Every finding on record at Good Samaritan Society - Blackduck

Based on observations, interview and document review, the facility failed to maintain an outcome surveillance program to track, trend and analyze resident actual and potential infections. In addition, the facility failed to implement timely isolation precaution measures for residents when a resident (R23) showed symptoms of potential infection, to mitigate the spread of infections throughout the facility. This had the potential to affect all 29 residents. Findings include:R23's quarterly MDS dated [DATE], identified R23 was alert, with no cognitive impairment. R23 required maximal assistance with all activities of daily living (ADLs) and was dependent with toileting. Diagnoses included osteoarthritis, asthma, and hypertension.During survey on 9/8/26, between 10:00 through 4:30 p.m. R23 was noted seated in her room in a recliner, watching television. R23 was heard with a frequent intermittent loose, productive sounding cough that could be heard in the hallway and conference room throughout the day.During survey on 9/9/26, at 4:45 p.m. R23 was noted seated in the recliner in her room with her legs elevated. The door to the room was fully open to the hall. Resident had a frequent, loose, wet sounding cough that could be heard in the hallway intermittently throughout the day. The door to the room was fully open to the hall. There was no evidence of efforts to isolate R23 from the nursing home population or staff use of personal protective equipment (PPE) to prevent spread of illness.R23's progress note were reviewed and identified the following: -On 9/7/26, R23 had an increase cough and complained she did not feel well. R23 reported she was very tired and fatigued and had a poor appetite. A COVID-19 test was completed and was negative. R23 refused to go the the emergency room to be evaluated. Contact precautions were not implemented.On 9/8/26, R23 continued to have a cough, although did have a baseline cough related to her medications, Lungs were clear and R23 was afebrile. Contact precautions were not implemented.On 9/10/26, R23 complained of shortness of breath and continued to have a persistent cough. Crackles were noted in her right lower lung field and temperature was 99.1. Contact precautions were not implemented.On 9/10/26, R23 had increase diaphoresis and shaking and blood glucose was 72. R23 had not been eating/drinking much due to being sick. R23 refused to go to the emergency room to be evaluated. A COVID test was completed and was negative. Later, oxygen saturation was 88% on room air. R23 did agree to go to the emergency room via ambulance as she complained of shortness of breath and cold symptoms for approximately five days. Contact precautions were not implemented.Review of the resident monthly infection surveillance logs September 1, 2026 through September 9, 2026, lacked documentation of R23's respiratory symptoms or potential illness.R10's quarterly MDS dated [DATE], identified R10 had no cognitive impairment and required maximal assistance with all ADLs. Diagnoses included bipolar disorder, schizoaffective disorder, dysphagia, hydronephrosis and sepsis.R10's progress note dated 8/28/26, identified R10 had copious amounts of thick, yellow, odorous vaginal discharge. R10 reported it burned when she voided.Review of the resident monthly infection surveillance logs August, 2026, lacked documentation of R10's vaginal symptoms or potential infection.During interview on 9/9/26, at 4:45 p.m. registered nurse (RN)-A and infection preventionist nurse stated if staff suspected a resident infection or illness, they would start a mini assessment form to monitor the symptoms. RN-A stated she also read the progress notes every day and the nurses also came and told her when residents were exhibiting symptoms. RN-A would then record that resident on her surveillance log but she felt the logs were mostly antibiotic tracking. She had not added R23 because it was difficult to keep up with the surveillance logs these last two weeks due to limited staffing. The facility had hired a new nurse but was still in training so she was covering some shifts until the new staff was fully trained. RN-A had been monitoring R23's symptoms and R23 had been self-isolating due to her symptoms. RN-A had not documented any of her assessments or that R23 was remaining in her room. RN-A stated she should have put R23 on precautions but had not done so. The facility policy was to put residents on isolation if demonstrated symptoms of illness, but she had not done so. RN-A had not been aware of R10's symptoms and was just learning of it now. RN-A stated she must have missed that during her review of progress notes and staff had not reported anything. The nurse who had documented R10's symptoms should have reported it so they could have done clinical monitoring for a couple days, increase in peri care, push fluids and see if the symptoms resided or needed further evaluation. RN-A stated she had not realized she should log all the resident symptoms and thought it was just to track the bigger things such as antibiotics or covid illness.During interview on 9/10/26, at 11:40 a.m. licensed practical nurse (LPN)-A stated she usually wrote a progress note if she noted resident had symptoms of infection or illness. LPN-A knew they had tested R23 for COVID a couple of times and they were all negative. Resident infections were handled mainly by RN-A. If on antibiotics they did put a resident on precautions. The staff communicated about resident illnesses in the progress notes or passed along in report. Usually only the director of nursing or RN-A determined if a resident needed to be placed on precautions.During joint interview with the DON and RN-A, on 9/10/26, at 1:35 p.m. RN-A stated she had not put R23 on isolation precautions because they had ruled out COVID and the resident isolated herself to her room. R23 should have been placed on precautions because of her respiratory symptoms and according to the facility policy but she had not been.The facility policy Identification/Surveillance, Management and Reporting of Suspected/Confirmed Infections dated 3/25/26, identified the infection preventionist would be notified of possible indicators of infection. The infection preventionist would determine appropriate infection prevention and control measures. The infection preventionist would track data related to the confirmed or suspected infection for infection surveillance purposes.

Based on observation, interview and document review, the facility failed to ensure residents with attached grab bars were comprehensively assessed for use for 1 of 3 residents (R16) whom had grab bars. Findings include:R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively aware and had diagnoses that included dementia, adult failure to thrive (FTT), and major depressive disorder. R16 was dependent on staff in all care areas.R16's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 6/23/26, identified R16 had an alteration activity of daily living (ADL) self-care performance related to weakness from diagnosis of FTT and some noted confusion with diagnosis of dementia. R16 was to maintain current level of function in bed mobility through the review date.R16's care plan revised 6/12/26, identified R16 had an alteration activity of daily living (ADL) self-care performance related to weakness from diagnosis of FTT and some noted confusion with diagnosis of dementia. Staff directed to assist R16 with turning while using the grab bars. R16 was dependent on 1 staff member for turning side to side in bed with use of bilateral grab bars on bed. Bed Rail/Grab bars were used for repositioning and increased independence with bed mobility and do not function as restraints. R16 would sometimes use the grab bars and sometimes not, it depends on how willing R16 was to help.R16's Physical Device and/or Restraint Evaluation and Review dated 8/25/26, identified R16 was able to use the assist/grab bars on the bed for repositioning.During an observation on 9/9/26 at 10:50 a.m., nursing assistant (NA)-A and NA-B provided R16 with incontinence cares while R16 was lying in bed. R16 had bilateral grab bars attached to her bed approximately at the level of R16's shoulders. NA-A and NA-B rolled R16 to her left and lowered R16's pants then rolled R16 to her right to expose R16's incontinence brief. NA-A nor NA-B encouraged R16 or provided R16 with hand over hand guidance to use the grab bar to assist with rolling.At 10:52 a.m., NA-B rolled R16 to the left and tucked R16's incontinence brief under R16 and cleaned R16's skin with a disposable wipe. NA-A assisted R16 to remain on her side until the task was complete. Neither NA-A nor NA-B encouraged R16 to use the grab bar. NA-B tucked a clean incontinence brief under R16.At 10:53 a.m., NA-A and NA-B rolled R16 to her right, removed the soiled incontinence brief and straightened the clean incontinence brief. NA-A and NA-B rolled R16 to her back and fastened R16's incontinence brief before rolling R16 left and right to pull up R16's pants. R16 did not use grab bar to assist with rolling.During an interview on 9/9/26 at 11:01 a.m., NA-B stated she had never seen R16 use the grab bar to assist with rolling. NA-A stated R16 would use the grab bars previously when R16 was more with it but that had been a long time ago. R16 had become more dependent on staff for turning and repositioning. During an interview on 9/10/26 at 11:21 a.m., licensed practical nurse (LPN)-A stated it was a good question if R16 could or could not use bilateral grab bars to assist with turning and repositioning. LPN-A stated it was a question for registered nurse (RN)-A. During an interview on 9/10/26 at 12:07 p.m., the director of nursing (DON) stated it really depended on the staff who assisted R16. The DON had worked night shifts, and you could tell R16 to use the grab bar and R16 would help to turn. The DON stated she was going to remove R16's grab bars but night shift staff had insisted R16 used the grab bars all the time. Staff were expected to offer the use of the grab bars to R16. The grab bars were on the care plan, and staff were expected to follow the care plan because it was individualized to R16. During an interview on 9/10/26 at 2:34 p.m., RN-A stated R16 needed hand over hand guidance to use the grab bars. Staff were expected to place R16's hand on the grab bar and to remind R16 to use them to help turn, but not all staff did that. However, RN-A stated the care plan did not direct staff to use hand over hand guidance and would not know how to do that unless they had worked with R16 before. Additionally, staff were expected to report R16's lack of use of the grab bars because R16 would need to be re-assessed. The team would then discuss R16's grab bar use and determine what was best for R16. A facility policy related to bedrails/grab bars was requested but not received.

Based on observation, interview and record review, the facility failed to ensure staff checked gastrostomy tube (G-tube) (a feeding tube inserted through the abdomen) placement prior to administration of medications, water flushes and feedings for 1 of 1 resident (R1) observed for medication administration via gastrostomy tube. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment and was dependent or maximal assistance with activities of daily living (ADLs). Diagnoses included progressive bulbar palsy (a motor neuron disease that affects the nerves controlling speech, swallow and facial muscles), dysarthria (speech disorder), diverticulosis of intestine, esophagitis and gastritis. On 9/8/26, at 8:17 a.m. licensed practical nurse (LPN)-B was observed passing morning medications. LPN-B prepared four medications for R1 and entered R1's room. LPN-B put on personal protective equipment (PPE) of a gown and gloves and prepared R1's enteral feeding with Fiber Source HN formula. LPN-B measured 125 millimeters of sterile water into a graduate and flushed R1's G-tube with a small amount of water using gravity and then administered each medication followed by a small amount of water. LPN-B finished administering the remaining water flush and proceeded to hook up the Fiber source HN formula to R1's G-tube. LPN-B removed her PPE and used alcohol-based hand gel and exited room. At no time did LPN-B check placement of R1's G tube. During interview on 9/8/26, at 8:30 a.m. LPN-B stated staff did not check placement of the G-tube prior to medication administration, water flushes or feedings. LPN-B was not sure why it was not being done. When interviewed on 9/8/26, at 6:00 p.m. registered nurse (RN)-A stated LPN-B had told her she had not been trained to check G-tube placement and was not sure how it was done. RN-A had instructed LPN-B that there was no need to check placement before medication administration and RN-A stated that was incorrect. RN-A stated she needed to do some education with all the facility staff nurses. RN-A planned to put check G-tube placement before feeding and medication administration on R1's Medication Administration Record (MAR) to be completed every day. Review of R1's MAR's May 2026 through September 8, 2026, identified a nursing order on all the MARS, which instructed the facility staff to check placement of G-tube before each feeding and flush three times per day. Start date for the nursing order was identified as 5/12/26. Scheduled times were midnight, 8:00 a.m. and 4:00 p.m., however, no staff had initialed the MARs to identify this had been completed. During interview on 9/9/26, at 11:31 a.m. the director of nursing (DON) stated it was the facility's practice to check G-tube placement before each feeding and water flushes three times per day. The DON was not sure if the all the facility nurses had been trained on checking tube placement. The DON had assumed that checking G-tube placement was a standard of practice and all nurses were trained on it. The DON planned to ensure all the facility nurses knew how to check placement and did so prior to administering R1's medications, feedings and water flushes. The facility's policy Tube-Gastrostomy or Jejunostomy-Enteral Feeding, Care, Replacement or Removal dated 10/31/25, identified a purpose to administer tube feedings in a safe manner. The policy identified it was best practice to check placement of gastric tubes that were permanetly placed, as some cases had shown they have become dislodged and could cause peritonitis (inflammation of the tissue that lines the inside of the stomach). The policy directed staff to check tube placement and patency prior to beginning of feeding and after episodes of vomiting, or any suctioning.

Based on interview and document review, the facility failed to develop a person centered comprehensive care plan for 1 of 2 residents (R1) reviewed for pressure ulcers. Findings include:R1's quarterly Minimum Data Set (MDS) 6/24/26, identified R1 was cognitively intact and had diagnoses that included progressive bulbar palsy (a rare motor neuron disease that attacks the lower brainstem, causing severe trouble with speaking, swallowing, and chewing). R1 was independent with eating for pleasure, substantial/maximal assistance with oral hygiene and upper body dressing and was dependent on staff for all other care areas.R1's care plan revised 6/23/26, identified R1 had weakness and needs assistance with bed mobility, transfers, eating, dressing, toilet use or personal hygiene. Staff were directed R1 required assist of two staff to boost up in bed and substantial assist of one staff to turn side to side. Additionally, R1's care plan identified R1 had a potential for pressure ulcer development related to R1's coccyx was excoriated on admission. Staff were directed to encourage, assist, supervise with the use of the grab bar, trapeze bar, etc for R1 to assist with turning. R1 had a pressure reducing mattress on his bed. However, the care plan failed to identify how often staff were to encourage or offer repositioning.R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 6/23/26, identified R1 was at risk for pressure/ulcer injury. During a continuous observation on 9/10/26 at 7:23 a.m. to 10:03 a.m., R1 was not encouraged or offered assistance with turning and/or repositioning. During an interview on 9/10/26 at 10:07 a.m., NA-B stated R1 was not at risk for pressure ulcer. R1 liked to sleep in so staff did not bug him until R1 turned on his call light. R1 usually wanted his urinal emptied or to have his incontinence brief changed. Staff did offer turning and repositioning at least once every day, but R1 usually refused. I think it just hurts him to move. During an interview on 9/10/26 at 10:19 a.m., LPN-A stated R1's condition had recently changed. Staff always believed R1 was at risk for pressure ulcers and were expected to offer assistance with repositioning every 2 hours, but R1 was usually refused. However, LPN-A then reviewed R1's care plan and stated the care plan did not direct to reposition R1 every 2 hours nor did it say how often R1 should be encouraged or offered assistance. But it should have been offered.During an interview on 9/10/26 at 12:18 p.m., the director of nursing (DON) stated R1 could boost himself in bed and turn side to side. Repositioning was not a concern for R1 because the DON had worked night shifts and had witnessed R1 repositioning himself. Staff were expected to offer repositioning to every resident at least every 3 hours unless the resident was very fragile because staff were unable to offer repositioning more frequently than that. At that time, the DON stated R1's repositioning needs should have been care planned for staff to know R1's needs. A facility policy related to care plans was requested but not received.

