R40's fingernails were approximately 3/4 inch long with a black substance noted underneath. During an observation on 5/20/25 at 8:29 a.m., R40 was seated in a recliner in his room. R40's fingernails continued to be approximately 3/4 inch long with a black substance noted underneath. During a joint interview on 5/20/25 at 8:37 a.m., nursing assistant (NA)-A and licensed practical nurse (LPN)-A verified R40's nails were long with a black substance present underneath. NA-A stated she had not offered to cut or clean R40's fingernails recently and was unsure of the last time R40's fingernails had been cut. LPN-A stated her expectation was that R40's fingernails were cleaned and cut weekly with his bath. 48583 R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 was at risk for dental care and had problems with cavities. R34's care plan dated 4/8/24, indicated R34 required assistance with oral cares and personal hygiene. R34 required substantial assistance of one for orals cares and R34 had his own natural teeth. Staff were to report any changes in oral health to the nurse. Additionally, staff were to monitor and document R34's ability to perform ADLs. Any changes of improvement or decline were to be reported to the medical doctor (MD). During an observation on 5/21/25 at 7:19 a.m., R34 was in R34's wheelchair propelling self down the hallway towards the dining room. In R34's bathroom a pink basin was located in the wooden bathroom cabinet on the right side of the bathroom when entering the bathroom. The pink basin contained a tube of toothpaste and a small laminated tooth with a smiley face on it. Located below the tooth was written in black bold lettering If found please return to case manager. No toothbrush had been seen in pink basin or bathroom. During an observation on 5/21/25 at 8:58 a.m., remained the same as above. Review of R34's progress notes dated 2/20/25 through 5/19/25, lacked documentation R34 refused oral cares or any changes with R34's oral cares. Review of R34's electronic medical record treatment notes dated 3/1/25 to 5/21/25, lacked documentation of R34 receiving oral cares. Review of Sunrise Cove/Golden Meadow resident report form undated lacked documentation R34 was to have assistance with oral cares. During an interview on 5/19/25 at 1:37 p.m., family member (FM)-D stated staff did not assist R34 with oral cares and FM-D had expressed concerns with the nursing staff regarding R34's oral cares. FM-D indicated FM-D had checked R34's toothpaste tube daily and the same tube had remained in the bathroom without being used. FM-D indicated R34 used to brush R34's teeth daily and R34 would want to have R34's teeth brushed daily at the facility. FM-D stated FM-D wanted R34's teeth brushed daily. During an interview on 5/21/25 at 9:38 a.m., trained medication aid (TMA)-A expressed staff worked together to get residents up and dressed for the day including completing oral cares. TMA-A was not aware R34 did not have oral cares completed and R34 did not have a toothbrush in the bathroom. TMA-A stated TMA-A had not assisted with R34's cares that day. During an interview on 5/21/25 at 9:46 a.m., clinical manager (CM)-A confirmed the facility had been completing audits for oral cares and the laminated tooth should have been brought to CM-A when staff assisted R34 with oral cares. CM-A stated FM-D had spoken to CM-A about R34 not having oral cares completed and the audit tooth had been placed in the basin a few days ago, I think three days ago. CM-A stated if R34 refused, staff were expected to inform the nurse and it should have been documented in the progress notes. CM-A indicated additional training needed to be done because oral cares were obliviously not being done. During an interview on 5/21/25 at 9:27 a.m., director of nursing (DON) stated her expectation was that all residents nails would be cut and cleaned weekly with their bath. During a follow-up interview on 5/21/25 at 3:18 p.m., DON was not aware R34 did not have oral cares completed. DON stated oral care audits were being completed and CM-A should have removed the audit card within 12 hours of placing it to ensure R34 had oral cares completed that day. DON indicated oral cares should have been completed two times a day and staff should have returned the card to the CM. DON stated her expectations were residents received oral cares two times daily. Review of a facility policy titled Activities of Daily Living (ADLs), Supporting revised 3/20/25, identified residents would be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Identified, appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, shaving, grooming, and oral care).

Based on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R21) reviewed for activities. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment and had diagnoses which included Alzheimer's disease and anxiety. Identified R21 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified watching the news was not important at all to R21. R21's care plan revised 3/22/25, indicated R21 was unable to carry out activities of past interest due to disease process. Indicated R21's personal interests included music (gospel),spiritual activity, animals, outdoors, looking through pictures, getting hair fixed, being with others, gardening, children. Identified resident spent ample time by TV day room. At most recent care conference, resident's family specified she had no past interest of watching the news or sports. Resident would benefit more from music or nature sounds. Further identified, set up music on R 21's CD player during afternoon rest time. During an observation on 5/20/25 at 11:00 a.m., R21 was sitting in her wheelchair in the day room and the television was on the news. During an observation on 5/20/25 at 12:35 p.m., nursing assistant (NA)-A wheeled R21 to her room and NA-A and NA-B assisted her to lie down in bed using the hoyer lift. R21's room was quiet no music was playing. During an observation on 5/20/25 at 1:25 p.m., R21 continued to lie in bed with no music playing in the room. During an observation on 5/20/25 at 3:35 p.m., NA-B and NA-C assisted R21 into her wheelchair using the hoyer lift. NA-B wheeled R21 to the day room where the TV was on the news R21 was the only one in the day room. During an observation on 5/20/25 at 4:07 p.m., R21 continued to be sitting in her wheelchair in the day room. The TV was on the news. Review of Resident Report Form undated, lacked R21's activity preferences. R21's care conference summary dated 3/22/25, stated activity interventions desired by family and to be included in R21's care plan at upcoming review date: transport to and from 2:00 Church on Sundays; set up Church live stream if no attendance at Church; turn on CD player in room during afternoon rest; continue assisting for visits w/spouse; adjust TV channel so Resident is not watching news/sports; engage in outdoor/garden activities (weather dependent). Review of the facility activities schedule for 2/19/25 through 2/21/25 , revealed the following: -Monday 2/19/25: 8:30 Daily Check- Ins 10:30 Spiritual Reading 11:00 Music Trivia 1:30 Chair Yoga 2:00 Golden Oldies 2:30 Coffee -Tuesday 2/20/25: 8:30 Daily Check -Ins 10:00 Men's Book club 10:30 Women's Book Club 1:30 Activity Planning Committee 2:00 Red Hat's Tea Party 3:00 Bingo -Wednesday 2/21/25 8:30 Daily Check In-s 9:30 Wednesday Wellness 10:30 Garden Club 10:30 Bingo 1:00 Resident and Food Council 2:30 Coffee And Social Time During an interview on 5/19/25 at 3:14 p.m., family member (FM)-B stated staff got R21 up early and she sat in the wheelchair most of the day. FM-A stated at the last care conference, R21's preference of not watching sports or news were discussed. FM-A indicated the family had requested for staff to lay R21 down in the afternoon and put music on for her in her room. During an interview on 5/20/25 at 4:33 p.m., NA-B stated she was not aware of R21's preference to listen to music in her room or to not watch the news while she was in the day room. NA-B indicated there was nothing on the Resident Report Form regarding R21's activity preferences. During an interview on 5/20/25 at 6:46 p.m., NA-C stated she was not aware of R21's preference to listen to music in her room or to not watch the news while she was in the day room. NA-B further indicated there was nothing on the Resident Report Form regarding R21's activity preferences. During an interview on 5/20/25 at 6:50 p.m., registered nurse (RN)-A verified R21 had been in the day room during his shift with the news playing and lying in her bed in her room without any music playing. RN-A stated he was not aware of R21's preference to listen to music in her room or to not watch the news while she is in the day room. RN-A stated he had not received any communication regarding R21's activity preferences. RN-A stated his expectation was that staff would have respected R21's activity wishes. During an interview on 5/21/25 at 7:25 a.m., FM-B stated her mom sat in the day room a lot and every time she visited the news was on. FM-B stated the family had talked to the facility about R21's preference of listening to music in her room and while in the day room R21 preferred to not listen to the news but she had not seen anything happen with their request for R21's activities. During an interview on 5/21/25 at 8:27 a.m., activity director (AD) stated she was aware of R21's activity preferences. AD stated she had discussed R21's activity preferences of listening to music in her room or in the day room and to not listen to news or sports in the day room at R21's last care conference with R21's family. AD stated she was unsure if R21's preferences were communicated to the staff working with R21 since the only form of communication was verbal. AD indicated R21 did not usually attend most group activities other than church so it was important for staff to look at R21's care plan to identify R21's activity preferences. During an interview on 5/21/25 at 8:49 a.m., clinical manager (CM)-A confirmed she had seen R21 in her room with no music playing and in the day room with the news on the TV. CM stated she was new to the facility and was not aware of R21's activity preferences. CM stated her expectation was that R21's activity preferences would have been followed. During an interview on 5/21/25 at 9:25 a.m., director of nursing (DON) confirmed the above findings. DON stated she was unsure why R21's activity preferences were not being followed. DON stated her expectation was that R21's activity preferences would have been followed. Review of a facility Policy titled Types of Activities revised 5/23, identified residents would be surveyed to determine their interest in the types of activities. Identified, individualized Care Plans would be developed with resident preferences, goals, and interventions, reviewed and updated with every MDS and PRN. .

Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 4 residents (R27) with a current pressure ulcer and for 2 of 4 residents (R21, R47) at risk for development of pressure ulcers. Further, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 4 residents (R21) reviewed for pressure ulcers. Findings Include: R27 R27's quarterly Minimum Data Set (MDS) dated [DATE], identified R27 had mild cognitive impairment and had diagnoses which included: dementia, cancer, and chronic obstructive pulmonary disease. R27 was dependent on staff to turn left to right, transfer, dressing, and personal and hygiene. Indicated R27 was at risk for pressure ulcers and had no unhealed pressure ulcers. R27 had an air pressure mattress, and received applications of non surgical dressings and ointments to skin other than to feet. R27 was receiving hospice care with a prognosis of six months or less to live. R27's Pressure Ulcer Care Area Assessment (CAA) dated 12/10/24, identified R27 had potential impairment to skin integrity related to fragile skin, bowel and bladder incontinence, non-healing lesion to right lateral inferior mid-back classified as basal cell carcinoma and blood thinners. R27's care plan revised 4/17/25, identified R27 had an activities of daily living (ADL) self care deficit with interventions which included dependent on staff for personal hygiene, transfers, and extensive assistance with bed mobility. Indicated R27 had a sacral (base of spine) ulcer related to immobility. Interventions included to turn and reposition R27 at least every two hours, more often as needed or requested, bed as flat as possible to reduce shear, float heels when in bed, and air pressure mattress. R27 had terminal prognosis related to Alzheimer's. R27's Braden Scale For Predicting Pressure Ulcer Risk assessment dated [DATE], identified R27 scored 15, which identified R27 was at risk for pressure ulcers. During continuous observation on 5/20/25 at 10:25 a.m. to 12:52 p.m., identified the following: -10:25 a.m.-R27 lying in bed, in street clothes, covered with bedding, eyes closed, lying on back, door open. R27's bed unable to view from doorway, unless enter room. -10:29 a.m.- staff member walked by room, did not look into room. -10:46 a.m.- multiple staff members walked by R27's room, did not go into room. -11:01 a.m.-R27 remained in same position, eyes remain closed. Multiple staff members have walked by room, but did not enter. -11:13 a.m.-R27 remained in same position, eyes remain closed. -11:34 a.m. -R27 remained in same position, eyes remain closed, multiple staff members have walked by R27's room, but did not enter. -11:54 a.m. R27 remained in same position, staff assisting other residents in dining room. Nurse and other staff walked by R27's room, but did not enter. During an observation on 5/20/25 at 12:12 p.m., nursing assistant (NA)-F entered R27's room and asked R27 if she wanted to eat lunch and then asked if could try some V8 juice. NA-F applied gloves and asked R27 if she could apply lip balm, then applied lip balm to R27's lips. NA-F removed her gloves and left R27's room. At 12:16 p.m., NA-F entered R27's room and asked if R27 could try some V8 juice. NA-F applied gloves, sat in a chair next to R27, raised the head of bed up, asked R27 if wanted to try drinking the V8 juice, which R27 responded yeah. NA-F attempted to assist R27 to drink juice from straw. R27 did not suck on the straw. NA-F asked R27 again if wanted to drink the V8 juice and R27 responded, no, later. NA-F then lowered R27's bed, and stated she had taken care of R27 today. NA-F then left R27's room. NA-F did not offer to assist R27 to turn and reposition while NA-F was in the room. During an observation on 5/20/25, at 12:50 p.m., surveyor informed licensed practical nurse (LPN)-C that it had been over two hours since R27 had last been repositioned. At 12:51 p.m. LPN-C entered R27's room and applied a gown and gloves. LPN-C informed surveyor that NA-H would assist with repositioning R27. At 12:52 p.m., NA-H entered the room, asked R27 if they could reposition R27, and applied gown and gloves. LPN-C and NA-H assisted R27 by checking her brief, which was dry, and assisted R27 to turn and reposition onto her right side. LPN-C and NA-H placed a pillow under her left side after they boosted her up in bed, and applied a pillow under her lower legs to float her heels. NA-H informed surveyor she had not worked with R27 earlier that day. NA-H applied lip balm to R27's lips, lowered R27's bed and they left the room after removing their gown and gloves. R27's Weekly Wound Documentation assessment dated [DATE], identified R27 had signs and symptoms of a [NAME] Ulcer (skin wound that appears during final weeks of life) first identified on 4/17/25, on sacrum (base of spine) two centimeters (cm) length, two cm width, zero cm depth, not staged. R27's wound was identified as 100% eschar (hardened dry black or brown dead tissue covering a wound bed), with moderate brown drainage and odor present and edges frail and irregular. R27's family and physician were notified. R27's Weekly Wound Documentation assessment dated [DATE], identified Kennedy ulcer pending, on sacrum measuring three cm length, two cm width and zero cm depth, unstagable ulcer, with 50% slough (yellow, tan, or white dead tissue within a wound, covering a wound bed), 50% eschar, moderate amount brown drainage, odor present and wound had declined. R27 complained of pain with repositioning and during treatment, case manager working with hospice on pain management. R27's Weekly Wound Documentation assessment dated [DATE], identified R27's wound as a pressure ulcer stage three on sacrum measuring two cm length, 2.5 cm width and 2.5 cm depth 2.5 cm tunneling with 50% slough and moderate amount yellow drainage, odor present, no change. Area was debrided on 4/24/25 by wound care nurse. R27 had much discomfort at site during treatment, hospice notified. R27's Weekly Wound Documentation assessment dated [DATE], identified sacrum pressure wound stage three, two point five cm length, two cm width, two point five cm depth, tunnel two point five cm with moderate amount brown drainage, no odor, no change. Pain managed with topical and oral medication, minimal discomfort during treatment. R27's Weekly Wound Documentation assessment dated [DATE], identified sacrum pressure ulcer stage three, two cm length, two cm width, two cm depth, tunnel two cm. Moderate amount serosanguinous (thin watery fluid pink in color and normal discharge from wound) drainage, no change. R27 complained of discomfort during treatment. During an interview on 5/20/25 at 12:59 p.m., LPN-C reviewed her documentation on R27's electronic medical record and verified the last time they repositioned R27 was at 9:38 a.m. During an interview on 5/20/25, at 1:26 p.m., NA-F indicated had thought she offered R27 to reposition in bed when offered lunch, then stated was not able to reposition R27 at noon due to staff assisting other residents in dining room. NA-F stated the last time R27 had been repositioned was around 10:00 a.m. with LPN-C. NA-F stated R27 was to be repositioned every two hours because she had a sore on her bottom. During an interview on 5/20/25 at 4:52 p.m., NA-G stated R27 was on hospice, and was to be repositioned every two hours. NA-G stated she had never had problems repositioning R27 while in bed, and if was unable to reposition R27 timely, NA-G would do it as soon as possible. During a follow up interview on 5/20/25 at 5:17 p.m. LPN-C indicated R27 was to be repositioned every two hours and it was located in R27's medical record as a nursing assistant task. LPN-C stated the last time R27 had been repositioned was at 9:38 a.m. with NA-F. LPN-C indicated it was important to reposition R27 every two hours for R27's comfort and to prevent skin break down, and confirmed it had been at least three hours since R27 had last been repositioned prior to 12:50 p.m. 45844 R21 R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment and diagnoses which included Alzheimer and asthma. Identified R21 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R21 was at risk for pressure ulcers. R21's annual CAA dated 10/4/24, identified R21 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R21 was incontinent of bowel and bladder. R21's care plan dated 3/13/2020, identified R22 had self care deficits and a potential for an alteration in skin integrity related to Alzheimer's disease and dependence on staff for repositioning in bed and wheelchair. Identified R21 was to wear blue padded boots to bilateral lower legs/feet while in bed or up in chair. Care plan lacked direction of how often to reposition R21 in bed and in the chair. R21's Braden Scale for Predicting Pressure Ulcer Risk dated 3/19/25, identified R21 was at moderate risk of developing a pressure ulcer. During a continuous observation on 5/20/25 from 3:35 p.m. to 6:27 p.m., the following was revealed: -3:35 p.m., R21 was seated in her wheelchair in the dayroom. R21 had only socks on her feet and both heels were resting on the foot pedals. -4:07 p.m.,R21 remained seated in her wheelchair in the day room wearing only socks on her feet and both heels were resting on the foot pedals. -4:33 p.m., R21 remained seated in her wheelchair in the day room wearing only socks on her feet and both heels were resting on the foot pedals. -4:51 p.m., R21 was wheeled into the dining room by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -5:35 p.m., R21 remained seated in her wheelchair in the dining room and was being fed by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -6:07 p.m., R21 remained seated in her wheelchair in the dining room and was being fed by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -6:23 p.m., NA-B wheeled R21 to the day room and placed her in front of the TV. - 6:25 p.m., R21 had remained seated in her wheelchair in the day room. Surveyor requested NA-B to reposition R21 after R21 remained seated in her wheelchair without the blue boots on her feet and not repositioned for almost three hours. During an observation on 5/20/25 at 6:32 p.m., NA-B wheeled R21 to her room. NA-B, NA-C, and registered nurse (RN)-A sanitized hands, hooked R21 up to the mechanical lift and placed R21 onto the bed. R21's incontinent product was changed and R21 was repositioned. R21's medication administration record (MAR) dated 3/11/25, identified R21 was to have blue boots to both feet while in bed and in wheelchair. During an interview on 5/19/25 at 3:40 p.m., family member (FM)-A stated staff usually got R21 up early in the morning and put R21 to bed early in the evening FM-A indicated R21 sat in her wheelchair for most of the day. During an interview on 5/20/25 at 11:17 a.m., complainant (C)-A stated R21 sat in the chair most of the day and was not being repositioned. During an interview on 5/20/25 at 6:38 p.m., NA-B stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times. NA-B stated she was unsure of the last time R21 had been repositioned because when she arrived to work at 4:00 p.m., R21 had already been sitting in her wheelchair. NA-B stated staff had not documented the time that R21 had been repositioned and stated R21 should have been repositioned every two hours to prevent skin breakdown. During an interview on 5/20/25 at 6:46 p.m., NA-C stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times. NA-C stated she was unsure of the last time R21 had been repositioned. NA-C stated R21 should have been repositioned every 2 hours to prevent skin breakdown. During an interview on 5/20/25 at 6:48 p.m., RN-A stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times RN-A stated he was unsure of the last time R21 had been repositioned since staff do not document times. RN-A stated the normal process was to reposition all residents on the even hour. RN-A stated his expectation was the R21 was repositioned at least every two hrs and that she would have had her blue boots on both feet to prevent skin breakdown. During an interview on 5/21/25 at 8:49 a.m., clinical manager (CM )-A stated R21 required staff assistance to reposition. CM-A stated R21 was at risk for skin breakdown and her expectation was R21 would have been repositioned at least every two hours and would have had blue boots to both feet at all times. 48583 R47 R47's annual MDS dated [DATE], identified R47 had severe cognitive impairment and diagnosis which included Alzheimer's, depression and anxiety. Identified R47 required extensive assistance with ADL's which included bed mobility, transfers, and toileting. Identified R47 was at risk for pressure ulcers. R47's annual CAA dated 4/1/25, identified R47 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R47 was incontinent of bowel and bladder. R47's care plan dated 5/25/23, identified R47 had self care deficits and a potential for an alteration in skin integrity related to Alzheimer disease. Identified R47 had total dependence of one to two for positioning, checking and changing incontinent product at least every two hours. R47's Braden Scale for Predicting Pressure Ulcer Risk dated 3/19/25, identified R47 was at moderate risk of developing a pressure ulcer. During a continuous observation on 5/20/25 from 3:38 p.m. to 6:20 p.m., the following was revealed: - 3:38 p.m., R47 was up in R47's wheelchair and brought out to the day room. R47 was positioned facing out the window and staff covered R47 up with a red blanket. - 4:29 p.m., R47 remained in the same position. - 4:51 p.m., R47 into the dining room and placed R47 at the table to be fed supper. - 5:55 p.m., R47 was being fed by staff in the dining room. - 6:15 p.m., R47 nursing assistant (NA)-B pushed R47 out of the dining room and to the dayroom. During an observation on 5/20/25 at 6:20 p.m., NA-B wheeled R47 to her room. NA-B, NA-C, and registered nurse (RN)-A sanitized hands, and hooked R47 up to the mechanical lift, placed R47 onto the bed, changed R47's incontinent product and repositioned R47. During an interview on 5/20/25 at 6:38 p.m., NA-B stated R47 required staff assistance to reposition and change incontinent products. NA-B stated she was unsure of the last time R47 had been repositioned because when she arrived to work at 4:00 p.m., R47 had already been sitting in her wheelchair. NA-B stated staff had not documented the time that R47 had been repositioned but stated R47 should have been repositioned every two hours to prevent skin breakdown. During an interview on 5/20/25 at 5:57 p.m. director of nursing (DON) stated the usual facility procedure for pressure ulcer repositioning depended on a resident's Braden assessment, location of the resident's pressure ulcer, and repositioning could have been completed between one to three hours. DON stated if it was care planned for every two hours repositioning, it was expected to be done, unless the resident or family refused. DON stated repositioning was important to reduce risk for further skin breakdown. DON stated R27's pressure ulcer was first assessed as a Kennedy ulcer however, was then changed to a stage three pressure ulcer after the clinic wound nurse assessed it. During a follow-up interview on 5/20/25 at 7:02 p.m., DON confirmed the above findings and stated the clinical managers set up the turning and reposition programs. DON indicated the facility did complete tissue tolerance tests and each resident was monitored through the Braden scale. DON stated she was not aware R21 was not wearing her blue boots. DON said her expectations were for staff to follow the care plan for each resident and reposition them as indicated. Review of facility policy titled Preventing & Managing Pressure Ulcers And Wound revised 3/5/25, identified that a resident who was admitted to this facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable, and that a resident who had an ulcer received cares and services to promote healing and to prevent additional ulcers. The policy included instructions for a body audit to be completed with the first 24 hours of admission, a Braden scale be completed on admission then weekly times four, quarterly, and with any significant change and annually. The individualized resident care plan would indicate the frequency of repositioning and/or off loading, special cushions or devises to be used in the bed or chair, and special nourishments. With the guidance of the registered nurse, wound care nurse, or physician, staff would follow the treatment orders to care for the wound, and weekly wound documentation would be completed by a registered nurse. Review of a facility policy titled Repositioning Policy revised 3/24, identified a resident's repositioning schedule would be identified in the care plan.

