Every finding on record at Good Samaritan Society - Stillwater

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, re-evaluate the effectiveness of the pain regimen, ensure accurate and complete documentation, and notify the physician of break through pain for 1 of 1 resident (R1) reviewed for pain management. Findings include:R1's face sheet printed 6/3/26, identified diagnoses of pain in left elbow, generalized muscle weakness, cervical spinal stenosis (narrowing of the spinal canal in the neck), lumbar spinal stenosis (narrowing of the spinal canal in the lower back), low back pain, anxiety disorder, and major depressive disorder (depression).R1's Care Area Assessment (CAA) dated 2/5/26, identified pain as an actual problem and triggered due to a pain numeric intensity rating of 7/10. The CAA identified multiple diagnoses and conditions that could contribute to pain, including cardiac disease, pneumonia, gastroesophageal reflux disease (GERD), arthritis, and dental problems. The CAA further identified pain could result in impaired ability to perform ADLs, reluctance to participate in therapy, poor healing, falls, and further functional and cognitive decline. The CAA identified pain would be addressed through care planning.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified cognition was intact. The MDS indicated R1 received a scheduled pain medication regimen and did not receive non-pharmacological pain interventions during the 5-day look-back period. R1 reported experiencing pain frequently and rated his worst pain as 3/10. The MDS further identified pain occasionally made it difficult for R1 to sleep at night and occasionally limited day-to-day activities. R1 was independent with most activities of daily living (ADLs).R1's care plan dated 1/16/24, identified a focus that R1 had generalized chronic and acute pain related to multiple chronic conditions and diagnoses, including osteoarthritis. The care plan noted pain could affect R1's ability to perform activities of daily living ADL's and quality of life. Interventions initiated 9/23/22, directed staff to assess pain using the Numeric Pain Scale (0-10); monitor and record pain characteristics, including quality, severity, location, onset, duration, aggravating factors, and relieving factors; monitor and document side effects of pain medications; report changes in activity attendance patterns or refusal to attend activities related to signs, symptoms, complaints of pain, or discomfort; notify the health care provider if interventions were unsuccessful or if pain represented a significant change from R1's usual pain pattern; and provide R1 and family information regarding pain and pain management options. An additional intervention initiated 2/2/24, directed staff to attempt non-pharmacological pain management interventions, including ice packs.Although R1's care plan identified R1's chronic and acute pain and included interventions for assessment, monitoring, reporting, medication side effects, provider notification, and non-pharmacological interventions, the care plan did not address resident-specific pain management goal or desired outcome such as acceptable pian level or desired outcome.R1's physician order summary identified an order dated 10/25/22, for acetaminophen tablet 500 milligram (mg), give 2 tablets by mouth three times daily for pain. On 5/6/26, directed staff to administer oxycodone HCl (narcotic pain medication) oral tablet 5 mg, give 2.5 mg by mouth every six hours as needed for pain rated 2-5 and give 5 mg by mouth every six hours as needed for pain rated 6-10. An additional order dated 5/11/26, directed staff to administer gabapentin (medication for nerve pain) 300 mg, give 2 capsules by mouth three times daily (600 mg three times daily) for neuropathy.R1's May 2026 MAR, progress notes, and occupational therapy documentation dated between 5/11/26 and 5/21/26 were reviewed and identified R1 continued to report left arm pain that interfered with daily activities despite ongoing treatment. The MAR identified R1 received PRN oxycodone on 47 occasions between 5/7/26 and 5/31/26 for reported pain ratings ranging from 6/10 to 10/10. Follow-up documentation identified the medication was ineffective on 13 occasions and effectiveness was documented as unknown on four occasions. When oxycodone was documented as ineffective, follow-up pain ratings remained elevated at 6/10, 7/10, 8/10, 9/10, and 10/10. Record review did not identify documentation that nursing staff completed additional pain assessments, notified the provider that prescribed pain interventions were unsuccessful, or revised the pain management plan following the repeated ineffective medication administrations. Although R1's care plan directed staff to attempt non-pharmacological pain management interventions, record review identified limited documentation of non-pharmacological interventions being offered or implemented. The only documented intervention following an ineffective pain medication administration was application of a cold compress on 5/15/26. Record review did not identify consistent documentation of other interventions attempted or offered such as ice, positioning, bracing, sling use, activity modification, rest periods, or other measures to address R1's ongoing pain.R1's progress note dated 5/7/26 at 11:03 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. The note indicated R1 reported increased pain with repositioning in the wheelchair. Record review did not identify documentation of a follow-up pain assessment, evaluation of the effectiveness of the medication administration, or additional interventions to address the resident's reported increase in pain.R1's progress note 5/9/26 at 2:21 a.m., R1 received oxycodone 5 mg for pain rated 6-10/10. Follow-up documentation indicated the administration was ineffective, and R1 continued to report pain at a level of 6/10.R1's progress note dated 5/11/26 at 6:19 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.R1's physician visit dated 5/11/26, identified R1 was evaluated for left arm pain. The physician documented R1 reported pain at the level of the elbow that sometimes extended toward the hand and had been present for approximately one week. R1 denied chest pain, denied radiation from the shoulder to the elbow, and denied trauma. Physical examination identified left elbow pain on palpation of both the medial (inside) and lateral (outside) epicondyles (bony areas on each side of the elbow) and pain with resisted extension. The physician assessed bilateral epicondylitis (inflammation and irritation of the tendons attached to the elbow, commonly known as tennis elbow), discussed use of a counterforce brace, encouraged R1 to minimize use of the left hand, ordered a therapy consultation, and increased gabapentin to 600 mg three times daily.R1's Occupational Therapy (OT) note dated 5/12/26, identified R1 reported constant left elbow pain rated 10/10, describing the pain as, The whole elbow - it's in so much pain, you wouldn't believe it. OT documented the pain limited R1's quality of life and daily functional tasks. Following ultrasound treatment, R1 reported temporary improvement from 10/10 to 0/10; however, nursing staff reported severe pain returned within 20 minutes.R1's progress note 5/13/26 at 7:21 p.m., R1 received oxycodone 5 mg for pain rated 6-10/10. Follow-up documentation indicated the medication was ineffective, stating pain still same, and R1 continued to report pain at 9/10.R1's progress note dated 5/14/26 at 2:22 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 6/10 following administration of the medication.R1's OT note dated 5/14/26, identified R1 continued to report constant left elbow pain rated 10/10 at rest. OT documented the pain was tender to touch, limited quality of life and daily functional tasks, increased with reaching, and caused grimacing with elbow movement. R1 reported continued use of pain medication, topical cream, and ice packs with ongoing pain.R1's progress note dated 5/15/26 at 7:15 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 10/10 following administration of the medication.R1's progress note dated 5/20/26 at 12:13 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 10/10 following administration of the medication.R1's progress note dated 5/21/26 at 8:54 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 10/10 following administration of the medication.R1's OT note dated 5/21/26, identified R1 reported constant left elbow pain rated 10/10 that limited quality of life and daily functional tasks. The OT documented the left elbow was tender to touch and pain increased with reaching. Nursing staff reported R1 had received pain medication approximately 4.5 hours earlier and could receive additional pain medication every six hours. R1 reported the best his pain improved with medication was 6/10. OT provided a left-sided half lap tray and an ice pack for pain management. After approximately 10 minutes of using the lap tray, R1 reported pain improved from 10/10 to 6/10; however, the pain remained constant. Post-treatment documentation identified left elbow pain remained at 6/10.R1's OT note dated 5/22/26, identified R1 stated, my elbow hurts so much. I'm not doing anything with it today, and declined stretching and strengthening activities due to pain.R1's progress note dated 5/22/26 at 9:10 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 9/10 following administration of the medication.R1's progress note dated 5/23/26 at 1:16 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.In review of R1's record between 5/11/26 (increase of the gabapentin) through 6/3/26 there was no indication R1's pharmacological pain management regimen in conjunction with non-pharmacological interventions was re-evaluated for effectiveness.R1's progress note dated 5/24/26 at 8:57 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 6/10 following administration of the medication.R1's progress note dated 5/24/26 at 6:20 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 8/10 following administration of the medication.R1's progress note dated 5/24/26 at 10:15 p.m., identified R1 complained of severe left arm pain that was not relieved by PRN oxycodone, scheduled acetaminophen, or elevation of the arm. Due to persistent pain, the on-call provider ordered transfer to the emergency department for evaluation.R1's emergency department (ED) note dated 5/24/26, identified R1 was transferred to the emergency department for left arm pain. The emergency department provider documented R1 reported several days of non-traumatic left forearm and wrist pain and denied recent falls or trauma to the arm. Physical examination identified range of motion of the left shoulder, elbow, and wrist was intact with no significant tenderness, redness, or swelling. X-rays identified no acute fracture or dislocation of the left wrist or forearm. The emergency department provider documented R1's pain improved after receiving pain medication and discharged R1 back to the facility with a clinical impression of left arm pain. The ER visit did not include any new orders or treatment plan. R1's progress note dated 5/25/26 at 12:23 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. The note indicated R1 stated the pain level didn't change much following administration of the medication. Follow-up documentation identified R1 continued to report pain at a level of 10/10.R1's progress note dated 5/25/26 at 11:45 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.R1's progress note dated 5/26/26 at 1:21 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.R1's progress note dated 5/26/26 at 9:53 a.