Based on observation, interview and document review, the facility failed to follow standards of practice related to indwelling urinary catheter orders for 1 of 1 resident (R7) observed to use an indwelling urinary catheter.Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had a severe cognitive impairment and diagnoses that included benign prostatic hyperplasia (BPH)(an enlarged prostate), Alzheimer's disease, dementia and malignant neoplasm of the prostate (prostate cancer). R7 and had an indwelling urinary catheter.R7's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 8/27/26, identified R7 had an indwelling urinary catheter and would not show signs/symptoms of urinary infection through review date.R7's care plan revised 9/2/26, identified R7 has indwelling urinary catheter. Staff were directed toMonitor/document for pain/discomfort due to catheter.Document intake and/or output. Monitor/record/report to health care provider for s/s UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Catheter care by nursing assistant (NA) (morning and bedtime).R7's Order Summary Report dated 9/10/26, failed to identify a physician order for R7's indwelling urinary catheter. R7's Interagency Transfer Orders dated 8/13/26, identified R7's urinary catheter should be exchanged every 4 weeks and as needed. However, the form failed to identify urinary catheter size or type.During an observation on 9/8/26 at 3:16 p.m., R7 was sitting in his recliner with his indwelling urinary catheter tubing coming out of his left pants leg and the catheter bag was hanging from the pocket on the recliner armrest with approximately 300 milliliter (mL) of clear yellow urine. Family member (FM)-A stated R7 had needed an indwelling foley catheter to void since R7 returned from the hospital on 8/13/26.During an interview on 9/10/26 at 10:32 a.m., licensed practical nurse (LPN)-A stated staff were made aware when a resident needed an indwelling foley catheter exchange by the electronic medication administration record (EMAR). The EMAR pulled the information from the resident's physician orders that were entered when the order was received. Orders were a two-step process. The nurse receiving the order would enter the order into the system, then the nurse on the next shift would double check to ensure the order was entered correctly. This process included hospital return orders. LPN-A reviewed R7's EMAR and physician orders, then stated it's not there. It was missed and it should be there or it won't get done. During an interview on 9/10/26 at 1:40 p.m., the director of nursing (DON) stated R7's Interagency Communication Form was used as communication between the hospital and the facility for hospital returns but was not an order. No order for R7's indwelling order had been received, and the admitting nurse should have contacted R7's provider to obtain the order to ensure the indwelling urinary catheter was needed and for instructions for continued care. A facility policy related to indwelling urinary catheters was requested but not received.A facility policy related to hospital return orders was requested but not received.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 2 residents (R1) who were at risk for the development of pressure ulcers.Findings include:R1's quarterly Minimum Data Set (MDS) 6/24/26, identified R1 was cognitively intact and had diagnoses that included progressive bulbar palsy (a rare motor neuron disease that attacks the lower brainstem, causing severe trouble with speaking, swallowing, and chewing). R1 was independent with eating for pleasure, substantial/maximal assistance with oral hygiene and upper body dressing and was dependent on staff for all other care areas. R1 used a feeding tube and a mechanically altered diet. R1's care plan revised 6/23/26, identified R1 had weakness and needs assistance with bed mobility, transfers, eating, dressing, toilet use or personal hygiene. Staff were directed R1 required assist of two staff to boost up in bed and substantial assist of one staff to turn side to side. Additionally, R1's care plan identified R1 had a potential for pressure ulcer development related to R1's coccyx was excoriated on admission. Staff were directed to encourage, assist, supervise with the use of the grab bar, trapeze bar, etc for R1 to assist with turning. R1 had a pressure reducing mattress on his bed. However, the care plan failed to identify how often staff were to encourage or offer repositioning.R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 6/23/26, identified R1 was at risk for pressure/ulcer injury. During a continuous observation on 9/10/26 at 7:23 a.m., R1 was sitting upright in bed. R1 was wearing a hospital gown, hair was disheveled and R1 was unshaven. R1 was asleep with his head tilted to the right.At 9:36 a.m., R1 turned on his call light. R1 continued to sit in the same position: upright in bed. Nursing assistant (NA)-B entered R1's room and asked R1 if he was hungry or having pain. R1 wrote on his communication board that he was having pain. NA-B stated she would let the nurse know before stating R1 wanted something for pain over the walkie. NA-B exited R1's room without offering repositioning.At 9:48 a.m., licensed practical nurse (LPN)-A entered R1's room and administered R1's pain medication. However, LPN-A did not offer R1 repositioning before leaving R1's room. LPN-A stated R1's condition was very sad. R1 had been independent and was taking food for pleasure up until the week prior. Suddenly, R1 went downhill and the need for assistance was all new for R1.At 10:03 a.m., NA-B entered R1's room and emptied R1's urinal. NA-B asked R1 if he needed anything and R1 pointed towards his brief. NA-B assisted R1 to unfasten his incontinent brief and placed R1's urinal for R1 to void. NA-B left R1's room without offering to assist R1 to reposition.During an interview on 9/10/26 at 10:07 a.m., NA-B stated R1 was not at risk for pressure ulcer. R1 liked to sleep in so staff did not bug him until R1 turned on his call light. R1 usually wanted his urinal emptied or to have his incontinence brief changed. Staff did offer turning and repositioning every day, but R1 usually refused. I think it just hurts him to move. During an interview on 9/10/26 at 10:19 a.m., LPN-A stated R1's condition had recently changed. Staff always believed R1 was at risk for pressure ulcers and offered repositioning every 2 hours, but R1 was usually refused. LPN-A stated she did not offer repositioning. LPN-A then reviewed R1's care plan and stated the care plan did not direct to reposition R1 every 2 hours, but it should have been offered.During an interview on 9/10/26 at 12:18 p.m., the director of nursing (DON) stated R1 could boost himself in bed and turn side to side. Repositioning was not a concern for R1 because the DON had worked night shifts and had witnessed R1 repositioning himself. Staff were expected to offer repositioning at least every 3 hours unless the resident was very fragile because staff were unable to offer repositioning more frequent than that. At that time, the DON stated R1's repositioning needs should have been care planned for staff to know R1's needs. A facility policy related to pressure ulcer prevention was requested but not received.

Based on observation, interview, and document review the facility failed to ensure mechanically altered diets were served as prescribed for 6 of 6 residents (R1, R2, R3, R4, R5, R7) with a physician ordered modified texture diet. This resulted in R1 receiving the incorrect diet, an unaltered piece of pizza, on 6/10/26. R1 required the Heimlich maneuver to dislodge the pizza from her throat. The immediate jeopardy (IJ) began on 6/10/26, at approximately 5:30 p.m., when facility staff served R1 the incorrect diet resulting in R1 needing the Heimlich maneuver performed to dislodge a piece of pizza from her throat. The IJ was identified on 7/1/26, the administrator was notified of the IJ on 7/1/26, at 3:15 p.m. The immediate jeopardy was removed on 6/11/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1 R1's admission Record indicated she was admitted to the facility 4/24/26. R1's diagnoses included hemiplegia/hemiparesis (paralysis or weakness on one side of the body), failure to thrive and dysphagia (difficulty or discomfort in swallowing). R1's admission Minimum Data Set (MDS) dated [DATE]. Indicated she required substantial/maximal assistance to eat. The MDS indicated R1 received a mechanically altered diet. R1's Dietician assessment dated [DATE], indicated R1 received a pureed diet with mildly thick liquids. R1's Physician Order Report dated 6/10/26 through 7/1/26, identified the following order: heart healthy diet, level 6 soft and bite sized (features tender, moist pieces no larger than 1.5 cm x 1.5 cm that can be mashed with a fork and require chewing before swallowing). R1's care plan dated 4/24/26, indicated she required a mechanically altered diet related to dysphagia. The care plan directed heart healthy diet, International Dysphagia Diet Standardization Initiative (ISSD) diet 6 soft and bite sized. The care plan identified a self-care deficit and indicated she required set up and supervision with eating due to choking risk. R1's Progress note dated 6/10/26, indicated licensed practical nurse (LPN)-A was called down to dining room during dinner. R1 was choking. LPN-A immediately viewed R1's mouth and did not see anything, LPN-A started doing the Heimlich maneuver, three-to-four (3-4) thrusts were given followed by 3-4 back blows. Registered nurse (RN)-A was notified and assisted. During interview on 7/1/26 at 11:21 a.m., RN-A stated on 6/10/26, she was called to assist in the dining room. R1 was choking and could not talk. RN-A took over for LPN-A and performed abdominal thrusts and back blows. RN-A stated R1 was able to cough up the food. The dislodged food looked like a piece of pizza crust. R1 had the wrong food consistency served to her and after making sure R1 was okay, RN-A verified with the kitchen staff, R1 was prescribed a soft and bite sized diet. RN-A stated the cook told her she thought if the food was cut up small enough it would have been appropriate for R1's diet type. RN-A stated everyone on a mechanically altered diet had received the incorrect diet type for the evening meal on 6/10/26. RN-A stated, since the incident they had changed the process and said staff were using diet slips and two staff verified the diet was correct prior to serving the residents. RN-A stated the facility had also implemented diet cards that staff attached to their name badges. The diet cards outlined each diet type and what food was appropriate for each diet type. During interview on 7/1/26 at 12:19 p.m., LPN-A stated she was in the nursing office during dinner, and a staff member asked her to come to the dining room. LPN-A said when she got to the dining room she saw R1 was in distress, scanned her mouth and said R1 was gasping for air. LPN-A said she performed the Heimlich maneuver and asked the staff what R1 had been eating. LPN-A also said she requested staff find RN-A to come and assist. LPN-A said everyone on an altered diet received pizza that evening. LPN-A said since the incident, audits were completed for all the residents and meal tickets were verified with two staff prior to serving. R2 R2's admission Record indicated he admitted to the facility 6/17/21. R2's diagnosis included dysphagia. R2's quarterly MDS dated [DATE], indicated he was dependent on staff to eat. The MDS indicated R2 required a therapeutic diet. R2's care plan dated 3/27/25, identified a minced and moist texture diet and indicated he required substantial assistance with meals and at times required staff to feed him. R3 R3's admission Record indicated he was admitted to the facility 9/14/21. R3's diagnosis included dysphagia. R3's quarterly MDS dated [DATE], indicated he was dependent on staff to eat. R3's care plan dated 6/12/26, indicated he required a mechanically altered diet related to risk for choking and directed staff to monitor closely for chewing/swallowing difficulties, coughing or choking. R4 R4's admission Record indicated she was admitted to the facility 5/30/24. R4's diagnoses included dementia and dysphagia. R4's quarterly MDS dated [DATE], indicated she was dependent on staff to eat. The MDS identified a mechanically altered diet. R4's care plan dated 4/28/26, identified a mechanically altered diet related to difficulty swallowing food. The care plan revised 5/12/26, indicated soft and bite sized textures and directed staff to monitor closely. R5 R5's admission Record indicated she was admitted to the facility 4/22/26. R5's diagnosis included dysphagia. R5's admission MDS dated [DATE], indicated she was able to eat independently. The MDS identified a mechanically altered diet. R5's care plan dated 4/22/26, identified a mechanically altered diet and a risk for choking as exhibited by soft and bite sized texture diet. The care plan directed staff to report signs of chewing/swallowing difficulties, coughing or choking. R7 R7's admission Record indicated she was admitted to the facility 7/25/24. R7's diagnoses included mild cognitive impairment and dysphagia. R7's quarterly MDS indicated she was able to eat independently. The MDS identified a mechanically altered diet. R7's care plan dated 1/7/25, identified a mechanically altered diet related to dysphagia and indicated she received a minced and moist texture diet. The care plan indicated R7 required set up and supervision with meals. During observation on 7/1/26 at 12:07 p.m., staff were serving the midday meal. Diet slips were on the window between the dining room and the kitchen. The staff in the dining room were observed reading the diet slip to the kitchen staff who dished up the meal. R1 received a thickened turkey biscuit bake with a pureed biscuit. Staff repeated the process for each resident throughout the dining service. During interview on 7/1/26 at 12:01 p.m., the speech language pathologist (SLP)-A stated the risk associated with residents being served an incorrect diet texture included choking, aspiration, aspiration pneumonia and death. During interview on 7/1/26 at 12:28 p.m., the administrator stated everyone who was prescribed a modified texture diet had received the incorrect diets on 6/10/26. The residents on modified textures should have received ravioli instead of pizza. The administrator said the cook looked at the meal tickets and read soft and bit sized and cut up the pizza and served it. Following the incident, all the residents who received incorrect diets were monitored for lung sounds and temperature for 72 hours. The facility reviewed and updated the meal tickets for all residents and implemented audits. In addition, all nursing and dietary staff were assigned training related to diet types. During interview on 7/1/26 at 12:40 p.m., the cook (cook)-A who served the meal on 6/10/26, stated she had not read the whole meal ticket and said she only read the diet consistency. R1 should have been served ravioli according to her diet order. Cook-A said, following the incident on 6/10/26, she received training to ensure she reviewed the whole meal ticket prior to serving food to residents. During interview on 7/1/26 at 12:43 p.m., the registered dietician (RD) stated following the incident on 6/10/26, the facility was focusing on the diet slips and had done a lot of training. The RD stated the diet slips were printed on the overnight shift and said if a diet change was ordered after hours or on a weekend, the diet slips would be manually changed at the time of the order. The RD stated she was auditing meals, and the diets were verified with two staff prior to serving the meal. Facility policy Texture Modified Diets revised 6/10/26, indicated food and nutrition services provided texture modified diets prescribed by the residents attending physician. The policy indicated that any diet could be modified to accommodate chewing, coughing, choking and swallowing concerns. The facility implemented the following on 6/11/26, therefore the deficiency is being issued at past non-compliance: Implemented a new process with focus on meal tickets. Staff education completed for nursing and dietary staff on: Policy review of texture modified diets. IDDSI food and drink standards and IDDSI food texture restrictions Implemented a badge buddy (IDDSI food and drink levels attached to staff name badge). All resident care plans, diet orders and meal tickets were reviewed for accuracy.

Based on interview and document review the facility failed to perform ongoing and accurate assessment of pressure ulcers for 2 of 3 residents (R1,R3) who were at risk for pressure ulcer development. In addition, the facility failed to implement interventions to reduce the risk for new or worsening pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Nursing Admit Re-Admit Data Collection dated 10/16/25 at 4:33 p.m., indicated skilled services to include wound care. Skin integrity assessment indicated a dehisced (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing) scar on the left side of her abdomen, left buttock: crease area unstageable ulcer due to previous location and a scratch on her arm.R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which indicated a stage III pressure ulcer. Wound margins were intact and pink.R1's Wound Data Collection dated 10/16/25 at 5:24 a.m., identified a wound (no description) on the left iliac crest (the curved area on the sides of the hip bones of the pelvic girdle) that measured 3.5 cm x 1 cm x .75 cm. Drainage present on dressing, surrounding tissue intact and tunneling (a chronic wound with an opening that extends into a narrow passageway or channel beneath the skin's surface) present. Wound characteristic not completed. Drainage amount indicated moderate, color indicated purulent (white, yellow, green, brown, or sometimes pink-tinged).R1's Wound RN (registered nurse) assessment dated [DATE] at 5:32 a.m., indicated an unstageable pressure ulcer to the left buttock, present on admission. The assessment indicated, continue with current plan of treatment.R1's Wound Data Collection dated 10/22/25 at 8:09 a.m., identified a stage I pressure ulcer (the earliest stage of a pressure injury, characterized by reddened, unbroken skin that does not turn white when pressed) to the left buttock that measured 3 cm x .35 cm. Wound characteristics indicated 100% granulation tissue. Surrounding tissue identified as macerated (softened, wrinkled tissue due to moisture) and reddened. RN to assess change in wound status.R1's Wound Data Collection dated 10/22/25 at 11:50 a.m., identified a wound on the coccyx (the final bone at the bottom of the spine) that measured 2.5 cm x 1 cm. Description was left blank. Wound characteristics indicated 100% granulation tissue. Surrounding tissue macerated and reddened. RN to assess change in wound status.R1's Wound RN assessment dated [DATE] at 3:40 p.m., identified a non-pressure related wound on the iliac crest. Tissue loss indicated full thickness loss (a severe wound that extends through all layers of the skin and into underlying structures like fat, muscle, tendon, or bone). Physician was notified regarding wound status, requesting wound consult.R1's Wound RN assessment dated [DATE] at 3:42 a.m., identified an unstageable pressure ulcer on the left buttock. R1's care plan dated 10/16/25, identified a self-care deficit related to weakness. The care plan directed staff to assist with bed mobility, transfers and toilet use. The care plan identified a potential and actual impairment to skin integrity and open wounds and an unstageable pressure ulcer on the left buttock. The care plan directed staff to monitor size, location and treatment of skin injury, provide pressure relieving device and or skin protective device (unspecified), on heels, elbows, etcetera (not specified). Frequency not specified. The care plan indicated avoid positioning on back. R1's care plan identified Parkinson's disease and indicated. monitor voiding pattern and continence and implement toileting program if needed. R1's Kardex (care guide) dated 10/31/25, lacked direction to staff related to mobility, transfers and frequency of repositioning or toileting.R1's discharge Minimum Data Set (MDS) dated [DATE], identified an unstageable deep tissue injury, present on admission.R1's Progress Notes identified the following:10/17/25, Daily vitals, medication administration, dressing changes. Wound still open, no swelling or redness surrounding (wound location not identified). Transfer assist of two with mechanical lift.10/19/25, R1 intermittently incontinent of large amounts of urine and required a full bed change over the past three overnight shifts.10/20/25, Daily vitals, medication administration, dressing changes. Wound is still open, no swelling or redness (wound location not identified). 10/21/25, Daily vitals, medication administration, dressing changes. Wound is still open, no swelling or redness (wound location not identified).10/22/25, R1 had a 10 cm diameter reddened coccyx and buttocks.10/22/25, R1 did not want to get out of bed. staff did frequent position changes.10/23/25, Small red area on sternum.10/24/25, R1 discharged to the hospital due to altered mental status. During interview on 10/30/25, at 2:09 p.m., R1's significant other (SO) stated every time he visited R1 at the facility she had been incontinent of bowel and not cleaned up. He said R1 was lying in feces every time he visited and said the time varied. The SO said R1 was currently in the hospital and was covered in sores. SO said when R1 admitted to the facility her sores had been healed up. The SO stated, I couldn't believe it when she got to the hospital and saw all of the sores.During interview on 10/31/25 at 10:27 a.m., licensed practical nurse (LPN)-A said skin assessments were completed every week on bath day. LPN-A said if a skin concern was identified it was noted and if no skin check was noted there was a spot on the form to indicate the skin check had been completed. LPN-A said R1 had multiple skin concerns, one on her abdominal fold and her coccyx. LPN-A said those were the wounds that had daily dressings. LPN-A said the wound on R1's coccyx was about the size of a quarter, red with blood-tinged fluid and looked like shearing (type of skin injury caused by opposing forces pulling on the skin and underlying tissues, often resulting in damage to deeper layers of skin and tissue). The abdominal fold was red and open, kind of oozy with clear drainage and about the size of a dime. LPN-A said she remembered a wound on the left buttock but did not recall what it looked like. On 10/31/25 at 11:21 a.m., NA-A and NA-B were interviewed. NA-A said they used the Kardex to determine how the care for the residents. NA-A said they had assignment sheets also because things changed often. If a new admission, NA-A said they asked the nurse for the information. NA-B said R1 had a lot of loose stools so she was changed every two hours and cream was applied. NA-B said she got pretty raw. NA-A said R1's coccyx was very red. NA-A said R1 always had a heated blanket on her chest and got a bigger sore that was red. During interview on 10/31/25 at 11:46 a.m., RN-A said she had not completed any of R1's wound assessments but had addressed the wound in progress notes. RN-A said R1 had two or three openings on the left side under her abdominal folds that had dressings placed on them. RN-A said R1 also had a wound on her coccyx, one on the gluteal cleft and one on her labia. RN-A said she had seen the wounds the day before R1 went to the hospital. RN-A said the labia wound looked like a scratch and said R1 had lines in her skin like her incontinent brief had been too tight. The gluteal cleft was described as a stage I, the top layer of skin was missing. RN-A described the coccyx wound as an opening with the top layer of skin missing. RN-A said R1's sternum was very prominent and said it looked her gown was always rubbing on it. She said R1 had a wound about the size of the tip of a pinky finger on her chest. R3's admission Record indicated he admitted to the facility 9/14/21. Diagnosis included dementia, heart disease, pain and history of falls.R3's care plan dated 6/5/25, identified limited physical mobility, and a self-care deficit and incontinence related to deconditioning. The care plan indicated R3 required the use of a mechanical lift for transfers and required assistance from staff for bed mobility and toileting. The care plan directed staff to check every two to three hours for incontinence. The care plan further identified an alteration in skin integrity related to reduced physical mobility and directed staff to assist to turn and reposition frequently during the day and at 12:00 a.m. and 4:00 a.m., use of a pressure reducing mattress and protective boots at night.R3's Braden Scale for Predicting Pressure Ulcers dated 9/24/25, identified a score of 12 which indicated high risk.R3's Wound RN assessment dated [DATE], identified a stage I pressure ulcer on the sacrum that measured 1 cm x 1 cm. The wound was described as an open area.R3's, Wound Data Collection dated 10/24/25. identified an open area on the coccyx that measured 1 cm x .5 cm. No drainage or bleeding identified. Surrounding tissue pink and intact. Wound bed 100% epithelialized (a newly formed layer of epithelial cells that regenerates to cover a wound surface, typically appearing translucent and lighter in color), indicating a stage II pressure ulcer. Wound margins or surrounding skin indicated it was denuded (skin that had the first protective layer removed). R1's medical record lacked evidence of wound assessments between 10/2/25 and 10/24/25.During interview on 10/31/25 at 10:27 a.m., licensed practical nurse (LPN)-A said R3 normally did not have a lot of skin issues but said currently they had been monitoring a little pressure sore on his coccyx. LPN-A said she had seen it a few weeks ago and it was the size of a dime.During interview on 10/31/25 at 11:55 a.m., RN-B said we have some issues with our wound charting. RN-B said the goal was to set aside a day each week to have two nurses look at the wounds, but it had not been implemented yet. 10/31/25 at approximately 1:00 p.m., the director of nursing (DON) said if a wound was observed, staff should complete the data collection form and an RN should complete the assessment if the initial assessment was completed by an LPN. The DON sated the facility did not have a process for regular wound rounds. The DON further stated nurses were supposed to complete skin checks weekly on bath day and acknowledged R3's skin checks were not being completed.Facility Policy Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 4/6/25, indicated if a pressure ulcer was identified, the RN should record the type of wound and the degree of tissue damage on the Wound RN Assessment. The licensed nurse records the location, area, measurements and the ulcer/wound characteristics on the Wound Data Collection assessment. Pressure ulcers should be evaluated at least weekly.