Based on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 1 (R15) residents identified at risk for falls. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included diabetes mellitus, depression, and anxiety. Indicated R15 required extensive assistance from staff with toileting, transfers, and personal hygiene. R15's care area assessment (CAA) dated 10/25/24, triggered for a risk of falls due to use of anti-depression medications and a history of falls. Review of R15's care plan dated 10/20/23, lacked the immediate intervention implemented from fall on 5/6/25. Review of R15's progress notes dated 5/6/25, revealed R15 had a fall on 5/6/25, in R15's bathroom. R15 stated R15 was trying to get to her bathroom call light and the non mechanical standaid was in the way. R15 tried to turn around and got stuck and could not get R15's chair to move forward again and slipped out of the wheelchair. R15 stated R15 hit her head when she fell . Facility had an immediate intervention implemented to remove the non mechanical standaid out of R15's bathroom when R15 was not using the non mechanical standaid for R15. During an observation on 5/19/25 3:05 p.m., non mechanical standaid was present in R15's bathroom. R15 had a fall on 5/6/25, and the intervention was to remove the non mechanical standaid from R15's bathroom when not in use. During an observation on 5/19/25 at 5:26 p.m., non mechanical standaid was placed in R15's bathroom. During an observation on 5/20/25 at 10:37 a.m., non mechanical standaid was placed in R15's bathroom. During an observation on 5/20/25 at 12:31 p.m., non mechanical standaid remained in R15's bathroom. R15 left the dining room and was self propelling herself back to her room. During an observation on 5/20/25 at 12:47 p.m., R15 was in her room and nursing assistant (NA)-E assisted R15 to lay down in her bed. When NA-E was done assisting R15, NA-E pushed the non mechanical standaid into R15's bathroom and left R15's room. During an observation on 5/20/25 at 1:18 p.m., R15 was laying in her bed covered up with a blanket. The non mechanical standaid remained in R15's bathroom. During an observation on 5/21/25 at 7:16 a.m., R15 was in the dining room. The standaid remained in R15's room. During an interview on 5/20/25 at 4:30 p.m., NA-E confirmed NA-E assisted R15 to bed on 5/20/25, and placed the non mechanical standaid back in the bathroom. NA-E stated she was unaware the non mechanical lift was not supposed to be stored in R15's bathroom. During an interview on 5/21/25 at 9:41 a.m., trained medical aid (TMA)-A stated TMA-A was not aware the non mechanical lift was to be removed from R15's room after staff assisted R15. During an interview on 5/21/25 at 9:43 a.m., clinical manager (CM) indicated she was not aware of the new intervention for R15. CM stated that was implemented by another staff. CM confirmed it was not updated in R15's care plan. During a follow-up interview on 5/21/25 at 12:30 p.m., CM stated R15's care plan had been updated to reflect the fall intervention and the non mechanical lift had been moved out of R15's bathroom. During an interview on 5/21/25 at 3:10 p.m., director of nursing (DON) confirmed the above findings and stated it should have been added to R15's care plan. DON stated her expectations were if a new intervention was put in place that it was added to the care plan and staff were to follow it. Facility policy titled Fall Prevention and Management dated 12/10/24, the staff nurse will review the occurrence report and will: - Assess all factors contributing to the fall event such as environment, equipment, medication factors and which interventions were in place at the time of the fall using Fall follow up form as a guideline. - Recommend interventions and changes to plan of care to prevent repeat fall. - Communicate and document results. - The staff nurse will complete the follow up documentation in the medical record by the following schedule.

Based on interview and document review, the facility's consultant pharmacist failed to identify and report irregularities related to prophylactic antibiotic use for 1 of 6 residents (R34) reviewed for unnecessary medications. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal R34 would remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to have R34's urostomy emptied every two hours. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxime Axetil Oral Tablet 500 milligrams (MG) (Cefuroxime Axetil). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs or when to reevaluate prophylaxis antibiotic usage. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's Pharmacist Recommendations to Nursing from 4/29/24 through 2/18/25, revealed no recommendations to monitor for signs and symptoms of a UTI or to reevaluate the use of the prophylaxis antibiotic. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed R34 had no documentation specifically related to R34's prophylaxis antibiotic usage. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to ask R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were entered into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have received a note to review this medication with the provider during last rounds. During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 did have a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documentation if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis and rationales with supporting documentation when receiving medications. During a follow-up phone interview on 5/22/25 at 10:46 a.m., medical director (MD) indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had experienced a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale on why the resident was taking the medication. Review of facility policy titled Antibiotic Stewardship Policy revised 2/21/25, it was the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners had documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

Based on interview and document review, the facility failed to ensure reevaluation for necessity and duration of ongoing antibiotic use for 1 of 1 residents (R34) reviewed for unnecessary medication use. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and had an indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal to remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to monitor/record/report to primary provider for signs and symptoms of UTI: pain, burning, blood tinged urine,cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. R34's care plan lacked a focus area for extended antibiotic use. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxime Axetil Oral Tablet 500 milligrams (MG) (Cefuroxime Axetil). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs, when to reevaluate prophylaxis antibiotic usage, and duration. R34's provider visit notes dated 1/23/25, 3/27/25, and 5/1/25, lacked documentation for continued use rationale and duration of extended antibiotic use. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's electronic treatment administration records (eTAR) from 3/1/25 through 5/21/25, lacked documentation of monitoring R34 for signs and symptoms of a UTI or extended antibiotic use. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed there was no documentation for reevaluation and duration of continued antibiotic use for R34. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to has R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have received a note to review this medication with the provider during last rounds. On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD). During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 had a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documention if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis, duration and rationales with supporting documentation when receiving medications. During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use. Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

Based on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 2 residents (R23) reviewed for call light accessibility. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and diagnoses which included hypertension (elevated blood pressure) and dementia. Identified R23 was dependent on staff for activities of daily living (ADLs) and mobility. R23's care plan dated 3/27/25, identified R23 was at risk for falls, with an intervention to ensure the call light was within reach and to encourage R23 to use the call light. During an observation on 5/19/25 at 11:26 a.m., R23 was seated in her reclining wheelchair in her room. Call light cord was attached to the wall and not within reach. During an observation on 5/19/25 at 3:09 p.m., R23 was lying in bed. Call light cord continued to be attached to the wall and was not within reach During an observation on 5/20/25 at 9:58 a.m., R23 was lying in bed. Call light cord was attached to the wall and not within reach. During a joint interview on 5/20/25 at 10:15 a.m., NA-A and LPN-A stated R23 was able to use the call light. NA-A verified call light cord was not within reach of R23 and removed the call light cord from the wall and placed the cord on the siderail next to R23. LPN-A stated R23 was able to use the call light and her expectation was that R23's call light would be placed within reach. During an interview on 5/21/25 at 9:25 a.m., director of nursing (DON) verified R23 was able to use the call light. DON stated her expectation was that R23's call light would have been within reach of R23 in her room. Review of a facility policy titled Call Light Policy revised 1/2024, identified, when the resident/patient was in bed or confined to a chair to be sure that the call light was within easy reach of the resident/patient, and that the resident/patient had a pendant on if they chose to do so.

Based on observation, interview, and document review, the facility failed to follow manufacturer's guidelines for a full body mechanical lift by ensuring the loops were secured to the hook on the lift, prior to lifting the resident for transfer for 1 of 3 residents (R1) reviewed. This resulted in actual harm when the hook came off the lift and R1 fell to the floor sustaining a large hematoma to the side of his head, a skin tear to finger and required an emergency department (ED) visit. Findings include: R1's care plan dated 6/15/23, indicated R1 had impaired functional status related to hemiparesis, history of stroke and had limited ability to complete activities of daily living (ADLs), dependent on staff for assistance, and utilized a wheelchair and mechanical lift. Further, R1's care plan identified R1 was dependent on staff for transfers with a mechanical lift and assist of two. R1's Fall-Witnessed incident report dated 1/7/25, indicated R1 was being transferred from the tub chair to the bed by two staff members with a Hoyer lift (full body lift). The Top right corner of the sling came off the lift and R1 fell towards the floor. R1 hit the floor with the top right side of his head. R1 was assessed for injury and vitals were obtained. R1 was hypertensive and R1 was wheezing at the time, was short of breath, and had a large hematoma on the right side of his head and skin tear to right fingers. At the time of the incident, R1 had reported 10/10 pain. R1 was sent to the ED. R1's progress note dated 1/9/25, registered nurse (RN) post fall follow up indicated R1 had sustained a skin tear to right fifth digit and a hematoma to right temple. R1 denied pain to area of trauma on the head and pain to the right hand/finger skin tear. Contributing factors related to R1's fall were identified as R1 had returned to his room following a bath. The lift sling was under him, and staff proceeded to hook R1 up to the mechanical lift and then called for assistance. The second aide came into the room and took the control to lift R1 with the lift and did not double check to ensure he was hooked up properly. Immediate education was provided to the staff involved on double checking the lift sheet before lifting the resident. Other interventions included lift sheet was checked and was the right size with no rips or tears, education with competency on lifts was completed for the aides involved in the incident. R1's ED Transfer Report dated 1/7/25, indicated per assessment R1 had a fall from Hoyer approximately 3-4 feet and had complaints of a headache and neck pain, and R1's blood pressure was noted to be 163/95. Discharge note revealed computed tomography (CT) imaging of R1's head, facial bones, and cervical spine did not show any evidence of bleeding within the skull, he did have a large hematoma on the right side of his head. There was no facial [NAME] fractures or neck fracture. R1's labs were stable. R1 was given a gram of IV Tylenol during his evaluation, and his pain appeared to be improved. On 1/9/25 at 1:23 p.m., R1 was sitting in his wheelchair in his room and appeared to be comfortable. R1 had a red spot on the right side of his head that did not appear to be an open wound and a Band-Aid was on his right pinky finger. R1 denied pain to the areas. R1 stated he could not recall the incident but stated they were banging me on the Hoyer. On 1/9/25 at 1:33 p.m. licensed practical nurse (LPN)-A stated R1 was totally dependent on staff for all ADLs due to left sided weakness, and R1 required assistance of two staff members for transfers using a Hoyer mechanical lift. LPN-A stated on 1/7/25 at approximately 12:50 p.m., she was standing outside of R1's room at her medication cart when she heard someone scream and then entered R1's room. LPN-A stated R1 was on the floor and LPN-A noted a large hematoma to the right side of R1's head that appeared to look like a rug burn and R1's head was hit hard. LPN-A assessed and determined staff could safely transfer him into bed, and LPN-A then noted the skin tear to his finger which was bleeding. LPN-A called the ambulance and R1 was sent to the ED. Further, LPN-A stated at the ED, R1 had received IV Tylenol for pain and a CT, and X-rays were obtained of R1's head and neck which came back normal. LPN-A stated since the incident, R1 had returned to his baseline and at times has had complaints of pain to his head which was treated with ice and elevating his head. In addition, LPN-A stated the two nursing assistants (NA) involved had both been re-educated immediately to double check the lift to ensure the hooks were properly secured prior to lifting the resident. LPN-A stated all staff education had not been provided due to the director of nursing (DON) being out of the facility at the time. On 1/9/25 at 2:00 p.m., NA-A stated R1 was totally dependent on staff with all ADLs and required assistance of two staff for transfers with a Hoyer lift. NA-A stated on 1/7/25, at approximately 1:00 p.m., she had assisted R1 