Every finding on record at Good Samaritan Society - Mary Jane Brown

Based on interview and document review the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 4) 2025 (July 1 through September 30) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the facility had excessively low staffing during Quarter 4, 2025 (July 1 through September 30). Review of the 1702D report for quarter 4 of 2025 (July 1 through September 30) and staffing schedules identified during an average week, Monday through Friday, during the day shift, there were several days that multiple registered nurses had been working. These hours had been submitted to PBJ as direct care RN'S rather than RN's with administrative duties. For example, on:8/26/25, 6 registered nurses were coded as RN's (direct care staff with no administrative duties) on the report. Staffing schedules identified 4 of 6 RN's were scheduled for administrative duties (RN-E, RN-C, RN-D, and the DON) and should not have been coded as direct care staff.8/27/25, 6 registered nurses were coded as RN's (direct care staff with no administrative duties) on the report. Staffing schedules identified 4 of 6 RN's were scheduled for administrative duties (RN-E, RN-C, RN-D, and the DON) and should not have been coded as direct care staff.9/30/25, 5 registered nurses were coded as RN's providing direct care on the report. Staffing schedules identified 3 of those RN's were scheduled for administrative duties (RN-E, RN-C, and RN-D) and should not have been coded as direct care staff. Interview on 4/1/26 at 9:57 a.m., with the director of nursing (DON) identified they had not separated weekday RN'S with administrative duties from RN'S who provide direct care to residents on the PBJ submission information. The DON reached out to an unidentified corporate manager who further revealed they were unaware RN'S with administrative duties should be coded by their job type and category and not as direct care RN's. The corporate manager and DON confirmed this was likely the reason for the staffing discrepancy between the weekday and weekend staffing hours. A policy was requested; however, none was provided by the end of the survey period.

Based on observation, interview and document review, the facility failed to monitor, clean 1 of 1 refrigerator in the dining room designated for food brought in for residents by family members. This had the potential to affect all 45 residents in the facility. Findings include: Observations on 3/30/26 at 11:53 a.m. with Cook-A of the refrigerator, located in the dining room, used for resident food brought into the facility from outside sources identified a log was posted on the front of the refrigerator titled Resident Fridge Food Items. On the log there were entries for Resident, Food item, Arrival Date, Open date, and Expiration Date. The log had dates of 3/17, 3/18, 4/19, 4/21, but no indication of the year was identified. The next dates were 12/28/25, 12/29/25, 12/30/25, and 3/5/26. A second sign, identifying instructions titled for Resident Food Only listed:All food must be labeled with name and date-Please use labels next to fridge.Food will be thrown away if it is expired.All food in open containers over 7 days will be thrown out.All food deemed inedible (ie: moldy, contaminated or curdled) will be thrown outLeftovers from meals served by the facility will not be kept.Only food for residents is to be stored here. Continued observation 3/30/26 at 11:53 a.m. with Cook-A identified inside of the refrigerator there were multiple bags, bottles, takeout food containers, and containers of condiments. Dried spills were noted on the lids and outside of the condiment containers. There were dried spills of a red colored liquid and food like particles noted on the shelves. A red dried liquid substance was puddled on the second shelf and it extended onto the lower shelf and into the freezer compartment, located on the lower portion of the refrigerator. Items in the refrigerator included:One bottle of Cocktail sauce, (usually bright red in color) had a dark, dried appearance and the cover was held open with a buildup of dried sauce under the lid and on the outside of the bottle. The bottle had no date of opening or identified a resident name. One 32-ounce (OZ) carton of heavy cream, with an manufacture's expiration date of 3/20/26. The carton did not contain a date when it was opened or a resident name. One tube of [NAME] (ready to eat sausage), opened with the paper partially wrapped over the open end of the tube. There was no date of when it had been opened, nor a resident name on the sausage. One small bowel (identified as dished from a large container) contained apple sauce and had been dated from the kitchen with a date of 1/2/26. The container had no resident name, and Cook-A indicated the date was when it had been prepared in the kitchen and likely taken from a meal tray. One-32 oz carton of egg nogg which had been opened and did not have a resident name or date when opened. 1 Takeout foam container with resident name no longer at the facility and a date of 2/5/26.1Takeout foam container dated 3/12/26, and no resident name1 folded down paper bag containing a package of Deli meat and a takeout foam container. Neither of the items had a resident name or date.1 opened single serving snack pak, that had no name or date.1 opened Taco dip platter that contained a white mold-like, furry substance on the surface of the dip. There was resident name or date.One 32 OZ bottle of coffee creamer opened and had a manufacture's date of 1/4/26. There was no resident name on the container. One 16 oz carton of sour cream which had been opened but had resident name or date to be discarded. 1 Bottle of Iced coffee with no resident name or date to be discarded.1 Bag containing 4 bagels dated 2/13/26, with no resident name identified. 1 Paper bag which contained a 1 lb bag of baby carrots that appeared slimy. There was no name or date.1 avocado which was black, soft, mushy and had no resident name. The Freezer located below the refrigerator was also observed to have spilled food items. 3 cartons of ice cream- 1 sealed, 1 open with the ice cream dried and had a cracked appearance, and a second which had been opened and a portion removed. Neither a resident name or date. 1 small round plastic container with a partially frozen red liquid inside and appeared to have spilled and frozen on in the freezer compartment. There was no resident name, or date on the container. Interview on 3/30/26 at 11:50 a.m. with cook-A identified dietary staff were responsible for the monitoring and cleaning of the Resident Food Refrigerator. He identified there was not a schedule or assignment list for cleaning and checking of the refrigerator and freezer. He also reported he had no idea when it had last been checked, and he would make certain it was cleaned right away. Interview on 4/01/26 at 9:51 a.m. with the administrator reported they did not currently have a certified dietary manager, or person that was certified as Serve Safe. She identified Cook-B had completed SERV Safe training and would take the test, which was completed on 3/30/26. The administrator had a documented plan for management of the dietary department by utilizing a certified dietary manager (CDM) from a sister facility in addition to the Registered Dietitian. She identified that the previous CDM had left the faciity on 3/27/26 and both the CDM and registered dietitian had assessed the status of the dietary department on 3/28/26. She confirmed the resident refrigerator in addition to other items in the kitchen had included a newly developed cleaning schedule and would be monitored to ensure compliance. She stated she was not aware the dietary department had not been maintained to her expectations and would be monitored to ensure compliance. Review of the plan for management of the dietary department included oversight by the sister facility certified dietary manager and registered dietitian. Education was initiated for dietary staff to ensure knowledge of policies and procedures, and a cleaning schedule was being implemented. A policy for cleaning of the resident designated refrigerator was requested but not provided by survey exit.

Based on observation, interview and document review the facility failed to ensure enteral feeding tube placement was confirmed prior to initiation of a feeding for 1 of 1 resident (R2). Findings include: R2's, undated, current Medical Diagnosis list identified diagnoses of hemiplegia (total loss of voluntary movement on one side) and hemiparesis (partial weakness, allowing some movement) following cerebral infarction (stroke) affecting his left side, dysphagia (difficulty swallowing), and severe cognitive impairment. R2's 1/28/26, quarterly Minimum Data Set (MDS) assessment identified he had severe cognitive impairment. R2 received 51% or more of his total calories through tube feeding, and 501 cc/day or more fluid intake by tube feeding. R2's current undated care plan, identified he had a nutritional problem or potential related to neuromuscular impairment and swallowing dysfunction (Dysphagia) following a stroke evidenced by hemiplegia and hemiparesis of his left side. Staff were to weigh R2 daily. And monitor/report to the nurse any signs or symptoms of complications of the tube feeding, such as (coughing, choking, nausea, or loose stools, etc.). R2 was to receive Osmolyte 1.5calorie at 80cc/hour for 4 hours via pump (through G-tube). R2's, 3/19/26, Clinical Physician Orders identified he was to receive enteral feeding two times a day, at 80cc/hr. via pump for 4 hours. Staff were to flush the tube with 20cc of water every one hour during the tube feeding. Medications were to be crushed and mixed with pudding or administered via the G-tube. Staff were to flush the tube with 30cc of water before and after medications administered via the G-tube and document the total amount of fluid administered. Observation on 3/30/26 at 7:31 p.m., with licensed practical nurse (LPN)-A while administering a tube feeding to R2 identified she obtained the required items to administer R2's tube feeding. She washed her hands, donned personal protective equipment (PPE), gathered the supplies and entered R2's room, where she explained she needed to set up his tube feeding. LPN-A took a graduated container into the bathroom and filled it with 700cc of tap water, which she placed into a new feeding bag and hung on the pump stand. She was not certain how much water was supposed to be placed in the second feeding pump bag, but she usually filled it with 600-700 cc. She then returned to the bathroom and refilled the graduated container with tap water, which she identified was for the 30cc G-tube flush. LPN-A filled a second new feeding bag, with 320 cc of Osmolyte 1.5 calorie nutritional feeding formula. She then primed the tubing and hung the tubing on the pump stand. She then told R2 she was going to hook up his feeding, moved his shirt to expose the G-tube, checked the clamp, filled the syringe with 30 cc of water from the container, opened the tube stopper, wiped with an alcohol pad, placed the syringe into the G-tube port. LPN-A then opened the clamp and pushed the water into the G-tube. She then removed the syringe with the plunger fully depressed, connected the feeding to the G-tube, checked the settings on the pump and confirmed it was set at 80cc/hour and turned on the pump. She then rechecked the G-tube to ensure the clamp was open. LPN-A failed to perform any checks to determine the G-tube was still in R2's stomach. Interview on 3/31/26, at 7:40 p.m. with LPN-A reported she had followed her usual procedure for flushing and administering the feeding through R2's G-tube. She identified she had not checked placement before administering the flush or starting the feeding, and she had not been trained to do so. Interview on 3/31/26 at 5:19 p.m. with the director of nursing (DON) identified nursing staff received training on tube feedings at orientation, which was documented on the orientation checkoff list. LPN-A's training was last completed in October 2025. Her expectation was for all nursing staff to follow the facility policy for administering G-tube feedings or medication administration. Following the above observation the nurse on duty had reviewed the procedure with LPN-A. Review of the October 2025, [NAME] Policy Tube-Gastrostomy or Jejunostomy-Enteral Feeding, Care, Replacement or Removal identified only licensed nurses were to administer tube feedings, with conformation of the type of feeding, rate of infusion if a pump was utilized, or gravity if no pump was used, in addition to the volume of feeding to be administered. The procedure identified the steps to be followed for administration:1). Verify the order.2). Follow EBP.3). Staff were to perform Hand hygiene before handling formula or equipment and ensure the equipment and formula was placed on a clean surface and apply gloves prior to beginning the procedure.4). Confirm correct feeding by checking orders and identifying the resident to receive the feeding. Check the expiration date, and ensure the formula was at room temperature.5.) Elevate the head of the bed 30-45 degrees during the feeding and keep it elevated for 30-60 minutes after feeding, unless a physician's order instructs otherwise.6). Check tube placement and patency before beginning a feeding or administering fluids or medications. Methods for checking include: a. Observe for change in the external length of the tube, by checking change in location of a mark placed on the tube on the level where it exits the skin. b. Remove the cap or plug from the feeding tube and use the syringe to inject 30 milliliters of air through the tube to clear it, then aspirate for observation of gastric contents to ensure the tube remains in the stomach.

Based on observation, interview, and document review the facility failed to ensure 5 of 5 residents (R4, R15, R18, R32 and R91's) discontinued controlled narcotic medications were not stored with in-use medications in 2 of 2 medication carts. Findings include: Observation and Medication Administration Record (MAR) on [DATE] at 6:03 p.m., with registered nurse (RN)-D and licensed practical nurse (LPN)-B during a controlled narcotic medication count of 2 of 2 medication carts identified: 1) R4 had 1 box of 5 Fentanyl 25 mcg patches stored in the East medication cart, which RN-D identified had been sent in error by the pharmacy and received by the facility on [DATE] or [DATE]. The pharmacy had been notified on [DATE] when the error had been discovered and confirmed none of the incorrect patches had been administered. She reported the patches had been left in the medication cart until they could be destroyed. 2) R18 had 2 unopened blister packs each containing 30 tablets of Lorazepam 0.5 milligrams (MG) which RN-D confirmed were discontinued on [DATE]. 3) R19's medical record identified he was deceased on [DATE] and his medications remained in the in-use narcotic box identified as: Morphine Sulfate 100 mg/5 milliliters (ml) unopened 15 ml bottle, 1 opened bottle of Morphine Sulfate 100 mg/5 ml with 8.75 ml remaining in the bottle, 2 blister packs of Lorazepam 0.5 mg tablets 1 blister package containing 1 tablet and 1 pack containing 30 tablets. The medical record identified the Lorazepam had been discontinued on [DATE]. 4) R32 had 2 unopened blister packs of Lorazepam 0.5 mg tablets with each blister package containing 30 tablets. The medical record identified this medication was discontinued on [DATE]. 5) R91 had 2 blister packs of Oxycodone HCl 5 mg tablets 1 blister pack contained 12 tablets, and 1 pack contained 30 tablets. The record identified the medication had been discontinued on [DATE]. Interview on [DATE] at 6:25 p.m. with RN-D and LPN-B identified when a controlled medication was changed or discontinued the medication continued to be counted with each narcotic count and stored in the narcotic boxes located on the medication carts, until 2 licensed staff had time to destroy them. Both nurses reported they were not aware discontinued medication was not to be stored with in-use medications. Interview on [DATE] at 6:33 p.m. with the interim director of nursing (DON) identified she was not aware discontinued controlled medications were being stored with in-use medications. When a controlled medication was discontinued or changed resulting in the need for destruction, it should be removed from the in-use medications and stored in a separate secured location until destroyed. The medications would still need to be counted with each narcotic count until destruction with appropriate documentation was completed. Interview on [DATE] at 4:25 p.m. with the consultant pharmacist confirmed discontinued controlled medications should not be commingled with in-use medications due to the potential for error or diversion. She was not aware this was occurring and would investigate the situation further with her next visit to the facility on [DATE]. Review of the [DATE], Policy Medication Administration failed to contain documentation on controlled medication storage, and no additional policies were provided by the end of the survey period.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R11) care plan was revised to show meal preferences. Findings include: R11's 12/16/24, significant change Minimum Data Set (MDS) assessment identified his cognition was moderately impaired, he required limited assistance with transfers and activities of daily living (ADL's). R11 had diagnosis of dementia, diabetes, Parkinson's disease, and anxiety disorder. Interview on 1/12/25 at 11:42 a.m., with family member (FM)-A identified she has told staff several times that he does not like fish or turkey, but they continue to serve it to him. Review of R11's nutritional assessment identified multiple foods that R11 did not like but made no mention of his request not to be served fish. R11's current care plan identified a nutritional focus with a goal for R11 to express that his nutritional needs are being met and that he feels supported. The staff were to discuss coping behaviors related to self-image concerns, he prefers to dine in his room, uses adaptive equipment and staff should monitor and report any signs of difficulty chewing or swallowing. The care plan made no mention of R11's food likes or dislikes. Observation and interview on 1/12/25 at 5:50 p.m., R11 was eating supper in his room, he identified he did not like fish and pointed to his sandwich. He said the sandwich was tuna fish and tasted like slop. Interview on 1/12/25 at 6:01 p.m., with nursing assistant (NA)-C identified residents get a menu slip each morning at breakfast to fill out their meal choices for the day. At the bottom of the slip, it lists dietary preferences and on the back, it lists the any-time menu options. Interview on 1/12/25, at 6:10 p.m., with cook-A identified the nursing assistants bring the menu slips to the kitchen and the cook reviews them as they are preparing the meal trays. Cook-A retrieved R11's menu slip for supper meal and revealed it was blank. Cook-A identified that R11's slip is often blank when it is returned to the kitchen. Observation of R11's menu slip identified the any-time menu items were not listed on his slip. R11's dietary preferences were listed at the bottom, however, there was no mention of his dislike of fish. R11's current treatment record identified a physician order for nursing to check with resident about meal choice, they were to be specific about each option on the menu and what foods he would like staff to cut up. They were to communicate R11's choices to the nursing assistant that is gathering menu slips so that it can be passed on to the kitchen due to his swallowing issues. Interview on 1/13/25 at 8:23 a.m., with the dietary manager (DM)-F identified he asks about preferences at the care conference meeting. He lists the preferences on each resident's diet card. The diet cart is a laminated card used in the kitchen while preparing meal trays. He revealed that R11's dietary card has NO FISH noted on the card, he agreed that R11 did receive fish at supper during the evening meal on 1/12/25. DM-F also identified that he was not aware that R11's menu slips were not being filled out prior to being returned to the kitchen. Observation of R11's laminated dietary card had noted NO FISH noted on the bottom left corner. A policy was requested but not provided by the end of the survey.