Based on interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect pressure ulcer staging for 1 of 3 residents (R1) reviewed with pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which indicated a stage III pressure ulcer. Wound margins were intact and pink.R1's Wound Data Collection dated 10/16/25 at 5:24 a.m., identified a wound (no description) on the left iliac crest (the curved area on the sides of the hip bones of the pelvic girdle) that measured 3.5 cm x 1 cm x .75 cm. Drainage present on dressing, surrounding tissue intact and tunneling (a chronic wound with an opening that extends into a narrow passageway or channel beneath the skin's surface) present. Wound characteristic not completed. Drainage amount indicated moderate, color indicated purulent (white, yellow, green, brown, or sometimes pink-tinged).R1's Wound RN (registered nurse) assessment dated [DATE] at 5:32 a.m., indicated an unstageable pressure ulcer to the left buttock, present on admission. The assessment indicated, continue with current plan of treatment.R1's Wound Data Collection dated 10/22/25 at 8:09 a.m., identified a stage I pressure ulcer (the earliest stage of a pressure injury, characterized by reddened, unbroken skin that does not turn white when pressed) to the left buttock that measured 3 cm x .35 cm. Wound characteristics indicated 100% granulation tissue. Surrounding tissue identified as macerated (softened, wrinkled tissue due to moisture) and reddened. RN to assess change in wound status.R1's Wound Data Collection dated 10/22/25 at 11:50 a.m., identified a wound on the coccyx (the final bone at the bottom of the spine) that measured 2.5 cm x 1 cm. Description was left blank. Wound characteristics indicated 100% granulation tissue. Surrounding tissue macerated and reddened. RN to assess change in wound status.R1's Wound RN assessment dated [DATE] at 3:40 p.m., identified a non-pressure related wound on the iliac crest. Tissue loss indicated full thickness loss (a severe wound that extends through all layers of the skin and into underlying structures like fat, muscle, tendon, or bone). Physician was notified regarding wound status, requesting wound consult.R1's Wound RN assessment dated [DATE] at 3:42 a.m., identified an unstageable pressure ulcer on the left buttock. During interview on 10/31/25 at 11:55 a.m., RN-B indicated she was new to her role and stated when coding the MDS, she looked at the nursing data collection. RN-B said the data collection she looked at said R1 had an unstageable pressure ulcer on admission which was why she coded it that way. RN-B said there were some issues with the facilities wound charting.

Based on interview and document review the facility failed to ensure a baseline care plan related to pressure ulcers was developed for 1 of 3 resident (R1) who admitted to the facility with a pressure ulcer and developed pressure ulcers.Findings include:R1's admission Record indicated she admitted to the facility on [DATE]. R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which indicated a stage III pressure ulcer. Wound margins were intact and pink.R1's Wound Data Collection dated 10/16/25 at 5:24 a.m., identified a wound (no description) on the left iliac crest (the curved area on the sides of the hip bones of the pelvic girdle) that measured 3.5 cm x 1 cm x .75 cm. Drainage present on dressing, surrounding tissue intact and tunneling (a chronic wound with an opening that extends into a narrow passageway or channel beneath the skin's surface) present. Wound characteristic not completed. Drainage amount indicated moderate, color indicated purulent (white, yellow, green, brown, or sometimes pink-tinged).R1's Wound RN (registered nurse) assessment dated [DATE] at 5:32 a.m., indicated an unstageable pressure ulcer to the left buttock, present on admission. The assessment indicated, continue with current plan of treatment.R1's Wound Data Collection dated 10/22/25 at 8:09 a.m., identified a stage I pressure ulcer (the earliest stage of a pressure injury, characterized by reddened, unbroken skin that does not turn white when pressed) to the left buttock that measured 3 cm x .35 cm. Wound characteristics indicated 100% granulation tissue. Surrounding tissue identified as macerated (softened, wrinkled tissue due to moisture) and reddened. RN to assess change in wound status.R1's Wound Data Collection dated 10/22/25 at 11:50 a.m., identified a wound on the coccyx (the final bone at the bottom of the spine) that measured 2.5 cm x 1 cm. Description was left blank. Wound characteristics indicated 100% granulation tissue. Surrounding tissue macerated and reddened. RN to assess change in wound status.R1's Wound RN assessment dated [DATE] at 3:40 p.m., identified a non-pressure related wound on the iliac crest. Tissue loss indicated full thickness loss (a severe wound that extends through all layers of the skin and into underlying structures like fat, muscle, tendon, or bone). Physician was notified regarding wound status, requesting wound consult.R1's Wound RN assessment dated [DATE] at 3:42 a.m., identified an unstageable pressure ulcer on the left buttock. R1's Nursing Admit Re-Admit Data Collection dated 10/16/25, indicated skilled services to include wound care. Skin integrity assessment indicated a dehisced (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing) scar on the left side of her abdomen, left buttock: crease area unstageable ulcer due to previous location and a scratch on her arm.R1's care plan dated 10/16/25, identified a self-care deficit related to weakness. The care plan directed staff to assist with bed mobility, transfers and toilet use. The care plan identified a potential and actual impairment to skin integrity and open wounds and an unstageable pressure ulcer on the left buttock. The care plan directed staff to monitor size, location and treatment of skin injury, provide pressure relieving device and or skin protective device (unspecified), on heels, elbows, etcetera (not specified). Frequency not specified. The care plan indicated avoid positioning on back. R1's care plan identified Parkinson's disease and indicated, monitor voiding pattern and continence and implement toileting program if needed. During interview on 10/31/25 at approximately 1:00 p.m., the director of nursing (DON) acknowledged R1 did not have a baseline care plan and stated the initial care plan was done with assessments and said the nurses can click buttons to add interventions to the care plan. The DON said the nurses must not have clicked the buttons on the assessments to link to the care plan. The DON stated after the initial care plan the MDS coordinator, RN-B completed the care plans.Facility policy Care Plan dated 12/2/24, indicated the baseline care plan includes instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care. The policy indicated each resident will have and individualized, person-centered, comprehensive care plan to include measurable goals and timetables directed toward achieving and maintaining the residents optimal medical, nursing, physical and functional needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument and review of physician orders.

Based on interview and document review, the facility failed to assess and analyze a resident fall with major injury to identify specific hazards and/or risks and to develop targeted interventions to reduce the potential for falls for 1 of 1 resident (R27) reviewed for falls.Findings include:R27's resident event form dated 8/8/25 at 4:45 p.m., identified on 8/8/25 R27 was observed peddling himself with his feet in the hallway, became tangled up in a computer table and fell out of his wheelchair. The wheelchair then fell on top of the resident. No immediate intervention put into place and unknown if there was an injury. R27's progress notes dated 8/11/25 at 4:50 p.m., identified R27 had a fall on 8/8/25 with a hip fracture and was currently in the hospital after hip nailing. Anti-roll backs would be applied to resident's wheelchair. However, the note failed to identify a description or cause of R27's fall.R27's falls tool report dated 8/15/25, identified R27 was at risk for falls related to an actual fall on 8/8/25, was taking 2 or more at risk medications, had moderately impaired cognition, reduced insight, delirium, poor memory and was impulsive. However, the tool failed to identify a description of or cause of R27's fall on 8/8/25.R27's care plan reviewed 8/18/25, identified R27 required staff assistance to transfer with a non-mechanical stand aide and did not ambulate. R27 had an actual fall with major injury and safety interventions included staff to remind resident not to bend over to pick up dropped items, use call light for assistance and keep personal items within reach.R27's medical record failed to identify a comprehensive assessment following the fall on 8/8/25, to include causal factors and/or root cause of R27's in an attempt to prevent further falls. R27's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], identified R27 was readmitted to the facility on [DATE], after an acute hospital stay. R27 was cognitively intact, required staff assistance with activities of daily living (ADL's), and had diagnoses including surgical repair of the right hip after a fall with major injury on 8/8/25.On 8/20/25 at 11:20 a.m., nursing assistant (NA)-E stated R27 had a fall recently when the resident reportedly fell in the lobby and fractured the right hip. Upon return from the hospital, R27 required more assistance with ADL's, couldn't stand on his own, and didn't call for help as much as previous. Staff used the manual sit-to-stand lift (a mobility aide designed to assist individuals in transitioning safely from sitting to standing) for all transfers. On 8/20/25 at 2:25 p.m., registered nurse (RN)-A stated R27 fell on 8/8/25, thought a note was entered in the EMR and remembered talking about the fall, although, upon request RN-A was unable to find documentation regarding the residents fall or discussions related to the fall. Further, RN-A stated R27's fall was not documented in the EMR.On 8/20/25 at 2:43 p.m., the DON stated the interdisciplinary team (IDT) met every Wednesday morning to discuss high risk incidents including resident falls. On 8/13/25 at 9:56 a.m., there was a note in the resident's chart identifying the IDT team met and discussed the residents fall, although the note failed to identify causal factors of the fall. The DON stated upon readmission, R27 had a fall tool was completed, although was uncertain what the assessment entailed or if the fall was assessed or analyzed to determine causal factors or a root cause. The DON stated interventions to prevent further falls included anti-roll backs on R27's wheelchair. The DON stated R27's fall was probably not documented in the medical record. The facility Fall Prevention and Management policy reviewed 4/8/25, included after stabilizing a resident from a fall with major injury, the nurse would complete a fall scene huddle worksheet, initiate an investigation into the fall, update the careplan, and document in Riskonnect. The completed fall scene huddle worksheet would be given to the fall committee chair or designee for review and follow-up.