with a bath and back to his room where she hooked R1's sling to the Hoyer and then called for assistance to transfer. NA-A stated NA-B entered the room, and she began controlling the mechanical lift and lifted R1 up off the tub chair. NA-A stated R1 was approximately 3 feet in the air when he suddenly dropped onto the floor and hit his head. NA-A stated R1 appeared to be in pain following the incident and was sent to the ED. Further, NA-A stated she was unsure what caused R1 to fall however stated she was not sure if staff were to secure the loop to the lift or just set it on top of the bar however, confirmed NA-B did not double check the loops prior to lifting R1. In addition, NA-A stated facility protocol for a mechanical lift was to always use two staff with the lift transfers, both staff were expected to hook the sling to the lift, double check to ensure the loops were secure properly to the lift prior to lifting the resident. NA-A stated she was immediately educated on the process following the incident and had further training regarding the mechanical lifts and a competency check on 1/9/25. On 1/9/25 at 2:12 p.m., NA-B stated R1 required assist of two staff for transfers with a Hoyer lift and assistance with all other ADLs. NA-B stated on 1/7/25, some time after noon meal, NA-B was called to R1's room by NA-A requesting assistance to transfer R1 into his bed following his bath. NA-B stated she entered R1's room, R1 was sitting on the tub chair, Hoyer sling under him and attached to the lift. NA-B stated she began operating the lift and lifted R1 up off the chair, when R1 was in the air the top of the sling came off the bar and R1 tipped out of the sling headfirst onto the floor. NA-B stated following the incident, R1 was joking with staff and there was a bump noted on the side of his head. Further, NA-B confirmed she did not double check to ensure NA-A had properly secured all the loops prior to transferring R1 as required however, stated going forward NA-A would be more careful as the incident taught her a valuable lesson. NA-B stated she was educated following the incident and had a competency check with mechanical lifts. On 1/9/25 at 3:59 p.m., RN-A stated R1 required assist of 2 with transfers utilizing a Hoyer lift and had chronic pain to his left side. RN-A stated on 1/7/25, after the noon meal, NA-A and NA-B had been transferring R1 with the Hoyer and NA-B had not ensured the loops were secured to the lift when they had started lifting R1 and he fell . RN-A believed R1 was more than two feet in the air when he fell . RN-A was notified immediately to come to R1's room by LPN-A. RN-A stated right when she looked at R1, she stated he needed to be sent to the ED immediately. RN-A stated while at the ED, they completed some imaging to rule out any fractures and administered medications for R1's pain. R1 had returned to the facility the same day with no new orders however, staff were monitoring R1's hematoma on his head and cleaned and applied Steri-strips to R1's skin tear on his finger. Further, RN-A stated all Hoyer lift transfers required assistance of two staff, however, one staff could hook the sling to the resident and the second staff should be verify all loops were secured prior to transferring the resident. RN-A stated both NA-s were educated immediately following the incident regarding facility process. In addition, RN-A stated DON and the administrator were both out of the facility and all staff training was to be scheduled for 1/14/25. On 1/10/25 at 9:45 a.m., LPN-A stated when she entered R1's room on 1/7/24, R1 was screaming out in pain, however, R1 does have a history of yelling out during cares. LPN-A stated it was obvious however, R1 was in 10/10 pain, and when asked what hurt R1 said his head hurt. On 1/10/25 at 9:52 a.m., NA-B and NA-C entered R1's room with the Hoyer lift due to R1 wanting to be transferred from his wheelchair into his bed. R1 had the Hoyer sling under him already, NA-B and NA-C both hooked the loops to the lift and NA-B then doubled checked all 4 loops. NA-B operated the mechanical lift while NA-C guided R1 to the bed. NA-B lowered R1 onto the bed. On 1/10/25 at 10:18 a.m., NA-C stated she was a contracted agency staff and had been working at the facility for approximately three weeks. NA-C stated R1 required assist of two staff to transfer utilizing the Hoyer lift. NA-C stated she was aware R1 had a fall from the Hoyer lift however, was unsure of the details regarding the incident. NA-C stated for all Hoyer transfers, staff were expected to ensure all 4 loops were secured to the lift prior to transferring resident. Further, NA-C confirmed following R1's fall there has been no education provided to staff regarding mechanical lifts. On 1/10/25 at 11:40 a.m., attempted interview with DON was unsuccessful. Review of EZ Way Smart Lift Operator's Instructions revised 10/24/24, directed staff to make a final check of all four loop attachment points to ensure each loop was sufficiently attached to the respective hook of the hanger bars, and while lifting the patient continue upward motion until there was tension on the sling legs, make sure all the loops on the sling were securely hooked on the hanger bars. Review of facility policy titled EZ Way Smart Lifts revised 11/2/21, directed staff to check the condition of the sling before every use by checking entire sling for damage or wear including the loops and stitching, and if there were concerns with resident safety while transferring, stop the transfer, get assistance to keep the resident safe while getting the charge nurse. However, the policy did not direct staff to verify the loops were securely hooked prior to lifting the resident.

Based on observation, interview and record review the facility failed to comprehensively assess and provide appropriate interventions to respect and promote resident rights and meet individual needs for 1 of 3 residents (R1) who had a Wander Guard placed on his wheelchair to restrict his access to the community despite his intact cognition, independent mobility with his electric wheelchair and the facility's failure to attempt least restrictive measures. Findings include: R1's Minimum Data Set, dated dated dated [DATE], identified intact cognition without behaviors. R1 felt little interest or pleasure in doing things and felt down, depressed, or hopeless 2 to 6 days out of 7 days and socially isolated himself. R1 felt it was very important to go outside to get fresh air when weather was good. R1 had functional limitation/impairment on both sides on upper and lower extremities. R1 used a electric motorized wheel chair for mobility. R1 required substantial/maximum assistance for toileting hygiene, shower/bathing, low body dressing, and application of footwear. R1 required supervision or touching assistance with sit to lying, lying to sitting, and partial/moderate assistance with sit to stand, chair/bed transfer, toilet transfers, and unable to ambulate. R1 was able to use motorized wheelchair independently once seated. R1 was occasionally incontinent of bowel and bladder. R1's diagnoses included stroke, aphasia (a brain disorder that affects speaking or understanding language), hemiplegia (one sided paralysis or weakness caused by brain or spinal cord problems), and seizure disorder/epilepsy, anxiety, and depression. No physical or electronic device (bed/chair alarms, wander guard, motion sensor) used to monitor and detect movement. R1's physician order dated 8/4/24, elopement-frequent checks (Note must be completed by a nurse). Follow paper form for frequent checks. Note on locations or attempts to leave facility every shift for one day. Order completed. R1's elopement risk assessment dated [DATE], BIMS score 0 and was identified as no wander risk. R1's elopement risk assessment dated [DATE], BIMS score 15 and was identified as no wander risk. Facility elopement investigation notes dated 8/4/24, identified R1 had never gone anywhere other than the sitting area at the front of the facility before. R1 was alert, orientated, and able to make his needs known but had a history of poor safety awareness AEB (as manifested by) call pendent not used to request assistance with transfers. Facility staff member identified over the past week she had seen R1 on the west side of the building on the sidewalk with no signs of attempting to leave the facility grounds. R1's sister had told facility he had again requested family purse possible admission to the local AL facility, frequently looked for a different room more suitable for himself at current facility he resided at. He had attempted on once occasion to leave facility through doors located by the chapel, redirected, and moved back into facility without question. R1 was transported to ER for evaluation, placed on frequent checks for 24 hours. Wander guard was placed on R1's motorized scooter as he was unable to walk or move independently in a manual wheelchair. R1's care area assessment (CAA) dated 6/12/24, identified recent change in mood; sad or anxious (e.g. crying, social withdrawal). R1's cognition was identified as having confusion, disorientation, and forgetfulness, and decreased ability to make self-understood or to understand others. R1 had a psychiatric or mood disorder and hearing or vision impairment that may have impacted his ability to process information (e.g. directions, reminders, and environmental cues). R1 had expressive communication (e.g. disruption in ability to speak, problems describing objects and events). R1 indicated he felt lonely and conditions identified that impede his ability to interact with others identified were: aphasia, depression, decline in functional abilities, and mood problems that impacted interpersonal relationships or that arises due to social isolation. R1's psychosocial change identified as recent move into a nursing home. R1 had little interest or pleasure in doing things and preferred group activities. Impairment on upper and lower extremity on one side. R1's care plan last updated on 8/5/24, identified communication problem and directed staff to use simple, brief and consistent words/cue and yes/no questions, and communication tools such as communication board/book, writing pad, gestures, signs, and pictures. R1's speech communication was limited to yes, no, bye, grunts in different tones that corresponded with his facial expressions to express his mood, and hand gestures. R1 was identified as an elopement risk on 8/5/24, as evidenced by (EVB) was not identified on care plan. Staff were directed to monitor location for at least 24 hours after elopement, wandering behaviors, and attempted diversion interventions in behavior log. Wander guard was located on back of R1's motorized scooter. R1 was allowed to sit in courtyard by himself with call light pendent and staff or family was required to be with resident if he wanted to sit outside the main entrance. R1 had limited physical mobility and identified with independent scooter use after transfer assistance into his chair. R1 had diagnosis of depression related to loss of independence from stroke that resulted in hemiplegia, loss of independence, separation from family, unable to communicate with others, not wanting to come out of his room and admitted to being lonely. Staff were directed to monitor/document/report signs/symptoms of depression, hopelessness, anxiety, sadness, insomnia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. R1's goal was to discharge to assisted living. Staff were directed to assist resident with tours of facilities and coordinate community services, and information about alterative living arrangements to R1 and representative. R1's occupational therapy treatment note dated 7/12/24, identified R1 was classified as stable and uncomplicated decision making and deemed safe to operate power scooter. R1's progress noted from 8/4/24, through 8/5/24, identified: -8/4/24 at 10:24 a.m., Late entry: Received a call from community member lived at a local assisted living (AL) facility Estates at approximately 11:10 and reported to charge nurse believed one of our residents [R1] was outside of her place of residence and stuck in a ditch. When questioned how she knew it was [R1] she indicated she visited a family member at this facility and was familiar with him. She indicated had called the police department but was told they were unable to assist her. The charge nurse checked and confirmed [R1] was missing. Community member called again and stated the police department was at the scene. The police department called charge nurse requested the residents full name and date of birth (DOB). After confirmation [R1] returned to facility at 11:25 a.m. with emergency medical EMT's and police. He was then sent to evaluation to ER (emergency room ) at 12:27 p.m. to ensure resident was safe after being out of the facility. POA (power of attorney) was notified by staff nurse and facility administrator notified at 11:48 am by charge nurse. [R1] returned from the ER with orders for antibiotics d/t (due to) urinalysis suggestive of a UTI (urinary tract infection). -8/4/24 at 3:47 p.m., Returned to facility via ambulance from hospital. -8/4/24 at 4:10 p.m., Change wander guard: please document initials, date, and serial number of new wander guard. Placed on back of electric scooter. Reason for placement explained to wife and [R1]. -8/5/24 at 2:59 p.m., Health Status Note: Elopement follow-up: Effective Date: 08/05/2024 14:59 Type: Health Status Note. Elopement Follow-up: Resident left building via motorized w/c (wheelchair) after breakfast. [R1] did not communicate to any staff he left facility. Destination was local assisted living facility to look inside facility at room availability. [R1's] wheelchair got stuck in a ditch on the way to the assisted living. Was assisted by local law enforcement and EMT and returned to facility. Was then taken to ER for evaluation. diagnosed with UTI (urinary tract infection). Started on Cipro 250 mg (milligrams) BID (two times a day ) x (times) 3 days. Interventions: BIMS (brief interview for mental status) score was 15.0 (intact cognition). Wander guard- placed on motorized w/c. [R1] must have someone sit with him when wanting to sit outside at the main entrance. Must inform staff when leaving facility with any family member by himself after . Be sure resident has call pendant on self when going in the courtyard. Resident is aware of the plan and in agreement. During an observation on 8/15/24 at 10:20 a.m., R1's door was closed to his room. R1 laid across his bed with feet placed on electric wheelchair. R1 woke up after surveyor knocked at the door and entered. Wander guard was noted attached to the electric wheelchair on the back side located just below the head rest. During an observation on 8/15/24 at 11:11 a.m. staff nursing assistant (NA)-A stopped by R1's room and checked to see how he was doing. Additionally, at 11:12 a.m. female staff stopped by R1's room checked on him and left room. During an observation on 8/15/24 at 11:20 a.m., R1 came out of his room fully dressed in electric wheelchair, went down hallway and made a loop around the facility independently. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/15/24 at 4:00 p.m. R1 sat in his room alone in silence and looked out of window. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/16/24 at 9:25 a.m., R1's room door was open and he sat in motorized wheel chair alone at his desk and painted on a ceramic duck. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/16/24 at 2:30 p.m., and 4:00 p.m. R1 laid on top of his bed with door open to room, eyes closed in silence. Wander guard intact on back side of wheelchair located just below the head rest. During an interview on 8/15/24 at 10:20 a.m., R1 stated had left facility over one week ago in the electric wheelchair to cruise around the neighborhood and check on an AL facility. R1 stated he wanted to move so he would have more independence. R1 stated was aware of his surroundings and felt safe leaving the facility grounds in the electric wheelchair. R1 stated most of the time when he left the grounds in the past had a family member with him. R1 stated staff had informed him he was unable to leave the facility grounds independently. During a follow up interview/observation on 8/16/24 at 9:30 a.m., R1 sat in electric wheelchair with wander guard attached to the bar located on the backside below the head rest of the wheel chair. R1 was positioned at a table and pained a ceramic duck. R1 stated felt more restricted after the placement of the wander guard and isolated more in his room than before. R1 stated staff do not have the time to take him outside, they were so busy. R1 was aware he could go out into the courtyard but had been closed recently due to dug up ground. R1 stated hardly ever went out in the front of building anymore unless family visited. R1 stated he felt sad, isolated, and very much restricted. R1 stated felt his depression had gotten worse since staff placed the wander guard and restricted his independence going outside. R1 confirmed he had no thoughts of hurting himself and he talked to his sister, and she listened. During an interview on 8/15/24 at 2:25 p.m., nursing assistance (NA)-A stated R1 preferred to be independent, and cognition intact with no confusion or forgetfulness. NA-A stated R1 was independent with use of electric wheelchair allowed to go outside independently but due to recent elopement wander guard was applied to wheelchair and R1 was restricted as to where he could go. NA-A stated R1 was allowed to go out to the courtyard independently but area was closed off to residents, due to the ground being dug up and not safe to enter. NA-A verified R1 was allowed to sit out front of building but only if accompanied by a family member or staff. During a telephone interview on 8/16/24 at 8:11 a.m., R1's family member (FM) stated they knew R1 left the facility not to long ago to check out the AL next door. FM indicated R1 had told her he was the youngest resident in the facility and felt out of place. FM stated R1 had also told her he was not aware he had to sign out of the building prior to leaving and felt he told the truth. FM also stated there were times when she had taken R1 out of the facility, staff had her sign him out, but sometimes they would just say ok and not ask where they were going or when we would return. FM verified they had found R1 on the on the back side of the AL facility, that he wanted to move, and had gone there to check out the area. FM stated the facility had informed her prior to R1 leaving the facility he could go out and about and that would not be a problem. FM stated R1 had left the facility by himself for a stroll around that side of town by the facility about two months ago without any problems. FM indicated she had planned on finding R1 a cell phone to carry with him while outside in case he needed assistance. FM stated R1's cognition had improved in the past year 90%, was severely impaired and now his cognition was intact. FM stated R1 told her he felt totally isolated at this facility and she was afraid he would get more depressed. FM verified she had seen sadness in R1 the past few days, gave her the shrug of his shoulders and indicated he could just as well lay in bed, unable to go outside anymore unless someone had time. FM stated R1 loved the lake, sensory, and needed fresh air. FM stated, thank God he had his painting he can do in his room, that was most likely what was saving him from getting too down on things until he moved. During an interview on 8/16/24 at 9:53 a.m., licensed practical nurse (LPN)-B stated R1 valued his independence, drove his electric wheelchair well, and was important to offer R1 choices. LPN-B stated they had not completed an assessment for application of a wander guard since she started work at the facility (three months ago). LPN-B also stated R1 had no history of elopement, loved the outdoors, sat out in the front of building, and did not wander aimlessly without a purpose. LPN-B confirmed R1 was unable to leave facility without family or someone with him. During a telephone interview on 8/16/24 at 11:18 a.m., registered nurse (RN)-A stated a wander guard had been placed by another staff on R1's wheelchair and management team decided the following day (Monday) R1 would be allowed to go outside in the courtyard by himself unsupervised. The courtyard door (a contained area) would set off the wander guard, R1 was ok with that and happy to have the ability to go out there alone. RN-A verified no assessment for a wander guard was required and was a nursing judgement call. RN-A stated after R1's initial elopement risk assessment was completed upon admission; had been an ongoing thing an assessment was not required prior to the application of the wander guard. RN-A stated when a resident lacked safety awareness, it was a motherly instinct that indicated a safety issue. RN-A indicated staff completed 15-minute checks for 24 hours once R1 returned from ER but no other interventions were tried prior to the placement of the wander guard, adding she was not sure what else could have been done. During an interview on 8/16/24 at 11:54 a.m., LPN-A stated they worked the day R1 left the facility. LPN-A indicated R1 was alert and oriented that morning and no signs of confusion were noted. LPN-A stated R1 had told her upon his return that day he just wanted to check things out at the local AL facility. LPN-A stated it appeared to be an isolated incident. LPN-A stated R1's cognition was intact, was forgetful at times, and should have signed out when he left facility. During an interview on 8/16/24 at 12:45 p.m., social worker (SW) stated the facility courtyard was closed to residents and most likely will be for the next two weeks. SW stated R1 was independent in his electric wheelchair on and off the unit (to other units within the facility), not real clear in R1's care plan as to where he could go independently prior to the elopement. SW stated R1 had a wander guard applied to the backside of his wheelchair and unable leave the facility until next review date without staff or family. SW stated the courtyard had not been torn up yet so he was allowed to go out there independently so that he would not feel like he had a babysitter with him. SW stated R1 had intact cognition, speech therapy attempted a SLUMS (St. Louis University Mental Status) (screening tool designed to detect early signs of mild cognition impairment and dementia) however because he was non-verbal the test was unable to be completed. SW stated R1 had not left the facility prior to his elopement, two assessments were completed upon admission 6/17/24, and annual review on 7/11/24 and identified no risk for elopement. SW stated a wander guard was applied to R1's wheelchair and he was made aware of it and was ok with it. SW stated R1 and his family asked if wander guard was a permanent thing and were told we do not want to take away his freedom and planned on getting back to where he will not need it. SW stated the wander guard was placed for a testing period so that staff were made aware when he exited the building. SW verified no assessment was completed prior to the application of the wander guard on 8/4/24, once he returned from the emergency room visit (ER). SW stated an assessment should have been completed on R1's safety level outside beyond the building. SW stated the wander guard will lock the exit doors (included the courtyard door) when the resident was positioned five feet in front of it and would restrict R1 from going outside. SW stated R1 would be required wait until staff swiped badge to have allowed R1 out of building. SW stated the first 24 hours after the elopement supervision was increased but after the 24 hours no other interventions or non-restrictive options were tried prior to the application of the wander guard. SW indicated R1 had not tired to exit the building alone since the elopement and the use of the wander guard should have be reassessed and possibly removed. During an interview on 8/16/24 at 2:00 p.m., case manager RN-C stated R1's cognition was intact. RN-C stated unable to identify in R1's care plan if he had been assessed and/or if he was able to leave the facility grounds safely prior to the elopement. RN-C indicated a wander guard was placed on the back of R1's wheelchair on Sunday (day after elopement) and unsure if less restrictive options were attempted prior to that. RN-C stated the last elopement risk assessment completed was 6/11/24. RN-C stated the wander guard alerted staff R1 had entered the area by an exit door and required staff to swipe badge to open the door. RN-C stated the use of the wander guard on R1 restricted his movement outside the building. RN-C stated they had not discussed with R1 how he felt about the wander guard yet and hoped that someone explained it to him and what it was used for. RN-C stated after review of R1's medical record did not see any monitoring being completed for mood and hoped staff would have reported if there were any changes. RN-C stated R1's care plan was changed after the elopement and he was now required to have staff or family member outside the facility main entrance and courtyard independently. RN-C stated the court yard had been torn up and no residents were allowed to be in that area. During an interview on 8/16/24 at 2:36 p.m., director of nursing (DON) stated R1 had intact cognition was aware of what he was doing, and was able to communicate with people out in the community to yes and no questions. DON indicated R1 was not an elopement risk, had no previous elopement attempts, and could have left the building if he wanted to. DON verified an elopement risk assessment was not completed after the 8/4/24 elopement and should have been, it would have triggered R1 was an elopement risk. DON stated a wander guard was placed on R1's wheelchair to prevent another elopement. DON indicated the wander guard alert system was used to alert staff R1 tried to exit the building. DON stated if R1 really wanted to get out of the facility he would just wait a few seconds then hold door handle down, would open, and then exit the building. DON stated the wander guard was used to alert staff he was at the door. DON stated she would have expected staff to have attempted other interventions such as checked on R1 more frequently after the 24 hours were up before the application of the wander guard. DON the use of the R1's wander guard should have been reviewed weekly. During an interview on 8/16/24 at 3:13 p.m. floor manager RN-B stated R1's BIMS (brief interview for mental status) indicated cognition was intact. RN-B stated SLUMS or MoCA (Montreal Cognitive Assessment) (used to identify impairment of cognition) was not completed due to R1's deficits and inability to write and answer questions easily. RN-B stated assumed R1 was independent on and off the unit and independent outside prior to the elopement but hard to determine that after review of care plan. RN-B stated R1 had communication barriers, wanted out of this facility, felt like he did not fit in, no dementia, and younger than the residents that resided in the facility. RN-B stated R1 had made staff aware he wished to be moved to AL for more independence and family indicated he wanted to go over there to be re-evaluated. RN-B stated prior to elopement R1 had been outside with family, during activities, and had been safe without issues. RN-B stated she had applied a wander guard to R1's wheel chair after he returned fromER on [DATE]. RN-B stated no assessment was completed to the application of the wander guard and should have been. RN-B also stated every 15 minute checks were started and completed 24 hours later. RN-B indicated the wander guard would restrict R1's mobility for going outside and staff would have to open the door for him. RN-B stated anyone could open the door 15 seconds after the wander guard alarmed, door lock would have released, and R1 was not prompted for that. RN-B stated R1 used an electric wheelchair, moved rather fast, found the wander guard was the only option, unable to have someone at all the exit doors when staff assisted other residents. RN-B stated R1 and family asked how long would the wander guard be used and informed unsure of the plan. RN-C indicted R1 had not attempted to exit the facility building since the wander guard was applied and an assessment had not been completed to identify if it was still needed. Facility policy Elopement assessment dated [DATE], revealed a safe environment would be expected to be provided for each resident of the facility. Elopement would be defined as leaving the facility without following the facility's policies and procedures for leave of absence. A thorough elopement risk assessment would be completed during admission, annually, and with any significant change in condition to identify if a resident was at high risk for elopement. Residents identified as high risk for elopement would have preventive interventions initiated on the resident's care plan, direct care staff informed of resident's risk, and when actively exit seeking would have a wander guard placed to ensure residents' safety. Facility policy Wander Guard Blue Devices dated 4/27/22, revealed resident(s) identified to wear a wander guard: assessed to be a potential wanderer, assessed for safety risks and had be determined little or no regard for their own safety, and new admits whose behaviors suggested they maybe a wandering risk. Consider monitoring the new admits until actual risk can be determined.