Based on observation, interview, and document review, the facility failed administer 1 of 1 medication (levothyroxine) according to labeled instructions for 1 of 25 medication administration observations. Findings include: Observation and interview on 1/13/25 at 8:29 a.m., with licensed practical nurse (LPN)-A as she obtained R 92's Levothyroxine 150 micrograms (mcg) from the medication cart. The order on the electronic medical record (MAR) identified: (Levothyroxine) Synthroid Oral tablet 150 mcg 1 tablet by mouth (PO) one time a day (QD) before breakfast. LPN-A removed the card containing the medication, checked it against the MAR and punched out a pill into the medication cup. The label on the bubble pack directed take 1 tablet PO QD before breakfast. Do not take with Iron, Aluminum, Magnesium, or Calcium containing products. LPN-A returned the card to the medication cart and continued dispensing R92's medications into the same medication cup. R92's medications in the same med cup included: Calcium 600 mg/D3 (Calcium supplement with vitamin D) 2 tablets PO Q AM, and Ferrous Sulfate (iron supplement) 325 milligrams (mg) PO Q AM. LPN-A took the cup containing the medications to R92's room and administered the cup of medications. Upon returning to the cart to document administration of the medications, LPN-A reviewed the levothyroxine. LPN-A reported she had not noted the instructions printed on the Levothyroxine label to not administer with Iron or calcium. The instructions had also not been included in the MAR. She reported she had not noticed the additional instructions printed on the Levothyroxine label and had always administered all of R92's morning medications at the same time. The instructions should have been included in the MAR and the Calcium/vitamin D and Ferrous Sulfate should have been scheduled at a different time. Interview on 1/13/25 at 8:40 a.m., with LPN-A identified she had checked the medication card against the MAR and determined it was the correct medication, but she had not noted the additional printed instructions. LPN-A would give the medication card to the charge nurse to be corrected in the MAR to ensure the error did not continue. Interview on 1/13/25 at 8:50 a.m., with the interim director of nursing (IDON) identified staff passing medications were expected to be reading and comparing medication cards against the MAR and if there was a discrepancy then checking with the charge nurse, and pharmacy for direction. She reported the Levothyroxine had likely been administered with the Calcium and Ferrous Sulfate for the past three days as they were documented as administered at the same time on the MAR. She reported she would have expected staff persons preparing the medication to have caught the label precaution. Review of the May 21, 2024: Medication: Administration Including Scheduling and Medications Aides policy identified the Six Rights of medication administration were to be followed by all staff administering medications to residents. Scheduling of medication administration was to be scheduled to avoid potential significant medication interactions identified as with food, or other medications. The administration procedure identified to review the MAR for medications that were due for administration, follow the Six Rights 1.) Right medication; 2.) right dose; 3) right resident; 4.) right route; 5.) right time; 6.) right documentation. Perform three checks: Read the label on the container/card and compare with the [DATE].) when removing from the cart; 2.) placing the medication in the cup; 3.) just before administering the medication.

Based on interview and record review the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) for 1 of 1 resident (R12) reviewed for unnecessary medications per facility policy and procedure. Findings include: R12 was admitted [DATE] and had a diagnosis of dementia, depression, and heart failure. He had taken Seroquel (treats schizophrenia, bipolar disorder, and manic disorder) 25 milligrams (mg) at bedtime for dementia with a start date of 1/19/24 and sertraline (treats depression) 100 mg daily for depression with a start date of 9/16/23. R12's, 12/11/24 Significant change Minimum Data Set (MDS) identified he was cognitively impaired had little interest or pleasure in doing things and had felt down, depressed, or hopeless never to 1 day. R12 had taken antipsychotics and antidepressants on a scheduled basis. R12's, medical record identified an initial AIMS (test used to assess abnormal movements in people with on anti-psychotic or psychotropic medication) in September 2023. The medical record had lacked evidence of a bi-annual or annual AIMS assessment thereafter. R12's current, undated care plan identified R12 had used psychotropic medication related to dementia and depression. Interventions were for staff to consult with pharmacy, health care provider to consider dosage reduction, discuss with health care provider for ongoing need of use of medications, educate resident/family about risks, benefits, side effects and toxic symptoms of medication, and would monitor target behaviors such as refusal of cares and lack of self-awareness related to safety. During interview on 1/13/25 at 4:34 p.m., with the interim director of nursing (IDON) identified she expected staff to perform updated AIMS assessment for residents taking psychotropic medication according to the facility policy, as indicated. Review of December 2024 Psychotropic Medications- Rehab/Skilled policy identified staff were to complete an initial antipsychotic medication assessment and an AIMS assessment to screen for signs or symptoms of potential Tardive Dyskinesia (abnormal movements caused by psychotropic medication). In addition, staff were to complete the AIMS assessment every 6 months. If a change was identified in a resident from the previous AIMS assessment the registered nurse would inform the primary care physician and family/legal guardian representative and would document the notification in the resident medical record.

Based on observation, interview, and document review, the facility failed to follow appropriate infection control practices for 1 of 2 residents (R2) indwelling catheter. Findings include: R2's, 12/11/24 Significant Change Minimum Data Set (MDS) assessment, identified she was cognitively intact and had a diagnosis of neurogenic bladder (bladder problems related to injury or disease), which required a urinary draining bag (tube that collects urine from the bladder). R2's, current, undated care plan identified interventions for staff to monitor, record, and report to the health care provider signs and symptoms of urinary tract infection (UTI), such as pain, burning, blood-tinged, foul-smelling urine, fever, altered mental status, change in behaviors, and change in eating patterns. During initial interview and observation on 1/12/25 at 11:46 a.m., with registered nurse (RN)-A and R2 identified R2 was seated in her recliner and the urinary drainage bag was hung from the trash can over a gray basin that was placed on the floor next to R2's recliner. R2 stated she and nursing staff hung her urinary drainage bag from the trash can to keep the catheter tubing below her bladder. Observation on 1/12/25 at 1:13 p.m., as the interim director of nursing (IDON) wheeled R2 to her room and assisted R2 with transfer to her recliner. When the IDON exited the room, R2's urinary drainage bag was hung from the trash can. Interview on 1/13/25 at 10:40 a.m., with nursing assistant (NA)-A reported R2 transferred her urinary drainage bag from her walker and hung it from the trash can. She informed R2 it was not a good idea for the urinary drainage bag to be hung from the trash can and offered to place the urinary drainage bag to another location. During interview on 1/13/25 at 10:43 a.m., with registered nurse (RN)-A she reported R2 was independent with her care needs and would need reinforcement and education of properly securing her urinary drainage bag to prevent contamination. Observation and interview on 1/13/25 at 4:14 p.m., with RN-B in attendance, noted R2's catheter bag was again hung from the trash can, upon entering R2's room. She confirmed it was not an acceptable infection control practice and would need to re-educate R2 of appropriate techniques to position her urinary drainage bag when in use. Observation and interview on 1/13/25 at 4:16 p.m., trained medication aide (TMA)-A in attendance, noted R2's urinary drainage bag was again hung from the trash can. TMA-A stated R2's urinary drainage bag that was hung from the trash can was not the appropriate place for the catheter bag and stated R2 had limited options on where she could hang her urinary drainage bag when seated in her recliner. During interview on 1/13/25 at 4:34 p.m., with the IDON she stated nursing staff and R2 would need further education on infection control practices related to urinary drainage bag placement to prevent complications and reduce infection control risks. Review of July 2024 Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen-AL, R/S & LTC policy identified the facility staff would maintain and properly secure catheters. Secondly, closed connection systems, such as, indwelling catheters that were found to be contaminated by inappropriate infection control practices were to be replaced, immediately. In addition, the facility staff would educate and document residents and/or family of the risk and benefits of indwelling catheters use.

Based on interview and document review the facility failed to ensure 1 of 8 staff received newly hired staff nursing assistant (NA-D) received initial training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem solving with challenging behaviors, and communication skills. This had the potential to affect all the residents in the facility. Findings include: Review of the employee file for nursing assistant (NA)-D had a hire date of 10/29/24. Interview on 1/13/25 at 4:41 p.m., with interim director of nursing would expect Alzheimer/Dementia training to be completed for all staff who are taking care of vulnerable adults at the facility. Review of August 2024 Facility Assessment identified the facility would train staff on Dementia and behavioral health during general orientation. In addition, the facility would provide annual staff in-services pertaining to Federal and State requirements related to continuity of care and resident safety. Copy of NA-D training policy was requested and not provided during survey.

Based on interview the facility failed to ensure resident mail was delivered consistently on Saturdays for 2 of 2 residents (R18, and R25) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 37 residents residing in the facility. Findings include: R25's 12/11/24, Significant Change in Condition Minimum Data Set (MDS) assessment identified R25's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Interview on 1/13/25 at 1:10 p.m., during the Resident Council meeting, R25 identified he did not always get mail on Saturdays because there was only one activity staff who worked on Saturdays so there were times when his mail was not delivered until Sunday or Monday. R18's 12/10/24, Significant Change in Condition MDS assessment identified R18's cognition was intact with a BIMS score of 15. Interview on 1/14/25 at 7:34 a.m., with R18 identified she did not receive mail every Saturday and it was a hit or miss as the activity staff were only here long enough to help feed residents at noon and then they left. Interview on 1/13/25 at 1:26 p.m., with social worker designee/activity director identified the mail was brought to the front desk and activity staff delivered the mail Monday through Saturday and there was no mail delivery on Sundays. She reported there was always activity staff working on Saturday however, if the mail came after the activity staff left for the day residents did not receive their mail until Monday morning. She identified that did not happen very often. She revealed the maintenance director brought the mail to the reception desk and placed it in a white basket daily and the activity staff delivered it. She confirmed that the maintenance director was the only staff member who picked the mail up out of the actual mailbox. Interview on 1/13/25 at 1:30 p.m., with the maintenance director identified he picked the mail up out of the mailbox located outside of the facility Monday through Friday and dropped it off at the receptionist desk. Interview on 1/13/25 at 1:40 p.m., with the administrator in training (AIT) identified if the mail was delivered on Saturday by the post office that anyone from the facility could pick it up from the mailbox and deliver it to the residents. She reported her expectation was that if the post office delivered mail on Saturday, then the residents would receive their mail on Saturday. Interview on 1/13/25 at 1:44 p.m., with social worker designee/activity director revealed that mail at times was delivered after 5:00 p.m., on Saturdays and that was the reason the residents not receive their mail until Monday. A mail service policy was requested but not provided. A policy for Resident Mail and Parcel Services for Senior Living and Affordable Housing policy was provided but did not include long term care.

Based on observation, interview, and document review, the facility failed to utilize enhanced barrier precautions (EBP) for 1 of 3 residents observed for infection prevention. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE] indicated R3 had intact cognition with diagnoses including stroke, diabetes, and depression. R3's care plan dated 12/4/24 indicated R3 required EBP related to indwelling medical devices: urinary catheter and feeding tube. R3's care plan instructs to don (put on) gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, checking and changing, device care and/or use, and wound care. On 12/27/24 at 11:17 a.m., registered nurse (RN)-A and nursing assistant (NA)-A were observed entering R3's room with a full mechanical lift. A magnet on the doorframe of the room indicated enhanced barrier precautions were required for high contact resident care activities including transferring. Neither RN-A or NA-A were observed to don a gown or gloves. Staff RN-A and NA-A were observed to transfer R3 from her wheelchair to the recliner with out wearing a gown or gloves. RN-A connected tubing from a feeding pump to the feeding tube on R3's abdomen. On 12/27/24 at 11:27 a.m., R3 stated staff wear a gown and gloves when they change her, but not when transferring from wheelchair to recliner. On 12/27/24 at 11:43 a.m., NA-A stated EBP should be worn when dressing a resident, providing catheter care or changing a resident's brief, but does not need to be worn when transferring a resident. She acknowledged she did not wear a gown when assisting with the transfer of R3. On 12/27/24 at 11:49 a.m., RN-A stated EBP needed to be utilized when dealing with whatever the resident is on EBP for, like catheters, wound care, and feeding tubes. EBP should also be worn when providing cares but did not need to be worn for transfers. She acknowledged she did not wear a gown when she assisted with the transfer or when attaching tubing to R3's feeding tube. She confirmed a gown and gloves should have been worn while working with R3's feeding tube. On 12/27/24 at 1:16 p.m., medical doctor (MD)-A stated lack of utilization of EBP could spread infections to other residents. Residents may be colonized (bacteria in the body without active infection) with bacteria the staff are unaware of. Residents with urinary catheters and indwelling medical devices have an increased risk of infection. On 12/27/24 at 1:46 p.m., RN-B stated EBP should be worn any time staff have direct contact with the resident or are working with something that is soiled. Examples of when EPB should be worn include caring for catheters or feeding tubes and during all transfers. EBP is worn to prevent spreading infection between residents. RN-B confirmed R3 requires EBP related to a feeding tube and urinary catheter. Residents who require EBP will have a magnet on the doorframe of their room. The Standard and Transmission-Based Precautions policy dated 4/2/24 informs EBP expand the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms to staff hands and clothing. High contact resident care activities include: transfers, urinary catheter care or use, and feeding tube care or use.