Based on observation, interview and document review, the facility failed to ensure a physician order for indwelling urinary catheter; and failed to ensure urinary catheter care was provided in a manner to prevent contamination and potential urinary tract infection (UTI) for 1 of 4 residents (R4) reviewed for urinary catheter. Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had a severe cognitive impairment and had diagnoses that included hematuria, neuromuscular bladder dysfunction (nerve damage that affects bladder control), reflux uropathy (the backward flow of urine from your bladder into your kidneys. Without treatment, the condition could lead to complications such as high blood pressure and chronic kidney disease.), type 2 diabetes, dementia and a methicillin resistant staphylococcus aureus (MRSA). R4 used an indwelling urinary catheter.R4's care plan revised 4/18/25, identified R4 had an indwelling catheter due to urinary retention and obstruction. Staff were instructed to:, Monitor/document for pain/discomfort due to catheter, Document intake and/or output., Monitor/document for pain/discomfort due to catheter, and Monitor/record/report to health care provider for signs/symptoms of urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increasedR4's Interagency Handoff Report dated 7/8/25, identified R4 was hospitalized due to kidney stones and had ureter stents placed. R4's indwelling catheter was replaced while hospitalized on [DATE] with a 24 French (FR) foley catheter with a 60 milliliter (ml) balloon. The report failed to identify an order for continued urinary catheter use.R4's Order Summary report dated 8/21/25, identified maintain 20 FR coude catheter (a urinary catheter with a curved tip) with 30 ml balloon. Change every 14 days and as needed for obstruction at bedtime every 2 weeks related to urinary retention and obstruction was discontinued on 7/8/25.R4's nursing progress note dated 7/22/25 at 3:11 p.m., identified R4 had a follow-up Urology appointment on 7/21/25 and R4 was scheduled for further imaging of his kidneys and a follow-up Urology appointment with the provider who performed R4's procedure. The note failed to identify an order was received for continued urinary catheter use.R4's nursing progress note dated 8/3/25 at 7:52 a.m., identified R4's indwelling foley catheter was replaced with a 20 FR foley catheter with a 5 ml and urinary catheter bag falling apart. R4's prior catheter was intact but had a blood clot on the tip blocking urine flow. The note failed to identify if a provider was contacted to obtain an order for replacement.During an observation on 8/18/25 at 6:44 p.m., nursing assistant (NA)-D assisted R4 with evening cares. NA-D wore gown, and gloves. When finished, NA-D hung R4's urinary catheter bag on the bedframe and lowered R4's bed to the floor. R4's urinary catheter bag port was not fastened to the holder and the bag rested on the floor. At 6:57 p.m., NA-D removed her soiled gloves, used hand sanitizer and put on new gloves. NA-D obtained a graduate from R4's closet and placed the graduate under R4's urinary catheter bag. NA-D drained approximately 500 cc of urinary from the bag then closed and cleaned the port with an alcohol wipe. NA-D poured the graduate into the toilet and set the graduate down. NA-D removed her gloves, washed her hands, then put on new gloves. NA-D then picked up the soiled graduate and placed it back into the closet. However, NA-D did not remove her soiled gloves. At 7:03 p.m., NA-D removed R4's teeth from his denture cap and placed them in R4's mouth. NA-D removed her soiled gloves/gown and used hand sanitizer before leaving the room. However, R4's urinary catheter bag remained on the floor.During an interview on 8/18/25 at 7:09 p.m., NA-D stated she did take off her gloves and wash her hands before putting away the graduate, but did not change her gloves before assisting R4 with his dentures because she thought the outside of the graduate was clean. Also, NA-D stated she left the urinary catheter bag touching the floor and R4 needed his bed lowered for safety. NA-D stated the urinary catheter bag should not lie on the floor because the floor was dirty, and it could lead to R4 getting an infection.During an interview on 8/20/25 at 11:12 a.m., registered nurse (RN)-A stated R4 had an order for his catheter before R4 was hospitalized but did not have a current order. RN-A stated he did see the note where R4's catheter was changed, and an order should have been obtained prior to changing. Also, when R4 returned from the hospital, the admitting nurse should have contacted R4's provider for further direction. Further a resident's catheter bag should never rest on the floor. The catheter bag should either be clipped higher or put in a cloth bag for basic hygiene and to keep the floor and catheter bag sanitary. Staff were expected to remove soiled gloves and wash hands prior to doing oral cares.During an interview on 8/20/25 at 1:19 p.m., the director of nursing (DON) stated the facility had a new policy to not flush or change a catheter unless there was a problem. R4 used to have weekly catheter changes and as needed. R4 returned to the facility with a 24 FR coude catheter and there was no order for weekly catheter changes, however, the DON was unaware R4 did not have an order for changes as needed. The staff should have ensured there was an order before changing the catheter on 8/3/25. The DON had worked the night shift on 8/3/25 and the day nurse said she could change R4's catheter and the DON went home. The DON stated she did not verify R4's orders. Further, a barrier should have been placed under R4's urinary catheter bag or the urinary catheter bag placed into a cloth bag to prevent infection. The nursing assistants are trained to removed soiled gloves and wash their hands prior to doing oral cares. During a telephone interview on 8/20/25 at 3:32 p.m., the urologist stated he had only evaluated R4 the one time postoperatively. The urologist didn't have enough data from R4's hospital stay to be able to fully care for R4. Because of that, he referred R4 back to urologist who performed R4's procedure and ordered a follow up CT to ensure they had all the possible information for that appointment. For the urinary catheter, the urologist stated he could not determine why R4 had a 24 FR coude catheter with a 60 ml balloon was placed after R4's procedure. Because of that, he would expect staff to contact the discharging physician to obtain further direction and to follow orders as given. During an interview on 8/20/25 at 4:26 p.m., the administrator stated he expected staff to follow facility policy and procedureThe facility policy Catheter Care: Insertion and Removal, Drainage Bags, Irrigation, Specimen revised 4/6/25, identified the following: Catheters will be inserted only with a physician's order and will include the type of catheter, size and balloon capacity for indwelling catheter. Catheter tubing should never be allowed to touch the floor. Non-obstructed downhill flow is always maintained. PROCEDURE Emptying Catheter Drainage Bag Equipment1. Perform beginning five and apply gloves.2. If splashing or spraying is anticipated use personal protected equipment (PPE).3. When emptying the catheter bag, place a fluid-impermeable pad beneath the measuring container and avoid placing the container on the floor.4. Open drainage port and allow urine to drain into measuring container placed underneath. Do not allow tip of tubing to touch sides of the measuring container or any surface.5. When done, clean drainage port tip with alcohol wipe and replace in the holder.6. Make sure the drainage bag and tubing are appropriately placed.7. In rehabilitation/skilled care, if resident is on Intake and Output measure urine volume and record in PCC-POC/EMR.8. Discard urine in toilet.9. Wash and dry measuring container according to location procedure. Do not store the measuring container on the floor.10. Perform ending five.11. Note amount and character of urine. Report any significant observations to licensed nurse (blood, mucous, low urine output).

Based on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were addressed and acted upon and documented in the medical record for 2 of 5 residents (R26, R7) reviewed for unnecessary medications.Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had a moderate cognitive impairment and had diagnoses that included dementia. R26 used antidepressant medication daily. R26's Order Summary Report dated 8/21/25, identified Trazodone HCl oral tablet (an antidepressant primarily used to treat major depressive disorder. It works by increasing serotonin levels in the brain, which can help improve mood, appetite, and energy levels, as well as reduce anxiety and insomnia related to depression. Additionally, trazodone is sometimes prescribed as a sleep aide due to its sedative effects, and it is considered non-addictive.) give 25 milligrams (mg) at bedtime related to unspecified dementia, moderate, with other behavioral disturbance was started on 1/28/25. R26's Consultant Pharmacist's Medication Review dated 7/11/25, identified R26 was prescribed Trazodone 25 mg at bedtime since 1/28/25. Per CMS guidelines, all psychotropic medications should be considered for a trial dose reduction at least twice within the first year of use. If a dose decrease is contraindicated, rigorous risk/benefit documentation should be provided. A review of recent provider progress notes did not yield a thorough risk/benefit assessment for this patient's psychotropic medications. Suggested course of action: Please evaluate the above psychotropic medications and consider reducing either the trazodone dose on a trial basis or provide clear clinical documentation as to why a dose reduction is contraindicated at this time. However, the form failed to identify a response from R26's physician. R26's medical record failed to identify R26's provider was contacted regarding R26's Trazodone and/or pharmacist's recommendations. During an interview on 8/20/25 at 11:28, the director of nursing (DON) stated she believed she missed R26 had an appointment with his physician, or she would have requested R26's Trazodone be discontinued. The DON preferred as many medication requests were done during appointments as possible because faxed requests usually did not generate a response. During an interview on 8/20/25 at 3:44 p.m., the consultant pharmacist stated, in general, after a resident was taking Trazodone for 6 months, a gradual dose reduction (GDR) was recommended. During an interview on 8/20/25 at 4:26 p.m., the administrator stated he expected staff to follow facility policy and procedure. R7's quarterly MDS dated [DATE], identified R7 had moderate cognition. Diagnoses included obsessive-compulsive disorder (mixed obsessional thoughts and acts), dementia, anxiety, depression and psychotic disorder. R7 received antipsychotics on a routine basis, a gradual dose reduction (GDR) had not been attempted or had not been documented by a physician as clinically contraindicated. R7's physician orders identified an order for olanzapine (antipsychotic medication) to be given twice daily related to depression and was started 1/19/23. R7 also received Sertraline given one time a day for depression with psychotic symptoms and was started 6/5/22. R7's Consultant Pharmacist's Medication Review, dated 6/6/25, identified Olanzapine 5 mg tablet take 1 tablet by mouth twice a day. This patient has been prescribed olanzapine since 1/20/22 and continued Sertraline 125 mg per day. Per Centers for Medicare and Medicaid Services (CMS) guidelines, all psychotropic medications should be considered for a trial dose reduction at least twice within the first year of use. If a dose decrease is contraindicated, rigorous risk/benefit documentation should be provided. A review of recent provider progress notes indicated R7 was followed by psychiatry for management of these medications, however, the most recent Psychiatry note on file in R7's electronic medical record (EMR) was 7/30/24, and while it stated to continue olanzapine 5 mg twice daily and Sertraline 125 mg daily, it does not include a thorough risk/benefit assessment for R7's psychotropic medications. Suggested course of action: if R7 was seen Psychiatry since the visit on 7/30/24, please obtain a copy of the progress note and file to the EMR, making sure that they addressed the ongoing need for the current psychotropic medications (why a dose reduction is clinically contraindicated). If R7 had not seen psychiatry since last July, consider scheduling a visit to have the provider assess the patient for a potential gradual dose reduction or if no longer followed by psychiatry, please have the primary evaluate R7 for a gradual dose reduction. Implementation time frame: nursing staff to address as soon as possible (ASAP) but no later than 30 days. R7's medical record lacked evidence a GDR had been attempted or identified a medical justification the resident was on the lowest effective dose within the past calendar year, or that the pharmacy recommendation had been followed up on. On 8/20/25 at 3:33 p.m., the director of nursing (DON) stated R7's last psychology visit was more than a year ago and had failed previous attempts for GDR's, however, the DON couldn't remember when GDR was attempted or if they were documented in R7's medical record. The DON stated she expected GDR's to be attempted or documented contraindications to be done yearly. On 8/20/25 at 4:21 p.m., a message was left for the consulting pharmacist requesting return call. The facility Psychotropic Medications policy reviewed 5/12/25, identified the consulting pharmacist would review resident medication records monthly for documentation/justification for the drug use and will recommend dosage reductions or modifications as appropriate. The facility policy Medication: Drug Regimen Review revised 12/2/24, identified a drug regimen review is performed for each resident at least once a month by a licensed pharmacist. This review must include a review of the residents' medical chart. The pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist will also complete the Medication Regimen Review Summary for QAPI Committee document. Both reports will be given to the director of nursing services upon completion of each monthly DRR. The reports must be shared with the attending physician and the location's medical director, and these reports must be acted upon. Should the consultant pharmacist detect a potential or actual problem that requires urgent action to protect the resident, he or she will promptly alert the direct care nurse for immediate action. If prescriber intervention is required, the consultant pharmacist will ensure proper communication is provided to the attending physician, nurse practitioner or physician's assistant to ensure resolution by midnight of the next business day. Drug irregularities will be reported to the medical director and attending physician by the director of nursing services or designee. The location must designate someone to ensure that these reports have been acted upon within 30 calendar days of the review and have been documented. Regarding psychopharmacological medications, the location will ensure that residents who have not used psychopharmacological medications and sedative/hypnotics are not given these unless this therapy is necessary to treat a specific condition, as diagnosed and documented in the medical record. In addition, those residents who do use these types of medications will receive gradual dose reductions or behavioral interventions, unless clinically contraindicated, in an effort to discontinue the drugs.