Based on interview and document review the facility failed to follow care plan fall interventions for 1 of 3 residents (R1) reviewed for falls. This failure resulted in R1 sustaining serious injuries requiring hospitalization and surgery. Due to complication related to the surgery, R1 died . This failure resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on [DATE] at 1:00 p.m., when R1 rolled out of bed, fell on to the floor, and sustained fractures of the hip, pelvis and humerus (long bone in the arm runs from shoulder to the elbow). R1 was hospitalized , underwent surgery to repair her hip fracture and died due to complications from the fractures. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:45 p.m. The facility immediately implemented corrective action and was corrected on [DATE], prior to the survey and therefore the deficiency was issued as past noncompliance. Findings include: R1's significant Minimum Data Set (MDS) dated [DATE], identified R1 had serve cognitive impairment and no behaviors. R1 required total dependence for transfers and locomotion, extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. R1 had functional limitation in range of motion (ROM) on one side and used wheelchair for mobility. R1 was frequently incontinent of bladder and always incontinent of bowel. R1's diagnoses included Alzheimer's disease and non-traumatic brain dysfunction. R1's diagnoses report dated [DATE], identified chronic obstructive pulmonary disease (COPD), contractures of muscle lower leg, dementia, dysphasia (difficulty swallowing), muscle wasting and atrophy (decrease in size or wasting of a body part or tissue), pain, and restlessness and agitation. R1's care plan dated [DATE], identified R1 had impaired cognition related to dementia, impaired thought process, potential for delirium, unable to verbalize any discomfort and could become fidgety at times. Staff were directed to have provided consistency in care givers to decrease confusion and avoid agitation. R1 was at risk for falls related to vision and hearing impairment, long and short-term memory loss, Alzheimer's disease, impaired mobility, periods of restlessness, stiffness in joints and impaired ROM in upper extremities. Staff were directed to anticipate and meet R1's needs, bed placed in low position, defined perimeter mattress, keep bed up against the wall, and head of bed facing north, place pillow between knees, blue pad against the wall when in bed to prevent right knee/leg rubbing the wall. R1's transfers were to be completed with a full body lift with medium sized sling. R1 had decreased ROM and muscle rigidity (stiffness). R1 was to be positioned with a pillow under right arm and left arm at all times when in bed and up in chair. Ensure environment was safe, bed in lowest position and wheels locked. R1 had self-care deficit with activities of daily living (ADLs). Staff were directed to check and change and reposition R1 at least every three hours with assistance of two. R1's Kardex dated [DATE], identified: -Bed in low position and at all times unless directly working with R1 at the time and bed wheels locked. -Keep bed up against the wall. Head of bed facing north. -Must use two staff to turn and reposition, dressing, changing incontinence padding. -Place pillow between knees on the right side of the bed with R1 when laying down. -Place resident on left side or on her back when laying down in bed to prevent her from swinging her legs and rolling out of bed. -Place blue pad against the wall in bed to prevent right knee/leg rubbing the wall. -Place blue positioning pillow under right arm at all times when up in geri-chair (a well-padded chair with wheels made for the geriatric population) and when in bed. -Place small pillow under left arm at all times. R1's fall risk with balance and functional limitations assessment dated [DATE], identified long term memory loss, disorientated time three, highly impaired vision, limited ROM to upper extremities, and contractures (shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints). Risk factors identified that may have contributed to R1's fall risk: end stage dementia, required assistance of two with transfers using full mechanical lift. R1 does not ambulate. Last fall [DATE], slide out of Broda Chair (a wheelchair allowed positioning capabilities such as tilt and recline). R1 continued to shift weight in chair and bed which was her greatest fall risk. Care plan up dated. Facility incident report dated [DATE], identified on [DATE] at 1:00 p.m., R1 was laid down in bed. R1 rolled out of bed onto the floor. Staff in room witnessed fall. Staff were transferring roommate. R1 transferred to emergency room (ER) where fractures/injuries were confirmed at 7:30 p.m. Facility 5-day review dated [DATE], identified R1 was laid down with full body lift in her bed on her right-side facing wall in middle of the bed. Bed remained in working position for staff. Two staff NA's assisted roommate and placed her in the sit to stand lift and stood roommate up. R1's bed remained in high working position height and then NA witnessed R1 flip her weight to her other side with her legs and rolled out of bed and onto the floor. NA heard a crack and supervisor noted R1's arm had been displaced. R1 sent to emergency room (ER). R1's radiology report CT (computed tomography) scan (medical imagining used to obtain detained internal images of the body) of the right shoulder dated [DATE], identified: -Acute comminuted (a bone broken in at least two places) reversal Hill-Sachs fracture (impaction fracture) of the humeral head (upper arm). -Acute displaced fracture of the anterior-inferior glenoid ramus (shoulder joint). -Soft tissue swelling. R1's radiology report CT scan of pelvis dated [DATE], identified an intertrochanteric (area located between the hip and the top of the thigh) fracture of the right hip with overlying soft tissue swelling. R1's progress noted dated [DATE] at 3:04 p.m. indicated fall occurred in R1's room at 1:00 p.m. R1 laid in bed on right side when she rolled toward the left and rolled off the bed and landed on the floor on right side shoulder. R1's fall was witnessed, and head was not hit. R1 was nonverbal, confused, lethargic, and displayed facial grimacing. R1 was transported from floor with Hoyer lift and assistance of two staff. R1 was sent to emergency room (ER). R1's progress notes dated [DATE] at 5:15 p.m. injury noted from fall, fractures. R1 hospitalized . Underlying acute/chronic health conditions that may have contributed to this fall: Alzheimer's, dementia, and contractures of muscle. R1 was laid down and fell while staff were transferring her roommate into bed. R1 shifted legs from the right to the left side of her bed. Due to R1's size and the weight shifted staff were unable to prevent her from rolling over the edge of the mattress. R1's bed should have been in the low position whenever staff are not directly working with her, this would not have prevented R1 from rolling out of bed but possibly reduced the severity of injury. R1 was to be placed on her left side or her back to prevent her from getting the momentum to shift her weight enough to have rolled out of bed. R1's hospital discharge summary dated [DATE], identified R1 was [AGE] years old, with diagnosis of Alzheimer's dementia, COPD without maintenance therapy, was nonverbal and non-ambulatory at baseline. R1 rolled out of bed at nursing home onto right side on [DATE]. Outside ER evaluation demonstrated right proximal (near the point of attachment) humerus fracture, right intertrochanteric hip fracture, and pelvis fracture. R1 was admitted to orthopedic service on [DATE], underweight ORIF (open reduction internal fixation surgery completed to repair the break in the top part of the femur, the ball that fits into the hip socket) of right hip fracture on [DATE]. R1's hospital course was complicated by worsening acute hypoxemic (lack of oxygen in blood) respiratory failure secondary to marked aspiration pneumonia. Discussed with family regarding goals of care. Given R1's underlying comorbidities (one or more other diseases or conditions) and acute injuries, family desired focus of care to be on comfort. Medications were used for shortness of breath, pain, and agitation. R1 passed away peacefully on the evening on [DATE] at 9:13 p.m. Family at bedside. R1's death certificate identified date of death [DATE]. R1's immediate death was determined to be caused by acute hypoxemic respiratory failure (a condition where you do not have enough oxygen in the tissues in your body to stay alive). R1's pneumonia and aspiration (infection of the lungs caused by food or liquid breathed into the airways or lungs, instead of being swallowed) were identified as conditions that lead up to the immediate cause of death. Other significant conditions contributing to death but not resulting in the underlying cause: advanced Alzheimer's disease, chronic COPD, fall injury with right intertrochanteric (a fracture of the region further down the hip joint in the portion of the upper femur (thigh) that extended outward), and right proximal humerus (top of the arm bone) fracture (occurred when the ball, of the ball and socket shoulder joint was broken). During an interview on [DATE] at 4:41 p.m. nursing assistant (NA)-A stated R1's fall interventions indicated should be placed on left side, bed must be placed in low position, pillows to support R1 better, and a mat against the wall which helped protect R1' knees and body from rubbing against the wall. NA-A stated the main thing was to keep R1's bed in the lowest position to the ground. NA-A indicated she had never seen R1 roll out of bed prior to this incident but was aware R1 had rolled herself out of the bed previously. NA-A stated on [DATE] they (NA-A and NA-B) placed R1 in bed with a total lift machine, lowered her down onto the middle of the bed, positioned facing the wall (on her right not, not left) and left the bed up to chest height (approximately four feet off the floor). NA-A stated, they were assisting R1's roommate when R1 rolled herself over, flew out of bed, and landed on the floor. NA-A stated she heard bones crack and R1 laid on floor until an ambulance arrived. NA-A added, R1 started to shake and moan really loud in pain. NA-A indicate she did not look at R1's Kardex prior to caring for her and was unaware R1 should not have been placed on her right side and was just going by what other staff had told her or were doing. During an interview on [DATE] at 12:12 p.m., licensed practical nurse (LPN)-A stated they entered R1's room immediately after her fall on [DATE], R1 laid on her right side on the floor. LPN-A identified during R1's assessment her right arm was displaced, she was moaning, and had facial grimacing. LPN-A stated they called an ambulance, ER, family and faxed the primary doctor. LPN-A stated R1 had rolled out of bed by shifting her weight in the past without injuries and care plan was updated to reflect that. LPN-A verified interventions on R1's care plan were not followed. LPN-A stated R1's bed was left in the high position, she was placed onto her right side in bed (care planned to be placed on her left side), faced the wall without a pillow in between her legs. LPN-A stated she had been informed by NA-A and NA-B they had planned on going back to check and change R1 after they had assisted her roommate. During an interview on [DATE] at 1:38 p.m. registered nurse (RN)-A stated she had completed R1's fall risk assessment on [DATE]. RN-A indicated R1 continued to shift weight and that was her greatest risk for fall, usually happened when R1 was incontinent, and the reason she was placed in a low bed. RN-A verified R1 had been moved to another unit in the facility on [DATE], and prior to that she had a special mattress with wings on the sides that helped avoid R1 from rolling out of bed and prevented falls. RN-A stated the biggest thing was a low bed to help prevent falls and now on hindsight it seemed obvious the staff should have never left the bed up in a high position and/or turned away from R1 especially without hands on her. RN-A stated R1's care plan was not followed. During a telephone interview on [DATE] at 8:25 a.m., medical doctor (MD)-A confirmed R1's fall resulted in fractured hip, pelvis and humorous (upper arm). MD-A stated the family opted for hip surgery and hoped it would have provided stability of the fractured hip to alleviate some of the pain and allowed more movement, at least sit up in a wheelchair again. MD- A verified from studies with numerous fractures you become less mobile and could have carried risks such as not breathing as deeply. MD-A stated when elderly residents, usually 70 plus age range, encounter fractures there