Based on observation, interview, and document review the facility failed to compressively assess falls for root cause, implement appropriate interventions and follow the care plan to prevent and/or reduce the risk of falls with major injury 2 of 2 residents (R2 and R3) with history of falls. This resulted in immediate jeopardy (IJ) for R2 who sustained multiple left rib fractures, left clavicle fracture and a subdural hematoma (brain bleed). The IJ began on 7/27/24 when staff failed to implement R2's care plan for close supervision resulting in R2's fifth (5th) unwitnessed fall, major head injury, and intensive care unit (ICU) admission. The administrator, regional nurse manager, and director of nursing (DON) were notified of the IJ on 8/2/24 at 3:00 p.m. The IJ was removed on 8/3/24 at 12:00 p.m., when the facility had implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings included: R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment and had diagnoses of hip fracture, other fracture, osteoporosis, and dementia. R2 had a history of falls prior to admission to the facility and two falls with injury since admission on 7/1/24. R2 had functional range of motion impairment on one upper and lower extremity. R1 used a walker and wheelchair. R2 required partial to substantial assistant for all his activities of daily living (ADLs) and required moderate assist for transfers and did not walk more than 10 feet. R2 was frequently incontinent of bowel and bladder and did not have a toileting plan. Review of R2's Fall Tool admission assessment dated [DATE], R2 was at medium risk for falls. R2 had history of one or more falls in the last three months, was taking medications that put him at risk, and mildly impaired cognition status. R2 risk factor for falls included mobility/transfers due to changes in mobility related to muscles weakness or strength, impaired balance or coordination and pain. Although R2 had mild cognition he had reduced insight, difficulties in orientation on new admission, medical problems which affected changes in his orientation/level of consciousness and was incontinent. R2 was referred to therapy and care plan was updated. R2's care plan dated 7/2/24, included an ADL focus that indicated R2 had a deficit related to recent hip surgery with interventions that directed to use one staff assistance with pivot/transfers. Fall focus identified R2 had an actual fall on 7/1/24 (sic) and was at risk for falls related to falls prior to hospitalization with the intervention that directed staff to ensure R2 was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan also identified R2's preferred wake time was 5:00 a.m. and his bedtime was 10:00 p.m. The care plan did not identify a toileting routine or program even though R2 was frequently incontinent of urine. R2's late entry progress note dated 7/3/24 at 11:42 a.m., indicated R2 was heard yelling from hallway. R2 was found lying across the bedside table legs, R2's head was facing the door and head at the foot of the bed and nightstand. Water pitcher and water spilled on the floor. R2 did not have shoes on. Skin tear noted to left elbow with complaints of pain in left shoulder, unable to abduct without pain or calling out. Pillow placed under head and removed bedside stand from under body. Vital signs obtained and transfer to emergency department (ED) initiated. Ambulance arrived at 8:10 a.m. and left 8:15 a.m. Progress note at 11:20 a.m. indicated the hospital ED called the facility to notify R2 had fractured his left scapula and several ribs on the left side. R2's Fall Huddle Sheet dated 7/3/24 at 7:50 a.m., identified the fall with the additional information of- R2 was ambulating and attempting to self-transfer, slipped and lost his balance. R2's bed was higher than it should have been and R2 had bare feet. Last toileted at 1:43 a.m. six hours before R2's fall. R2's incident report dated 7/3/24 at 7:50 a.m., included the fall information identified in the progress note and Fall Huddle with the following additional information: R2 had on brief and t-shirt, R2 recently had right hip replacement, which he was able to move appropriately, and R2 stated that he was getting up to go take a shower initially and then later thought he was in the copy/print room at his newspaper job in Colorado. R2's records did not include a comprehensive fall analysis for root cause and interventions that identified risk factors from the incident and huddle reports such as (but not limited) to the bed height, self-transfers/impulsivity, and duration of time documented between toileting. R2's progress note dated 7/9/24, identified R2 returned from the hospital and his care plan was updated with interventions to reduce the risk for falls. R2's care plan was revised on 7/8/24 to reflect the following interventions, educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. R2's care plan was revised on 7/9/24 to reflect the following interventions: Make sure resident wears glasses when up/out of bed; Keep urinal within reach, check and empty frequently (frequency was not defined); Fall mat placed on floor next to bed; signs placed in room to remind R2 to use call light and wait for assistance. Staff to ask for OT to evaluate room arrangement and will trial non-spill cup that R2 can keep in bed with him. New focuses added included: R2 had sleep disturbance evidenced by complaints of feeling tired, change in ability to perform ADLs, and change in gait/falls with interventions that included follow R2's usual bedtime routine. New focus of R2 had behavior symptoms evidenced by impulsiveness and lack of safety awareness with interventions that included praise any indication of R2's progress/improvement in behavior and prefers the diversional activity of ready books. Review of R2's record between 7/9/24 to 7/22/24, did not indicate OT had completed an evaluation of R2's room arrangement. R2's progress note dated 7/10/24 at 7:00 p.m., identified background, assessment, and recommendation (SBAR) was sent to physician indicating R2 had fallen when he went to stand up. Was wearing appropriate footwear and had call light and personal items within reach. At 7:25 p.m. R2 was sent to the ED via ambulance. R2 had head computer tomography (CT) without evidence of injury or bleed and laceration on right side of forehead. R2's Fall Huddle Sheet dated 7/10/24 at 7:00 p.m., identified the fall information and included the additional information of- fall was unwitnessed. R2 reported he was trying to stand up to empty his urinal and lost his balance. Causal factors included the bed/chair height was not appropriate and R2 does not ask for assistance. R2's incident report dated 7/10/24 at 7:00 p.m., identified the aforementioned fall information from the Fall Huddle and progress notes. Additional information included: Urinal was of dresser and only 1/3 full; R2 seemed confused on where he was and what he was doing; impaired memory and lack of safety awareness put him at increased risk for falls. The incident report was updated on 7/15/24 included Have been constantly reminding resident to wait for assistance, and this has been helping. R2's records did not identify a comprehensive fall analysis for root cause that addressed risk factors identified on the incident and huddle reports such as (but not limited to) height of the bed, urinal usage, and self-transfers/impulsivity. R2's ED notes dated 7/10/24, identified R2 presented after a fall with a laceration to his scalp that was 2 centimeters (cm) on his right forehead near the hairline that required sutures. We recommend tabs alarm [a device that alarms audibly or silently (i.e. box at nursing desk) with movement of resident from a surface such as a bed or chair] or closer supervision to prevent falls. R2's progress note dated 7/10/24 at 10:26 p.m. indicated director of nursing (DON) had concerns with R2 returning to the facility. DON informed them [hospital] that nursing home unable to provide 1:1 supervision with resident d/t [do to] staffing and TABS are not appropriate in this setting. MD stated no medical reason for hospitalization , R2 would be returning to facility. R2's progress note dated 7/10/24 at 11:30 p.m. indicated R2 arrived back to the facility from ED with no acute pathology and received orders for TABS alarm at all times if possible or supervision. DON explained that TABS alarms are not used at the facility d/t it being considered a restraint .actually create a fall . Facility to provide increased supervisor of resident by having resident in recliner chair out by nurse's station so his safety can be closely monitored by staff. R2's care plan was revised on 7/11/24, to include Ensure/provide a safe environment: avoid isolation and place resident by chair by nurse's station to offer closer supervision as ordered by the physician. R2's record did not identify an assessment that determined and/or defined frequency of checks/supervision R2 required based on his risk factors, mannerisms, and behaviors. Furthermore, there was no indication the medically recommended device (tabs) based on a physician's evaluation to prevent R2 falls was comprehensively assessed by the facility prior to the determining the device would not be effective. Review of R2's record between 7/11/24 to 7/29/24, there was no indication R2's care plan interventions that directed staff to provide closer supervision and placing R2 by the nurse's stations were implemented and/or evaluated for effectiveness. R2's progress note dated 7/14/24 at 3:00 p.m., indicated R2 had an unwitnessed fall in his room. Staff found R2 on the floor with head on dresser and feet towards bed. Staff assisted R2 to wheelchair and out to lounge area. R2 stated he wanted to go to the basement. R2 noted to transfer self during morning shift to bathroom and to recliner after dinner. R2 was asked if attempted to ambulate self and replied yes, because I don't need any help. Review of R2's Fall Huddle Sheet dated 7/14/24 at 3:00 p.m. identified the fall information with the additional information of- causal factors included R2 gets more confused @ night Corrective actions taken: Resident education/training or re-instruction. No care plan interventions were identified. R2's incident report dated 7/14/24 at 3:00 p.m., identified the fall information. Additional information included-Resident alert and orientated x 3 during the day but as time gets later, he gets more confused. The report was updated on 7/15/24 to include, the interdisciplinary team (IDT) reviewed Incident: Intervention will be to put a sign in his room. Resident loves to read, so we are thinking this will be a better intervention that constant telling him to Wait for help In review of R2's records identified a comprehensive fall analysis for root cause and interventions was not completed that addressed risk factors included on the incident and huddle reports such as (but not limited to) even though the reports identified R2 had increased confusion at night, the intervention for closer supervision was not individualized and/or assessed to address that risk factor. Additionally, not evident the care plan was revised to include signage intervention. R2's progress note dated 7/16/24 at 2:45 a.m., staff was going down hallway and noticed R2's door closed, stopped to open, and found R2 lying on the floor stretched out next to his bedside. Had a smile on his face and denied any new pain. R2 states he slipped off the edge of his bed. R2 was assisted off the floor. Bed was lowered to lowest position and fall mat applied to floor at bedside. Call light within reach. Review of R2's Fall Huddle Sheet dated 7/16/24 3:19 a.m., identified fall information in addition to R2 stated he fell while trying to reach his water. Action taken was water glass in bed no spill cup No injuries. R2's incident report dated 7/16/24 at 3:19 a.m., identified fall information with no other additional information. The report was updated on 7/22/24 to include IDT reviewed Incident: Will attempt to give resident a new cup that won't spill and he can keep closer to himself in bed. Also, will talk to therapy to check out resident's room to see if we can rearrange to make it easier for Resident to navigate (according to the care plan both interventions were supposed to be already in place on 7/9/24). Review of R2's record lacked a comprehensive analysis of causal factors that included if the intervention of close supervision was provided and was evaluated for effectiveness. Further not evident the care plan was revised to reduce R2's risk for falls and/or falls with major injury. R2's progress note dated 7/27/24 at 6:00 p.m., nursing assistant observed R2 on floor by closet door with head towards his bed. ROM within normal limits, pupils equal and reactive to light, assist with two staff to wheelchair without difficulty and taken to lounge area to watch TV with other residents. Nurse noted a bump to left side of head in which R2 refused an ice pack, also noted a blood blister on left elbow, covered with band aid. Facility surveillance video footage recorded on 7/27/24 from 5:55 p.m. to 6:19 p.m. was reviewed with the administrator. -At 5:56 p.m. licensed practical nurse (LPN)-B walked by R2's room. LPN-B looked in the room but did not stop. LPN-B assisted a female resident to her room at the end of the hallway. -At 5:59 p.m. LPN-B walked back up the hallway and entered R2's room for approximately 15 seconds and then exits the room without R2. -At 6:09 p.m. NA-P walked down hallway and looked in R2's room, entered the room, and activated the emergency call light. NA-Z and LPN-B walked to and entered R2's room. -At 6:11 p.m., NA-Z left R2's room and walked towards the nursing station. NA-P left the room, got the standing mechanical lift from the other end of the hallway, and brought it back to R2's room along with wheelchair at 6:14 p.m. -At 6:16 p.m., NA-P exited R2's room with the standing lift. -At 6:19 p.m., LPN-K exited the room, looked to be prompting R2 to follow her, R2 self-propelled his wheelchair out of the room toward the nurse's station. Review of R2's Fall Huddle Sheet dated 7/27/24 at 6:00 p.m., R2 had an unwitnessed fall in his room when he was ambulating to bathroom using a device (not specified). Last seen by a staff member around 5:30 p.m. Causal factors included resident left in room unattended. The form indicated the investigation was completed on 7/29/24. Corrective action taken was documented as the roommate moved to a different room to make R2's room private and staff suspension/terminated. R2's incident report dated 7/27/24 6:00 p.m., identified the fall information. In addition, R2 reported I was just walking. The form was revised on 7/29/24 to include IDT Team reviewed incident: Noted that Roommates walker was next to him after fall. Intervention: Ensure roommate's walker is out of reach and out of the way to ensure R2 does not attempt to use it. R2's progress notes on 7/29/24 at 8:04 a.m., indicated a nurse was called to R2's room. R2 was orientated to self only. The physician and power of attorney were notified. Progress note at 8:16 a.m. indicated an order to send R2 to ED. Progress note at 12:29 p.m. indicated the hospital ED called to notify facility compressions (cardio pulmonary resuscitation) was started. R2's hospital progress note dated 7/29/24 indicated that R2 was being evaluated for a fall with head injury that occurred 3 days prior and at 8:30 a.m. on 7/29/24, was noted to be more confused and not following commands. R2's last known well time was 11:00 p.m. on 7/28/24. R2 had a head CT that showed 1.) an acute right subdural hematoma over the right vertebral hemisphere which measures up to 10 millimeters (mm) in thickness. A mild localized mass effect without midline shift. 2.) Hemorrhagic contusion most notable in the right temporal lobe, with a smaller hemorrhagic contusion involving the inferior right frontal lobe. 3.) Left parietal scalp trauma without associated skull fracture. During his ER stay R2 was transferred to higher level of care hospital by ground ambulance. R2's higher level hospital progress note dated 7/29/24, indicated R2 was admitted to the intensive Care Unit (ICU) with diagnoses of traumatic bran injury, sub [NAME] hematoma, temporal contusion, seizure, encephalopathy and hyponatremia. R2 had a repeat head CT upon arrival that agreed with the first hospital but added but added a thin subdural blood product along posterior falx (curved shape) and right tentorial leaflet, up to 1mm. R2 received antiseizure medications. During interview on 8/6/24 at 11:22, registered nurse (RN)-B reported R2 had been discharged from the hospital to a hospice facility however, was not aware of the date he was discharged . During an interview on 8/1/24 at 1:52 p.m., trained medication assistant (TMA)-A stated R2 had fallen a lot since admission. There was one fall where he fell and broke his shoulder and some ribs. TMA-A stated R2 would attempt to self-transfer and forget to ask for help. TMA-S stated if R2 was in his room staff needed to visualize R2 and make sure he was OK or R2 needed to be in the common area by nurses' station, so staff could see him. TMA-A indicated the checks were not documented anywhere. During an interview on 8/1/24 at 2:33 p.m., NA-B stated R2 had behaviors where he would get up by himself in his room then fall or wander around in his wheelchair. NA-B was not able to articulate R2's fall interventions. During an interview on 8/2/24 at 11:20 a.m., TMA-D stated R2 was alert and oriented. TMA-D remembered R2 had two falls while she was worker but could not recall the dates of the falls. TM-D explained R2 had slid out of his recliner after he had used the remote to raise the chair up too high. TMA-D could not remember what caused the other fall, but neither fall resulted in injuries. TMA-D could not remember R2's fall interventions. During an interview on 8/2/24 at 11:25 a.m., NA-J stated R2 would not listen; she would put R2 in his recliner with the reminder to use his call light however a few minutes later she would walk by his room to find R2 attempting to self transfer. NA-J remembered R2 had one fall while she was working. NA-J thought R2 was trying to self-transfer from his recliner to his wheelchair and got a goose egg on his forehead and a black eye. During an interview of 8/1/24 at 2:59 p.m., LPN-A stated R2 was a frequent faller, and was to be in the commons area by the nurse' station so staff could supervise him. LPN-A indicated she had been working on evening when R2 fell , LPN-A could not recall the date, she had opened R2's door and found R2 on the floor beside his bed with things under his head, like he had been there awhile. LPN-A stated R2 did not have any injuries with that fall and she had instructed staff working to leave R2's door open for closer monitoring when he was in bed. LPN-A indicated she had not added the intervention to R2's care plan. During an interview of 8/1/24 at 3:20 p.m. NA-Z stated R2 was confused and did not use his call light and liked to be independent. NA-Z explained she had been working on 7/27/24, when R2 fall. NA-Z recalled the fall had happened and dinner and staff were busy with other residents. NA-Z had been talking with LPN-B by the dining room hallway when NA-P turned on the emergency call light. NA-Z got to R2's room with LPN-B and R2 had his head against the register under the window and R2's legs were entangled in a walker. NA-Z indicated she was not aware of how or why R2 was in his room unsupervised. During an interview on 8/2/24 at 8:15 a.m., NA-S stated R2 was impulsive and would not use his call light. According to R2's care plan he was supposed to be out at the nurse's station when he was out of bed, especially after meals. NA-S thought staff would forget this because R2 seemed like he was alert. On 7/29/24, NA-S went into get R2 up for the day around 8:00 a.m., and he was not responding like himself. R2 would respond verbally with yeah to her questions but would not move. NA-S sent NA-T for the nurse and LPN-K came and brought RN-B. R2 was sent to the local ER and then airlifted to a higher level of care. During interview on 8/2/24 at 11:51 a.m., LPN-B stated on 7/27/24, she was called to R2's room around 6:10 p.m. via the emergency staff alert. LPN-B entered R2's room and R2 was on the floor by the window and his head was not touching the wall or the floor. LPN-B stated she looked at R2's head and did not see any blood and R2 had answered her questions appropriately. LPN-B was not aware of how or why R2 was in his room alone. LPN-B stated on 7/29/24 at approximately 8:00 a.m., a nursing assistant had notified her R2 was not right. LPN-B went to R2's room, he was lying in bed in the fetal position facing towards the wall. LPN-B indicated she was unable to get R2 to open his eyes and notified RN-B and decided to send R2 to the emergency room for further evaluation. During an interview on 8/2/24 at 1:44 p.m., RN-B stated she was called to R2's room on 7/29/24 because R2 was not responding per his normal. R2 was rigid, in a fetal position and pale in color. RN-B stated R2 needed to go to the ED immediately and helped initiate the transfer. During an interview on 8/1/24 at 3:49 p.m., director of nursing (DON) explained after a fall occurs after each fall nursing staff were to implement immediate interventions to prevent another fall. The IDT would then meet the following morning (Monday through Friday) to discuss the fall, try to determine what the cause was, and what appropriate interventions should be in place including the immediate intervention that had been immediately implemented. DON indicated R2's falls that happened after 7/11/24 happened because his care plan for supervision was not followed; All these falls took place in R2 ' s room and were unwitnessed. DON stated she had been made aware of R2's fall that occurred on 7/27/24 when she arrived to work on 7/29/24 and R2 was being transferred to the ED. During an interview on 8/6/24 at 1:55 p.m., medical director (MD)-A, stated the R2 had a history of drug abuse, seemed forgetful, and did not always listen to staff. R2 had numerous falls while at the facility. MD-A could not say for sure when the brain bleed happened. R2 had a head CT on 7/3/24 and 7/10/24 that did not show a brain bleed but the head CT on 7/29/24 did. R3 R3's admission Falls Tool dated 6/11/24, indicated R3 was at low risk for falls. R3 had no falls in the past 12 months, was taking medications that could cause falls and had mild cognitive impairment. Risk factors included cognitive status, reduced insight, and impulsiveness; environmental risk factors of difficulty with orientation and was a new admission. There was nothing checked under the action plan. R3's admission MDS date 6/12/24, indicated R3 to have severely impaired cognition with diagnoses of atrial fibrillation, congestive heart failure, arthritis, osteoporosis, and Parkinson's disease. R3 was independent with transfers, walking and ADL's and used a walker for mobility. R3 had no history of falls. R3's ADL care plan dated 6/13/24, indicated R1 needed one staff assist with, gait belt and four wheeled walker (4WW) for ambulation, bed mobility, toilet use and transfers. Fall care plan indicated R3 had an actual fall with no injury with interventions dated 7/16/24, to provide activities that promote exercise and strength building where possible, consult physical therapy (PT) and occupational therapy (OT) for strength and mobility, and educate R3 and family on safe use of assistive devices. R3's progress notes dated 7/15/24 at 9:30 a.m., indicated a fax was sent to the provider to notify of R3's fall. R3's assessment, neuros, and vital signs were at baseline and denied pain. R3 thought it happened due to legs feeling weaker since R3 had worked with therapy. R3's Fall Huddle Worksheet dated 7/15/24 at 7:15 a.m., indicated R3 had an unwitnessed fall in the bathroom, after attempting to self-ambulate and last staff to see resident were NA-J and NA-K with no date and time listed. Did not identify the last time R3 was assisted with ADL's. R3's Incident Report dated 7/15/24 at 7:15 a.m., identified R3's fall information from the progress notes and fall Huddle with additional information of: R3 received an abrasion to left 2nd toe. Care plan and order were updated with providing activities to promote strength building, consult PT and OT for mobility and strength and to educate R3 and family on safe use of assistive devices. R3's record did not identify a completed comprehensive analysis of causal factors and/root cause to determine appropriate interventions to prevent falls or reduce the risk of falls with major injury. R3's Fall Huddle Worksheet dated 7/16/24 at 7:34 a.m., indicated R3 had an unwitnessed fall in his room where he was found on his knees attempting to self-transfer, lost his strength/knees buckled while R3 used his walker. Did not identify the last time R3 was assisted with ADL's. R3's Incident Report dated 7/16/24 at 7:34 a.m., identified R3's fall information from the fall Huddle with the additional information of: R3 was holding onto his walker and had bumped his head on the walker while trying to stand. R3 stated he was trying to get up for breakfast. R3 was complaining of low back pain, was seen the week prior and noted to have compression fracture in low back. No care plan interventions noted. R3's progress note dated 7/16/24 at 9:38 a.m., indicated IDT reviewed R3's fall from 7/15/24 at 7:45 a.m. and 7/16/24 at 7:34 a.m., R3 was found on the bathroom floor on 7/15/24 and found on floor next to bed on 7/16/24. R3 was attempting to get up to go to breakfast. Will fax provider for a urinalysis related to back/flank pain and increased weakness and confusion. Will also ask for PT/OT orders for strengthening following fall. R3's record did not identify a completed comprehensive analysis of causal factors and/root cause to determine appropriate interventions to prevent falls or reduce the risk of falls with major injury while waiting for laboratory test results with any follow-up treatment and while R3 gained strength from working with PT/OT. R3's progress note dated 7/20/24 at 8:22 a.m., indicated R3 was found on the floor in his room at 4:30 a.m., no injuries noted, see incident in risk management for details. Further noted at 8:33 a.m. a fax was sent to physician for R3's unwitnessed fall with no injury along with uncontrolled back pain and the scheduled Tylenol 1000 milligrams (mg) was ineffective. Staff requested stronger pain medication. R3's Fall Huddle Worksheet dated 7/20/24 at 4:30 a.m., indicated R3 had an unwitnessed fall in his room while R3 was attempting to self-ambulate, lost his balance while wearing slipper socks and using his walker. Last time staff saw R3 was 30 minutes prior to fall, when staff saw R3 in recliner. Did not identify the last time R3 was assisted with ADL's. R3's Incident report dated 7/20/24 at 4:30 a.m., indicated R3 was found on the floor in front of the recliner when the nurse arrived R3 was lying on floor holding his head up. R3's record did not identify a completed comprehensive analysis of causal factors and/root cause to determine appropriate interventions to prevent falls or reduce the risk of falls with major injury. R3's progress note dated 7/30/24 at 4:31 p.m., indicated nurse summoned to R3's room as laundry staff observed R3 seated on the floor in front of his recliner with one foot at his side and one foot on the chair. R3 then ambulated with FWW in his room to his wheelchair and was brought to lounge area with vital signs taken frequently. R3's Fall Huddle Worksheet dated 7/30/24 at 4:00 p.m., indicated R3 had an unwitnessed fall while reaching to move trash bucket out of the way and lost his balance, was wearing shoes and using his walker at time of the incident. Last staff to see resident, resident ambulating per self with 4WW throughout facility, all staff allowing this to happen. No name of staff or date and time listed for last seen by. Does not identify the last time R3 was assisted with ADL's. R3's Incident Report dated 7/30/24 at 4:00 p.m., indicated R3 was found sitting on floor in front of the recliner by the laundry. R3's feet were out in front of him and one at the side out of the chair. On 7/30/24, order received to discontinue the Oxycodone per R3's request and an order received for lidocaine external patch 4%, apply one patch a day for up to 12 hours. R3's medical record lacked root cause analysis and implementation of prevention interventions for R3's numerous falls to mitigate the risk for future falls. During an observation on 8/1/24 at 12:57 p.m., R3 was self-propelling his wheelchair from the dining room. At 4:00 p.m., R3 was seated in his wheelchair in the common area. During an interview on 8/1/24 at 1:52 p.m., TMA-A stated R3 had a change in status over the past month, felt R3's memory was getting worse as R3 would not remember to ask for assistance or use his call light. TMA-A further stated that R3 was having more pain and nursing was working with the provider on this. During an interview on 8/1/24 at 2:25 p.m., NA-E stated R3 was not independent, used a wheelchair and staff were to leave his door open to watch in case he self-transferred. During an interview on 8/1/24 at 2:33 p.m., NA-B stated R3 was confused and attempted to self-transfer. R3 needed 1 staff assist with transfers with the use of a gait belt. During an interview on 8/1/24 at 3:20 p.m., NA-Z stated R3 was independent when he arrived about a month ago but has gone downhill lately. NA-Z further stated R3 had increased confusion, does not like to stay in his wheelchair, forgets to ask for assistance and gets frustrated quickly when staff remind him to ask for assistance or use his call light. During an interview on 8/2/24 at 8:15 a.m., NA-S stated R3 was admitted to the facility independent and continent, but after some falls, he was to use wheelchair and was needing more care from staff with his ADLs including going to the bathroom and changing his brief or pull up. R2 would let staff know when he had to go to the bathroom or the staff would catch him self transferring. During an interview on 8/1/24 at 3:49 p.m., DON indicated after reviewing R3's falls, a comprehensive analysis of the falls had not been completed for appropriate interventions. DON indicated the facility had identified gaps in the falls program with causal analysis to which the facility implemented a quality assurance performance improvement (QAPI) project in June 2024; the cause analysis was a work in progress. DON stated she expected staff to follow the resident's care plans and the fall policy and procedures. Review of facility's policy entitled Fall Resource Packet - Rehab/Skilled, dated 5/7/24, indicated the following: - refer to Fall Prevention and Management policy, INTERACT Fall- Care Path, AMDA clinical practice guideline (CPGs) and AMDA Know-it-All card for additional information regarding actions to take post-fall. - Staff were to complete the following PCC: -Falls Tool UDA -Change in Condition (if applicable) -neuro Check UDA (triggered from risk management incident types: slipped or fell , found on the floor, fall involving mechanical lift) -pain evaluation -vital signs -risk management module- new incident, for the type of fall. -Check the care plan to determine if the cause of the fall is addressed (to avoid additional falls from the same cause). Consider setting a short-term goal to assist with monitoring the fall interventions closely to determine effectiveness; if not effe [TRUNCATED]