Based on interview and document review, the facility failed to ensure there was a comprehensive assessment and monitoring for prescribing a psychotropic medication for sleep for 1 of 6 (R26); and failed to provide evidence a gradual dose reduction (GDR) or a clinical justification of a psychotropic medication was completed for 1 of 6 residents (R26, R7) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had a moderate cognitive impairment and had diagnoses that included dementia. R26 used antidepressant medication daily. R26's Order Summary Report dated 1/28/25, identified Trazodone HCl oral tablet (an antidepressant primarily used to treat major depressive disorder. It works by increasing serotonin levels in the brain, which can help improve mood, appetite, and energy levels, as well as reduce anxiety and insomnia related to depression. Additionally, trazodone is sometimes prescribed as a sleep aide due to its sedative effects, and it is considered non-addictive.) give 25 milligrams (mg) at bedtime related to unspecified dementia, moderate, with other behavioral disturbance with a start date of 1/28/25. R26's medication record failed to identify R26's sleep was assessed prior to starting Trazodone or after starting the medication to ensure it was effective. R26's care plan revised 2/23/25, identified R26 was on antidepressant medication therapy related to depression. Staff were directed to: Monitor R26's condition based on clinical practice guidelines or clinical standards of practice related to the use of Trazodone, and Consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate. R26's nursing note(s) identified the following: 6/26/25 at 3:46 p.m., identified the Mood/Behavior Committee met and reviewed R26's behavior/mood monitoring: hallucinations/delusions. R26's care plan and interventions were reviewed and continued to be appropriate. R26 had been sleeping a lot more lately. The note failed to identify if R26's sleep was monitored for potential side effects. 7/2/25 at 4:55p.m, identified R26 had a diagnosis of Dementia with Psychotic Disturbances and Dementia with Behavioral disturbances. R26 was alert although not always orientated. At times, R26 had thoughts that he needed to go to Blackduck and that he was not here already. Other times, R26 was fine. PHQ-9 Scored a 03 compared to 00 on last one. R26 said he was tired all the time. R26 answered all questions for interviews. There were no incidents over quarter. Staff were monitoring hallucinations and/or delusions. R26 had 60 occurrences over the quarter. There was four days in the look back period where R26 was confused where he was and got verbally aggressive with staff on one and was hollering out unsure where he was at. All four days involved not knowing where he was. Per staff interview, intervention remained appropriated. IDT Team and Behavior Committee just met and R26's mood/behavior monitoring continued to be appropriate. The note failed to identify if R26 had a sleep assessment and/or if R26's sleep was monitored for potential side effects. R26's Consultant Pharmacist's Medication Review dated 7/11/25, identified R26 was prescribed Trazodone 25 mg at bedtime since 1/28/25. Per CMS guidelines, all psychotropic medications should be considered for a trial dose reduction at least twice within the first year of use. If a dose decrease is contraindicated, rigorous risk/benefit documentation should be provided. A review of recent provider progress notes did not yield a thorough risk/benefit assessment for this patient's psychotropic medications. Suggested course of action: Please evaluate the above psychotropic medications and consider reducing either the trazodone dose on a trial basis or provide clear clinical documentation as to why a dose reduction is contraindicated at this time. However, the form failed to identify a response from R26's physician. R26's medical record failed to identify R26's provider was contacted regarding R26's Trazodone and/or pharmacist's recommendations. R26's care conference note dated 7/22/25 at 1:30 p.m., identified R26 was sleeping and could not wake up. Could not ask R26 or family questions. R26 did a lot of sleeping during the day. Going to talk to the doctor about if he still needs the trazodone. The note failed to identify any further action. During an observation on 8/18/25 at 3:20 p.m., R26 was lying in bed asleep. R26 was sleeping since survey entrance and did not wake when greeted. During an observation on 8/19/25 at 8:34 a.m., R26 was in his room sitting reclined with his feet up in his wheelchair. Blankets covered R26 to his chin. R26's eyes were closed and did not respond when greeted. During an observation on 8/19/25 at 3:42 p.m., R26 was lying in bed asleep on his right side. R26 did not respond when greeted. During an observation on 8/20/25 at 7:32 a.m., R26 was lying in bed with the head of the bed elevated. R26 was covered to his chin with blankets. R26 was asleep and looked up when greeted but laid his head back down and closed his eyes. During an interview on 8/20/25 at 8:50 a.m., nursing assistant (NA)-D stated R26's eyesight was poor. R26 used to make comments like the sun was out but R26 didn't even do that anymore. R26 was pretty set in his ways but R26 did sleep a lot. During an interview on 8/20/25 at 11:08 a.m., registered nurse (RN)-A stated R26 was pretty much like that: pretty laid back, relaxed and slept a lot. RN-A stated he was surprised R26 was on Trazodone because R26 slept a lot, and Trazodone would make R26 even more tired. The only sleep assessment ever conducted for R26 was on 4/4/16. RN-A could not determine why R26 was started on Trazodone and, normally, there was documentation to show why a medication like that was started. When a resident was taking a medication like Trazodone a sleep assessment should be done at least annually if not more often. During an interview on 8/20/25 at 11:28, the director of nursing (DON) stated she believed she missed R26 had an appointment with his physician, or she would have requested R26's Trazodone be discontinued. The DON preferred as many medication requests were done during appointments as possible because faxed requests usually did not generate a response. During an interview on 8/20/25 at 3:44 p.m., the consultant pharmacist stated, in general, after a resident was taking Trazodone for 6 months, a gradual dose reduction (GDR) was recommended. During an interview on 8/20/25 at 3:14 p.m., social services designee (SSD)-A stated she completed the annual and quarterly MDS for sections C, D, and F. If there was a Care Area Assessment (CAA) for activities, SSD-A completed that as well. If a resident was on a medication for sleep, SSD-A entered a sleep study as well. SSD-A looked at the diagnosis on the medication sheet and if it stated the medication was for sleep, that would indicate a sleep study was needed. For R26, the medication diagnosis was for hallucinations, and a sleep study was not done. SSD-A stated, for side effects, a sleep assessment was a nursing responsibility. During an interview on 8/20/25 at 3:40 p.m., the DON stated she believed SSD-A did a sleep study for all residents on Trazodone, whether prescribed for sleep or not, because it has a sedating effect. We need to improve our communication. The DON stated a any drug that affected brain activities associated with mental processes and behavior could be considered a chemical restraint and it should be monitored appropriately, and our documentation should show the rationale for use. It should be a team approach and never one nurse requesting a medication like that. Staff should always try other interventions first. During an interview on 8/20/25 at 3:44 p.m., the consultant pharmacist stated, in general, after a resident was taking Trazodone for 6 months, a gradual dose reduction (GDR) was recommended. During that time, the staff should be monitoring the resident and documenting the resident was benefitting from the medication. If for sleep, for example, the resident should be sleeping better. If for mood, it should be controlling their mood. However, staff should be monitoring for side effects of Trazodone because Trazodone could be very sedating. During an interview on 8/20/25 at 4:26 p.m., the administrator stated he expected staff to follow facility policy and procedure. R7's quarterly MDS dated [DATE], identified R7 had moderate cognition. Diagnoses included obsessive-compulsive disorder (mixed obsessional thoughts and acts), dementia, anxiety, depression and psychotic disorder. R7 received antipsychotics on a routine basis. A gradual dose reduction (GDR) had not been attempted or had not been documented by a physician as clinically contraindicated. R7's physician orders identified an order for olanzapine (antipsychotic medication) to be given twice daily related to depression and was started 1/19/23. R7 also received Sertraline given one time a day for depression with psychotic symptoms and was started 6/5/22. R7's medical record lacked evidence a GDR had been attempted or identified a medical justification the resident was on the lowest effective dose within the past calendar year for the olanzapine or sertraline. R7's provider nursing home rounds report dated 7/18/25, identified psychiatry followed R7 for anxiety, major depression, dementia with behavioral disturbance, and obsessional thoughts/acts. The note identified R7 had failed previous attempts of medication tapers although failed to identify what medications were tapered and when the medications were tapered. R7's behavioral health visit note dated 7/30/24, identified R7 was to return to the clinic in 6 months or sooner, and continue olanzapine twice daily and sertraline daily. The note failed to identify if the medications were the lowest effective dose or if a GDR should be attempted. On 8/20/25 at 3:33 p.m., the DON stated R7's last psychology visit was more than a year ago and R7 had failed previous attempts for GDR's, however, the DON couldn't remember when GDR was attempted or if they were documented in R7's medical record. The DON stated she thought R7's primary provider was following the residents psych medications but was uncertain since it wasn't documented in the medical record. On 8/20/25 at 4:21 p.m., a message was left for the consulting pharmacist (CP) requesting return call. The facility policy Psychotropic Medications revised 5/12/25, identified throughout the administration of a psychotropic medication, the following must be completed, Mood and behavior documentation must continue to monitor the effect the medication has on the behavior, Monitor for side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in the electronic medical record (EMR) and notify the physician and family/legal representative of this change in condition., Monitor for effectiveness and potential adverse consequences., Gradual dose reductions must be done according to federal regulations. For the guidelines for dose reductions, see the Gradual Dose Reductions section of this procedure, The reduction committee will review the need for psychotropic medications at least every three months and document the rationale for continuing the medication. The committee also will need to evaluate: The resident's target symptoms and the effect of the medication on the severity, frequency and other characteristics, Any changes in the resident's function during the last quarter; this can be done by reviewing the MDS, Whether the resident experienced any medication-related adverse consequences during the previous quarter, and Fax the Fax Communication to Physician to the prescriber. Scan the completed form into OnBase as part of the medical record.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 3 residents (R2) reviewed for pressure ulcers.Findings include:R2's quarterly Minimum Data Set, dated [DATE], identified R2 had moderate cognitive impairment. Diagnoses included dementia, renal insufficiency and anemia. R2 was at risk of pressure injury/ulcer and required substantial/maximal assistance for bed mobility and was dependent on staff for transfers.R2's Braden Scale for Predicting Pressure Sore Risk dated 5/28/25, identified R2 was at high risk for pressure injury/ulcer.R2's care plan revised 5/29/24, included interventions to check and reposition R2 frequently during the day, 12:00 a.m. and 4:00 a.m. at night; turn from Side to Side: R2 required substantial/max assist of 1 staff member for turning side to side in bed with use of bilateral grab bars on bed.- During a continuous observation on 8/20/25 at 7:18 a.m., R2 was lying in bed. R2's head of bed (HOB) was approximately elevated to 30 degrees and R2's tv was on. R2's overbed table was in front of R2. R2 was rubbing her eyes and stated she was tired that morning. At 7:20 a.m., nursing assistant (NA)-E stepped into R2's room and stated R2 wanted to eat breakfast in her room that morning. NA-E requested R2's breakfast order then raised R2's HOB so R2 was sitting upright. NA-E did not offer or reposition R2 before leaving the room. At 7:42 a.m., R2's breakfast tray was delivered and set up by kitchen staff. At 8:00 a.m., NA-C stepped into R2's doorway and asked R2 if she was doing ok. R2 was eating her breakfast. NA-C did not offer or reposition R2. At 8:53 a.m., R2 continued to sit in the same position. R2's finished breakfast remained in front of her on the overbed table. At 9:46 a.m., NA-F entered R2's room and told R2 NA-F was going to check her. NA-F removed R2's breakfast tray, performed incontinence cares and transferred R2 to her wheelchair with the full body mechanical lift and NA-E.- During an interview on 8/20/25 at 9:58 a.m., NA-F stated R2 needed to be turned and/or repositioned every two to three ours.During an interview on 8/20/25 at 10:02 a.m., NA-B and NA-C stated R2 needed to be turned and repositioned every two hours. NA-B stated the electronic point of care (POC) module directed the staff when residents were due and, once completed, the nursing assistants signed it off. NA-C stated she did R2's cares that morning before 7:00 a.m. and stopped into R2's room at 8:00 a.m. to reposition R2 but R2 was eating. However, NA-C did not offer to reposition R2 nor returned to R2's room after R2 was finished eating. NA-C stated someone should have.During an interview on 8/20/25 at 11:11 a.m., registered nurse (RN)-A stated R2 was at risk for pressure injury/ulcer and the nursing assistants should have offered to turn and reposition R2 was she was done eating breakfast.During an interview on 8/20/25 at 11:31 a.m., the director of nursing (DON) stated R2 typically had morning cares between 6:00 a.m. and 7:00 a.m. R2 liked to stay in bed for breakfast and the nursing would get R2 up into her wheelchair later in the morning. The DON stated staff should have offered to turn and reposition R2 approximately a half hour after eating.During an interview on 8/20/25 at 4:26 p.m., the administrator stated he expected staff to follow policy and procedure.The facility policy revised 4/6/25, identified Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation UDA is a required tool that is used to determine an individualized repositioning plan. The positioning schedule should be communicated to the nursing assistants using the Kardex in PCC-POC. Any resident at risk will be placed on a pressure redistribution surface as determined appropriate.

Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. Findings include: The Monthly Infection Summary February 2024, identified resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance criteria met. However, the log failed to identify any resident not treated with an anitmicrobial (an agent that kills microorganisms (microbicide) or stops their growth (bacteriostatic agent).The log failed to identify R4, R23, R14, R12, R22 signs and symptoms of potential respirator infection [identified below]. The Monthly Infection Summary March 2024, identified identified resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance criteria met. The log did identify R1 had a other respiratory tract infection between 3/23/24 - 3/26/24, however, no other residents not requiring an antimicrobial were listed. The Monthly Infection Summary April 2024, identified resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance criteria met. However, the log failed to identify any resident not treated with an anitmicrobial. The Monthly Infection Summary May 2024, identified resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance criteria met. However, the log failed to identify any resident not treated with an anitmicrobial. R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was [AGE] years old and had diagnoses that included Parkinson's disease, hypertension, and chronic kidney disease.R4's COVID-19 (Novel Corornavirus) Screening V15 dated 2/15/24, identified R4 had no new symptoms including fever of 100.0 or greater, chills, shortness of breath, difficulty breathing, new or change in cough, sore throat, new loss of taste or smell, new sputum production, congestion, runny nose (rhinorrhea), fatigue, muscle or body aches, headache, nausea or vomiting, or diarrhea; R4 was not exposed to anyone with a confirmed COVID-19 test; and tested negative for COVID-19 with an antigen COVID-19 test. However, the screening failed to identify if any interventions were implemented for R4. R4's nursing progress note dated 2/15/24 at 11:02 a.m., R4 was noted to have a nonproductive cough and afebrile (without a fever). Covid rapid test completed and was negative. R4's medical record failed to identify if R4 had a confirmatory COVID-19 test and/or if/when R31 had been placed in isolation. R23's quarterly MDS dated [DATE], identified R23 was [AGE] years old and had diagnoses that included hypertension, pyogenic arthritis, chronic obstructive pulmonary disease (COPD) and Type 2 Diabetes. R23's nursing progress note dated 2/15/24 at 11:04 a.m., identified R23 noted to have a nonproductive cough, afebrile. Covid rapid antigen test completed and was negative. - On 2/18/24 at 9:52 p.m., R23 had a nonproductive cough, chest congestion, temperature 97.6 degrees Fahrenheit (F), oxygen saturations were 93% on room air. R23's medical record failed to identify if R23 had a confirmatory COVID-19 test and/or if/when R23 had been placed in isolation. R14's quarterly MDS dated [DATE], identified R14 was [AGE] years old and had diagnoses that included chronic kidney disease, Type 2 Diabetes, hypertension, and mild cognitive impairment. R14's nursing progress notes identified the following: - On 2/22/24 at 5:20 p.m., R14 was complaining of not feeling good that day. R14 was afebrile, catheter was patent with clear yellow urine. Staff would continue to monitor. - On 2/28/24 at 3:50 a.m., R14 was having cold symptoms with chest congestion and a cough. - On 2/28024 at 1:36 p.m., R14 had some congestion noted with nonproductive cough. Vital signs stable, afebrile with some fine crackles noted in upper lobes. Will continue to monitor and update provider. - At 11:08 p.m., R14 continued to have cold symptoms, crackles lower lobes bilaterally, oxygen saturations were 91% on room air, temperature 97.6 degrees F, pulse 68, respirations 18, and blood pressure 144/44. R14's head of bed was elevated. - On 2/29/24 at 2:40 a.m., R14's oxygen saturation was 85% on room air, pulse 65, respirations 20 and temperature 97.9 degrees F. Oxygen was applied at 2L per nc and her oxygen saturations went up to 90.-91%. Blood sugar was 135. R14 was congested with bilateral lower lobe crackles. R14 was lethargic and confused. R14 had not been feeling well for the past 5 days. R14 was transferred to the emergency department for evaluation. - On 3/6/24 at 2:00 p.m., R14 returned to the facility after hospitalization . R14 did not know self or where she was. R14 did not recognize staff and stated she could not breathe, was coughing really bad and that no one knew where she was. R14 was very confused, crying and disorientednot know where she was at and when told does not remember even being here. Did not know any staff that has seen her so far. Said she could not breath and coughing really bad. Said that no one knows where she is at. Very confused, crying, and not oriented at all. Nurse notified. - At 4:06 p.m., R14 returned from the hospital stay via medivan. R14 was disoriented and drowsy. Lung sounds had fine crackles but no shortness of breath noted. Reason R14 was hospitalized or received services at a hospital: metapneumovirus, acute hypoxic respiratory failure. R14's medical record failed to identify if/when R14 had been placed in isolation. R12's significant change MDS dated [DATE], identified R12 was [AGE] years and had diagnoses that included dementia, hypertension, obstructive sleep apnea, and Type 2 Diabetes. R12's nursing progress notes identified the following: - On 2/25/24 at 11:32 p.m., R12 had an altered level of consciousness, reported hallucinations by the day nurse. R12 had a cough for several days, refused to eat or drink, refused medications, and was diaphoretic (excessive sweating). R12 complained of pain but was unable to verbalize where. - At 11:41 p.m. R12 was transferred to the hospital. - On 2/28/24 at 12:27 p.m., R12 returned to the facility after hospitalization for hypoxia (low oxygen) related to acute bronchitis due to HMPV. R12's medical record failed to identify if/when R12 had been placed in isolation. R22's quarterly MDS dated [DATE], identfied R22 was [AGE] years old and had diagnoses that included hypertension and Type 2 Diabetes. R22's nursing progress note dated 2/28/24 at 11:13 p.m. identfiied R22 had cold symptoms and was weak. R22's medical record failed to identify if R22 was tested for COVID-19, had a confirmatory COVID-19 test and/or if/when R22 had been placed in isolation. R1's quarterly MDS dated [DATE], identified R1 was [AGE] years old and had diagnoses that included dementia, heart disease, and Type 2 Diabetes. R1's nursing progress note dated 3/31/24 at 9:37 p.m., R1 had a nonproductive cough that has been going on for the past 3 days. R1 stated that he felt okay. 128/62,97.4,57,16, 97% on RA. R1's family was requesting Vicks Vaporub ( a mentholated ointment that may help with cough, congestion, and sore muscles) and a fax was sent to R1's provider requesting an order for Vicks. R1's nursing progress note dated 4/3/24 at 8:38 p.m., R1 continued to have a nonproductive cough, vitals stable and afebrile. R15's quarterly MDS dated [DATE], identified R15 was [AGE] years old and had diagnoses that included heart failure, atrial fibrillation (irregular heart beat), and emphysema. R15's nursing progress note dated 5/16/2024 at 5:19 a.m., identified R15 had multiple emesis that shift starting at 7:30 p.m. the evening before (05/15/24). R15 was unable to keep down her bedtime pills and threw them up shortly after. R15'slast main meal was lunch 5/15/24 and a big breakfast. R15 had remained afebrile. R15 some relief from ginger ale soda. R15's last emesis 2:30 a.m - At 2:10 p.m., R15 was having occasional emesis since last evening. Confusion, oxygen saturations at 90%, supplemental oxygen was put on. R15's temperature was 101.3 degrees F orally 2 hours post Tylenol (anti-fever medication) administration. - On 5/17/24 at 3:30 a.m., R15 was feeling better since last evening. No confusion or emesis that shift. Resident was wearing oxygen at 2 liters (L) per nasal canula with oxygen saturations at 97%. R15's temperature was 98.1 degrees F, pulse 81, and blood pressure 132/59. R15 was drinking water at the bedside. R15's medical record failed to identify if R15 was tested for COVID-19, had a confirmatory COVID-19 test and/or if/when R15 had been placed in isolation. During an interview on 6/11/24 at 4:23 p.m., registered nurse (RN)-A stated she was responsible for the facility's Infection Prevention (IP) program with the director of nursing's (DON) help. RN-A stated she was unsure what was expected but created a binder. The 3 inch teal-colored binder included a handwritten list of COVID-19 positive staff from the last facility COVID-19 outbreak in January 2024, a Monthly Infection Summary for January 2024 to June 2024, and facilitiy policies. RN-A stated the monthly summaries listed residents who had required an antibiotic for treatment and there was a clinical monitoring form completed in the resident electronic medical records to track symptoms of illness, but RN-A was having difficulty getting the staff to use it. One nurse was new to her role and needed instructions but others refused to fill it out until an antibiotic was prescribed. RN-A stated she had filled out the form when she worked the floor for residents who showed symptoms of illness and nursing staff got mad at her because it created work for them. RN-A stated she had nothing to show for viral illness tracking and/or trending since January 2024 During an interview on 6/11/24 at 5:08 p.m. the director of nursing (DON) stated they talked about all resident symptoms during report and would mark them on the calendar. Additionally, they would do floor mapping to determine potential areas of spread. RN-A was taking notes at the morning stand up meeting every day, Monday through Friday. RN-A officially took over the Infection Prevention program 6/1/24, but was assisting the DON prior to that. The DON stated she preferred a paper log system, but had been directed by the corporate infection prevention nurse to use the electronic medical record to track. The DON stated staff should complete a clinical monitoring form in the electronic medical record when a resident was symptomatic for an infection. During an interview with registered nurse (RN)-C and RN-D on 6/11/24 at 6:03 p.m., RN-C stated, if a resident was feeling ill, she would check vitals and see if there was anything she could do for them. Nausea, or a cough, RN-C would test the resident for COVID-19. If negative, RN-C would place them into isolation and get a second test because some people tested positive a few days later. RN-C would document this in a progress note and place a physician's order for the second test to be completed. RN-D stated she would complete a clinical monitoring form in the assessment tab of the resident's electronic medical records when a resident was showing symptoms of COVID-19. However, staff always talked about resident symptoms in report and would put in a progress note. Let's say someone threw up and it might be a 24-hour thing. RN-D would put in a progress note but not a clinical monitoring form because the infection prevention nurse was able to run a report for all nursing progress notes entered in the previous 24 hours. However, RN-C then stated the facility did not have a infection prevention nurse and RN-D stated well, yea. RN-D then stated staff would write on the 24 hour report sheets if a resident tested negative for COVID-19 and their signs and symptoms and the resident would stay in their room until that's done. During an interview on 6/12/24 at 11:00 a.m., the DON stated whenever a COVID-19 test was completed for a resident the clinical monitoring form should have been completed. However, the DON stated no symptomatic resident would be placed into isolation with a confirmatory test collected 48 hours later. The DON stated she was unaware of CDC guidance to collect a confirmatory test and/or to place a symptomatic resident into isolation until the confirmatory test was collected. The DON stated staff were expected to follow CDC guidelines. During an interview on 6/12/24 at 8:51 a.m., trained medication assistant (TMA)-A stated if a resident was coughing, was throwing up or not feeling well, she would look to see if there was something she could give them; like cough syrup. If there wasn't, TMA-A would talk to the nurse. TMA-A was able to document a resident nursing progress note, but if the as needed medication helped, TMA-A would not document. During an interview on 6/12/24 at 8:56 a.m., RN-B stated if a resident was feeling ill, he would need to do an assessment to determine what was going on. Nausea, vomitting, coughing, RN-B would complete a clinical monitoring form in the resident's electronic medical record. RN-B would probably do a COVID-19 test and, if negative, talk to the resident about staying in their room, but no isolation would be put into place. RN-B stated he would need to look at the guidance but believed another test would need to be collected in 48 hours. If a clinical monitoring form was completed, the system automatically reminded staff to get another test when it was due. If staff did not complete a clinical monitoring form, staff would need to rely on report and pass it down the line, and we both know how well that goes. During a phone interview on 6/13/24 at 8:39 a.m., the infection prevention lead (IP) (the corporate infection prevention nurse) stated she did not recall the facility reaching out for assistance with guidance regarding resident illness, surveillance and/or isolation recommendations. The IP stated the facilty policies correlated CDC surveillance guidelines and with the CDC Appendix A Type and Duration. Staff were expected to follow facility policies and procedures. During an iterview with the DON and RN-A on 6/13/24 at 8:49 a.m., the DON stated the lack of documentation of resident illnesses and symptoms was probably a reflection of changing of staff. RN-A stated while the DON was out of the facilty RN-A did pull the 72 hour report that identified all nursing progress notes entered in the timeframe and asked nursing if the residents with documented concerns were still being monitored. RN-A did not verify if nursing collected a confirmatory test, if the resident was placed into isolation until the confirmatory test results were collected and/or if the nurses followed the facilities documentation process. The DON was unaware symptomatic residents required isolation and a confirmatory test after 48 hours, but staff were expected to follow guidance and to follow the facility's process to track signs/symptoms of infection. RN-A didn't know anything about R12 or R14's illnesses at first. The only reason RN-A knew they tested positive for HMPV was because she found it in their hospital records. RN-A completed an internet search which stated HMPV was much like RSV. RN-A identified RSV did have the potential to cause death in an elderly person and wondered how the hospital found it and found out the hospital's respiratory laboratory panel could detect 19 different illnesses. RN-A did identify the positive residents needed isolation to protect other residents. RN-A stated she did consider R1 was symptomatic for HMPV, but did not for the other symptomatic residents nor reached out to any medical provider for guidance. RN-A did not reach out to the DON nor the IP for recommendations. RN-A stated she would not have researched HMPV on the CDC Appendix A because she was unaware it was available. Normally, RN-A would have reached out to the DON but stated she didn't even think of that. The DON was aware R12 had returned to the facility from the hospital with prescribed antibiotics for pneumonia but was unaware he was diagnosed with HMPV and neither R12 or R14 were placed into isolation. The DON and RN-A both stated R12 and R14 should have been placed into isolation until their illnesses resolved to prevent potential transmission to other residents, staff and visitors. The facility's policy Infection Prevention and Control Program revised 10/30/23, identified facilities were directed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Infection Prevention and Control Program was a facility-wide effort involving all disciplines and individuals and was an integral part of the Quality Assurance and Performance Improvement Program. Surveillance 1. The facility had established a system for surveillance based upon national standards of practice and the facility assessment, including the resident population and the services and care provided. 2. The facility's surveillance system includes a data collection tool and the use of a nationally-recognized surveillance criteria (I.e., McGeer Criteria), to define infections. a. Society Locations: Resident infection surveillance was completed in the Infection and Antimicrobial Tracking Tool. b. Legacy [NAME] Locations: Resident infection surveillance was completed in Safety Zone. 3. Process surveillance (ex, hand hygiene compliance program) and outcome surveillance (ex, monthly infection rates) were used as measures of the Infection Prevention and Control Program effectiveness. The facility's Surveillance and Mitigation Plan for SNF's updated 4/26/23, identified the facilities should plan to manage residents with COVID-19 in a way that prevented transmissions of the infection to others. If symptomatic residents test negative with a POC antigen test, they should be placed into transmission-based precautions, and in a single room if possible, but not cohorted with a known positive resident until a confirmation test with a PCR is received or confirmation with another negative antigen test 48 hours later. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. - If using NAAT (molecular) (A Nucleic Acid Amplification Test is a type of viral diagnostic test for SARS-CoV-2, the virus that causes COVID-19. NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. - If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. - If a patient suspected of having SARS-CoV-2 infection is never tested , the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. According to the CDC, HMPV is a respiratory virus identified in 2001 that commonly affects the respiratory tract, particularly in children, older adults, and those with weakened immune systems. Similar to the common cold or flu, HMPV infections present with symptoms like cough, congestion, runny nose, sore throat, fever, and fatigue. In some cases, particularly in vulnerable populations, HMPV infections can lead to more severe respiratory conditions such as bronchiolitis or pneumonia, requiring medical intervention. The CDC Appendix A Type and Duration dated 11/27/23, identfiied HMPV was assumed to be contact transmission as for Respiratory Syncytial Virus (RSV) since the viruses are closely related and have similar clinical manifestations and epidemiology. Healthcare workers were directed to wear masks according to Standard Precautions. Residents diagnosed with HMPV required Contact Precautions for the duration of the illness.