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 6/10 following administration of the medication.R1's OT note dated 5/26/26, identified R1 reported constant left elbow pain rated 10/10 at rest. Nursing staff reported R1 had recently been sent to the emergency department due to uncontrolled left upper extremity pain and returned to the facility with no changes to the pain management regimen. OT documented R1 continued to receive oxycodone and use ice packs for pain management. OT assessed the left upper extremity and applied kinesiology tape (a specialized elastic therapeutic tape used to provide support, reduce pain, and improve movement) to the elbow for lateral epicondylitis. Following the intervention, R1 reported immediate improvement in pain control and stated his pain decreased from 10/10 to 9/10. R1 described the pain as feeling like when you hit your funny bone. OT further documented R1 actively participated in treatment and reported improved pain management with use of kinesiology tape.R1's progress note dated 5/26/26 at 11:23 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective. Follow-up documentation identified R1 continued to report pain at a level of 7/10 following administration of the medication.R1's occupational therapy (OT) note dated 5/28/26, identified OT received an elbow brace and applied it after removing the kinesiology tape. OT documented no skin irritation was present. Upon application of the brace, R1 smiled and stated, That feels good! OT educated R1 regarding use of the brace and encouraged positioning that promoted elbow extension. OT also provided education to nursing staff regarding the purpose and use of the elbow brace. Nursing staff reported R1 had been spending more time resting in bed and a certified nursing assistant reported R1 had been in a lot of pain earlier. OT requested an order for R1 to wear the left elbow brace as needed and for nursing staff to complete daily skin checks.R1's progress note dated 5/28/26 at 2:02 a.m., documented oxycodone 2.5 mg administered for pain rated 2-5. The effectiveness of the medication was documented as Unknown. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.R1's progress note dated 5/31/26 at 1:39 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10 was ineffective and lacked a follow up pain scale rating.R1's progress note dated 5/31/26 at 1:39 p.m., documented oxycodone 2.5 mg administered for pain rated 2-5 was ineffective. The note indicated R1 continued to rate the pain at 10/10 following administration of the medication.R1's medication administration record (MAR) dated 6/1/26 through 6/3/26 identified acetaminophen and gabapentin were administered as prescribed. Review of the MAR further identified R1 received PRN (as needed) oxycodone on seven occasions between 6/1/26 and 6/3/26 for reported pain ratings ranging from 6/10 to 10/10. Six of the seven administrations were for pain ratings of 7/10 or greater, including documented pain ratings of 9/10 and 10/10. Follow-up documentation identified the effectiveness of the medication was unknown on two occasions despite facility expectations to evaluate the effectiveness of pain management interventions.R1's OT note dated 6/1/26, identified R1 reported left elbow pain that comes and goes and rated the pain 7/10 at rest while lying in bed with the elbow extended. OT documented R1 was not feeling well and remained in bed for lunch. R1 reported increased left elbow pain rated 10/10 when sitting at the edge of the bed. OT further documented R1 was not wearing the prescribed elbow brace and staff were unable to locate it despite searching R1's room and contacting other staff. R1 agreed to application of kinesiology tape (a specialized elastic therapeutic tape used to provide support, reduce pain, and improve movement) to the left elbow and reported mild pain relief following the intervention.R1's progress note dated 6/1/26 at 8:46 p.m., documented oxycodone 5 mg administered for pain rated 6-10/10. The effectiveness of the medication was documented as Unknown. The note further indicated R1 continued to complain of pain in the left arm following administration of the medication. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.During an observation and interview on 6/2/26 at 3:48 p.m., R1 was observed seated in a wheelchair in his room. During the interview, R1 suddenly bent to the left side, exhibited facial grimacing, moaning, and crying, and stated he was experiencing left elbow pain that radiated down his arm into his fingers. R1 rated his pain as 10/10 and later stated his pain was a 12. R1 stated staff should allow him to receive pain medication every four hours and reported staff had informed him it was too early for his next pain medication, and he would need to wait an additional two hours. R1 repeatedly stated staff were allowing him to suffer in pain and reported delays in receiving pain medication were worse on the evening shift. R1 was observed holding his left arm and hand, rocking back and forth, crying, and keeping his eyes closed while reporting pain. R1 described the pain as feeling like his funny bone had been hit. R1 stated the pain affected his sleep and had been present for years. R1 further stated acetaminophen helped his pain; however, he continued crying and stated he could not handle the pain. The surveyor left the room to notify nursing staff of R1's reported severe pain.During an interview on 6/2/26 at 4:03 p.m., registered nurse (RN)-A was informed R1 was experiencing pain rated as a 12 in the left elbow, was doubled over in pain, and was crying. When asked whether she would assess R1's pain, RN-A stated the provider was aware of R1's left elbow pain and confirmed R1 had reported pain levels as high as 12 out of 10 in the past. RN-A stated R1 received oxycodone 5 mg at 12:20 p.m. for left arm pain and could receive oxycodone every six hours as needed (PRN). RN-A stated R1 also received scheduled acetaminophen 1,000 mg three times daily. R1's left elbow pain was chronic, and staff utilized alternative pain management measures including ice packs, relaxation, distraction, and reminders not to rest his left arm on hard surfaces. RN-A stated R1 requested additional oxycodone at approximately 3:00 p.m.; however, it was too early for another dose based on the physician's order. RN-A had no additional medication available to administer for pain at that time. RN-A would assess R1's pain and document the assessment in a progress note. When asked under what circumstances she would notify the provider regarding R1's ongoing severe pain, RN-A stated the provider was aware of the pain but did not identify any circumstances that would prompt additional provider notification.During an observation and interview on 6/2/26 at 4:13 p.m., R1 was observed seated in his wheelchair holding his left arm, moaning, and crying. At 4:14 p.m., RN-A entered the room and asked R1 whether he would like to lie down to help him relax. R1 declined and stated he wanted to remain up to eat supper. RN-A offered to adjust R1's ice pack; however, R1 stated the ice pack did not help his pain. RN-A did not ask R1 to rate his pain or otherwise assess the characteristics, location, severity, aggravating factors, or relieving factors associated with the pain and stated she could clearly see he was in pain. When asked how she would document her pain assessment, RN-A stated she could clearly observe R1 was experiencing pain. RN-A further stated the physician was aware of R1's pain and then exited the room. During the interview, R1 continued to cry and reported a constant burning pain that originated in his left elbow and radiated into his fingers, causing tingling in his thumb, index finger, and middle finger. R1 stated the pain occasionally lessened for a few minutes but quickly returned. R1 reported he had recently been evaluated at the hospital for the pain, but no cause had been identified. The pain also caused neck pain and sensitivity to touch. R1 reported the pain had worsened since admission to the facility and that pain medication provided only a few hours of relief. R1 repeatedly cried and stated he was tired of living with the pain, wanted pain relief, and felt his concerns were not resulting in adequate pain management.R1's progress note dated 6/2/26 at 5:01 p.m., identified R1 was in excruciating pain prior to receiving PRN oxycodone. Staff applied Biofreeze (a cooling pain-relief product that works similarly to putting an ice pack on sore muscles or joints). and repositioned ice packs in addition to administering pain medication. Following intervention, R1 reported some relief and his pain score decreased to 3/10.During an interview on 6/2/26 at 4:37 p.m., nurse practitioner (NP)-A was notified by the surveyor that R1 was currently experiencing uncontrolled left elbow pain and was not due for another dose of oxycodone for approximately 11/2 hours. NP-A stated she had been away the previous week, and the medical director had diagnosed R1 with lateral epicondylitis (tennis elbow) on 5/11/26. NP-A stated R1's pain was believed to be related to nerve impingement (pressure on a nerve) and associated swelling. R1 had previously been provided a sling, which R1 reported helped relieve the pain, but the sling had been lost and recently reordered. NP-A further stated R1 had a brace, and his gabapentin had been increased due to nerve pain. NP-A acknowledged she was aware of R1's left elbow pain and stated oxycodone was unlikely to fully relieve the condition. NP-A stated treatment options were becoming limited and future discussions could include whether hospice services and morphine should be considered for pain management.During an interview on 6/2/26 at 5:13 p.m., interim director of nursing (IDON)-A was informed R1 was currently experiencing uncontrolled left elbow pain, was crying and doubled over in pain, and was not due for another dose of oxycodone for approximately 11/2 hours. IDON-A acknowledged awareness that R1 had been experiencing left elbow pain.R1's progress note dated 6/3/26 at 6:01 a.m., documented oxycodone 2.5 mg administered for pain rated 2-5. The effectiveness of the medication was documented as Unknown. The note indicated R1 was not giving me a