was a 30% mortality (death) rate within the first year because of decreased mobility and the body lacked the same relevancy to recover. MD-A indicated R1 would have not needed surgery without the fall and had potential complications such as infection, death was always a possibility. During a telephone interview on [DATE] at 9:29 a.m., MD-B stated R1 sustained three fractures, right humorous, right trochanter hip, and pelvis after most recent fall on [DATE]. MD-B indicated had been difficult to determine R1's baseline due to dementia and different assessment skills were used to assess her pain levels and R1 displayed: grimacing, elevated heart rate, and required pain management. MD-B stated R1 laid in a fetal position and was non-verbal. MD-B stated R1's family wanted her to be able to sit up in a chair again and opted for the hip surgery for pain control, improved transfers, and mobilization. MD-B stated any fracture in an elderly person would have increased mortality within one year, fractures reduced life expectancy in the elderly person. MD-B indicated R1's life expectancy was not as long as it should have been, the fractures escalated the process, brought her into the hospital she experienced complications. MD-B stated R1's fractures increased the risk of pneumonia, not being mobile at base line, and pronounced dementia with aspiration. MD-B also stated R1 had right lower lobe pneumonia from baseline swallowing issues, inability to clean secretions due to not able to deep breath, sit up right, use incentive spirometer (handheld medical device used to help improve the functioning of the lungs to help prevent pulmonary complications after surgery), and promoting secretion clearing, the fractures and pain contributed to this outcome. During an interview with the director of nursing (DON) on [DATE] at 12:00 p.m., stated R1's care plan indicated she was to be placed on her left side to avoid her from rolling out of the bed. DON stated when R1 became uncomfortable she would throw her leg over to reposition herself, gained momentum, shifted her weight enough to roll out of bed and therefore should have been placed on the left side to help avoid falls. DON verified R1's care plan was not followed on [DATE], and after staff transferred R1 onto the bed, it should have been lowered while staff attended to her roommate. DON also stated the correct positioning of R1 according to the care plan may have prevented the fall. DON stated without the hip surgery R1 would not have had the opportunity to transfer to a chair and instead be bed ridden and the family chose to have the surgery completed. DON stated the fall with fractures short termed R1's life and resulted in surgery, airway issues, and pneumonia. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: Education provided to staff [DATE], regarding falls included: -For most residents keep bed in the lowest position at all times. -One in every 10 residents who fell had a serious injury. -Of deaths caused by a fall, 60% involved people who are over [AGE] years of age. -Falls account for 87% of all fractures in people over [AGE] years old. -Basic every resident need: when resident in bed alone, bed is no higher than what the resident can put their feet on the floor. -Kardex/Care plan: items for everyone to review are transfers, mobility, and bed mobility and fall interventions will be updated in care plan and trigger onto Kardex if appropriate for NA's. Facility policy titled Identify Resident Risk of Falling dated [DATE], identified residents in high risk for falling in order to put proper interventions into place to prevent/reduce falls. Interventions need to be reviewed periodically by fall team to determine appropriateness. Care plan will be updated to reflect individual needs for safety. Facility policy titled Fall Prevention and Management dated [DATE], identified prior to admission the resident will be screened for fall risk and appropriate interventions will be implemented at the time of admission, annually, quarterly, and with significant change using the fall risk assessment form. Nursing interventions will be implemented and placed in the care plan according to resident specific risk factors.

Based on interview and document review, the facility failed to follow physician's orders for 1 of 3 residents (R1), when R1's medication change was omitted for 7 days. This resulted in harm when R1 was hospitalization and had a decline in activities of daily living (ADLs) as a result of the error. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS indicated R1 had no cognitive impairments and required extensive assistance by one staff member for activities of daily living (ADLs) such as bed transfers, ambulation, dressing and toileting. Review of facility report to the State Agency (SA) dated 2/10/22, indicated R1 received an order on 2/3/22, with medication changes. The order was omitted and not processed. R1 received a basic metabolic panel (BMP) lab on 2/8/21, which revealed increased levels. Review of facility's 5-day investigation to the SA dated 2/15/22, indicated a FAX was sent to R1's doctor on 1/23/22, to update on increased blood pressure. Facility received order from doctor on 2/3/22, with medication changes for R1 decreasing [MEDICATION(S)] and adding Spirolactone as well as a lab order for a BMP after increasing the medication regimen. Registered nurse (RN)-A and licensed practical nurse (LPN)-A were unable to locate a doctor's signature on the order and placed order under case manager's door. On 2/8/22, R1 had a BMP lab completed and results were faxed to R1's medical doctor (MD). On 2/8/22, R1 reported shortness of breath and weakness. On 2/10/22, facility updated MD on resident condition. MD contact the facility on 2/10/22, regarding BMP lab results. On 2/10/22, RN-B found the order from 2/3/22, in the unit's mailbox and brought order to case manager (CM)-A. MD was updated on omitted order from 2/3/22, and MD ordered a chest x-ray due to heart failure and gave the facility verbal order to implement the medication changes. On 2/11/22, R1 went to the clinic for chest x-ray and was returned to the facility and required the use of oxygen later that evening. On 2/12/22, resident was sent to the emergency room and was admitted to the hospital. Review of facility's internal investigation, indicated the order from MD on 2/3/22, was change [MEDICATION(S)] to 10 mg, add [MEDICATION(S)] 12.5 mg every morning, and check BMP in three to five days of start. There was a note attached to this order from RN-B indicating the order did not have a MD signature and I thought I would give it back to you. On 3/3/22, at 2:09 p.m. RN-A indicated on the night shift of 2/3/22, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A indicated there was not a signature from the doctor on the order and both LPN-A and RN-A got busy and decided to place the order in the station's mailbox for the case manager to look at. RN-A indicated the licensed staff are expected to process the order and then send it back to the doctor for a signature, however on this night shift due to becoming busy with other residents both LPN-A and RN-A did not have time to process the order. In addition, RN-A indicated the director of nursing (DON) provided education related to the protocol for processing a doctor's order and if the licensed nursing staff is unable to get the order completed then they are directed to put the order in the file folder for the case manager assigned to the unit. In addition, action taken to prevent reoccurrence to resident and others included educating all licensed staff on Physician Orders policy. On 3/3/22, at 2:28 p.m. family member (FM)-A indicated R1 was hospitalized on [DATE], due to heart failure exacerbation which happened quickly. Further, FM-A indicated R1 reported to the facility staff that she felt short of breath (SOB) and staff spoke with R1's primary doctor who then ordered a chest x-ray on 2/11/22. FM-A indicated the chest x-ray showed R1's heart failure was increasing and the next thing she knew R1 was in bad heart failure. In addition, FM-A indicated since R1's return to the facility following this hospitalization , R1 is not ambulating and requiring a mechanical lift for transfers. On 3/3/22, at 4:29 p.m. observed nursing assistant (NA)-A and case manager (CM)-A assisting R1 into the bathroom utilizing a mechanical standing lift. On 3/3/22, at 4:37 p.m. NA-A indicated R1 was able to ambulate with a walker prior to recent hospitalization and is now requiring a mechanical standing lift for transfers. On 3/4/22, at 8:02 a.m. LPN-A indicated it was approximately 3:00 a.m. during her shift on 2/3/22, and noticed RN-A had a lot of call lights going off so LPN-A asked to assist. LPN-A indicated she was unable to find a doctor's signature on the order for R1's medication changes and notified RN-A. Further, LPN-A stated she was still not privy on the facility's protocol for processing orders and what she is expected to do if she cannot find a doctor's signature on the order. In addition, LPN-A confirmed since R1's hospitalization she requires the use of stand mechanical lift due to weakness. On 3/4/22, at 8:53 a.m. RN-B indicated on 2/12/22, R1 was noted to report SOB and having a hard time breathing to the nursing staff. R1 was provided a nebulizer and oxygen which showed no improvements. R1 transferred to the emergency room to be further evaluated. RN-B indicated she was admitted to the hospital for congestive heart failure exacerbation and was there a few days. RN-B indicated upon returning to the facility, R1 now requires the use of a mechanical stand lift for transfers due to weakness. On 3/4/22, at 9:25 a.m. when asked what the facility's policy was regarding processing physician orders, CM-A indicated if staff were unsure or something was missing, the order would then get passed onto the case manager or the oncoming nurse. Further, CM-A indicated the night nursing staff do not typically process orders, especially if there were clarifications needed. CM-A indicated on 2/3/22, when the order for medication changes was received RN-A and LPN-A reviewed the order and it got late and they were unsure what to do with it, so they left the order with a note in the mailboxes. Further, CM-A indicated there was a 7-day delay by the time the order with the note attached was given to CM-A. CM-A indicated she was unsure where the order was for the week but seemed like a neglect situation especially with a person so fragile as [R1] is. CM-A updated R1's MD on 2/10/22, and MD ordered to implement the medication changes. The medication changes were ordered and started on 2/12/22. On 2/12/22, R1 reported she felt SOB, and her oxygen stats were dropping, and she was getting anxious. R1 was sent to the emergency room and admitted to the hospital with heart failure. In addition, CM-A indicated since R1 had returned from hospital she is requiring a mechanical stand lift for transfers, does not ambulate anymore, and is more deconditioned. On 3/4/22, at 12:09 p.m. director of nursing (DON) indicated R1's hospitalization could have been delayed if the medication changes ordered on 2/3/22, would have been implemented timely. Further, DON indicated the medication changes would have assisted to help R1's blood pressures and take away fluid. DON indicated licensed nursing staff were educated on facility's Physician Orders policy which included how to process an order. DON confirmed there was one licensed nurse who worked on the floor on 3/3/22, who had not completed the education at this time. On 3/8/22, at 12:09 p.m. interview with MD and clinic nurse (CN)-A indicated the lack of implementation of R1's medication changes ordered on 2/3/22, could have contributed to R1's hospitalization on [DATE]. Review of facility policy titled Physician Orders revised 2/12/22, directed staff as follows: orders are taken by a licensed nursing staff (RN or LPN), orders are given by a medical doctor, physician assistant, or nurse practitioner, orders which are received by phone or FAX must include date and time, check for a doctor signature and if there is not a signature enter the order as a verbal/telephone order. Further review of policy directs licensed nursing staff to make a note on the 24-hour report sheet that there is anew order and where it is, report to the on-coming charge nurse the new order, document in resident record with progress note, pass order to a second licensed nurse to double check input into records is correct. In addition, the facility policy directs licensed nursing staff if the order is missing any information contact the medical doctor for clarification and progress note the issue found, document on 24-hour report sheet and pass off on shift change.