Based on interview and document review, the facility failed to ensure there was a qualified infection preventionist (IP) to adequately assess, develop, implement, monitor, and maintain the infection prevention and control program. This had the potential to affect all 29 residents residing in the facility including staff and visitors. Findings include: See also F880: Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. During a phone interview on 6/13/24 at 8:39 a.m., the facility's infection preventionist lead (IP) stated her corporate role involved creating facility policies, updating those policies, acting as a resource for facilities to interpret guidance and/or to train new infection prevention nurses to their role. The IP was aware the director of nursing (DON) was responsible for the facility's infection prevention program but was unaware the DON had been out of the facility for an extended period of time when the duties were delegated to registered nurse (RN)-A nor that RN-A had formally taken over the program in June of 2024. RN-A was not on the IP's list for training. Between 1/1/24 and 6/13/24, the IP and DON had emailed communication regarding employee illness and return to work criteria and the facility's vaccination program. The IP could not recall the facility reaching out for guidance regarding resident illness, isolation recommendations, and/or questions regarding expectations of duties. During an interview on 6/13/24 at 8:49 a.m., with the DON and RN-A , RN-A stated the only training she had received to take over the IP program was the corporate annual inservice trainings that were required by all staff and the CDC Nursing Home Infection Preventionist Training. The DON stated that RN-A had not been provided training but had the ability to call the DON with questions. During an interview on 6/13/24 at 1:14 p.m., the administrator stated he was aware the DON was previously responsible for the facility's infection prevention progam, and had required intermittent leave from the facility. They had delegated infection prevention responsiblities to registered nurse (RN)-A. The administrator stated an infection prevention dashboard was presented at the quality assurance meetings and, because of this, the administrator assumed all the required infection prevention tasks were completed as expected. However, there was no plan or process to ensure RN-A received training and/or support in her new role. The administrator stated there was disconnect between where RN-A was in her understanding of infection prevention and where RN-A really was. The facility policy Infection Prevention and Control Program revised 10/30/23, identified the facility was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A. The Infection Prevention and Control Program Is developed to address facility-specific infection prevention needs and requirements identified by the facility assessment and infection control risk assessment. B. The Infection Prevention and Control Program is reviewed annually and as needed by the Infection Preventionist, or appointed designee, to reflect nationally accepted standards of practice. The Skilled Nursing Facility has designated at least one Individual as the Infection Preventionlst, who is responsible for the facility's Infection Prevention and Control Program. The SNF Infection Preventionist must: a. Have primary professional training In nursing, medical technology, microbiology, epidemiology, or other related field; b. Be qualified by education, training, experience, or certification; c. Work at least part-time onsite at the facility; and d. Have completed specialized training In Infection prevention and control. The Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training updated 3/2/24, identified the course was for individuals responsible for infection prevention and control (IPC) programs in nursing homes. The specialized nursing home training covered: - Core activities of effective IPC programs. - Recommended IPC practices to reduce pathogen transmission. - Healthcare-associated infections and antibiotic resistance. - Policy and procedure templates, audit tools, and outbreak investigation tools.

Based on interview, and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities and develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware of that had the potential to adversely affect all 29 residents residing in the facility. Findings include: See also 880: the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissable organisms. Additionally, the facility failed to implement timely transmission-based precautions (TBP) and testing for COVID-19 according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff. See also 882: the facility infection preventionist (IP) failed to adequately assess, develop, implement, monitor, and maintain the infection prevention and control program. This had the potential to affect all 29 residents residing in the facility including staff and visitors. During an interview on 6/13/24 at 1:14 p.m., the administrator stated he was aware the director of nursing (DON) was previously responsible for the facility's infection prevention progam, and had required intermittent leave from the facility. They had delegated infection prevention responsiblities to registered nurse (RN)-A. The administrator stated an Infection Prevention Dashboard was presented at the QAPI meetings and, because of this, the administrator assumed all the required Infection Prevention tasks were completed as expected. However, there was no plan or process to ensure RN-A received training and/or support in her new role. The administrator stated there was disconnect between where RN-A was in her understanding of Infection Prevention and where RN-A really was. The facility's undated Quality Assurance Performance Improvement (QAPI) plan identified the current focus areas: 1. Continuous survey readiness process 2. Improved hand hygiene compliance 3. Percent of residents whos ability to move independently worsened. 4. Weight loss w/o program 5. UTI's The plan failed to identify the facility's plan for a continuous Infection Prevention program.

Based on observation, interview and document review, the facility failed to maintain clean and sanitary conditions in the dry storage of the kitchen. This practice had the potential to affect all 29 residents residing in the facility. Findings include: During the initial tour on 6/11/24 at 10:53 a.m., the dry storage was toured. There was dented can of tomato juice on the shelf for use. There were two large covered plastic bins. The first contained an opened 50 pound (lb) bag of cake mix with a bunched up, gaping top. The bin cover remained open to air. The second bin's cover was lying on a rack shelf and there were two 50 lb opened bags in the bin. The tops of the bags were bunched up and gaping open. The opened bag of biscuit mix had no date to determine when the bag had been opened and the opened bag of sweet cornbread mix was dated as opened 2/15/24. [NAME] (C)-A stated that was how they always were. C-A had no idea how long they were good for, how often they were used and/or if the cover should be on. C-A did not know who was responsible for the dry storage area and the kitchen staff did not really have a manager. During an interview on 6/11/24 at 12:02 p.m., the food service manager (FSM) stated the biscuit mix had no date to identify when it was opened and the cornbread mix was opened 2/15/24. The FSM stated the bags should have been rolled up and closed with a clip. The FSM pulled the bin cover from the rack shelf and placed on the bin and stated it's just bad habits. The FSM had begun her role approximately 6 months prior and was working to standardize practices in the kitchen. A process to ensure cleanliness and checking of outdates was in process. Dented cans should be pulled right away and the FSM would reach out to food service for replacement/reimbursement. The FSM stated she had no formal direction for the kitchen staff regarding maintaining the dry storage. It was word of mouth and there was no way to know the last time it had occurred. These practices could lead to contamination or a pest problem. The facility's Cooks Daily Kitchen Cleaning dated May 2024 and Dietary Assistant Daily Cleaning dated May 2024 failed to identify a process for dry storage sanitation. The facility policy Food Supply Storage revised 5/7/24, identified food from approved food sources is stored in sanitary conditions and is not exposed to prolonged periods of excessive heat. The policy further directed staff to: 1. Use the principle of First-In, First-Out (FIFO) in all areas of food and drink storage for rotation of food items. Refer to Date Marking policy and procedure. 2. The storeroom is well-lit, well-ventilated and pest free. 3. Use of containers or cardboard boxes in food storage areas: a. Stock may be placed on shelves in original containers or cardboard boxes that contain valuable manufacturer and date compliance information (i.e., manufacture dates, delivery date, best-by date, etc.). b. Plastic bins may be used if preferred but must be in good repair and washed routinely. c. Stock items are individually dated with delivery date if removed from the original container. d. Cardboard containers are not re-used. They are discarded when empty or if in disrepair. 4. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. The facility's policy General Sanitation Food and Nutrition revised 1/22/24, identified guidelines to limit the chance of foodborne illness at locations that prepare and/or serve food. The policy directed the location's food preparation, kitchen and serving areas were cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illness. However, the policy failed to direct staff to maintain a clean and sanitized dry storage area.

Based on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of a facility-initiated transfer for 1 of 1 resident (R14) reviewed for hospitalization . Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R14's progress notes identified the following: - R14 was admitted to the hospital on 2/29/24, and returned to the facility on [DATE]. The facility lacked any evidence identifying the OOLTC was notified of the transfer. - R14 was admitted to the hospital on 3/20/24, and returned to the facility on [DATE]. The facility lacked any evidence identifying the OOLTC was notified of the transfer. During an interview on 6/13/24 at 11:25 a.m., the business office coordinator (BOC) stated when residents were transferred, she was in charge of getting bed hold form in resident's chart. The BOC was unaware if they had to notify the OOLTC when a resident was transferred. If it was their job, they were not told and had not notified the OOLTC about any hospital transfers. During an interview on 6/13/24 at 11:52 a.m., the director of nursing (DON) stated the OOLTC should be notified of resident transfers and the BOC was in charge of ensuring the bed hold forms were completed and the OOLTC was notified. If BOC was not notifying the OOLTC, then it was not being done. The facility's Discharge and Transfer policy dated 1/3/24, identified when a resident was hospitalized the facility was submit a notification of transfer to the OOLTC.