Based on interview and record review the facility failed to complete a comprehensive bladder assessment and develop an individualized toileting program to restore, maintain, or prevent a decline in continence for 2 of 2 residents; R3 who had a change in mobility and R2 who had a documented decline in continence. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment with diagnoses of cancer, heart failure, arthritis, and Parkinson's disease. R3 had no impairment of range of motion and used a walker. R3 was independent with his activities of daily living (ADLs) except needed supervision with eating and oral hygiene. R3 had no history of falls. R3 was always continent of bowel and bladder and did not have a toileting program. R3's bowel and bladder assessment from the Nursing Admit Re-Admit data collection ([NAME]) tool, dated 6/6/24, indicated R3 was continent of bowel and bladder. No other bowel and bladder information was included on the assessment. R3's care plan (current at the time of the suvey) did not identify bladder/bowel focus that identified R3's toileting needs. The ADL care plan dated 7/23/24 identified the following: -ambulation with assist of one, gait belt and four wheeled walker (4WW), dated 7/23/24, -bed mobility with assist of one, gait belt and 4WW, date 7/23/24, -toilet use with assist of one, gait belt and 4WW, dated 7/23/24. During an interview on 8/2/24 at 8:15 a.m., nursing assistant (NA)-S stated R3 was admitted to the faciity independent and continent, but after some falls, he was to use wheelchair and was needing more care from staff with his ADLs including going to the bathroom and changing his brief or pull up. NA-S indicated R3 did not have a toileting program, R3 would let staff know when he had to go to the bathroom or the staff would catch him self- transferring to the bathroom. During an interview on 8/6/24 at 12:46 p.m., NA-D indicated R3 needed assistance to transfer, had confusion, would attempt to self-transfer, and did not have a toileting schedule. During an interview on 8/6/24 at 3:07 p.m., NA-P stated she would take R3 to the bathroom at least before and after supper. R3 did not have a toileting schedule. R2's bowel and bladder assessment from the [NAME] tool, dated 7/9/24, indicated R2 was continent of bowel and bladder, used a urinal, had urgency, and needed assistance with clothing management. The assessment did not include any other information. R2's care plan did not include identify a toileting program. The care plan included: - R2 required staff assist of one with clothing management, dated 7/9/24. -Staff to keep urinal in reach, check and empty frequently, dated 7/9/24. R2's admission MDS dated [DATE], indicated intact cognition with diagnoses of hip fracture, other fracture, osteoporosis, and dementia. R2 did not have a toileting program and was frequently incontinent of bowel and bladder. R2 had impairment on one upper and lower extremity range of motion (ROM). R2 used a walker and wheelchair. R2 required partial to substantial assistant for all his activities of daily living (ADLs). R2 required moderate assist for transfers and did not walk more than 10 feet. R2's record did not include a comprehensive assessment in R2's change in level of continence nor physician notification of R2's bladder control changes. Further the care plan did not address individualized interventions to restore, maintain, or prevent worsening. During an interview on 8/2/24 at 8:15 a.m., NA-S indicated R2 would use urinal if he remembered but wore brief and staff were responsible for changing. NA-S further stated R2 was not on scheduled toileting or check and change program. During an interview on 8/6/24 at 12:46 p.m., NA-D stated R2 used a urinal and wore a brief. R2 was frequently incontinent and needed staff assist with managing his brief. NA-D was not aware if R2 was on a scheduled toileting or check and change program. During an interview on 8/2/24, DON stated the bowel and bladder assessment was completed on admission. If the resident was continent it would not trigger a care plan focus for bowel and bladder. DON stated it was her expectation staff followed the facility's bowel and bladder evaluation policy. Review of facility's policy entitled Bowel and Bladder: Evaluation. Assessment, Toileting Programs- Rehab/Skilled, dated 5/21/24, did not identify timing of assessments outside completion of Care Area Assessment and/or protocals for when residents had a change in condition/function. The policy included the following: -Based on the resident's comprehensive assessment, the location will ensure that each resident with bowel and bladder incontinence will receive appropriate treatment and services to restore as much normal bowel and bladder functioning as possible. -Check and change every two hours would not be considered a scheduled toileting program on the MDS. -The type of incontinence should be identified based on information obtained and evaluated using the Bladder Evaluation UDS, and the Care Area Assessment (CAA). -Care plan interventions should be individualized based on the CAA and modified as appropriate based on an assessment/evaluation of the resident's response to the interventions and success with attaining/maintaining bladder continence. -individualized program will be communicated to staff members via PCC/POC-Kardex and the 24-hour Report and Shift Report in PCC.