number, just crying in pain. Record review did not identify documentation of a follow-up pain assessment or evaluation of the effectiveness of the medication administration.R1's OT note dated 6/3/26, identified R1 was crying in pain while seated at the breakfast table. OT documented nursing staff were aware of the pain and educating R1 regarding when the next pain medication would be available. OT located R1's elbow brace, applied it, and R1 immediately stated, that's already feeling better. OT continued to evaluate positioning devices and arm supports to improve R1's comfort and positioning. OT documented R1 declined additional interventions to the left upper extremity due to pain. Later that day, OT reviewed R1's pain management plan and educated R1 regarding additional positioning options. OT documented R1 continued to experience left elbow pain that limited positioning and participation in daily tasks.R1's progress note dated 6/3/26 at 2:24 p.m., identified R1 complained of left arm pain rated 8/10 and requested PRN oxycodone; however, staff documented it was too soon to administer the medication. R1 received scheduled gabapentin and a lidocaine patch and agreed to wait until the next PRN dose was available. At 10:40 a.m., R1 received oxycodone for pain rated 9/10. Follow-up assessment at noon identified pain remained at 6/10.R1's progress note dated 6/3/26 at 10:50 p.m., identified R1 reported pain rated 7/10 and received oxycodone 5 mg and an ice pack. Follow-up documentation identified the medication was effective; however, R1 reported only little relief and continued to report pain rated 6/10.During an interview on 6/3/26 at 12:14 p.m., nursing assistant (NA)-A stated R1 was previously largely independent with many activities and required minimal assistance; however, beginning in early to mid-May 2026, R1 developed significant left elbow pain and became weaker. NA-A reported R1 had experienced constant left elbow pain over the previous three weeks and frequently reported pain levels of 10/10 or 11/10. NA-A stated R1 was often observed crying, doubled over, and unwilling to be disturbed due to pain. NA-A further stated she had observed R1 doubled over in pain on multiple occasions and reported other residents had expressed concern regarding the severity of his pain. According to NA-A, R1's pain medication appeared to provide relief for the first few hours after administration; however, once the medication wore off, R1 would again be observed doubled over and writhing in pain. NA-A stated R1's pain was severe and needed to be better controlled.During an interview on 6/3/26 at 1:02 p.m., NA-B stated R1's left elbow pain began a couple of weeks earlier and had become more frequent over the previous several days. NA-B stated she observed R1 holding his elbow, groaning, crying, and requesting staff obtain a nurse because he was experiencing severe pain. NA-B stated she did not believe R1's pain was well controlled and had observed R1 experiencing significantly more pain than in the past. NA-B further stated R1 now required additional assistance with activities of daily living (ADLs) due to pain in his left arm.During an interview on 6/3/26 at 1:15 p.m., licensed practical nurse (LPN)-A stated R1 had developed left elbow pain several weeks earlier and was using a brace for treatment of tennis elbow. LPN-A stated today R1 received oxycodone 5 mg at 4:40 a.m. and began requesting additional pain medication at approximately 8:40 a.m. when he rated his pain as 8/10. LPN-A stated R1 received another dose of oxycodone at approximately 10:40 a.m. when he rated his pain as 9/10. LPN-A stated the medication reduced R1's pain temporarily; however, by approximately 12:55 p.m., R1 reported his pain had increased to 7/10. LPN-A stated R1 also received gabapentin, scheduled acetaminophen, and used a brace for pain management. LPN-A stated she did not believe R1's pain was well controlled and estimated the oxycodone provided relief for only about four hours despite being ordered every six hours as needed. LPN-A stated she was unaware of additional interventions available to address R1's pain other than oxycodone and ice packs.During an interview on 6/3/26 at 3:21 p.m., IDON stated R1 complained of left elbow pain rated 10/10 on 5/24/26. IDON-A stated the provider was notified, R1 received PRN oxycodone and acetaminophen, and was subsequently transferred to the emergency department due to uncontrolled pain. IDON acknowledged R1 had experienced increased left elbow pain, frequently cried due to pain, and stated the current pain management plan had not been effective. IDON-A further stated she would expect the provider to be notified when a resident's pain was not adequately controlled so the pain management plan could be reevaluated.During a phone interview on 6/4/26 at 9:34 a.m., LPN-B stated R1's left elbow pain began several weeks earlier, and staff observed R1 frequently resting his left elbow on hard surfaces while completing puzzles. LPN-B stated staff implemented multiple interventions, including a gel pad for the wheelchair armrest, an elbow compression brace, ice packs, a sling, occupational therapy (OT), and positioning interventions. LPN-B stated R1's gabapentin dose was increased on 5/11/26. LPN-B stated R1 would appear comfortable at times and then suddenly begin crying due to severe pain. LPN-B stated oxycodone did not provide significant relief for the nerve pain and staff frequently encouraged R1 to use ice packs, remove pressure from the elbow, and rest in bed, which appeared to lessen his pain. LPN-B stated R1 occasionally requested oxycodone before it was due and staff would offer non-pharmacological interventions until the medication could be administered. LPN-B stated R1's pain was generally worse during the daytime and evening hours and confirmed R1 would cry due to pain on occasion.During a phone interview on 6/4/26 at 10:05 a.m., the medical director stated R1 was evaluated on 5/11/26 for left elbow pain and his gabapentin was increased to 600 mg three times daily. The medical director stated R1's examination was consistent with epicondylitis (inflammation of the tendons around the elbow) and multiple treatment interventions had been attempted, including gabapentin, oxycodone, occupational therapy, bracing, positioning interventions, and ultrasound therapy. The medical director stated occupational therapy had reported improvement with ultrasound treatment and an orthopedic consultation had recently been discussed during therapy rounds. When informed that R1 continued to experience severe breakthrough pain between medication doses, was observed bent over, crying, and moaning in pain, and reported pain radiating from his elbow into his hand with tingling of the thumb, index finger, and middle finger, the medical director stated nursing staff should complete a comprehensive pain assessment, document the findings, and notify the on-call provider when pain remained uncontrolled. The medical director stated the facility had 24-hour provider coverage available for consultation. The medical director further stated uncontrolled pain should be communicated through the nurse practitioner communication process and acknowledged she would expect additional notification if a resident was observed bent over, crying, and moaning in pain despite current interventions. The medical director stated additional treatment options could include increasing oxycodone from every six hours to every four hours as needed, steroid injections, or referral to an orthopedic specialist. During the interview, the medical director stated she will provide an order to change R1's oxycodone from every six hours as needed to every four hours as needed for pain.Facility policy entitled, Pain Management - R/S, LTC, Therapy & Rehab, reviewed/revised 1/29/26, identified the licensed nurse would assess current pain levels; review the resident's response to medication interventions; work closely with the physician to develop an individualized pain management plan; continually monitor and observe the resident for success of the pain management plan; report to the prescriber as necessary to keep the resident comfortable; include the resident's goal for pain control in the care plan; and monitor and evaluate the effectiveness of the pain management plan. The policy further identified non-pharmacological interventions should be utilized and the care plan should be updated as needed to reflect current effective interventions.Facility policy was not followed when staff failed to adequat

Based on observation, interview, and record review, the facility failed to assess, monitor, and provide appropriate clinical oversight of a urinary collection device used to manage chronic urinary incontinence for 1 of 1 resident (R1) reviewed for urinary incontinence.Findings include:R1's face sheet printed 6/3/26, identified diagnoses including chronic kidney disease stage 3, lymphedema (swelling caused by a buildup of fluid), chronic combined systolic and diastolic heart failure, chronic right-sided heart failure, benign prostatic hyperplasia (enlarged prostate) with urinary symptoms, localized edema (swelling), acute cystitis with hematuria (bladder infection with blood in the urine), and muscle weakness.R1's care area assessment (CAA) for urinary incontinence dated 2/5/26, identified urinary incontinence as an actual problem. The CAA identified R1 required assistance with toileting and was occasionally incontinent of urine. Contributing factors identified in the assessment included pain, restricted mobility, benign prostatic hyperplasia (enlarged prostate), congestive heart failure, use of diuretic medications, and opioid medications. The CAA further identified urinary incontinence placed R1 at risk for urinary tract infections, skin injury, loss of dignity, social isolation, and further functional decline. The assessment determined the issue would be addressed through care planning.