Based on observation, interview, and document review, the facility failed to adequately manage the behavioral symptoms of wandering, and inappropriate resident interactions of 1 of 2 residents (R6) in the sample with wandering behaviors and to provide medically related social services to attain or maintain the highest practicable mental and psychosocial well-being related to feeling safe and/or comfortable in their living environment for 7 of 30 (R37, R29, R30, R14, R10, R2, R22) residents in the facility related to R6's wandering behaviors and inappropriate interactions with other residents. R37 and R29 had sustained psychosocial harm including fear and anxiety that impacted their daily routines related to the facility's lack of adequate assessment and implementation of appropriate interventions and supervision to manage the behavioral symptoms of R6. Findings include: The facility's failure to adequately assess R6's continued behavioral symptoms and implement appropriate interventions and supervision to manage the behaviors resulted in the ongoing psychosocial issues of fear, anxiety, and discomfort for multiple residents residing in the facility. R37 had verbalized recurrent fears and anxiety related to R6's behavioral symptoms and had sustained psychosocial harm. R29 had also expressed recurrent fear and anxiety related to contacts with R6 and had sustained psychosocial harm. R6's [DIAGNOSES REDACTED]. The MDS indicated R6 walked independently, and displayed physical and verbal behaviors. The significant change MDS dated [DATE], indicated R6's physical (such as hitting, kicking, pushing, grabbing others) and verbal (such as threatening others, screaming at others) behavioral symptoms occurred 4-6 days, but less than daily. The MDS identified R6 wandered daily which significantly intruded on privacy and activities of others. The Behavioral Symptoms Care Area Assessment (CAA) dated 12/19/11, identified R6's behaviors had increased in the past quarter, and the verbal, and physical abuse was directed at the caregiver and had never been directed to any of the other residents. The current plan of care (POC) dated 3/20/12, identified R6's wandering into others rooms. A revision to the POC dated 4/13/12, directed staff to redirect R6 to other areas when invading others' space, and to gently redirect, provide 1:1 (one staff-to-one resident care) or diversional activity when behaviors escalate. An additional intervention identified social services would be provided as needed. The Nursing Documentation form dated 4/23/12, identified R6 had been wandering in and out of residents rooms, taking items from lobby, office, dining room, and was resistive when giving back the items, and was also resistive with cares at times. Review of R6's record including interdisciplinary assessments and summary reviews, and progress notes from August 2011 to the present lacked documentation of social service involvement and interventions related to R6's wandering behaviors and inappropriate interactions with other residents. On 4/25/12, at 1:09 p.m. the activity director (AD) stated R6's behaviors had gotten worse. The AD stated R6 responded to herself and the other activity staff person very well. However, some residents reported to her that R6's behaviors were the worst around 8:00 at night, when the activity staff was no longer working. Therefore, activity staff were not available to provide additional diversional activities during the times when R6's behaviors were identified as being the worst. The AD stated other residents were afraid of R6. On 4/25/12, at 6:40 p.m. licensed practical nurse (LPN)-B stated R6 wanders into other residents rooms, takes their personal belongings, moves their things and other residents get agitated with him. At 6:51 p.m. LPN-C stated R6 scared other residents due to his difficulty to redirect when wandering into other residents' rooms. LPN-C stated R6 could not be adequately supervised for the evening. On 4/26/12, at 11:15 a.m. nurse assistant (NA)-C stated it was difficult to supervise R6 when it was busy. At 11:58 a.m. registered nurse (RN)-A stated R6 was progressing with his dementia. RN-A stated staff was aware that a number of female residents were upset that R6 wandered into their rooms and they have voiced concerns. R37 was admitted on [DATE], diagnosed with [REDACTED]. The POC dated 4/17/12, identified R37 was fearful of a male resident. The interventions included were for staff to offer reassurance when R37 expressed fearfulness and keep a yellow band across R37's doorway. On 4/12/12, at 8:00 a.m. the social service designee (SSD) documented in the interdisciplinary progress notes a conversation she had with R37. R37 had reported to a NA an incident occurring between two other residents. The SSD documented the resident was unable to remember when this occurred and an investigation would follow. On 4/12/12, at 4:00 p.m. the SSD documented she had a conversation with R37 and the resident became upset and started crying. R37 stated, "I should never have said anything." R37 stated a male resident had come into her room and she became frightened. R37 stated this had happened "a while ago." R37 had stated she felt frightened but believed the male resident would never hurt her. R37 stated she did not want to be questioned about the reported incident again. Review of the submission to the state agency indicated on 4/12/12, R37 reported she had observed R6 "molest" R29. R37 had described molesting as touching or harassing. Upon further interview, R37 could no longer remember any details about the reported incident. On 4/17/12, SSD documented in the interdisciplinary progress notes a conversation she had with R37. R37 had expressed concern about a male resident who wandered and had stated, "He's come in my room and scared me." The note indicated R37 only remembered one time that the male resident came into her room. The note went on to indicate R37 had stated, "I'm sure he won't hurt me I'm just not used to that." On 4/23/12, at 2:09 p.m. R37 stated R6 had came into her room. She stated she had been seated in her recliner half asleep in her room, and had woken up and saw the male resident (R6) standing in front of her and was afraid. She stated another evening she was in bed and while the nurse brought her medications in to her, R6 had poked his head under the arm of the nurse and looked at her. She added the nurses watch the resident but stated, "He is so sneaky." She stated R6 puts his back up against the wall and just waits for a chance to get in to her room. She stated, "I had to report it." R37 also indicated she had told family member (FM)-A about the situation and they thought something should be done. R37 stated the facility staff knows about R6. She stated she had complained to the staff and they put a yellow ribbon across her door. She stated she kept her door shut in the afternoon to keep R6 out. R37 became teary eyed during the interview. At 2:25 p.m. FM-A stated, "I don't believe my mom should have to put up with the fear or annoyance." FM-A added the male resident (R6) has dementia and wanders. FM-A added staff have told him the resident wanders into other resident rooms. FM-A stated, "I had a care conference and I brought it up." FM-A stated she was told the facility does not turn any resident away from the community. FM-A added, "I don't like to see my mom have to put up with that. That is not fair to her." On 4/24/12, at 1:15 p.m. R37's room door was observed to be closed. A yellow Velcro ribbon was attached to the left side of the door, however, the strip was not pulled across the door. On 4/25/12, at 1:08 p.m. R37 was observed in her recliner in her room with her walker in front of her. The resident had her door open 1/4 of the way. The yellow ribbon was attached to the left side of the door, however, it was not across the doorway. At 1:09 p.m. AD stated R6's behaviors had gotten worse and other residents were afraid of R6. When asked which residents in particular were afraid of R6, the AD responded R37 may be afraid of him. At 1:38 p.m. NA-C stated the nurses are right across from R37's room. NA-C stated R37 keeps her door closed most of the time. She stated staff only put the ribbon up if R37 asks, or if R6 is wandering a lot. At 1:53 p.m. NA-D stated she was told by staff to make sure R6 was not in R37's room. At this same time, NA-C stated R37 will ask them to shut her door or put the yellow strip across her door and wants this done when she has company or is lying down. At 2:08 p.m. RN-B stated when R37 rests, she wants the door closed. At 2:16 p.m.LPN-A stated R37 had reported to her R6 was "molesting that young girl" and was wondering if she had any parents around. LPN-A stated R37 had indicated the young girl was another resident (R29). LPN-A stated R37 was then afraid to leave her room. LPN-A stated R37 also had an incident when she saw R6 at the foot of her bed. At 4:44 p.m. NA-E stated that today R37 had stated she was scared of R6 to her. NA-E stated that was the first she had heard of it. NA-E stated she usually assisted the resident to get ready for bed. NA-E stated she had been walking R37 back to her room, and R6 was walking by. NA-E stated R6 had not done anything and R37 had stated, "He scares me." NA-E stated R37 has the yellow ribbon on her door, and she has never found R6 in R37's room. NA-E stated the yellow ribbon was supposed to always be up, even when the door was closed. At 6:40 p.m. LPN-B stated R6 wandered into other residents rooms, takes their personal belongings, moves their things and other residents get agitated with him. LPN-B stated R37 was afraid of him and has stated it was difficult to sleep due to R6. At 6:51 p.m. LPN-C stated R6 scares other residents due to his difficulty to redirect when wandering into other residents' rooms. LPN-C stated some residents have learned to accept him but R37 is "deathly" afraid of R6. At 8:32 p.m. FM-A was interviewed via phone. FM-A stated, "I don't like to see her be fearful of somebody there. It is annoying to think he wanders into the rooms." FM-A added that at the last care conference she had asked why he (R6) was there and they had stated they do not turn anyone away from the community. FM-A indicated R37 definitely did not want R6 coming into her room. FM-A stated R37 had mentioned both of the incidents to her. She stated that during the incident with the nurse present giving R37 her medications, the nurse was probably trying to back R6 out of the room. FM-A added, "It does seem to be pretty upsetting to her." FM-A stated R37 mentions it to her every time she has come to visit about 3 times a week. FM-A added, "I think she feels guilty about saying something as she does not want to get anybody in trouble." On 4/26/12, at 9:01 a.m. activity aide(AA)-A stated she had heard through report that R6 had been in R37's room. The AA stated the intervention was to watch R6 closely and put the yellow ribbon up. On 4/26/12, at 10:59 a.m. during an interview with the administrator, director of nursing services (DNS) and the SSD, the following was reported: -The SSD stated she had a conversation with R37 when she complained about a male resident, however, R37 had not been able to give a name. She reported that R37 told her about the incident when R37 was in the recliner, but the resident could not remember when that had exactly occurred. The SSD stated R37 had stated, "I am not use to that." The SSD stated she had spoken with FM-A during the care conference and they had talked about trying to meet the needs of residents in the community. FM-A had stated she did not like R6 coming into R37's room. The SSD stated FM-A had also asked why the facility would accept a resident like R6. The SSD reported that she had explained R6 did not have wandering behaviors when admitted to the facility. The SSD stated the yellow ribbon was to be up whenever R37 was in her room. The SSD stated she hoped R37 would not need the door closed all the time. -The DNS stated she had not attended the care conference. The DNS added that neither FM-A, nor R37 had complained to her. -The administrator stated she had talked to R37 and R37 had stated she was fearful of R6. The administrator stated she had talked with FM-A on multiple occasions and when asked how things were going, did not indicate any problems. On 4/26/12, at 11:15 a.m. NA-C stated R37 was fearful of R6. NA-C stated it was difficult to supervise R6 when it was busy. On 4/26/12, at 11:44 a.m. the administrator stated, "We don't want anyone to be afraid in their home." The administrator added other residents were being irritated by R6. On 4/26/12, at 11:58 a.m. RN-A stated R37 was anxious around R6. On 4/27/12, at 9:00 a.m. R37's door was observed to be closed. The resident was in her room seated in her recliner. She stated she had her door shut because of the man wandering up and down the halls. She stated, "Sure as shootin, if I have my door open, he will come in." She stated, "I hate having to have my door shut," and added, "I feel like I'm in jail or something." R29 was diagnosed with [REDACTED]. The quarterly MDS dated [DATE], indicated R29 had severe cognitive impairment, was independent with mobility and required extensive assistance from staff with activities of daily living (ADLs). The MDS indicated R29 exhibited an increase in wandering which occurred daily but no other behaviors were noted. The Behavioral Symptoms CAA dated 8/24/11, indicated R29 appeared restless at times, wandered at no particular time of the day and did not follow patterns. The CAA indicated R29 never disturbed other residents and was always happy and smiling. The Psychosocial Well-being CAA dated 8/24/11, indicated R29 was well adjusted to the facility routines and did not express discontent in the setting. The POC dated 2/29/12, directed staff to provide gentle reality orientation to R29, and to have R29 with other people because she did not like being alone and wandered throughout the facility. The POC indicated R29 was diagnosed with [REDACTED]. The POC directed staff to bring R29 into an area away from the male resident due to anxiety related to this male resident. The Initial Antipsychotic Medication assessment dated [DATE], indicated R29 exhibited anxiety, pacing, depression, pacing, shaking, and weight loss which required repeated redirection to a quiet setting in the lobby, to the couch with a friend, to room, walking or talking with staff, or calling family. The assessment indicated R29 had experienced a weight decrease, paced in the halls, yelled at a certain male resident, and had increased diarrhea which required treatment with Seroquel (an antipsychotic medication). On 4/25/12, at 1:00 p.m. R29 was observed to wander around the dayroom. The facility was observed to be small in size, having one main dayroom, with couches and a television, in which many residents congregated. R6 was observed walking with staff in his room. R29 was observed to be calm with no signs of distress. At 1:24 p.m. R6 was observed to follow R29 down the hall towards the dining room. R6 placed his hands on R29's arm. R29 was observed to become visibly upset and shake her fist at R6. R29's facial expression changed to a grimace and appeared upset by R6's presence. R6 persisted in talking and touching R29's arm. Staff was observed to intervene and attempt to get R6 to walk in the other direction. The staff was unable to get R6 to leave R29 alone, so the staff then walked with R29 into her room. At 2:54 p.m. R29 was observed seated at an activity in the dining room with multiple residents present. R6 was observed to go up to R29 and get close to her while she was in her chair. R6 touched R29's chair and was talking to her. R29 was visibly upset and tried to scoot away from R6. Staff intervened and redirected R6 after some coaxing. At 6:35 p.m. R6 was observed wandering in the hall. At this time, R6 did not bother R29, but R29 was observed to watch R6 as he wandered. At 7:00 p.m. R29 appeared distressed when walking down the hall. The resident approached the surveyor, and tried to express herself verbally. When asked if there was anything she needed, R29 stated, "That guy," then took some time to add, "Sometimes he stands by the door." Further record review indicated: The Interdisciplinary Progress Notes (IPN) indicated on 8/7/11, at HS (bedtime) R6 was found lying in R29's bed. R29 became very upset when she saw this and was shaky, sobbing hysterically and had stated she was afraid to sleep in there after R6 was in there. R29 was difficult to calm down and wanted her bed linens changed. R29 stated R6 did not hurt her but "scared the hell" out of her. A review of the IPN noted from 8/7/11, thru 2/23/12, indicated no increase in behaviors for R29. On 2/22/12, the physician progress notes [REDACTED]. R29 behaviors were noted as stable. The IPN on 2/23/12, at 3:00 p.m. indicated R29 became very anxious, pacing and was unsure what to do after lunch. R29's skin was noted to be clammy and she had a worried facial expression. R29 had stated she did not know what was wrong. On 2/29/12, the Interdisciplinary Assessments and Summary Review (IASR) notes indicated R29's increased anxiety, restlessness and pacing had been discussed at her care conference. The IPN from 3/3/12, to 4/10/12, identifed increased behaviors of anxiety, pacing, wandering halls, wriggling clothing in her hands, pacing, worried expressions, angry, and being unable to express what was bothering her. The IPN on 3/18/12, indicated at HS R29 hit another resident (which was not identified) with her cast, and had an angry look on her face. (On 4/25/12, at 12:30 p.m.FM-C stated it was reported to her that R29 had hit R6 in the groin with her cast.) The IPN on 4/12/12, at 4:00 p.m. indicated a vulnerable adult report was filed due to a reported incident between R29 and R6. A review of the submission to the State agency indicated on 4/11/12, R37 reported she had observed R6 to "molest" R29. R37 had described "molesting" as touching or harassing. Upon further interview, R37 could no longer remember any details about the reported incident. On 4/13/12, at 1:00 p.m. the IASR notes indicated staff met with family regarding recent concerns and an incident involving a male resident and R29's increased anxiety. The discussion revolved around R29's anxiety and the cause of the increased anxiety. R29 had told her family that she did not want male caregivers. Staff agreed to no longer have male caregivers provide care. In addition, they discussed the presence of the male resident who was causing R29's anxiety. The IPN on 4/15/12, at 1:00 p.m. indicated R29 was restless during the morning and afternoon, wandering most of the morning, would not stay seated, appeared agitated, anxious, frustrated, and shaking fists her fist at another resident on two occasions. The IPN on 4/16/12, at HS indicated R29 was noted to get angry with a male resident who was also wandering. Staff intervened numerous times, but were unable to separate them for long periods of time. The IPN on 4/17/12, at 10:30 a.m. indicated R29 was very anxious, pacing up and down the hall ways, pulling on clothing, wringing hands together, refusing to do restorative nursing program and told the staff not to tell her what to do. On 4/18/12, the physician progress notes [REDACTED]. The staff had attempted conservative interventions of redirections without much success. A dose of Seroquel (an Antipsychotic) was trialed but discontinued. Xanax (an antianxiety medication) in the morning would be attempted and may be increased as need. The physician indicated R29's family was aware of the anxiety and was also considering placement in a facility they felt would offer her less stimuli. The IPN on 4/18/12, at HS indicated R29 was noted to very anxious in the evening, pacing non-stop, became very upset when a male resident who also wandered stopped to talk to her, and was yelling and threatening the male resident. R29 raised her fists at the male resident. R29 became angry with staff when they attempted to intervene. The IPN on 4/19/12, at 2:30 p.m. indicated R29 was noted to be very restless, wandering, leaning backwards pulling on pants leg, and swinging arms out when she passed another resident. The Physician order [REDACTED]. The IPNs from 4/20/12, to 4/22/12, continued to identify R29's pacing, anger, wandering, and anxiousness with pulling on her clothing. On 4/24/12, 2:48 p.m. FM-C stated R29 had some anxiety when R6 gets in her personal space. FM-C stated she was not sure when R29's anxiety started to get worse, but did wonder if R6 was not contributing to it. FM-C was unaware of any physical contact between R29 and R6. FM-C did recall R29 being very upset in the past when R6 was found in her bed. On 4/25/12, at 12:30 p.m. FM-C stated R29 has not liked R6 since she moved here. FM-C stated R6 is a big part of R29's anxiety. FM-C stated R29 yelled at R6 yesterday when he came up to her and FM-C did talk to staff about it. FM-C stated there may be just too much stimuli for R29 at the facility. FM-C stated she thinks the evenings are worse for R29's anxiety. On 4 /25/12, at 2:16 p.m. LPN-A stated R37 had reported to her that R6 was "molesting that young girl" and was wondering if she had any parents around. LPN-A stated R37 indicated the young girl was R29. LPN-A stated R29 does not like having R6 around and shows signs of anxiety when he is nearby such as rubbing her hands together. LPN-A stated R6 follows the nursing medication cart around and so wanders throughout the facility. LPN-A stated they try and monitor the residents and try to keep R29 and R6 apart. At 4:00 p.m. NA-A was asked if he was aware of any residents who were afraid of R6. NA-A responded, "One resident tends to want to move away." When asked who that resident was, NA-A replied it was R29. At 4:50 p.m. NA-E stated R29 was afraid of R6. NA-E stated she has not observed any physical contact between the residents, but R6 does approach R29. NA-E stated R29 has a history of anxiety and R6 just elevates it. NA-E stated they just try and separate whoever is easiest to redirect. NA-E stated it was hard in the evening because they have not found any activities to keep the residents occupied. NA-E stated if there was a safety concern it would be "more pressing" to keep R6 away from R29. NA-E added it was hard in the evening because there were no activities and meals are finishing up. At 6:15 p.m. dietary aide (DA)-A stated R29 is afraid of R6 and was fidgety around him. DA-A stated a couple weeks ago, R6 went up to R29 in the dining room and grabbed her arm. DA-A stated she did not think R6 was trying to hurt R29, but was just trying to get her to sit down. DA-A intervened and reported the situation to the nursing staff. DA-A stated R29 was upset by the interaction. At 6:40 p.m. LPN-B stated R6 wanders into other residents rooms, takes their personal belongings, moves their things and other residents get agitated with him. LPN-B stated R29 gets very nervous around him. LPN-A stated R29 was very upset when R6 was found in her bed. LPN-B stated R6 seems to gravitate towards R29. LPN-B stated the facility was not the right setting for R6 and she had felt this way for a long time. LPN-B stated the evenings and weekends were very difficult to monitor R6 due to assisting other residents with evening cares and limited staff. At 6:51 p.m. LPN-C stated R6 scares other residents due to his difficulty to redirect when wandering into other residents' rooms. LPN-C stated some residents have learned to accept him but R29 appears afraid of him. LPN-C stated R6 could not be adequately supervised for the evening. LPN-C stated R6's wandering is worse from 3:00 p.m. on. LPN-C stated she felt the facility was not the appropriate setting for R6. On 4/26/12, at 9:00 a.m. R10 stated he was not scared of R6 but was upset that R6 comes into his room and touches his belongings. R10 stated they had placed a yellow stop sign on his door, but R6 just took it down. R10 stated there was no specific time R6 wanders. R10 added it was all the time. R10 stated R6 grabs on to other residents' arms and he thought that scares them. At 11:00 a.m. R14 stated she used to be afraid of R6, but is not anymore. R14 stated R6 goes into other residents' rooms and messes with their things. R14 stated R6 bugs everyone, but she has just learned to deal with him. At 11:15 a.m. NA-C stated it was difficult to supervise R6 when it is busy. The just try and check on him frequently. NA-C stated she had never seen any physical contact between R6 and other residents. At 11:22 a.m. NA-D stated R29 was more "antsy" and restless in the evenings with more wandering. NA-D stated if R29 sees R6, she gets more upset. NA-D stated R29 keeps an eye on R6 and she seems fearful or afraid of him. NA-D stated R29 has seemed more anxious in the past month. NA-D had not seen any physical contact between R29 and R6. NA-D stated R6 was more difficult to monitor in the evenings. NA-D stated he goes into other residents rooms and takes their mail. At 11:44 a.m. NA-F stated R29 was not fond of R6 and gets annoyed with him. NA-F stated she thinks R6 just tries to have conversations with R29. At 11:58 a.m. RN-A stated R6 was progressing with his dementia. RN-A stated staff was aware that a number of female residents were upset that R6 wanders into their rooms and they have voiced concerns. RN-A stated no physical contact has been observed with R6 and other residents and he was not hurting anyone. RN-A stated R6 was on 15 minute checks, yellow stop ribbons have been put up, and she felt staff were monitoring him. RN-A stated R6's wandering was increased in the evening and there was not enough to keep him interested at that time of night. RN-A stated R29 does not show that she is afraid of R6 or that she is anxious around him. RN-A stated if R29 was wandering in the hallways, R6 will follow her. If staff sees R29 and R6 are close, they will lead them away from each other. RN-A stated R29's anxiety was increased over the past 3 months. The signs of anxiety she noted were twisting clothes, wandering, increased restlessness, and sitting up and down. RN-A stated R29's anxiety was not always when R6 was around. RN-A stated R29 has had an increase in anxiety medications. At 12:45 p.m. an interview occurred with the DNS, the administrator, and the SSD. The administrator stated R29 and R6 had no interaction between the two of them. The SSD also stated the residents do not interact. The SSD stated R29 has never liked R6. The DNS stated R29 appears very anxious when R6 was wandering. The administrator stated R6 never approached R29. The DNS, administrator and SSD all stated R29's anxiety was increasing because of her disease process. However, they verified R29's plan of care addressed a male resident which was causing anxiety for R29. They identified that male resident as R6. R30 was involved in two physical altercations with R6. R30 was diagnosed with [REDACTED]. The quarterly MDS dated [DATE], also identified the resident as having severe cognitive impairment. The POC dated 4/3/12, identified R30 had a potential for alteration in psychosocial being due to a long standing relationship with a male resident initiated when she lived in the community. The POC also noted R30 still wanted to spend private time with the other resident and on occasion each would get irritated with each other. R30 was noted to have a history of hitting the male resident. The interventions included one on one with the SS) addressing psychosocial adjustment, allowing to spend private time together. Families were supportive of the relationship. Staff were to monitor for physical and or emotional changes and encourage R30 to spend time alone and eat with others when irritated with the male friend. When hitting male resident friend, staff were to redirect away from the male resident. The IPN notes by LPN-D dated 2/4/12, in the evening indicated the writer heard the resident swearing in the hallway. Found R30 standing with (R6). Both residents yelling at each other. Noted R6 had R30 by her wrist with one hand and was holding a Kleenex box raised by her head in the other hand and was threatening to hit her with it. R30 struck R6 with her free hand and yelling, "leave me alone damn it." This writer intervened immediately taking R6's hand off R30's wrist and taking the Kleenex box away from R6. R6 stated she hit me first. Residents were separated with no further issue. An incident report dated 4/12/12, at 11:45 a.m. indicated staff were assisting residents to the dining room. A male resident R6 with dementia slapped R30 in the butt causing her to jump. On 4/26/12, at 8:50 a.m. R30 was seated at the breakfast table next to R6. On 4/26/12, at 11:11 a.m. an interview was completed with the DNS, SSD, and the administrator and the following was reported: -The SSD stated R30 and R6 lived in the same apartment complex prior to moving into the facility. R6 was admitted first and then R30. The SSD stated both of the residents have progressed in their dementia process. The SSD stated there were times when R30 would get angry with R6 when he would not do what she wanted. The SSD stated she was not aware of the incident that occurred on 2/4/11, between R30 and R6. The SSD stated when she spoke with the nursing assistants regarding the incident on 4/12/12, she was told R30 got up from the couch and R6 slapped her and she kept on walking. -The DNS stated according to the incident report R30 jumped a little bit. The DNS stated she had not read the documentation from the incident on 2/4/11. The DNS stated she had heard through report that one of them was going to hit the other with a Kleenex box. The DNS stated there was a generic passing comment that one was going to hit the other with a Kleenex box; however, no investigation was done. R2 verbalized anxiety related to an incident when R6 wandered into his room. R2 was diagnosed with [REDACTED]. R2's quarterly MDS dated [DATE], identified R2 was cognitively intact. The IPN in R6's medical record indicated on 4/17/12, (time not specified but read "hs" or bedtime), R6 entered R2's room through the adjoining bathroom and "had taken pillows, garbage, etc. and layed it on top of res. (resident) and under res special chin call light causing res in in (room number) to be unable to push his call light...Res in (room number) states he did not get hurt but was worried about what res. might do." The note indicated the bathroom door was locked to prevent R6 from entering the room from the bathroom. On 4/26/12, at 7:00 a.m. R2 was interviewed regarding the incident on 4/17/12. When asked if he was concerned or afraid of R6 since that incident, R2 stated no. On 4/26/12, at 11:12 a.m. NA-B stated one of the other nursing assistants told him R2 was afraid of R6 because R6 wandered a lot. NA-B stated he had not seen R6 in R2's room since 4/17/12. NA-B added staff locks the adjoining bathroom door when R6 wanders to prevent R6 from entering R2's room without staff seeing the resident go in there. On 4/26/12, at 11:45 a.m. NA-F stated she had been working when the incident occurred on 4/17/12. NA-F verified R2 was not hurt after the incident, but stated R2 told her, "I just don't want him in here." On 4/