Based on observation, interview, and document review the facility failed to ensure an injury of unknown was consistently assessed and monitored for healing progress for 1 of 3 residents (R1) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/4/24, indicated R1 was at risk for pressure ulcer development and R1 always required heel protectors on while in bed. R1's physician progress note dated 1/9/24, revealed R1 was assessed, and no skin concerns were identified. R1's Skin Observation revealed: -On 1/21/24, R1 was noted to have a small brown area on left heel. -On 1/28/24, lacked evidence of R1's heel progress. -On 2/4/24, R1's left outer heel had a small, scabbed area. R1's Wound Data Collection dated 2/6/24, indicated R1 had a distal scabbed area on left heel and was noted to be 2 centimeters (cm) in length and 1 cm wide. Scab was noted to be firmly attached and no redness or drainage was noted. Further, documented indicated scabbed area was left open to air and heel protectors were on. On 2/8/24 at 1:15 p.m., director of nursing (DON) stated R1 was at risk for developing pressure ulcers due to diagnosis or paraplegia as well as incontinent of bowel. DON stated she was made aware of the wound on R1's heel on 1/17/24 by R1's family. DON stated she observed and assessed the wound on 1/17/24 and noted there was a small, scabbed area. DON stated she was unsure how R1 obtained the wound on his heel, since R1 was quadriplegic and unable to move his legs and required heel protectors on while in bed. DON stated she only interviewed staff that were on shift on the evening of 1/17/24 when she was made aware of the scab and did not have evidence for those interviews. R1's record lacked evidence of an incident occurring between 1/9/24, when R1 was assessed by a physician, and 1/17/24, when facility management were made aware by family of a wound on R1's ankle. R1's record lacked evidence of new and/or revised interventions following a new wound on his ankle as well as any additional staff monitoring/auditing to ensure staff were utilizing R1's heel protectors appropriately to prevent wounds on R1's ankles. Review of facility policy titled Abuse and Neglect revised on 7/6/23, indicated the investigation team will review all incidents no later than the next working day following the incident, ensure someone was assigned to complete the investigation and that the care plan has been updated with any new interventions. Further, policy indicated the investigation may include interviewing employees, residents or other witnesses to the incident, interview all involved including the resident.

Based on observation, interview, and document review the facility failed to provide an altered diet as prescribed for 1 of 2 residents (R3) reviewed for nutrition. Findings include: R3's quarterly Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included dementia, diabetes, and dysphagia. Further, MDS revealed R3 had severely impaired cognition and required a mechanically altered and therapeutic diet. R3's physician orders dated 10/2/23, indicated R3 required a pureed textured diet. R3's care plan as of 2/6/24, indicated R3 was able to independently eat at times however required cues from staff as R3 was noted to stop chewing. Staff were expected to assist R3 was eating if needed and give R3 small bites. On 2/6/24 at 5:45 p.m., R3 was served her dinner plate by dietary aid (DA)-A. Nursing assistant (NA)-A was seated on R3's right side, assisting R3 with her meal. NA-A was noted to say R3 would not eat for NA-A. R3 was observed to have mashed potatoes and pasta noodles with red sauce on her plate. NA-A stated she was assisting R3 with her meal but was unsure what kind of diet R3 required. At 5:51 p.m., NA-B confirmed R3 required pureed food and stated, she was unsure why her pasta was like everyone else's and was so noodly. NA-B removed R3's dinner plate and brings the plate to the kitchen window where director of nursing (DON) was standing and stated R3 needed a new plate as she required pureed food. At 5:54 p.m., NA-A confirmed R3 did not eat any of the pasta, but NA-A attempted to give R3 bites of the pasta. DON brought R3 a different plate with pureed food. R3 was not observed to be coughing or in any distress during the observation. On 2/7/24 at 12:02 p.m. cook (C)-A stated the cook would be expected to dish each resident's meal according to their diet order which was located at the top of each resident's diet card. Prior to giving the plate to the resident, staff would be expected to verify the plate was the correct diet and the plate was going to the correct resident. On 2/7/24 at 1:49 p.m., C-B stated staff were expected to refer to each resident's dietary order that was listed on their dietary card while dishing up food to the plate. Once the food was on the plate, the plate and card were given to the next staff who would then ensure they have the right person and the correct diet. On 2/7/24 at 1:52 p.m., C-C stated each resident's diet order was on their dietary card that staff were expected to reference while dishing up the resident's plate. C-C stated the plate then was handed to another staff and they are expected to verify the plate matches the diet order and the correct resident prior to serving the resident the plate. Further, C-C stated on the evening of 2/6/24, the two dietary aids began to lay out the dietary cards for the cook and they would get them mixed up. C-C stated she recalled R3's plate returning to the kitchen as it was not the correct diet or the correct resident the plate was given too. C-C stated on that same evening this happened approximately 2-3 times plates were brought back due to the dietary aids not paying attention and not jiving. On 2/7/24 at 2:21 p.m., NA-C stated each resident's diet was listed in their chart in the electronic record system as well as the dietary staff had dietary cards that listed the diet order as well. NA-C stated each staff would be expected to verify the dietary card prior to serving the plate to the resident to ensure they receive the correct diet. Further, NA-C stated R3 required pureed food and was not aware of any incidents of R3 choking or not receiving the correct diet. On 2/7/24 at 3:06 p.m., NA-B stated each resident's diet was listed on their care plan or on their dietary card. However, NA-B stated if staff were assisting a resident at the table and did not assist with serving the plate or if the staff was new, staff would not be aware of the resident's diet order as the staff who delivers the plate to the resident would be expected to verify the plate with the diet order prior to serving the plate and takes the dietary card back to the kitchen. Further, NA-B stated she was unsure what had exactly happened on 2/6/24,but stated the dietary aids did not do their double check to verify it was the correct resident and correct diet prior to serving when R3 was served a regular diet meal instead of pureed. NA-B stated there have not been any incidents of R3 choking that she was aware of. On 2/7/24, DA-A stated each resident had their own dietary card which staff would be expected to verify the plate with the dietary card to ensure they match prior to delivering the plate to the resident. Further, DA-A stated on the evening of 2/6/24, was chaotic and confirmed he did not complete the double check to verify the diet order and the plate matched prior to serving R3 her meal. On 2/7/24 at 3:29 p.m., DON stated the cook was expected to verify resident's diet order when dishing up their plate, then hand the plate and dietary card to another staff member who will look at the dietary card and plate and verify the correct diet and deliver the plate to the resident. DON stated she was aware R3 did not receive pureed diet and has since re-educated all staff on the facility process for verifying diets. Review of facility policy titled Diet Orders- Food and Nutrition revised 5/3/23, revealed a diet card is a communication tool that informs employees of resident diet information and preferences. The policy lacked staff direction of meal delivery process to ensure resident's receive correct diet per physician orders.

Based on observation, interview, and record review, the facility failed to accommodate the needs for 1 of 1 residents (R1) who required a two-handled cup for drinking liquids. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/5/24, directed staff to place table over bed lined up with paper on the wall, in front of R1 but not over his hands. R1 requires moderately thick water to be on the table in a double handled cup with a lid. On 2/6/24 at 4:51 p.m., R1 was observed laying in his bed which was along the wall, bed side table was noted to be in the middle of the room and had a one handled water pitcher on it. There was a bright orange sign posted on the wall, on R1's right side, that directed staff to place bedside table lined up with the paper and moderately thick water to be placed on the table in a double handle cup with a lid. There was also a plastic disposable cup with thickened water placed on R1's nightstand. R1 confirmed he was not able to reach either cup of water without having to call for staff assistance. On 2/6/24 at 5:06 p.m., nursing assistant (NA)-A and NA-B enter R1's room to assist R1 and upon exiting R1's room NA-B offered R1 a drink from the plastic disposable cup however, R1 declined. After exiting the room, NA-B was asked about the sign posted to R1's wall, however NA-B was unaware of the sign. NA-B stated she had never seen R1 have a double handled cup and was unaware he required one. NA-B stated usually R1 had a one handled mug and a disposable plastic cup with thickened water in his room. NA-B continued to walk down the hallway and did not return to R1's room with a two handled cup of thickened water and did not move R1's bedside table to be within reach of R1. At 5:56 p.m., R1 continued to be in his room, bed side table remained in the middle of his room with a one handled pitcher on it and out of reach for R1. On 2/7/24 at 2:21 p.m., NA-C stated R1 required moderately thick liquids with a double handled cup and staff were directed to ensure bed side table within front of R1 within reach. On 2/7/24 at 3:40 p.m., licensed practical nurse (LPN)-A stated R1 required thickened liquids in a two handled cup due to limited movement in his arms. On 2/8/24 at 10:06 a.m., registered nurse (RN)-A stated R1 was admitted to the facility following an accident which resulted in a neck fracture and now was unable to move legs and had some movement of arms. R1 required thickened liquids in a two handled cup so he would be able to independently take a drink when desired. On 2/8/24 at 1:15 p.m., director of nursing (DON) stated R1 required total assistance by staff for activities of daily living (ADLs). Further, DON stated R1 required thickened liquids in a two handled cup as the handles were easier for R1 to grab onto with his limited mobility of arms and hands. Review of facility policy titled Care Plan revise 11/1/23, revealed each resident would have individualized, person-centered, comprehensive plan of care that would include measurable goals directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs.