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified cognition was intact. The MDS further identified R1 was always incontinent of urine and received diuretic medication.R1's care plan identified a focus, revised 8/18/25, that R1 had a history of urinary tract infections (UTIs) and benign prostatic hyperplasia (enlarged prostate). The care plan goal directed staff to prevent skin breakdown related to incontinence and brief use. Interventions initiated 11/9/22, directed staff to encourage fluid intake during the morning and afternoon, limit fluids during the evening, avoid foods and beverages that may irritate the bladder, and monitor for signs and symptoms of a UTI, including pain, burning, blood in the urine, cloudy urine, decreased urine output, foul-smelling urine, fever, chills, changes in mental status, and changes in behavior. An additional intervention initiated and revised 8/18/25, identified R1 preferred use of a urinal, refused briefs, would request assistance as needed, and had PRN orders for a condom catheter. An additional care plan focus, revised 2/12/24, identified R1 had a self-care deficit related to a history of fractures, limited mobility, and pain. The care plan goal directed staff to maintain R1's current level of function with bed mobility, transfers, eating, dressing, toileting, and personal hygiene. An intervention revised 11/15/24, directed staff to assist with toilet use by offering help to the bathroom and assistance with emptying the urinal upon arising, before and after meals, and at night.R1's Kardex dated 6/3/26, identified R1 preferred use of a urinal, refused briefs, and would request staff assistance as needed. The Kardex directed staff to assist with emptying the urinal and identified PRN condom catheter orders. The Kardex further directed staff to offer assistance with toileting and empty the urinal upon arising, before and after meals, and at night.R1's progress note dated 5/2/26 at 11:54 a.m., identified R1 required standby assistance to transfer to the toilet and extensive assistance with personal care and dressing. The note further identified R1 was unable to control his urine stream, was incontinent of urine, and left the urinal in his pants.R1's progress note dated 5/8/26 at 4:23 p.m., identified R1 reported constant urinary dribbling and stated he kept a urinal between his legs at all times because he was afraid of spilling urine. R1 further reported his penis was enlarged from having it in the urinal all the time. Staff educated R1 that he could rest in bed or a recliner and request assistance with the urinal before transferring to prevent spills. The note further identified R1 agreed to lie in bed and was later observed sleeping.R1's progress note dated 5/25/26 at 1:55 a.m., identified R1 returned from the hospital with a diagnosis of cystitis (bladder infection). The note further identified the provider recommended discontinuing use of the external condom catheter until the urinary infection was treated and cleared R1 to use a urinal.During a phone interview on 6/4/26 at 9:34 a.m., LPN-B stated the Geiserailie urinary collection device was first applied approximately two days before R1 was sent to the emergency department on 5/24/26 and was reapplied on 6/1/26. When asked what assessment she completed before directing staff to apply the device on 5/23/26, LPN-B stated, I didn't do one, we were just trialing it. LPN-B acknowledged she did not document an assessment on 5/23/26 or when the device was reapplied on 6/1/26 and stated, I didn't do a formal one. LPN-B further stated no assessments had been completed and no care directions had been developed regarding prevention of skin breakdown, reduction of infection risk, or monitoring for complications associated with device use. When asked how she determined the device was safe to continue using after the hospital documented penile edema and cystitis, LPN-B stated she was instructed by the interim director of nursing to continue the trial. When asked what findings would indicate the device was causing a complication, LPN-B stated, I am not sure if he would have gotten a rash, infection .Review of R1's toileting response history identified staff documented R1's urinary continence as not rated due to use of an indwelling catheter on 5/23/26 at 6:25 p.m., 5/24/26 at 5:59 a.m., 9:36 a.m., and 8:35 p.m., 6/1/26 at 7:17 p.m., and 6/3/26 at 5:59 a.m. The toileting response history further identified staff documented R1's urinary continence as not rated due to condom catheter on 6/3/26 at 2:05 p.m. and 9:35 p.m.R1's weekly skin checks dated 5/4/26, 5/11/26, 5/18/26, and 5/27/26, identified R1's skin was warm and dry, skin color was within normal limits, skin turgor was normal, and no external devices were present. The skin did not identify use of the urinary collection device or document assessment of the penile skin and surrounding tissue related to device use.In review of R1's record there was no indication a physician order had been obtained for the use of the Geiserailie device nor evident the care plan was revised. Further not evident of ongoing assessments and monitoring of device effectiveness and skin integrity.During an observation and interview on 6/2/26 at 3:48 p.m., R1 was observed seated in his wheelchair in his room. R1 stated, I have a condom catheter. It's the penis and the thing that goes over it. It's not inside. Observation identified a drainage bag containing urine was positioned in a white pillowcase attached to the left side of the wheelchair. R1 stated he was unsure how often staff emptied the bag and reported staff changed the device when it needed to be changed. R1 stated staff were responsible for managing the device and he did not know how it worked. R1 denied having sores or pain to his penis. R1 stated the device was being used because urine would leak from the urinal and result in a wet bed.During an interview on 6/2/26 at 4:37 p.m., nurse practitioner (NP)-A stated R1 was using an external urinary collection device obtained by the facility. NP-A stated the device was not a condom catheter but consisted of a support garment with a plastic receptacle that fit over the penis and drained into a closed urinary drainage bag. NP-A stated use of the device allowed R1 to sleep in bed rather than in his wheelchair with a urinal positioned between his legs. NP-A further stated the device had recently been reordered after it was discarded during R1's recent hospital stay. When asked about skin concerns related to the device, NP-A stated she was not aware of any skin issues. NP-A stated she approved use of the device but had not written orders regarding use of the device, routine maintenance, cleaning procedures, skin integrity monitoring, or infection prevention measures.During an interview on 6/3/26 at 12:14 p.m., nursing assistant (NA)-A stated she had emptied the drainage bag but had not applied the device. NA-A stated she had not received instructions regarding changing, cleaning, maintenance, or skin assessment related to the device and was unaware of any procedures for monitoring complications.During an observation and interview on 6/3/26 at 12:40 p.m., R1 was observed lying in bed with NA-A present. R1 was using an external urinary collection device consisting of a Y-shaped collection cup positioned around the penis and connected to tubing and a drainage bag. The penis was observed within the collection cup. R1 stated staff did not change or clean the device and reported, I have had it in for about 3 days. The drainage bag was observed attached to a Velcro strap and placed inside a black bag hanging from the side of the bed. NA-A stated she believed the drainage bag was intended to be secured to R1's leg; however, the tubing was too long. NA-A stated she initially hung the drainage bag from the side of the bed, later placed it on the bed, and was unsure how it should be positioned. NA-A further stated she obtained a Velcro strap from the supply room and used it to secure the drainage bag. The support garment surrounding the collection cup had dried urine staining and a urine odor. When the drainage bag was placed on the bed, R1 stated urine could back flush and requested the bag be hung over the side of the bed. NA-A complied and repositioned the drainage bag.During an interview on 6/3/26 at 1:02 p.m., NA-B stated staff were not provided instructions regarding cleaning, changing, or maintaining the urinary collection device. NA-B stated she checked the waistband for irritation but would need to remove the device to assess the penile skin and had not been directed to do so. NA-B further stated she was unaware of how often the device should be changed and had not received guidance regarding monitoring for complications.During an interview on 6/3/26 at 1:15 p.m., licensed practical nurse (LPN)-A stated she was unable to locate practitioner orders addressing use of the device and was not aware of its care or maintenance requirements. LPN-A stated there were no current orders directing staff to assess skin integrity related to device use and she was unsure whether staff were removing the device to perform skin assessments.During an interview on 6/3/26 at 3:21 p.m., the interim director of nursing (IDON) stated she initiated use of the Geiserailie three-piece urinary collection system for R1. IDON stated a physician or nurse practitioner order was not obtained prior to implementation of the device. The IDON further stated the care plan was not updated, no baseline assessment was completed prior to implementation, and no routine assessments were established after implementation. Staff were not provided training regarding application, cleaning, emptying, monitoring, or removal of the device and manufacturer instructions were not available. IDON stated there was no established process or frequency for assessment of R1's penis or foreskin while using the device. IDON further stated the nurse practitioner was notified after the device had already been implemented. IDON could not determine whether penile edema was present prior to implementation because assessments had not been completed or documented.During a phone interview on 6/4/26 at 10:05 a.m., the medical director verified a provider order was not obtained prior to implementation of the Geiserailie urinary collection device. The medical director stated the intervention should have been care planned and staff provided direction regarding application, monitoring, cleaning, and maintenance of the device. Nursing staff should have completed and documented baseline and ongoing assessments of the penis and foreskin. The medical director noted the emergency department documented distal penile edema and cystitis, although no obvious penile infection was identified. The medical director stated the skin should be assessed at least daily, the device should be changed daily, and distal penile edema should be reported to the provider. A provider order should be obtained prior to initiating any new urinary collection device.Facility undated policy, Catheter Care, identified that urinary drainage systems should be maintained as a closed drainage system. The policy directed staff to secure the drainage bag with straps, observe the skin for irritation or changes and report concerns to the licensed nurse, empty the drainage bag routinely to prevent overfilling, and clean drainage bags according to established procedures. The policy further identified drainage bags should be cleaned with appropriate cleaning solutions and allowed to dry before reuse. The policy further identified staff were to observe the skin for irritation or changes and report concerns to the licensed nurse.Contrary to facility policy, staff did not routinely assess the skin, were not instructed regarding cleaning procedures, improvised methods for securing the drainage bag, and were unable to describe maintenance requirements for the urinary collection system.