Based on observation, interview, policy review, and record review, the facility failed to provide the necessary care and services to promote healing and prevent the development and/or progression of pressure related ulcers for 3 of 4 (R43, R17, R79) residents reviewed in the sample with pressure ulcers. R43 and R17 sustained actual harm. Findings include: R43 lacked reassessment and implementation of interventions to promote healing of a pressure related ulcer to the second toe on the left foot. The resident sustained [REDACTED]. R43's [DIAGNOSES REDACTED]. The 9/23/10, annual Minimum Data Set (MDS) indicated intact memory and independent decision making skills. The MDS identified R43 required total assistance of two staff for bed mobility, and transferring needs, and extensive assist of two staff for dressing and personal hygiene needs. In addition, the MDS also indicated R43 had one stage 4 pressure ulcer. The 9/30/10, Pressure Ulcer Resident Assessment Protocol (RAP) stated R43 currently had a stage 4 pressure ulcer to left toe. It further indicated the ulcer was related to overlapping toes creating source of pressure and complicated with delayed healing from [MEDICAL CONDITION], and stated R43 had history of pressure ulcers to feet. The 9/30/10, Resident Care Plan identified a left, second toe stage two (partial thickness loss of skin layers) ulcer. The 6/15/10, Weekly Wound documentation form identified a stage two wound measuring 0.5 cm x 0.5 cm. width 0.1 cm to the second toe on the left foot. The 6/25/10, Weekly Wound documentation form identified a 1.5 x 0.5 cm with 0.1 cm depth wound on the second toe. The 7/2/10, Weekly Wound documentation form identified a stage two wound measuring 1.5 cm x 1.5 cm and 0.2 depth on the second toe. The 7/8/10, Weekly Wound documentation form identified a stage two wound measuring 1 cm x 1 cm with 0.2 cm depth on the second toe. The 8/18/10, Weekly Wound documentation form identified a stage two wound measuring 1 cm x 1 cm with 0.4 cm depth on second toe. The 8/24/10, Weekly wound documentation form identified a stage 4 (a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone) pressure ulcer measuring 1 cm x 1.3 cm and 0.2 cm depth. The clinical record lacked an assessment of the change in condition to the pressure ulcer and no new interventions were implemented. The 10/2/10 Interdisciplinary Note indicated R43 was seen 8/24/10, by the rounding physician which prescribed a ten day antibiotic course for [MEDICAL CONDITION] to the second left toe. A wound culture was completed at that time. The note went on to state the 8/24/10, wound culture was positive for "heavy growth" of [DIAGNOSES REDACTED] Aureus and the antibiotic was continued for a total of 14 days. In addition, the note stated R43 was seen in the emergency roiagnom on [DATE], for changes in the second left toe with no new orders received. On 11/4/10, at 7:50 a.m. RN-A stated the pressure ulcer was initially identified in June 2010, and was classified as a stage two pressure related ulcer. At 9:41 a.m. R43 was observed to have on lower extremity Jobst compression stockings and slippers on both feet. RN-A removed the articles of clothing from the left foot. The left great toe was observed pressing into the second toe wound. The wound was observed to be covered with a thin wound dressing. RN-A removed the dressing. The wound was observed to be open with a red wound bed with purulent like drainage to the distal bilateral edges. The wound was cleaned with wound cleanser. RN-A measured the wound to be 1.1 cm X 1.3 CM. RN-A re-applied Allevyn wound dressing to the ulcer then reapplied the Jobst stocking and slippers. At 12:17 p.m. RN-A stated the original cause of the wound was due to the long, great toe nail on the left foot rubbing against the second toe. She verified R43 was not seen by a podiatrist related to toe nail care. RN-A verified the wound progressed from a stage two pressure wound to a stage 4 wound on 8/18/10, and that 2 x 2 gauze pads were used to prevent pressure between the toes. RN-A added, "We stopped because there wasn't any pressure being caused." RN-A went on to state, "We have not thought of attempting interventions to keep pressure off, it would make sense for us to do that." At 1:32 p.m. RN-A verified a comprehensive re-assessment of risk factors and interventions was not completed with identification of progression of the pressure ulcer stating she should have completed one at that time. R17 did not have a comprehensive skin assessment completed to reflect two new stage one pressure ulcers to her right foot, and was not re-assessed for tissue tolerance (ability of the skin to withstand pressure) after the development of a stage 2 ulcer to the coccyx (tailbone area). This caused actual harm to R17. R17 had the [DIAGNOSES REDACTED]. R17 had a current stage II pressure ulcer to her coccyx area and a nearly healed stage 4 pressure ulcer to her right great toe. The Quarterly MDS on 8/19/10, identified that R17 had severe cognitive impairment and was unable to make her needs known. R17 was totally dependent on staff in all activities of daily living and had bowel and bladder incontinence with no control present. R17 had one stage 4 pressure ulcer (a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone). On 11/4/10, at 10:30 a.m. R17 was observed lying in bed with a blue cushion under her legs which kept her legs from crossing, and her feet were off the mattress. R17's feet were assessed and two stage one pressure ulcers were identified by the surveyor (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) to the right lateral foot. There was also a very small dried area on the right great toe (healing stage 4 pressure ulcer). The R17 was also observed to have an Allevyn dressing to the coccyx area. The dressing was removed by the nurse and a stage two pressure ulcer to the coccyx (slit) that was approximately 1 cm x 1 cm was noted. Review of the facility's Interdisciplinary Notes and current Weekly Wound Progress Sheets did not identify these new areas to R17's feet. The Weekly Progress Sheets identified Allevyn dressing changes to the coccyx and leaving the right great toe open to air. The Tissue Tolerance Testing (to determine an appropriate repositioning schedule) assessment on 8/7/10, indicated that R17 could tolerate a 1 1/2 hour repositioning program when in bed and a two hour repositioning program when in the wheelchair. Another Tissue Tolerance Assessment was done by the facility on 10/25/10, however, the bottom portion of the assessment which identified repositioning when in bed had not been completed. The Weekly Wound Progress Sheet completed by RN-B on 10/31/10, stated, "Tissue Tolerance Test indicated every two hour repositioning remains appropriate. Staff will monitor skin daily with routine cares and reassess if indicated." 0n 10/8/10, the Weekly Wound Progress note completed by RN-B stated, "Resident continues to have red areas when resting in bed, areas improve within 20 minutes after repositioning." However, the progress note failed to address where the red areas were located. Review of the facility's Temporary Care Plan on 10/19/10, revealed that R17 had developed an open area to the upper coccyx. The approaches included Allevyn dressing and identified for positioning indicated to turn and reposition the resident every two hours even though the previous Tissue Tolerance Assessment had already identified that R17's skin became red at a two hour interval at the time of the Tissue Tolerance Testing completed in bed on 8/7/10. The Temporary Care Plan did not identify the two stage one pressure areas that were observed by the surveyor on 11/4/10. NA-B was interviewed on 11/5/10, at 11:00 a.m. and remarked that R17 was repositioned every two hours. The RN Clinical Manager (RN-B) was interviewed on 11/5/10, at 10:43 a.m. RN-B was interviewed about why the RN skin assessments did not reflect the two other stage I pressure ulcers to R17's feet, and she stated that the areas were not there the last time she assessed R17. RN-B verified that staff are to monitor the resident's skin daily and to report any new areas. RN-B was unable to verify what the exact repositioning schedule for R17 was. RN-B revealed that the staff provide repositioning every one to two hours but could not specify a more precise time frame. RN-B stated, "(R17's) skin seems to be brewing to a new place, she has had calloused areas on her feet for quite some time, what we learned from the tissue tolerance assessment is that the tissue returns to normal within 20 minutes but because of her frail condition, we turn her every one to two hours, it appears that she is changing and it's time we step it up a bit." RN-B acknowledged that data is collected to identify risk factors for pressure ulcer prevention but the data is not comprehensively analyzed specifically to the resident's unique needs. R79 was not comprehensively assessed regarding risk for pressure ulcers. In addition, the resident was not reassessed following the development of a stage 2 pressure ulcer to the spine. R79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], identified the resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene and required total assistance with transferring. The pressure ulcer Resident Assessment Protocol (RAP) dated 9/15/10 identified, "2 pressure ulcers at this time ...left great toe and left medial dorsal part of foot ... " However, the RAP did not comprehensively assess the resident's risk factors for the development of pressure ulcers identified by the facility i.e. friction, shear and pain. A Tissue Tolerance Assessment was completed on 9/1/10 and identified the resident could tolerate a repositioning for lying and sitting at every two hours. During observations on 11/4/10, at 9:32 a.m., R79 was sitting up in bed with the head of the bed raised approximately 45 degrees. The resident was observed to have two stage 2 pressure ulcers on the left foot, which were open to the air. The resident's back was observed to have a beige square occlusive dressing on the bony prominent ridge on his mid spine. An irregular shaped, open area with a red center, white edges with a small amount of dark red drainage was observed under the beige dressing. The resident was observed to be tall and kyphotic (curvature of the spine). The Weekly Wound Progress Notes documented weekly measurement and progress of the pressure ulcers: 10/29/10 - Left top of foot, stage 2, 3 cm by 3 cm, depth superficial, 50% granulation tissue, new tissue growth, no exudate, no pain and open to air. 11/5/10 - Left great toe, stage 4, unstageable 1 cm by 1 cm, eschar, new tissue growth, no exudate, no pain, current treatment leave open to air. 11/5/10 - Mid spine, 2 cm by 1.3 cm, no depth, 40% granulation tissue with 60% slough, new tissue growth, small amount of yellow drainage, has pain, cleansed with soap and water, skin prep, Allevyn pad, Tylenol prn (as needed). Review of the form titled, "Skin risk factors and interventions" identified by Registered Nurse (RN)-A as completed on admission, identified the Braden risk score for "moisture ...activity ...mobility ...friction and shear ... " and other risk factors as "contractures of left foot drop, assist with ADLs, pain, fracture, brace and [MEDICAL CONDITION]. " Review of the Interdisciplinary Notes from 9/1/10 through 11/4/10 revealed on 10/5/10, " ...3 cm by 3 cm red and dry area on his mid spine over bony area. Center of area is open it measures 1.5 cm by 1 cm ... " Treatment was implemented at that time which included to cleanse the wound and apply Allevyn thin dressing, monitor three times daily. However, a reassessment of the resident's risk factors related to pressure ulcer development was not completed once the stage 2 pressure ulcer developed. The repositioning schedule remained the same at every two hours, even though the resident was not reassessed for tissue tolerance to determine if every two hours was still appropriate. The current care plan dated 10/29/10 identified the pressure ulcer to the spine and the feet and included interventions to turn and reposition every two hours, cushion in wheelchair and recliner, and MD treatment as ordered. Review of the facility policy titled, "Preventing and Managing Pressure Ulcers and Wounds," revised 1/10, identified, "The first step in prevention is the identification of the resident at risk of developing pressure ulcers ... " and included completion of " skin risk factors and interventions" as a tool utilized by the facility to identify residents at risk. On 11/4/10, at 10:10 a.m., RN-A confirmed the resident had developed a new stage 2 pressure ulcer on the bony prominence of his mid back on 10/5/10. RN-A stated the resident had impaired mobility and "slides" in bed at times. RN-A confirmed the admission skin assessment did not comprehensively assess the resident's status that included contributing factors of possible friction, shearing, and pain with immobility.