Based on observation, interview, and document review the facility failed to ensure an injury of unknown was consistently assessed and monitored for healing progress for 1 of 3 residents (R1) reviewed. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of quadriplegia, fracture of neck and dysphagia. R1's care plan revised on 1/4/24, indicated R1 was at risk for pressure ulcer development and R1 always required heel protectors on while in bed. R1's physician progress note dated 1/9/24, revealed R1 was assessed, and no skin concerns were identified. R1's Skin Observation revealed: -On 1/21/24, R1 was noted to have a small brown area on left heel. -On 1/28/24, lacked evidence of R1's heel progress. -On 2/4/24, R1's left outer heel had a small, scabbed area. R1's Wound Data Collection dated 2/6/24, indicated R1 had a distal scabbed area on left heel and was noted to be 2 centimeters (cm) in length and 1 cm wide. Scab was noted to be firmly attached and no redness or drainage was noted. Further, documented indicated scabbed area was left open to air and heel protectors were on. On 2/7/24 at 8:30 a.m., family member (FM)-A stated on the day of R1's care conference, R1 had a pressure ulcer on his left heel and FM-A had reported it to staff as well as reiterating the importance of staff utilizing R1's heel protectors while he was in bed. FM-A stated staff were not aware of R1's heel and there had been nothing documented at that time in R1's medical record regarding his heel. On 2/7/24 at 2:21 p.m., nursing assistant (NA)-C stated R1 required total assistance with all activities of daily living (ADLs). Further, NA-C stated R1 had one sore on his heel and required heel protectors on while he was in bed. On 2/7/24 at 3:06 p.m., NA-B stated R1 was required to wear heel protectors while in bed however was not aware of any wounds on R1's heels. On 2/7/24 at 3:40 p.m., licensed practical nurse (LPN)-A stated licensed nursing staff were expected to complete a skin assessment at least weekly and when no skin impairments are observed. LPN-A stated if there are new skin impairments noted, registered nurse (RN)-A would be notified as well to assess the resident. Further, LPN-A stated R1 was quadriplegic and required heel protectors. LPN-A stated there was no open sore on R1's heel currently. On 2/8/24 at 9:04 a.m., LPN-B stated R1 had a small circle wound on his heel but had not seen his heel for a while so was unsure what it currently looked like. LPN-B stated the would was pressure related due to R1 spending prolonged time in bed however R1 always wears heel protectors. At 9:13 a.m. LPN-B entered R1's room, removed R1's heel protector and stated there was an area on his left heel that appeared to be scabbed over and looked like it was healing. On 2/8/24 at 10:06 a.m., RN-A stated a skin observation assessment would be expected to be completed by a licensed nurse weekly on each bath day and if something new was noted. A wound assessment would be completed if a wound was identified which would be completed by the resident's case manager. Further, RN-A stated R1 was admitted to the facility following a fall which resulted in a neck fracture, and R1 was unable to move his legs but had some movement in his arms. RN-A stated she was made aware of R1's wound on his heel in January and stated the wound could be pressure related but looks like a regular scab currently. RN-A stated R1 was at risk for pressure ulcers and staff were to apply heel protector boots onto both of R1's feet. RN-A stated staff were utilizing R1's heel protector boots but was unsure how a wound could have occurred on R1's heels but stated the wound has not changed since RN-A first saw it on 1/17/24. RN-A was unsure what could have caused the wound on R1's heel and stated the wound could be pressure related or and incident had occurred with staff bumping R1's ankle on something. However, RN-A had not received any incident reports regarding any incidents. Further, LPN-A confirmed once R1's wound on his left heel was identified, the licensed nurse should have been monitoring the wound at least weekly and documenting the assessment in R1's medical record. On 2/8/24 at 1:15 p.m., director of nursing (DON) stated R1 was at risk for developing pressure ulcers due to diagnosis or paraplegia as well as incontinent of bowel. DON stated she was made aware of the wound on R1's heel on 1/17/24 by R1's family. DON stated she observed and assessed the wound on 1/17/24 and noted there was a small, scabbed area. DON stated she did not think R1's wound was pressure related but was unsure if a licensed nurse completed an assessment in R1's medical record regarding the wound. Further, DON stated if a wound was identified, RN-A would be expected to complete a weekly wound assessment until the wound was healed. Review of facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised on 4/26/23, directed staff if a bruise, contusion, skin tear, or abrasion was noted it should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation assessment and on the resident's care plan.

Based on observation, interview, and document review, the facility failed to mark/date opened containers of food stored in one of three kitchen refrigerators, stand-up freezer, and walk-in freezer, failed to ensure expired food were identified and removed, and failed to ensure the walk-in freezer vent was in safe working condition and food was stored away from leaking vent. This had the potential to affect all 47 residents who were served food and beverages from the facility kitchen. Findings include: During observation and interview of the kitchen on [DATE] at 12:36 p.m., with dietary manager (DM)-A, observed food items in the walk-in refrigerator, walk-in freezer, standup freezer, and resident refrigerator that were not dated or marked and/or were expired. DM-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators and freezers should be gone through at least weekly to check for expired or damaged food. DM-A indicated if any food or drink item was not marked/dated when opened, it should be removed immediately. DM-A indicated all left-over prepared food items when marked were good for 7 days from prepared date if refrigerated or 1 year if frozen. The following items were observed during tour: Walk-in refrigerator: 1. Pre-packaged clear 2 lb bag of spinach, ,d+[DATE] full, unmarked/undated, packaging arrival date [DATE], spinach appeared dried/shriveled 2. Pre-packaged clear 2 lb bag of romaine lettuce, ,d+[DATE] full, unmarked/undated, packaging arrival date [DATE], lettuce appeared brown in discoloration, had increased moisture present 3. Mrs. Gerry's egg salad 5 lb. container, opened [DATE], expiration on container [DATE] 4. Coleslaw in facility container, ,d+[DATE] full, prepared on [DATE], no use by date, appeared to have a moderate amount of clear liquid on top of coleslaw Stand-up freezer: 1. [NAME] O Turkey- 2 lbs, expiration date of [DATE], uncovered, moderate amount of ice present to meat 2. Corn beef in facility container, ,d+[DATE] full, prepared on [DATE], lid unsecured from container, moderate amount of ice inside container covering corn beef Resident refrigerator: 1.15 small fresh tomatoes in a plastic grocery bag, unmarked/undated, tomatoes appeared moist with dark discoloration, white discolored areas with white fuzz present, foul in odor Walk-in freezer: 1. Hamburger patties (approx. 8) present in clear plastic packaging, opened to air, unmarked/undated, moderate amount of ice particle present to patties 2. Hot dogs (approx. 4) unsealed in plastic packaging, open to air, unmarked/undated, moderate amount of ice particle present to hot dogs An initial walk through of the kitchen was completed with dietary manager (DM)-A on [DATE] at 1:07 p.m., observed the walk-in freezer had a large amount of condensation present to freezer vent, large amount of ice present on coiling, a ,d+[DATE] tier metal rack containing frozen food items directly below freezer vent, top tier containing frozen sealed loafs of bread were completely covered with large chunks of ice, sporadic smaller ice chunks on boxes containing frozen foods to rest of metal tiers, ice spots noted to walk-in freezer flooring next to metal rack. DM-A indicated awareness of condensation build-up to freezer vent over past ,d+[DATE] weeks, maintenance checked out and cleared condensation build-up, stated condensation continued. DM-A stated same issue occurred approx. ,d+[DATE] months. ago, had to contact refrigeration company to fix. DM-A indicated would notify maintenance to check freezer vent, stated administrator aware of freezer vent not working appropriately. While interviewed on [DATE] at 11:25 a.m., DM-A indicated maintenance evaluated walk-in freezer vent, maintenance stated insulation to freezer vent was failing and needed to replace which could take up to approx. 1 week, depending upon arrival of parts needed to fix insulation. During an interview on [DATE] at 6:00 p.m., the administrator indicated was notified of walk-in freezer vent malfunctioning per DM-A earlier today, stated was not aware issue had been going on for at least 1 week nor was aware walk-in freezer vent had malfunctioning issues ,d+[DATE] months. ago. The administrator indicated dietary staff should notify maintenance right away if equipment was not working properly for first time issues, stated if equipment malfunctioning is a recurrence, staff were aware and it was his expectation to notify him first of concerns right away. A walk through of the kitchen walk-in freezer was completed with the administrator and regional nursing director (RND) on [DATE] at 6:11 p.m., administrator and RND confirmed walk-in freezer had large amount of condensation present to freezer vent, large amount of ice present on coiling, metal racks containing frozen food items present directly below freezer vent and covered with ice chunks, and ice spots present to flooring next to metal rack. RND indicated food boxes on metal rack, directly below freezer vent, should be removed immediately to prevent any possible food contamination. The administrator indicated would follow-up to ensure freezer vent was fixed as soon as possible. Facility policy titled Food-Supply Storage, dated revised/reviewed [DATE], indicated foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly; dates are checked on a regular basis, foods/fluids that have expired or are otherwise unsafe for use are discarded; food items prepared for the service that were not served subsequently are stored for use within 7 days per food code; product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Facility policy for safe operating equipment was requested, not received.