Based on interview and document review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service. This had the potential to affect all 34 residents who resided in the facility.Findings include:Dietary manager qualifications were requested however were not received. The registered dietitian worked part time at facility. When interviewed on 2/11/26 at 2:00 p.m., the administrator stated the facility had a part time dietitian who worked between two facilities. The administrator stated dietary manager did not have required qualifications however was signed up for classes. When interviewed on 2/12/26 at 1:08 p.m. stated DM had accepted the role in November as DM. DM verified she was not currently qualified however had re-enrolled in classes.

Based on observation, interview, and document review, the facility failed to ensure weekly wound assessments and measurements were completed for 1 of 1 resident (R3) reviewed for pressure ulcers (PU).Findings include:R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, required partial to substantial assistance with most activities of daily living (ADLs), did not display rejection of care behaviors, and has one stage-four pressure ulcer. R3's diagnoses included fracture of left arm, open wound on left elbow, received intravenous (IV) medications and osteomyelitis (a bone infection). R3's care area assessment (CAA) dated 1/19/26, indicated, Pressure injury to left elbow related to fracture, impaired ROM [range of motion], Osteomyelitis/cellulitis [bone/skin infection] infection puts patient at risk of complications like sepsis, increased care needs, further functional or cognitive decline and disability. R3's care plan (CP) dated 1/13/26, indicated R3 had potential and actual skin impairment and an actual stage four pressure ulcer with osteomyelitis to the left elbow. The care plan instructed staff to, Monitor location, size and treatment of skin injury .Assess/record/monitor wound healing daily with daily dressing changes. R3's physician order dated 1/19/26, indicated, document wound measurements every Monday. R3's progress note (PN) dated 1/13/26, indicated, Deep pressure wound over left elbow olecranon [the bony prominence of the elbow], visible bone with purulent drainage. The PN had no indication of size of wound. R3's PN dated 1/16/26, indicated, Wound cares to left elbow. No further assessment of wound documented. R3's PN dated 1/20/26, indicated, wound cares.no signs of wound infection. No further assessment or measurement of wound documented. R3's PN dated 1/23/26, indicated, wound cares to left elbow. No further assessment or measurement of wound documented. R3's PN dated 1/27/26 at 3:32 p.m., indicated (R3) returned from orthopedics appointment and note from ortho indicated, Left elbow 3x3 cm open wound/draining bursitis. Diagnosis: Infected left olecranon bursitis left proximal humerus. A second PN at 11:42 p.m., indicated, wound care and dressing changes to left elbow. No further assessment of wound. R3's PN dated 2/6/26, indicated, wound care completed as ordered. No further assessment or measurement of wound documented. R3's wound data collection form dated 1/30/26, indicated left elbow wound with intact dressing, no drainage, pink and intact tissue surrounding dressing. No wound characteristics to include appearance or measurements documented. cleansed with wound cleanser. The form further indicated, Required for documenting daily monitoring of pressure ulcers. Required at least weekly when skin integrity is impaired or open area is present.Measurements-Required at least once every 7 days. Review of additional wound data collection forms indicated initial form completed on 1/16/26, and subsequent form dated 1/29/26, lacked evidence of any wound measurements. R3's wound RN assessment dated [DATE], indicated, Required at least every 7 days and PRN [as needed] when skin integrity is impaired or open area is present. The assessment indicated a wound present with full thickness tissue loss and interventions in place. The assessment lacked any further wound assessment or measurements. R3's January 2026, treatment administration record (TAR) indicated, document wound measurement every Monday, start date 1/26/26. Documented as completed on 1/26/26. Review of R3's electronic medical record (EMR) lacked evidence of any measurements documented on 1/26/26. R3's February 2026, TAR indicated, document wound measurement every Monday, start date 1/26/26. Documented as completed on 2/2/26 and 2/9/26. Review of R3's EMR lacked evidence of any measurements documented on 2/2/26. Or 2/9/26. During observation and interview on 2/10/26 at 1:32 p.m., licensed practical nurse (LPN)-A cleansed R3's wound and replaced the dressing that had fallen off. LPN-A stated she had already completed full wound care this morning but since the dressing had fallen off, she cleaned it again prior to replacing the dressing. LPN-A stated R3 admitted with the stage 4 pressure ulcer, and it had not changed since then; no better no worse. During observation on 2/11/26 at 7:34 a.m., registered nurse (RN)-A completed R3's wound care. Review of R3's EMR lacked evidence of any wound assessment or measurements documented on 2/10/26 or 2/11/26. During interview on 2/12/26 at 9:51 a.m., LPN-A stated wounds should be assessed with wound care and weekly with wound rounds. LPN-A stated the assessments should be completed by the nurse and documented in the EMR-either in a progress note or one of the wound forms. LPN-A stated the assessments should include a description and weekly wound measurements and findings should be documented in the EMR. LPN-A further stated an initial assessment with measurements should be obtained and documented in order to base any changes observed on the weekly assessments. During interview on 2/12/26 at 10:49 a.m., director of nursing (DON) stated expectations for wound assessments with wound description and measurements should be completed every seven days and findings documented, and an initial assessment of those findings should be completed within 24 hours of admission. DON stated she and the nurse practitioner round weekly and measure and take pictures of the wounds. DON was not sure where the pictures, assessments or measurements were routinely being documented, nor who was completing the documentation. DON stated there were currently three different forms for skin/wound assessment and realized the system was broken. During follow up interview on 2/12/26 at 12:48 p.m., DON stated weekly wound measurements were being collected from several sources throughout the EMR and transferred to a separate spreadsheet and sent to corporate every month. DON could not explain why there was not a more streamlined process for documenting the wound assessments and why they could not all be located in the EMR. DON stated again the system was broken. Facility policy Wound and Pressure Ulcer Management dated 7/7/25, indicated accurate assessment and documentation of wounds were used to promote healing, pain and prevention of complications of wounds and contribute to appropriate wound management.

Based on observation, interview, and document review the facility failed to identify prior appropriate interventions prior to use of grab bars, assess for risk of entrapment, and obtain consent 1 of 1 resident (R12) reviewed for the use of grab bars. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of muscular sclerosis (disease that causes breakdown of the protective covering of nerves) and chronic kidney disease (condition in which the kidneys gradually lose their ability to function properly). It further indicated bilateral impairment of the lower extremities ([NAME]) and R12 required substantial assistance with bed mobility.During interview and observation on 2/09/2026 at 3:05 p.m., R12 had bilateral grab bars on her bed. R12 stated she didn't use the bars and was able to reposition herself. She further indicated she thinks the facility uses them to keep us in bed.R12's physical device assessment dated [DATE], lacked indication the facility identified and used appropriate alternatives prior to use of grab bars, educated R12 on risks versus benefits of grab bars. assessed R12's risk for entrapment or obtained informed consent. R12's care plan dated 1/12/26, indicated R12 had an activity of daily living (ADL) self-care performance deficit related to multiple sclerosis as evidenced by deconditioning and weakness. It further included the following interventions:-Bed mobility: extensive assist of one staff with lower extremities. Can assist with turning and repositioning in bed with use of assist bars. Offer to lay down after naps. Resident is able to use her bilateral assist bars to help with turning and repositioning. -Bed mobility: sitting to lying- assist of two staff with total body lift and guided maneuvering of [NAME].-Resident can roll side to side with extensive assist of one staff using grab/assist bars and staff guiding lower extremities that does not restrict freedom of movement.During interview on 2/12/26 at 9:42 a.m., nursing assistant (NA)-C stated R12 used the grab bars to assist staff to reposition her. During interview on 2/12/26 at 9:54 a.m., licensed practical nurse (LPN)-B stated nurses were responsible for assessing residents for grab bars and it should be documented on the physical device assessment. During interview on 2/12/26 at 10:37 a.m., registered nurse (RN)-B stated nurses were responsible for assessing residents for grab bars and it should be documented in the physical device assessment. RN-B also verified R12's grab bars had not been assessed and should have been.During interview on 2/12/26 11:54 a.m., the director of nursing (DON) stated nurses were responsible for assessing the residents for grab bars to ensure they meet criteria for safe use. There also needs to be collaboration with the provider and consent for their use. Documentation of this would be on the physical device assessment. DON stated this was important to ensure resident safety. The facility's policy on bed safety dated 9/30/25, indicated prior to use of bed rails, side rails, safety rails, grab bars and assist bars a PhysicalDevice and Restraint Assessment or Matrix equivalent will be completed.