Based on observation, interview, record review, and review of facility incident reports, the facility failed to ensure adequate interventions had been implemented to minimize the risk of injury for 1 of 4 residents (R18) reviewed at risk for accidents. Findings include: R18 had sustained repeated accidents involving R18 hitting her head on equipment during transfers with a mechanical lift. The facility failed to complete a comprehensive assessment of the causal factors of an accident sustained during a transfer with the lift on 1/25/11. The resident sustained [REDACTED]. R18 was [AGE] years old with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R18 with no short or long term memory deficits and identified no cognitive impairment. The MDS indicated R18 was totally dependent on staff for transfers and required 2 persons for physical assistance. The ADL Function/Rehabilitation Potential Resident Assessment Protocol (RAP) dated 4/14/10, indicated that R18 needed total assistance with all cares and was transferred with a hoyer lift due to the CVA and hemiparesis. The current care plan dated 12/29/10, identified R18's need for transfers with assist of 2, and a mechanical lift. An update dated 2/8/11, indicated a medium full body sling was to be used. On 2/15/11, at 4:03 p.m. R18 was observed to have dark purple bruising under and around the right eye. A fading brownish bruising along the right eyebrow was also noted. At this time, R18 stated the bruising was from the mechanical lift hitting her head about four days ago. R18 stated that this had happened in the past also. A review of the Interdisciplinary Progress Notes dated 2/12/11, indicated that during a transfer for R18, the mechanical lift's wheel had got stuck on something which caused the lift's bar to swing and hit the resident on the right orbital area. A small bruise and bump was noted with no other injuries. A review of the incident reports for R18 identified accidents with the mechanical lift on 12/31/10, 1/25/11 and 2/12/11. The incident report dated 1/1/11, identified R18 was observed to have swelling in the left eye socket with a bruise on 1/1/11. R18 told staff she had bumped it on the mechanical lift the previous evening (12/31/10) but had not told the staff. The report noted R18 may have bumped her head on the mechanical lift or may have bumped her head on the roll bar during turning in bed. The physician was notified, but no further medical attention was required. The 1/3/11, corrective action identified was employee education/training or re-instruction. The second incident report dated 1/25/11, identified R18 was being transferred with the mechanical lift when the wheel of the wheelchair stuck on the mechanical lift leg. The resident "came down" and fell forward bumping her eye on the sling bar. The physician was notified, but no further medical attention was required. The 1/28/11 corrective actions to be taken included staff education on mechanical lift transfers and safety issues planned for 2/3/11. In addition, the sling type was changed per Physical Therapy recommendations. The Therapy Daily/Weekly Documentation form indicated that on 1/27/11, the physical therapist (PT) had observed nursing staff transfer R18 with the mechanical lift and the PT recommended a change in the lift pad. However, documentation was lacking related to an assessment of the possible causal factor of the wheelchair wheel becoming stuck on the mechanical lift leg as noted on the incident report dated 1/25/11. The third incident report dated 2/12/11, indicated when R18 was transferred from the wheelchair in the sling of the mechanical lift, one wheel got stuck when pulling the lift away from the wheelchair. The lift bar swung and hit R18 in the head. The physician was notified, but no further medical attention was required. The 2/13/11, corrective actions to be taken were identified as employee education/training or re-instruction and that all staff would be observed operating the mechanical lift to determine any safety issues. In addition, the lift bar was to be padded. On 2/16/11, the therapy notes indicated the PT recommended the continued use of the current lift sling. The new recommendation was to remove the wheelchair's foot/leg rest prior to transfers and staff were to stand behind the wheelchair to position it. However, the care plan was not revised with the recommendations until 2/18/11. On 2/17/11, at 9:15 a.m. NA-A stated that R18's bruise to the right eye had been from a transfer with the mechanical lift. NA-A stated the foot peddle from the wheelchair got stuck on the platform of the hoyer lift. NA-A stated that when they when they went to lift the leg rest/foot peddle off the platform on 2/12/11, the resident fell forward in the sling and struck her eye and forehead into the middle brace on the lift bar. On 2/17/11, at 9:48 a.m. NA-B stated that with transfers with the lift, if the resident is pushed from the front and the wheelchair gets stuck on the hoyer the resident can swing in the sling. NA-B stated they have been instructed by the DON to go from behind and they that they are to hold the sling with one hand and push the hoyer back with the other hand. NA-B stated the DON reviewed this with them last week. NA-B stated that changes they have made as a result of the incidents with the sling included changing the sling used and that this occurred prior to the 2/12/11 incident. NA-B stated that they have added towels to pad the bar area on the sling that the resident has hit after the 2/12/11 incident. On 2/17/11, at 1:06 p.m. RN-A stated that she was aware that there had been incidents with the use of the mechanical lift for R18. RN-A stated that with one incident it had been with how the wheelchair was positioned and that sometimes the wheel gets caught. RN-A stated that they have recently added towels to area of the hoyer that the resident was hitting. RN-A stated the facility had done training with the nurse aide staff that included taking their time and holding the resident's head. On 2/17/11, at 1:16 p.m., LPN-A stated she was aware of the incident with the lift on 2/12/11 and stated she did not know how that could happen. LPN-A stated that the staff should hold R18's head. LPN-A stated the resident was upset about the incident and that she "didn't want to even get up for lunch after that because she was afraid." On 2/17/11, at 6:00 p.m. R18's daughter stated she was not aware of the 2/12/11, incident but that another family member may have been called. R18's daughter stated she had talked to the facility about these incidents in the past and she has talked to her mother. R18's daughter stated that her mother has mentioned something about the wheels getting stuck and that she felt her mother was afraid of the lift. On 2/18/11, at 9:48 a.m. R18 was observed being transferred from the wheelchair to the bed by NA-D and LPN-B. R18's wheelchair foot/leg rests were not removed. LPN-B guided the resident holding her feet while NA-D pushed the hoyer lift from the wheelchair to the bed. The bar for the sling to attach to was padded with towels at both ends and over the center brace. Once R18 was in bed she was asked by the surveyor if she was afraid of the lift and she stated, "Yes." On 2/18/11, at 10:25 a.m. the DON was interviewed regarding the incidents with R18 and the use of the mechanical lift. The DON stated that with the first incident she was not sure if this involved the mechanical lift, or was from the grab bar on the bed. The DON stated the facility did do staff education with the nursing assistants. The DON stated that with the second incident it sounded like the wheel on the wheelchair got stuck on the hoyer leg. The DON stated that they did get physical therapy involved and the PT had recommended a change in the sling used. The DON stated that an education day was set for the nursing assistant staff for 2/3/11, which was held with three staff attending. The DON stated that after the last incident on 2/12/11, she decided to do an individual staff competency training for the nursing assistants that included observation of a transfer with the lift for this resident with 7 of 11 NAs completed. The DON stated that when she observed NAs with a transfer on 2/15/11, she observed that they were not removing the wheelchair leg rests and that she began instructing the NAs to always remove these before transferring R18 with the lift. The DON stated she was not aware that PT had written this as a recommendation also on 2/16/11. The DON verified that this intervention had not been added to the care plan. The DON also verified this information was not on the NAs' handheld communication device. The DON was asked if she instructed staff to lock the wheelchair and she stated that she knew this was the number one step with any transfer. The DON had provided the surveyor with the manufacturer's recommendations on use of the hoyer lift and verified that wheelchair brakes were to be locked. The recommendations did not include any instruction related to the use of wheelchair leg rests. The DON stated, "To be honest with you I had never looked at that Hoyer (mechanical) lift manual" until it had been requested by the surveyor. The DON verified that at this time no restrictions were in place on staff for transferring R18 with the lift until they had completed the educational training component and that it was planned only for the nursing assistants. The DON was asked if she had talked to R18 about being afraid with the use of the hoyer lift and she stated, "No." She added that she knew after the last incident R18 did not want to get up with the lift until the nurse talked to her. On 2/18/11, at 11:55 a.m. the DON stated that she was not going to allow any staff including NAs and nurses, to transfer R18 with the lift until they had completed the "Check-Off to Mechanical Lift Program" education which included a direct observational competency with her and they would be required to watch the on-line educational training on mechanical lifts provided by the facility. The DON stated that the staff that not had completed any component of this program prior to 2/15/11, when the issue with the wheelchair's leg rest was identified, would have to repeat the training. The DON stated she had now added the direction to remove the wheelchair leg rests to the care plan and to the NAs' handheld communication device.