Based on observation, interview and document review, the facility failed to ensure sufficient staff to provide and meet the assessed needs for 4 of 4 residents (R26, R27, R35, R250) who voiced concern with lack of sufficient staffing in the facility and/or were observed to have assessed needs not provided per staff. In addition, the facility failed to ensure sufficient staff to provide assistance with meals. The lack of sufficient staff had the potential to affect all 47 residents who resided in the facility. Findings include: R26 R26's face sheet printed on 10/18/23, included diagnoses of Parkinson's disease (abnormal body movement), muscle weakness, atrial fibrillation (abnormal heart rate), gait abnormality, cognitive-communicative deficit (abnormal thinking/speaking), hypovolemia (low blood volume), hypotension (low blood pressure), abnormal coagulation (blood clotting), and frequency of micturition (frequency of urination) R26's significant change in status minimum data set (MDS) assessment dated [DATE], identified R26 had moderately impaired cognition, had clear speech, was able to understand and was understood by others. R26 required substantial/maximal assistance from staff for bed mobility, dressing, bathing, and ambulation, and partial/moderate assistance from 1 staff with transfers, toileting, and personal hygiene. R26 used a walker and wheelchair for mobility, was independent of locomotion in wheelchair. R26's care plan printed on 10/18/23, indicated R26 needed assistance from 1 staff member with ambulation, bathing, bed mobility, transfers, personal hygiene, and toileting. Staff responsible for these activities were identified as nursing assistants and nurses. During an interview on 10/16/23 at 5:03 p.m., R26 reported facility not having enough staff present, indicated at times only 1 nursing assistant (NA) available to care for all residents on unit, occasionally waited longer than 20 minutes for staff to provide assistance which occurred more during evening hours. While interviewed on 10/18/23 at 10:25 a.m., R26 indicated it upset her and made her feel uncared for about by staff when having to wait long times for staff assistance. R26 stated she realizes staff were busy and caring for other residents too, would like to be notified by staff if going to be awhile caring for other residents, being left to sit and wonder if anyone knows she's waiting or wondering if staff are even around on unit was bothersome. R26 reported she was paying a lot of money for services and not getting money's worth. R27 R27's face sheet printed on 10/18/23, indicated diagnoses of hemiplegia and hemiparesis (paralysis) of left side of body, cerebral infarction (stroke), type 2 diabetes mellitus ((DM)- abnormal blood sugar), cognitive-communicative deficit, muscle weakness, major depression (mood disorder), and pain. R27's quarterly MDS assessment dated [DATE], indicated R27 had intact cognition, had clear speech, was able to understand others and was understood by others, had impairment to left upper extremity and bilateral lower extremities. R27 required set-up by staff for meals, was dependent upon 2 staff members for bed mobility, transfers, toileting, dependent upon 1 staff member for dressing lower body, personal hygiene, and locomotion in wheelchair off unit, and required substantial/maximal assistance from 1 staff member for bathing and dressing upper body. R27 did not ambulate. R27's care plan printed on 10/18/23, indicated R27 required 2 staff to assist with bed mobility, transfers, dressing, needed 1 staff to assist with bathing cares- whirlpools 3 times each week per provider orders for muscle spasms; required 1-2 staff assistance for personal hygiene, staff to check on R27 every 2 hours and assist with toileting as needed. Staff responsible for these activities were identified as nursing assistants and nurses. During an interview on 10/16/23 at 6:47 p.m., R27 indicated there were times she didn't receive 3 baths as scheduled each week because there was not enough staff available to provide all scheduled baths for residents for the day, stated she was typically provided 2 baths each week. R27 reported because of being short-staffed, she has had to wait for staff assistance 30-60 minutes, staffing worse during evening hours and on weekends, sometimes had only 1 NA available to assist residents for entire unit. R27 indicated staff will also come into room to shut call-light off and say they will be back in just a couple minutes after helping another resident, staff occasionally would not come back to room, R27 would put call-light on again. While observed and interviewed on 10/16/23 at 6:57 p.m., R27 visualized eating supper meal in room, stated supper meal typically served between 5-5:30 p.m., indicated received supper meal tray at approx. 6:15 p.m. R27 reported she always ate meals in room, meals routinely served late and typically were cold when served. R27 reported while eating meal, meal at time served was cold, staff warmed meal up and was better. R35 R35's face sheet printed 10/18/23, indicated diagnosis of dementia (brain disorder), macular degeneration (visual impairment), rheumatoid arthritis (inflammation of joints), chronic pain, muscle weakness, malaise (tiredness), and anxiety. R35's quarterly MDS assessment dated [DATE], indicated R35 had intact cognition, had adequate hearing and vision, clear speech, was understood and could understand others. R35 required partial/moderate assistance from 1 staff for bed mobility and transferring to chair, substantial/maximal assistance from 1 staff with dressing, toilet transfers, toileting hygiene, and ambulation in room with walker. R35 required 1 staff to assist with locomotion off unit in wheelchair. In addition, the MDS indicated R35 had occasional urinary incontinence, was always continent of bowel. R35's care plan printed on 10/18/23, indicated R35 required 1 staff to assist with ambulation and use of walker while in room, to use wheelchair for longer distances; needed 1 staff to assist with bed mobility, transfers, bathing, dressing, grooming personal hygiene, and toileting. Care plan also indicated for staff to toilet every 3 hours and as needed, wake up per R35's request to toilet between 5-5:30 a.m. Staff responsible for these activities were identified as nursing assistants and nurses. During an interview on 10/16/23 at 2:23 p.m., R35 indicated waiting more than 20 minutes for staff assistance frequently, at least 3 times each week, typically occurs during morning. R35 reported waiting longer than 45 minutes this morning, had a urinary accident, stated rarely incontinent of urine, urinary accident due to waiting too long for staff assistance. While interviewed on 10/18/23 at 10:22 a.m., R35 indicated had been informed per staff to wait until staff could assist with transfers, couldn't hold urine any longer as it had been a long time waiting for staff assistance, made her feel bad about herself having urinary accident. R250 R250's care plan was revised and printed on 10/18/23; indicated R250 was an early riser, staff to offer to assist or supervise with AM/PM cares, required supervision and cues with personal hygiene- offer to assist if required, and staff to assist with bathing cares twice weekly on Tuesday and Saturday during day. R250's face sheet printed 10/18/23, indicated diagnoses of failure to thrive (overall decline in general health), scoliosis (abnormal curvature of spine), and spondylosis (spinal degeneration). R250's admission MDS assessment dated [DATE], indicated R250 had intact cognition, had adequate hearing and vision, clear speech, was understood and understands others. R250 required supervision to limited assistance by 1 staff for all activities of daily living (ADLs), bathing cares completed twice weekly. R250's care plan printed on 10/18/23, indicated R250 required staff to supervise and/or provide 1 staff to assist with AM/bedtime (HS) cares, bathing cares to be provided on Tuesday/Saturday day shift, toileting schedule every 2 hours. Staff responsible for these activities were identified as nursing assistants and nurses. During an interview on 10/16/23 at 2:40 p.m., R250 indicated had 1 bath since admission on 10/4/23, stated scheduled to have bath twice weekly, unsure of scheduled days. R250 reported facility was short staffed and does not always have time to complete resident cares. Call-lights reviewed for R26, R27, R35, and R250, reviewed from 10/3/23-10/15/23, concerns of long wait times noted for R27 and R35. R27 10/9/23 at 8:20 a.m. waited 1-hour 40 min. 10/9/23 at 7:28 p.m. waited 44 min. 10/10/23 at 6:06 a.m. waited 57 min 10/10/23 at 7:37 a.m. waited 1-hour 16 min. R35 10/7/23 at 8:56 p.m. waited 44 min. 10/9/23 at 7:36 a.m. waited 50 min. 10/10/23 at 6:19 a.m. waited 1-hour 29 min. 10/13/23 at 6:47 p.m. waited 40 min. 10/15/23 at 7:30 a.m. waited 1-hour 12 min. 10/16/23 at 7:37 a.m. waited 1-hour 12 min- had a urinary accident. Bathing reviewed for R26, R27, R35, and R250, reviewed from 7/1/23-9/30/23, concerns of scheduled bathing cares not provided based on documentation noted for R27 and R250. R27 7/3/23- not provided 7/10/23- not provided 7/22/23- not provided 7/24/23- not provided 7/26/23- not provided 7/29/23- not provided 8/5/23- not provided 8/19/23- not provided 8/21/23- not provided 8/23/23- not provided 8/26/23- not provided 8/28/23- not provided 8/30/23- not provided 9/27/23- not provided 9/30/23- not provided R35 10/7/23- not provided 10/10/23- not provided 10/14/23- not provided 10/17/23- not provided Dining An interview was completed during initial kitchen tour on 10/16/23 at 12:36 p.m., with dietary manager (DM)-A, indicated had open dining, mealtimes served at 7:30 a.m. until 9 a.m., 12 p.m., and 5:30 p.m. During an observation on 10/16/23 at 5:16 p.m., noted 27 residents lined up in hallway, behind closed doors to dining room entrance, doors to dining room opened at 5:20 p.m. Staff began seating residents at assigned seat at table, dining room staff began delivering meals to residents seated at tables. At 5:54 p.m. 5 unknown residents dispersed between 2 tables designated for staff to assist with reminders/cues for meal, 5 unknown residents dispersed between 2 additional tables designated for staff to assist with feeding of meal. NA-F began assisting with feeding of 3 residents at one table, NA-G began feeding 2 residents at another table. Both NAs would frequently get up from feeding residents at table to walk over to reminder/cue tables to remind/cue, occasionally assist with feeding other 5 residents. Both NAs appeared hurried with feeding cares between the 4 tables. While interviewed on 10/16/23 at 5:55 p.m., NA-F indicated difficulty trying to assistance with feedings indicated for 10 residents sitting at 4 different tables, reported feeling short-staffed, stated had informed management of feeling overwhelmed with cares and being short-staffed, had not received any support from management. During an interview on 10/16/23 at 6:02 p.m., NA-G indicated staffing had been good over summer months, a lot of staff went back to college this fall and now was short-staffed. NA-G reported short-staff worsening with many staff calling-in reporting not able to work. NA-G indicated management aware of staffing issues, had an all staff meeting to discuss concerns with short-staffing 1 week ago, management listened to staff concerns, management had not provided resolution to short staff issues at time. While observed and interviewed on 10/16/23 at 6:19 p.m., noted last meal being served, on covered tray on cart to R27. R27 stated meal served late, tasted fine, and temperature of meal served was ok. During an observation and interview on 10/17/23 at 10:41 a.m., R27 noted to have just finished breakfast meal in room, stated breakfast was served to room late at approx. 10 a.m., had oatmeal and a pastry, indicated breakfast meal tasted good and temperature was ok. While interviewed on 10/17/23 at 10:56 a.m., DM-A indicated meal trays were served to units when nursing staff informed dietary staff of being ready to deliver meal trays to rooms, stated if meal trays delivered to resident units were late, needed to check with nursing staff as to why meal trays delivered late. During an interview on 10/17/23 at 11:05 a.m., NA-D indicated facility short-staffed, stated feels rushed to complete resident cares and sometimes cares not able to be completed. NA-D reported 1-2 NAs per entire facility during shift, stated should have 2-3 NAs to sufficiently care for residents, indicated lots of staff call-in to report not able to work scheduled shifts. While interviewed on 10/17/23 at 1:30 p.m., NA-B indicated confirmed resident cares were not completed timely, sometimes cares missed, cares. NA-B stated residents waited a long time for staff assistance, occasionally more than 30 min, confirmed scheduled baths missed, scheduled toileting late, and meal trays delivered to residents on unit untimely. NA-B stated nursing was short-staffed, management aware of short-staffing and management informed nursing staff to do what they can get done during shift as solution, management does not assist nursing when asked. During an observation on 10/17/23 at 1:51 p.m., observed R27's dinner meal tray on bedside table, R27 meal tray not delivered until 1:15 p.m., R27 reported food tasted good and meal served was hot. While interviewed on 10/18/23 at 5:16 p.m., registered nurse (RN)-C, also known as case manager and social services (SS)-A, confirmed awareness of short staffing. RN-C indicated staffing had started to improve over past 2 months. RN-C and SS-A indicated besides their roles at time, had also been pulled to work on floor frequently during day/evening hours and weekends. RN-C stated when pulled to work on the floor, had to work as licensed nurse and NA. SS-A indicated when pulled to work on floor worked as NA. NA-C and SS-A confirmed due to short staffing, residents had missed scheduled baths, call-lights were answered late, toileting and repositioning cares missed or untimely, meals served late. RN-C indicated administrator and director of nursing (DON) aware of staffing issues and working to correct, RN-C stated nursing staff were informed per administrator and DON that the corporate manager reviewed acuity level of cares being provided and the census of residents residing in facility, based on review acuity lower than census, therefore no need to hire more staff. RN-C indicated the ability to hire more staff was based on a point system, point system based on nursing staff documentation. RN-C reported inaccuracies in nursing documentation, stated nursing staff would document basic information needed in medical records as not given time needed to complete accurate assessments and documentation, indicated all nursing staff too busy caring for residents, thus affecting the point system to reflect lower acuity and no additional staffing need. SS-A reported staffing issues also due to newly hired staff pushed to floor when not ready and orientation not fully completed, newly hired staff became overwhelmed and exhausted by workload expectations right away and then quit. During an interview on 10/18/23 at 5:45 p.m., the administrator confirmed staffing issues, verified resident cares missed and/or not completed timely, meals served late. The administrator indicated for concerns due to short-staffing, administrator had been advertising through talent acquisition and rotary, offering bonuses and incentives for staff to pick up open shifts, had contracted agency staffing to reduce workload for regular employees and allow for regular employees to have additional time to document and complete assessments more accurately, and was working with corporate QAPI coordinator to root cause staffing issues. The administrator reported meeting with family members more often to address any resident care concerns they had, expected staff to notify management of resident care concerns right away when occurred to follow-up on timelier, indicated was in process of working with corporate management on re-development plans for staffing and resident care concerns. -Facility policy titled Nursing Services Staff, date reviewed/revised 10/21/22, indicated to provide appropriate staff for resident care in the nursing services department, the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; the facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Other nursing personnel, including but not limited to nurse aides. -Facility policy titled Activities of Daily Living, date reviewed/revised 11/29/22, indicated purpose to provide residents with the appropriate treatment and services to maintain or improve abilities in activities of daily living (ADLs) for the well-being of mind, body, and soul. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. -Facility policy titled Bathing, date reviewed/revised 8/29/23, indicated purpose to promote cleanliness and general hygiene. Procedure: 1. Review in EMR for bathing instructions -Facility policy titled Dining Service Standards, date reviewed/revised 7/21/23, indicated employees will: as necessary, provide assistance in dining in a way that maintains dignity and focuses on quality of life.

Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 47 residents. Findings include: Review of quarterly QAPI meetings from January 2023 through April 2023, identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to analyze and document that process identified in: January 2023 1. The aim was to reduce falls with major injury, the data identified the state norm, the national norm, and the facility rate. The QAPI minutes lacked any indication of a measurable goal, or an action plan to improve the rate of falls with major injury. 2. The aim was to reduce significant weight loss with a goal to have less than 3 residents without a program trigger for significant weight loss. The data identified there were 4 triggered in November and 3 triggered in December. The QAPI minutes lacked any indication of an action plan or plan for follow up. April 2023 1. The aim was again to reduce falls with major injury, the data submitted identified falls with major injury at the facility had increased to 5.1% since the January QAPI meeting. The action plan was to Dig into falls with major injury triggers The data lacked any indication that the committee completed any analysis to determine what was causing the falls or an indication that they had developed any meaningful action plan to help reduce the prevalence of falls at the facility. 2. High risk pressure ulcers were identified, the data submitted identified the state norm was 7.6% and the facility rate was 11.5%. The QAPI minutes again lacked any indication that the data had been analyzed to identify what may be causing the increase in pressure ulcers or any indication of an action plan to help reduce the risk for pressure ulcers. April 2023 QAPI minutes also identified a performance improvement project (PIP) Glucometer cleaning, the minutes noted under action plan will continue to review every QAPI. The minutes did not identify a meaningful action plan or any other data regarding the PIP. Interview on 10/17/23 at 11:54 a.m., QAPI coordinator identified that he oversees the QAPI program but that he is new to this position and is still learning the process for his role as QAPI program coordinator. Interview on 10/18/23 at 4:04 p.m., administrator identified it is his expectation that the QAPI committee would identify problems, analyze the data, and implement an action plan per the facility policy and any state or federal regulations. Review of the 2023, QAPI plan identified the committee would systematically analyze and prioritize quality deficiencies, develop action plans, and monitor for effectiveness.