Based on observation, interview, and document review the facility failed to ensure staff used appropriate personal protective equipment (PPE) for 2 of 2 residents (R3, R27) observed for enhanced barrier precautions (EBP).Findings include:R3 R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact, required partial to substantial assistance with most activities of daily living (ADLs), did not display rejection of care behaviors, and has one stage-four pressure ulcer. R3's diagnoses included fracture of left arm, open wound on left elbow, received intravenous (IV) medications and osteomyelitis (a bone infection). R3's care area assessment (CAA) dated 1/19/26, indicated, Pressure injury to left elbow related to fracture, impaired ROM [range of motion], Osteomyelitis/cellulitis [skin infection] infection puts patient at risk of complications like sepsis, increased care needs, further functional or cognitive decline and disability. R3's care plan dated 1/13/26, indicated R3 required IV medication via Single Lumen-Right Basilic [peripherally inserted central catheter-PICC]-placed 1/9 for Long Term antibiotics [ATB]. The care plan further indicated R3 required EBP due to open wound growing Staph Aureus (infection) and instructed staff to Don [put on] gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene.device care and/or use, and wound care. R3's provider order report printed 2/11/26, included the following: -wound soak with warm soapy water three times a day to left elbow three times a day -wound care to left elbow three times a week -change PCC line dressing and caps weekly -IV ATB until 2/20/26 During observation and interview on 2/11/26 at 7:34 a.m., registered nurse (RN)-A entered R3's room. RN-A did not don gloves or gown. R3 sitting in recliner. RN-A proceeded to fill a basin with warm soapy water and soaked R3's elbow in the water. After soaking, RA-A placed new dressing to cover wound. RN-A washed hands and then gathered supplies for the IV administration. RN-A flushed R3's PICC line and attached the IV ATB medicine ball (an enclosed self-infusing system). When asked, RN-A stated, I should be wearing gloves, but I'm old school. Upon exit from R3's room, RN-A confirmed EBP signs and PPE present on R3's door and stated she should have donned a gown and glove to perform the tasks she just completed. During interview on 2/12/26 at 10:21 a.m., director of nursing, who is also the infection preventionist (DON/IP) interview stated expectation that EBP should be followed when there is an indwelling device like an IV or PICC and when with open wounds. DON further stated when a resident was on EBP, gown and glove should always be worn during direct patient care. R27 R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], was moderate cognitively impairment with slow mentation, R27 had range of motion limitations to upper and lower extremities, and was dependent on staff for lower body care, bed mobility, and transfers. It also indicated R27 had a urinary catheter and hospice care on admission, history of traumatic brain injury, and acute kidney failure. R27's physician order dated 11/26/25, indicated R27 had an indwelling catheter for traumatic brain injury. Urinary catheter had a bag covered for dignity, and catheter care documented. Enhanced barrier protocol (EBP) to be implemented for cares of R27. R27's catheter care plan dated 11/26/25, indicated R27 had indwelling catheter related to traumatic brain injury. Interventions included documented intake/output, monitor, record and report to provider for signs and symptoms of urinary tract infection (pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior or eating patterns). Catheter cares completed every shift. R27's EBP care plan updated on 2/10/26, for indwelling catheter, urine had multidrug resistant organisms (MRDO) that made infections hard to treat. Interventions were put on gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. Take off gown and gloves inside resident room, then perform hand hygiene. During observation and interview on 2/10/26 at 11:06 a.m., Outside of R27's room had no signs or EBP supplies. Certified nursing assistant (CNA)-B entered R27's room without wearing a gown or gloves. CNA- B proceeded to complete R27's catheter cares were performed without EBP. CNA-B stated the care plan and Kardex gave information if a resident was on EBP. If there was not a yellow door holder on the resident's door or plastic bin in the hallway with EBP supplies or a sign on the door, a resident was not on EBP. CNA-B verified R27's door did not have a sign and no EBP supplies were outside of R27's room, therefore not on EBP. During interview on 2/11/26 at 7:24 a.m., licensed practical nurse (LPN)-A stated EBP was to be used when physical cares were provided to residents on EBP. The care plan interventions are listed for EBP, such as yellow holder and signage on door with EBP supplies in it, and the treatment administration record to document cares. The training was provided by facility, online, skill fairs, staff meetings and demonstrations. During interview on 2/12/26 at 12:30 p.m., CNA-A stated received education on catheter care online education provided by facility. The expectations for catheter care were to empty bag at end of shift, wear gloves, clean end with alcohol wipe, document intake and output, report changes to nurse. CNA-A further stated other PPE was not necessary for catheter cares. During interview on 2/12/26 at 2:25 p.m., the infection preventionist (IP)/ director of nursing (DON) stated the expectation of staff was to adhere to the policy for enhanced barrier precautions. Staff was to properly don and doff protective personal equipment, every single time when doing cares with a resident on EBP. R27 should have been on EBP since admission. The rationale was to decrease the risk of transmission, decrease infections, keep staff and residents healthy. A policy titled Standard, Enhanced Barrier and Transmission Based Precautions dated 7/7/25, directed staff to use EBP in 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 MDROs to staff hands and clothing. Enhanced barrier precautions are also used for residents with indwelling medical devices, central lines, hemodialysis catheters, and indwelling urinary catheters. High-contact resident care activities include transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, changing linens, indwelling urinary catheter, and wound care. Enhanced barrier precautions are intended to be used for the duration of a resident's stay.

Based on interview and document review, the facility failed to ensure a root cause analysis was completed and implement new interventions following a fall for 1 of 3 residents (R11).Findings include: R11's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia (decline in cognitive ability), abnormalities of gait and mobility, difficulty in walking, muscle weakness, and repeated falls. It further indicated R11 required partial to moderate assistance with ambulation and had two or more falls since admission, one with injury. R11's progress note dated 10/23/25, indicated R11 was found on the floor in middle of the dining room. Her wheelchair was 10 feet away from the table and the other chairs surrounding her were 5 feet away. R11 was assessed for injuries and lacerations were noted on her head. Neurological checks were initiated with no changes and vital signs were stable. The patient was assisted off the floor by two staff. Patient was able to bend her knees and assist. Ice was placed on her head to control the bleeding. Her daughter was called and requested that the patient be seen at the hospital. The provider and director of nursing (DON) were updated as well. The patient was sent to the hospital for evaluation and treatment. R11's care plan reviewed on 2/9/26, showed: -On 2/18/25, R11 required a gait belt, walker, and stand by assist with one staff contact guard for ambulation in room and to and from meal/activities. -R11 had an actual fall on 9/15/25, with intervention to establish toileting plan and review history of recurrent falls. -R11 had an actual fall on 9/15/25, had a fall and Interventions directed staff to provide activities to promote exercise and strength building when possible.However, R11's care plan did not indicate R11 fell on10/23/25 or show any new fall interventions had been implemented. R11's [NAME] Accountability for Excellence (SAFE) resident event report (undated), indicated R11 had an unwitnessed fall in the dining room on 10/23/25, with an immediate intervention to assist R11 to her room after meals. This intervention had already been initiated on 2/18/25. The SAFE report also lacked indication of a root cause analysis. R11's 10/23/25 fall's root cause analysis was requested however was not received. During interview on 2/11/26 at 10:12 a.m., licensed practical nurse (LPN)-A stated when a resident falls, nurses were responsible for documenting it in a SAFE event incident report which would then also trigger a variety of other reports such as the Fall Tools assessment, pain assessment, etc. LPN-A further stated nurses were expected to put in a new intervention with each fall and add it to the care plan. Then the MDS nurse was responsible for making sure the interventions were appropriate and ensuring they were added to the care plan. During interview on 2/11/26 at 1:24 p.m., registered nurse (RN)-B stated nurses were responsible for filling out a SAFE event report and a new intervention each time a resident fell. Then the Interdisciplinary Team (IDT) will assess the interventions to determine if they are appropriate and add or remove them as needed. RN-B verified R11 did not have any new interventions on her care plan or Kardex, following her fall on 10/23/25. Staff should be looking at the Kardex in order to know what specific care each resident needs. During interview on 2/12/26 at 11:54 a.m., the director of nursing (DON) stated when a resident falls, nurses were responsible for documenting it on the SAFE event report. They should be documenting a description of the incident, the assessment of the resident, and picking an intervention from the list and adding it to the care plan. The DON further stated she and RN-B were responsible for ensuring the interventions were appropriate and new stating you can't use the same one twice. They were also responsible for completing a root cause analysis in order to prevent the incident from happening again. The nurses should be looking at the care plan when determining what type of care each resident needs and the nursing assistants should utilize the Kardex. The surveyor asked for documentation of the root cause analysis for R11's fall on 10/23/25 and upon giving me the SAFE event report for that date, the DON stated she could only give me part of the report, because the rest of it was QAPI protected. The facility policy regarding fall prevention and management dated 10/14/25, indicated in step 16 of the procedure for a resident who has fallen was to review and update the care plan with any changes/new interventions. Furthermore, the policy directed staff to complete the fall investigation in the notes tab of risk management.

Based on interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 resident (R1) who had a history of trauma.Findings include:R1's admit Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R1 was independent for all activities of daily living (ADLs), with occasional incontinence. R1 ambulated around facility with a wheeled walker. R1's diagnoses included post-traumatic stress disorder (PTSD) and bipolar disorder (mood disorder).R1's trauma assessment dated [DATE], indicated the purpose of the assessment was to identify residents who are trauma survivors. R1's trauma assessment indicated R1 did not have past trauma. R1's care plan dated [DATE], indicated R1 had sleep disturbance related to PTSD. Staff directed to monitor for complaints of feeling tired, irritability, dozing during activities, dark circles under eyes, change ability to perform ADL's, change in walking/falls, change in energy level, or change in medication. Interventions included to observe and document sleep. Furthermore, the care plan lacked identification of any PTDS triggers or interventions. R1's nursing assistant Kardex was requested however was not received. During an interview on [DATE] at 3:50 p.m., R1 stated he had PTSD and had known triggers. R1 stated staff at the facility had never talked to him about his triggers or past trauma. R1 stated triggers, included loud noises or being unaware of people behind him. R1 stated he was willing to talk to staff about triggers. R1 discussed his PTSD, started from being in Vietnam war and then found his wife deceased . During an interview on [DATE] at 12:17 p.m., certified nursing assistant (CNA)-A stated if a resident had a history of PTSD and had triggers it would be important to know what their triggers were to better care for them. CNA-A stated their triggers would be on the care plan and Kardex if a resident had PTSD. During an interview on [DATE] at 2:15p.m., licensed practical nurse (LPN)-A stated they identify individual resident's needs would be on the care plan and the Kardex. The nurses and MDS put the information from the chart into the care plan.During an interview on [DATE] at 2:47 p.m., director of nursing (DON) stated if a resident had PTSD they needed to be assessed for triggers, and those triggers would be documented on the care plan to help better care for the residents. DON stated assessments for triggers were done upon admission, and as needed, and stated these assessments would help identify any triggers, and behaviors would also be monitored. DON stated that she was unaware the Trauma Assessment was answered incorrectly and that the R1 care plan did not have triggers or any information regarding the diagnosis of PTSD.A facility policy titled Trauma Informed Care dated [DATE], directed staff to ensure that residents who experienced trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. Each employee will have training in caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or posttraumatic stress disorder.

Based on observation, interview, and document review, the facility failed to ensure the daily staff posting displayed accurate data regarding the resident census, along with the total number and actual hours worked per shift by nursing staff. This had the potential to affect all 34 residents residing in the facility and their visitor who may wish to review the information.Findings include: Actual working staff schedules on daily assignment sheets for 2/1/26 - 2/11/26 indicated the following:2/1: 6 nurses, 8 CNAs2/2: 6 nurses, 7 CNAs2/3: 6 nurses, 8 CNAs2/4: 6 nurses, 9 CNAs2/5: 5 nurses, 10 CNAs2/6: 6 nurses, 8 CNAs2/7: 6 nurses, 7 CNAs2/8: 6 nurses, 10 CNAs2/9: 6 nurses, 9 CNAs2/10: 6 nurses, 8 CNAs2/11: 6 nurse, 8 CNAs Daily staff postings for 2/1/26 - 2/11/26 indicated the following:2/1: 6 nurses, 5 CNAs2/2: 6 nurses, 6 CNAs2/3: 6 nurses, 6 CNAs2/4: 6 nurses, 6 CNAs2/5: 5 nurses, 6 CNAs2/6: not provided2/7: not provided2/8: 5 nurses, 7 CNAs 2/9: 5 nurses, 5 CNAs2/10: 6 nurses, 6 CNAs2/11: 5 nurse, 6 CNAs During observation on 2/11/26 at 8:24 a.m., facility staff posting at the reception desk indicated a date of 2/11/26, with a census of 35. Census in the electronic health record (EHR) indicated current census of 34. The staff posting further indicated 6 certified nursing assistants for the day. The daily staff schedule for 2/11/26 indicated 8 CNAs for the day. In addition, the daily staff postings for 2/12/26 through 2/15/26 were already posted behind the current daily posting in a plastic display frame all indicating a census of 35 and pre-populated staff numbers and hours. During interview on 2/11/26 at 10:50 a.m., scheduler stated the process was to print the daily postings about a week in advance and place them in the display stand at the front desk. Then someone from the night staff would remove the top sheet every day and place it in the mailbox for retention. Scheduler stated the daily posting was not updated daily to reflect the actual census or the actual staff working each day. During interview on 2/12/26 at 10:44 a.m., director of nursing (DON) stated the scheduler printed the staff posting the day prior and then it was posted in the morning. DON stated the scheduler should be updating the information to reflect the actual census and daily staff numbers and hours so that the posted sheet displayed accurate data. During observation on 2/12/26 at 12:08 p.m., the daily staff posting was dated 2/11/26. During interview on 2/12/26 at 12:11 p.m., administrator verified current staff posting displayed was dated 2/11/26. Administrator further stated expectation that the daily staff posting would be current and accurate and reflect the current resident census and direct care staff numbers and hours. Facility policy Nursing Staff Daily Posting Requirements dated 12/1/25, indicated a daily staff posting would include the location, date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff. The policy further indicated, It is important to keep the report updated by making changes as thy occur to the electronic schedule.and a new report will need to be printed and posted.