Based on interview and document review the facility failed to ensure the resident care plan was updated to reflect the most recent comprehensive assessment to assure safe transfers for 1 of 5 residents (R1) reviewed for transfers. The facility's failures resulted in harm when R1 suffered a femur fracture after being inappropriately transferred. Findings include Facility Reported Incident (FRI) submitted to the State Agency on [DATE], identified nursing assistant (NA)-A had pivot transferred R1 to the sit on the toilet when R1 complained of pain in her left knee and could not stand to transfer off the toilet to the wheelchair. NA-A used a mechanical sit-to-stand lift to attempt to transfer her when R1's knee gave out and she was lowered to the floor. NA-A summoned a nurse to assess R1 which resulted in further evaluation at the emergency room . R2 was noted to have a fractured left leg. According to a follow-up report, R2 returned to the facility on [DATE] and died on [DATE]. R1's face sheet dated [DATE], identified a diagnosis of Alzheimer's Disease, [CONDITION(S)], and a history of a left femur (upper leg) fracture. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and required two staff assist with transfers between surfaces and one staff assist for transfers to the toilet. R1 did not walk and required use of a wheelchair for mobility. R1's most recent Sit-Stand-Walk Data Collection Tool dated [DATE], indicated R1 could not pull herself to a standing position and required the use of a sit-to-stand mechanical lift for transfers with a medium sized harness. The tool did not include the number of employees required to assist. R1's most recent MDS progress note dated [DATE], identified R2 required one (1) assist with mechanical sit-to-stand or total lift for transfers and toileting. R1's toileting care plan dated [DATE], gave staff a choice to either toilet with one (1) staff with mechanical sit-to-stand lift and medium harness or have R1 use the grab bars in bathroom to stand. R1's transfer care plan dated [DATE] directed staff to use the mechanical sit-to-stand and medium harness or two (2) staff assist with total lift and medium high back mesh sling when too weak or in pain. R1's care plan was not updated to reflect R1 required the sit-to-stand mechanical lift with one staff assist that was updated on [DATE], Sit-Stand-Walk Data Collection Tool. R1's nursing progress note dated, [DATE], identified the nurse was called to the room by NA-A. R1 was noted to be sitting on the floor leaning against the toilet with legs curled up. NA-A reported the resident became weak and was not able to complete the transfer properly resulting in resident to lose balance and fell to the ground. R1 complained of pain in her buttocks and top of left knee. The nurse's assessment identified R1 had swelling and bruising above left knee and R1 was complaining of severe pain. R1 was transferred to the emergency room by ambulance. A follow up progress note dated [DATE], indicated R1 was admitted to the hospital for a diagnosis of severe distal femur fracture. A progress note dated [DATE], included R1 was not a candidate for surgery and was readmitted to the facility on hospice/palliative cares. Progress dated [DATE], indicated R1 died . During an interview on [DATE], at 12:25 p.m. NA-B indicated she provided cares for R1 and always used the sit-to-stand mechanical lift for transfers. During an interview on [DATE], at 1:50 p.m. NA-C stated she always used a sit-to-stand lift to transfer R1. She further stated although the care plan said you can pivot transfer or use the lift; it had been a long time since she had seen R1 transferred by pivot transfer. During an interview on [DATE], at 2:15p.m. licensed practical nurse (LPN)-A indicated she was working the night of R1's fall and responded to NA-A's request for help. She indicated the sit-to-stand lift was in R1's room with the sling attached to it and R1 was on the bathroom floor. R1's left knee began to swell quickly and sent her to the emergency room . LPN-A stated NA-A had pivot transferred from her wheelchair to the toilet in the bathroom. Stated there were a lot of new NAs. NA's were supposed to follow the resident's Kardex (abbreviated care plan used by direct care staff) or the flow sheet with resident's transfer status on it for quick reference. LPN-A reviewed and verified R1's transfer status on the flow sheet was pivot transfer or sit-to-stand mechanical lift. LPN-A indicated the transfer flow sheet and Kardex did not reflect the most recent transfer assessment on [DATE]. During an interview on [DATE], at 10:35 a.m. NA-D indicated the resident transfer ability was communicated on the computer Kardex; NA's had a printed sheet for quick reference. NA-D indicated R1 always transferred to the toilet with the sit-to-stand lift. R1 could not pivot transfer because even with the use of the sit-to-stand, R1's knees would creak and crack. During an interview on [DATE], at 10:40 a.m. NA-E stated staff followed the resident's Kardex. The Kardex told them how residents were supposed to be transferred according to the care plan. NA-E explained R1 always used the sit-to-stand lift and did not know if R1 would have been able to pivot transfer. During an interview on [DATE], at 10:45 a.m. LPN-B indicated R1 was a sit-to-stand transfer and the NAs were to refer to the resident Kardex for the care planned transfer method. During an interview on [DATE], at 7:15 a.m. NA-A stated she assisted R1 at the time of the incident. NA-A indicated she was employed by a staffing agency but had worked at the facility for a couple months. NA-A explained she had pivot transferred R1 to the toilet and did not use a mechanical lift. However, when it was time to stand up R1 could not stand because her knees hurt. The attempted to stand R1 using the sit-to-stand lift. When she was lifting R1 up, R1's knee gave out so she lowered R1 to the floor. NA-A then took the sit-to-stand sling off, removed the lift from the bathroom, and called the nurse. NA-A indicated she had been trained to transfer R1. NA-A stated she was following the Kardex and R1 could pivot transfer or use the sit-to-stand lift in the bathroom. During an interview on [DATE], at 12:50 p.m. the director of nursing (DON) indicated she did not complete the resident assessments and did not know if the sit/stand/walk assessment determined if a resident could pivot transfer. DON reviewed R1's functional ability assessment and verified the assessment did not identify R1's ability to pivot transfer. Further verified the Kardex was what the NAs would reference to determine how to transfer a resident as the Kardex reflects what the care planned interventions were. DON indicated the facility's incident investigation identified R1 was care planned for either a pivot transfer or a sit-to-stand depending on how she was doing and did not identify the lack of revision to R1's care plan with results from the [DATE] assessment. DON indicated R1's care plan should have been revised after the assessment was completed. The facility did not provide a policy for updating the care plan or mechanical lift transfers.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R3) reviewed who were at risk for pressure ulcer development/deterioration. The facility's failure resulted in R3 sustaining harm when a stage II pressure ulcer on the [MEDICATION NAME] spine became infected resulting in hospitalization and deterioration to a Stage IV pressure ulcer. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) definition of Stage 2 pressure ulcer includes: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. The NPUAP definition of a Stage 4 pressure ulcer includes: Full thickness, skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some part of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. Suspected deep tissue injury are idenfied as persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. R3's face sheet printed 9/17/19, indicated R3 had been admitted to the facility 11/14/13, with [DIAGNOSES REDACTED]. of the aorta and inferior vena cava). R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had intact cognition, occasional incontinence of bowel and bladder, and required extensive assistance of one for bed mobility, transfers, dressing, toileting, personal hygiene and locomotion. Review of R3's Care Area Assessment (CAA) dated 10/5/18, indicated R3 was at potential risk for skin breakdown, although there was no risk score on the Braden assessment, and no current skin issues related to pressure. The CAA identified risk factors including: pressure requiring special mattress or seat cushion to reduce or relieve pressure, altered mental status, newly readmitted , pain and [MEDICAL CONDITION]. Review of R3's plan of care dated 4/2/19, indicated R3 had limited physical mobility related to [MEDICAL CONDITION] and pain. Interventions revised on 9/3/19 included: Turn and reposition as needed; Encourage resident to lay in bed to off load buttock and spine; and Pressure reduction mat in recliner. R3 was identified as having potential/actual impairment to skin integrity related to pain initiated 5/22/14, with last revision 9/13/19. Interventions included: Education to resident/family of causative factors and measures to prevent skin injury; Monitor location, size and treatment of [REDACTED]. During observation and interview on 9/16/19 at 3:55 p.m., R3 was in observed on her bed. There was a specialty air bed mattress on her bed, with the head of the bed set at approximately 9 degrees. R3 stated she previously gone two days without staff changing the dressing on her back, resulting in hospitalization for a week with an infected wound. R3 also stated she had experienced increased pain in her back where the infection and pressure ulcer were located. R3 stated the pain was currently at an 8 on a scale of 1-10 with 10 being the worst pain. However, R3 stated staff give her pain medications to help relieve the pain and stated the specialty air mattress has helped also. Review of a wound assessment conducted 7/17/19 by a registered nurse (RN), indicated R3 had a traumatic wound with modifications to interventions identified as friction/shear management, and to continue with current plan of treatment. Wound data documentation dated 7/17/19, was identified as an initial data collection. The wound site was identified as lower mid-vertebrae with measurements including: length 1.5 centimeters (cm) and width 0.75 cm. The wound description was identified as: Blister, red and purple color, lifting of skin, red surrounding tissue, with no drainage present. The treatment was identified as a [MEDICATION NAME] dressing (a special wound dressing designed to serve as an absorbent dressing for a wide range of exudate for leg and foot ulcers, pressure ulcers, surgical incisions, and traumatic wounds, such as skin tears, blisters, abrasions and secondary healing wounds), to be applied over wound. A message sent electronically to the medical doctor (MD) 7/19/19, included a request for an order for [REDACTED]. Review of an RN wound assessment dated [DATE], indicated R3 had a traumatic wound, and interventions included for staff to continue with current plan of treatment. Wound data collected 7/25/19, indicated the wound was on the vertebrae, measuring length: 1.5 cm and width: 0.75 cm. The assessment indicated a dressing was present and intact with no drainage present. Further the assessment indicated R3 denied pain related to the wound and indicated there was no presence of possible complications. The wound margins or surrounding skin were described as intact and pink. Dressing and/or treatment remained [MEDICATION NAME] dressing. A message sent electronically to the MD 7/29/19, included a request for an order for [REDACTED]. Review of an RN wound assessment dated [DATE], indicated the wound was a suspected deep tissue injury with no modifications to interventions or plan of care. There was no wound data indicated descriptions or measurements of the wound. A nursing home physician notification form dated 8/1/19, indicated R3's wound on her back and coccyx area was enlarging, and included: Just an FYI (for your information) for when you see her on rounds this month. Review of an RN wound assessment dated [DATE], indicated R3's wound was a pressure ulcer stage 2, with no modifications to interventions. A wound data collection tool dated 8/9/19, for the vertebral site included no measurements, and indicated a dressing was present and intact with no drainage present. Further, the wound data collection tool indicated, No presence of possible complications, increasing area of ulceration or soft tissue infection. The wound margins were described as intact and pink, with no undermining or tunneling present. Review of an RN wound assessment dated [DATE], indicated R3's pressure ulcer was a stage 2 with no modifications to interventions necessary for the vertebral site. The wound data collection dated 8/15/19, identified measurements of 1.6 cm length and 1.9 cm width, and indicated an intact dressing was present with no drainage present. The document indicated, there were no possible complications present, wound margins were reddened and the resident was using a [MEDICATION NAME] dressing. Review of a wound data collection tool document dated 8/20/19, lacked measurements of the vertebral wound however, indicated an intact dressing was present with no drainage. No presence of possible complications were present with wound margins intact and pink. A message to the MD dated 8/20/19, indicated R3's wound on the spine was becoming more errythemic (reddened). Request to change foam [MEDICATION NAME] to a foam dressing to be changed every day and as needed. The MD response dated 8/20/19 included: Okay for order. Review of an RN wound assessment dated [DATE], indicated R3's vertebral wound was a stage 2 pressure ulcer. Review of an RN wound assessment dated [DATE], indicated R3 had a stage 2 pressure ulcer on the vertebral spine. The wound data collection tool dated 8/30/19, indicated the pressure ulcer on the vertebral site measured: length of 3 cm, width 3 cm and depth 0.8 cm. The wound data collection documentation further indicated a dressing was present and intact with drainage present and included: No presence of possible complications. However, there was also documentation indicating the wound had drainage, described as moderate serosanguineous (clear liquid swirled with blood) and odor present. The documentation also indicated the dressing and treatment included a foam pad. An electronic message to the MD 8/30/19, indicated R3 Has an open are on her vertebrae, currently dressing with a foam dressing. Measurements are 3 cm x 3 cm x 0.8 cm with serosanguinous drainage. Please advise. The MD response recevied the same day, 8/30/19, included: Continue with foam dressing and change every three days and as needed. Use [MEDICATION NAME] to open areas until healed. R3's treatment administration record (TAR) indicated a foam dressing change was done every 3 days and as needed if soiled, and included [MEDICATION NAME] to open areas until healed to start 8/30/19, at 3:00 p.m. The TAR indicated the treatment was held on 8/30/19 and to see nurses' notes. A progress note dated 8/31/19 at 12:03 a.m., indicated the resident was either in bed or in her recliner. An X was recorded on the TAR for 8/31/19. On 9/1/19, the TAR documentation indicated R3 had refused twice. A progress note documented by an RN 9/1/19 at 9:48 a.m., indicated the resident had informed the nurse she hadn't had the dressing to her back changed for the prior two evenings (8/30 and 8/31). Further the nurse documented she'd found the dressing to R3's back was recorded as on hold for 8/30/19, and for 8/31/19, there was no progress note and the TAR indicated the task had not been completed. No further actions were documented. A wound care assessment dated [DATE], indicated R3's wound dressing was saturated with drainage leaking around the dressing. The assessment further indicated there was a foul smell, and indicated the increased serosanguineous drainage present caused the bandage to detach from R3's skin. Further, the wound was identified as increased in size and R3 complained of pain in the wound area. The documentation indicated [MEDICATION NAME] and a sponge bandage were applied after the wound had been cleansed with normal saline. No measurements were documented. A progress noted dated 9/3/19 at 11:00 a.m., indicated a call had been placed to the clinic regarding R3's deteriorating wound, and an appointment had been made for 1:45 p.m In addition, at 11:03 a.m. a fax was sent to the primary care provider requesting a wound nurse consult for R3's deteriorating wound on her back. The progress notes indicated at 4:05 p.m., R3 was transferred from the clinic to the hospital due to the skin wound/ulcer. The hospital History and Physical documentation dated 9/3/19, indicated R3 had an infected right lower [MEDICATION NAME] wound and had been admitted to the hospital for treatment. A plastics and reconstructive surgery consult note dated 9/4/19 at 5:11 p.m., indicated R3 had a posterior [MEDICATION NAME] wound with thick persistent eschar, slough, and the wound was positive for a foul odor. The note included: The wound measures approximately 4.3 cm x 3 cm x 2 cm and undermines at the 1-4 o'clock positions and the 9-12 o'clock positions at 4.2 cm in depth. A nursing progress note dated 9/13/19, indicated R3 had been discharged from the hospital and readmitted to the facility. A wound assessment completed at the nursing home 9/14/19, indicated R3 had a stage 4 pressure ulcer with the wound requiring debridement using a enzymatic topical application. The wound data collection indicated the wound measured: 3.5 cm length, by 3 cm width, and 2 cm depth. The documentation indicated a dressing was present and there was a moderate amount of serosanguinous drainage with leakage around the dressing, and the wound treatment included a dressing and Santyl ointment with dry gauze daily. During interview with the director of nursing (DON) at 3:50 p.m. on 9/16/19, the DON stated on 9/3/19, she received a visit from a family member who was concerned the facility wasn't working urgently enough on R3's wound and requested a clinic appointment be made for evaluation of the wound. The DON stated after the family member left, an event report was located indicating the dressing changes had been omitted. The DON confirmed upon investigation, there was a two day period in which the MD orders from 8/30/19, for the [MEDICATION NAME] and foam dressing, were not completed. The DON stated R3 had reported to the nurse 9/1/19 that the wound dressing had not been changed in a few days, so the nurse had rescheduled the dressing change for 9/1/19 during the evening shift. However, the DON stated the scheduled wound care was again not completed. The DON stated R3 was sent to the medical clinic on 9/3/19, for evaluation of the wound and was subsequently transferred from the clinic to the hospital. The DON stated she had spoken with the staff member involved who confirmed the dressing changes were not completed. During interview with R3 on 917/19 at 8:17 a.m., R3 consented to allow the surveyor to view the dressing change to her vertebral wound. R3 was observed lying on an air therapy mattress with the head of her bed elevated to 9 degrees. A dressing was observed in place on R3's lower [MEDICATION NAME] vertebral area. The dressing was dated 9/16/19. Registered nurse (RN)-A and licensed practical nurse (LPN)-A were present during the dressing change. After performing hand hygiene, LPN-A removed the old dressing, which was observed to have a moderate amount of serosanguineous drainage present. The wound was confirmed as a stage four pressure ulcer by both LPN-A and RN-[NAME] RN-A completed measurements of the wound which were identified as: 4 cm length by 4 cm width with 3 cm of tunneling present. There was redness present and extending approximately 3 cm around the wound site. The wound was cleansed with sterile saline and sterile gauze, and Santyl was applied to a sterile four by four gauze pad and applied to the wound which was then covered by a second four by four gauze and anchored with a [MEDICATION NAME] dressing. LPN-A stated she had only seen the wound for the past two days, and stated there had been no change in the wound. RN-A stated this was her first visual inspection of the wound. During interview on 9/17/19, at 9:25 a.m., nursing assistant (NA)-A stated they reposition R3 every 2 hours or sooner upon her request. NA-A stated prior to her hospitalization , R3 was in her recliner most of the time but was still repositioned every two or three hours with toileting. During interview on 9/17/19, at 9:32 a.m., NA-B stated they resposition R3 every hour or earlier upon R3's request. NA-B stated R3 was previously in her recliner most of the day, but was up and down frequently to the bathroom. During interview on 9/17/19 at 10:03 a.m., RN-A stated wound cultures grew out two different bacteria from R3's vertebral wound, and stated R3 had been readmitted on an oral antibiotic, [MEDICATION NAME] to be continued until her next appointment with the infectious disease providers on 9/18/19. The facility's 1/2017 policy Pressure Ulcers, included: Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. The facility's 3/2019 procedure, Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements included: Daily monitoring when a pressure ulcer is present to include the following: An evaluation of the ulcer if no dressing is present; An evaluation of the status of the dressing; if present (whether it is intact and whether draining is present , if dressing is leaking or is not leaking; The status of the area surrounding the ulcer; The presence of possible complications, such as signs of increasing areas of ulceration or soft tissue infection; The pressure ulcer should be assessed/evaluated at least weekly and documented on by the RN wound assessment and if the resident is on Medicare, document daily on the wound data collection with every treatment change. In addition, the procedure indicated observations of the ulcer's characteristics should be documented by a licensed nurse and should include at least the following: - Measurements - length, width, depth, - Characteristics of the ulcer - including wound bed, undermining and tunneling, exudate, surrounding skin etc. - Presence of Pain and - Current treatments