Based on interview and document review, the facility failed to ensure liquid morphine (opioid analgesic used to treat severe pain) was administered per physician orders for 1 of 1 resident (R1) who was administered ten times the ordered dose.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated diagnosis of anemia, heart failure, diabetes mellitus, and seizure disorder. The MDS indicated she was moderate cognitively intact and required assistance with activities of daily living. The MDS indicated R1 received scheduled pain medication and had a condition or chronic disease that may result in life expectancy of less than 6 months and received hospice care.R1's Care Plan dated 10/13/25, indicated R1 had acute and chronic pain/discomfort related to history of cerebral vascular accident and weakness. The care plan indicated nursing to evaluate the effectiveness of pain interventions after administration of pain medication, satisfaction with results, impact on functional ability and impact on cognition. The Care Plan further indicated R1 had terminal prognosis related to acute on chronic heart failure and was on hospice. R1's Physicians Orders dated 10/1025 indicated morphine sulfate (concentrate) oral solution 20 milligrams (mg)/ milliliters (ml), give 0.75 ml one hour as needed for pain or dyspnea.R1's Medication Administration Record (MAR) indicated on 10/10/25 R1 received 0.75 ml on 6:53 a.m. and 9:02 a.m. The order was increased to give 20mg/ml, give 1 ml as needed every one hour as needed for pain or dyspnea on 10/10/25, the MAR indicated this dose was never given.A Hospice Client -New Orders dated 10/10/25, ordered from hospice physician (over the phone) and transcribed by hospice nurse, registered nurse (HRN)-A to discontinue morphine 20mg/ml to give 1ml every one hour as needed (PRN). Begin morphine 20 mg(ml) give 15mg/7.5 ml oral/ sublingual every four hours for restlessness, and morphine 20 mg/ml may have 15 mg/7.5 ml every one hour for dyspnea or pain. (This went from the 0.75 ml dose R1 received to 7.5 ml which is ten times the dosage and transcribed incorrectly) The MAR indicated on 10/10/25 at 12:00 p.m., R1 received 7.5 ml of Morphine Sulfate concentrate for pain level of four.R1's MAR indicated she received Narcan 4 mg, also known as Naloxone (naloxone, a front-line defense in the nation's overdose crisis. Naloxone is a life-saving drug that, when sprayed into the nose or injected, quickly reverses the powerful effects of opioids during an overdose) on 10/10/25, at 9:18 p.m. and 10:53 p.m. with all doses listed as effective.A Provider follow up Note Progress Note dated 10/10/25, indicated R1 presented with hypertensive heart disease with chronic diastolic heart failure, hospice care, hemiparesis, and expressive aphasia. The note indicated patient was seen multiple times today this afternoon and evening dule to medication error with administration of morphine sulfate. Extensive discussion with patient's daughter, granddaughter. Spoke with hospice staff and hospice medical director. Narcan 4 mg was administered 4:00 p.m. and as of 8:30 pm. patient has not required another dose. Respiration rate (RR) remaining above 8 and around 8:00 p.m. was 18. Director of nursing and nursing staff are monitoring patient closely and checking RR every 15-30 minutes. At 8:40 p.m. patient was seen and had been repositioned. Breathing was shallower, rate appeared to be decreasing. Discussed with DON and we opted to give another dose of Narcan 4mg. Once given patients breathing appeared to improve, she was yawning and moving her mouth more and seemed less sedated. Nursing will be monitoring closely through the night. Again, extensive discussion with family at bedside, questions addressed, concerns addressed. Daughter plans on leaving to go home around 9:00 p.m. Was informed by text message that a third dose of Narcan was given just before 10:00 p.m. due changes in respirations.A requested MAR to the DON on 11/06/25, was not received until 11/18/25, by the facility administrator which indicated the dose that was given at 10:53 p.m. was in error and that was actually given at 4:50 p.m. and received it at 9:18 p.m. (which does not match what the NP indicated in her notes R1 received three doses of Narcan)Interview on 10/29/25 at 1:16 p.m., the director of nursing (DON) stated on 10/09/25, R1 was up in her wheelchair seemed perfectly fine normally arguing with me not wanting to go to bed then on 10/10/25, in the morning when I came in around 10:00 a.m. the nursing staff told me she had a stroke. The DON stated the hospice nurse came in and evaluated R1 and felt she had cardiac or CVA (cerebral vascular accident) and increased her morphine. The hospice nurse made a medication error and instead of transcribing morphine .75 ml to be given she transcribed 7.5 ml and the at 12:00 p.m., RN-A administered morphine sulfate 7.5 ml. from an existing bottle of morphine R1 had. The DON stated the evening nurse licensed practical nurse (LPN)-A noticed the medication error when the new morphine medication arrived with the prescription label that indicated to give .75ml instead of 7.5 ml. LPN-A then informed hospice and orders for Narcan were given and she corrected the transcription in the MAR to read to give 7.5 ml. The DON stated the first dose of Narcan was given after they repositioned R1 and she had a few episodes of apnea, and they were not sure if it was from the repositioning or the medication error, so they administered the Narcan and gave the other doses prophylactically. The DON stated she discussed with RN-B how they could learn from this and started education right away and explained how this was a transcription error and how we need to slow down and asses and question if this is an appropriate order especially if someone is taking an opioid.During interview on 10/30/25 at 10:27 a.m., hospice medical director stated she was informed the morning of 10/10/25 R1 was having stroke-like symptoms, and the hospice nurse increased her morphine due to signs of being uncomfortable, increased breathing and restlessness. Which were signs of pain and labored breathing. The medical director then stated she was informed the hospice nurse transcribed the order with the correct mg but the incorrect ml which was 7.5 and the facility nurse gave the morphine at 7.5 ml. The medical director stated R1 was not receiving much morphine and a dose like that could have killed her although the dose would be out of her system by 8 hours which in her case it did. During interview on 10/30/25 at 12:34 p.m., RN-B stated R1 was in distress the morning of 10/10/25, and the hospice nurse arrived and placed new orders to increase her morphine concentrate to 7.5 ml. RN-B stated R1 already had morphine on hand and at 12:00 p.m. she used what she had and in order to dose that much she had to use eight syringes which she thought was a lot but never said anything to anyone and administered the medication to R1. Later that day around 3:00 p.m. she received a phone call from the evening nurse LPN-A who informed her the new morphine medication arrived with the label reading .75 ml not 7.5 ml and realized it was a medication error. RN-B stated she immediately informed the DON and the Nurse Practitioner (NP) that were present in the building and Narcan was ordered as needed and 15-minute respiratory checks for R1. RN-B stated she did not recall receiving any re-education on the medication error from the DON. During interview on 10/30/25 at 1:05 p.m., LPN-B stated she worked on 10/11/25 and 10/12/25 and stated R1 stated in bed all weekend and she was unresponsive she did not open her eyes. LPN-B stated she knew not to ever give anyone more the 2ml of morphine and couldn't believe the order went through and fell through the cracks and was not caught until after R1 received the dosage. LPN-B stated they double check new orders with new admissions but not with orders that come through from hospice. During interview on 10/30/25 at 3:15 p.m., DON stated hospice MD sends an electronic script (e-script) to the pharmacy to have the morphine filled, that is why R1 received the correct dosage on 10/10/25 and LPN-A caught the medication error when the medication arrived that day at 3:00 p.m. and immediately called RN-B who gave the medication to inform her she gave a medication error. The DON stated she didn't consider this an error on their end since the hospice nurse wrote the error and their nurse just gave the medication according to their order. The DON did state she did provide Narcotic education to her staff which included standards of best practice when it comes to providing pain management, having a questioning attitude prior to administering medication and explaining the importance of checks and balance system. [NAME] Policy revised 4/08/25, the location will have medication error rates of five percent or less and those residents are free of significant medication errors. When a medication error occurs, it will be reported promptly to the attending physician, resident and or responsible party. The policy indicated a significant medication error is one which causes the resident discomfort or jeopardizes his or her health and safety.

Based on observation, interview and document review, the facility failed to ensure personal privacy was maintained to promote dignity for 1 of 1 resident (R21) observed with bare skin and undergarments visible from the hallway to other residents, visitors, and staff. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment, displayed disorganized thinking, had physical behaviors directed towards others (sexual), that interfered with care, or social interactions, did not reject care, and required maximal assistance for activities of daily living (ADLs). Further, the MDS identified R21 was incontinent of both bowel and bladder, had diagnoses of dementia, Parkinson's disease, coronary artery disease (CAD), peripheral vascular disease (PVD), heart failure, and had a history of falls. R21's Care Plan dated 1/28/25, lacked information regarding preserving privacy and dignity. The care plan indicated brief use for incontinence, check upon rising, before and after meals, at bedtime, on NOC rounds and as needed. R21 was incontinent of bowel and bladder and dependent on staff for hygiene. Furthermore, R21's care plan identified inappropriate sexual advances towards residents and staff with the intervention of providing care with two staff members but failed to identify how to preserve dignity while keeping R21 safe in between cares. R21's Kardex dated 1/30/25, indicated staff ensured safety for R21 by offering to help resident lay down in bed after meals when tired and to provide a safe environment, R21 moved closer to the nursing station to increase observation on 12/31/24, and the door was to be left ajar to avoid isolation. During an interview on 1/27/25 at 5:25 p.m., family member (FM)-A, stated, the last time she visited, R21 was lying in a wet brief in his room, and further stated her and her family were embarrassed seeing R21 in just a brief, and was also embarrassed for R21 because he would be embarrassed if he realized he was lying in a brief with the door open. During an observation on 1/28/25 at 1:15 p.m., R21 was lying in bed in his private room with the door wide open, and fully visible to the hallway. R21 had the overhead lights off, was wearing a t-shirt, cream colored brief, bare legs, pants pushed down to his socks, and a sheet and blanket pulled to the side. R21's room had a visible track installed on the ceiling which had metallic hooking devices, however, the room lacked privacy curtains. During an observation on 1/28/25 at 1:21 p.m., social services designee (SS)-A walked past R21's room that had the door wide open, SS-A looked in R21's room, and kept walking. During an observation on 1/28/25 at 1:23 p.m., SS-A walked back down the hall and looked in R21's room, but did not talk to staff regarding R21 laying in the bed in a t-shirt and brief and the blankets pushed aside. During an observation on 1/28/25 1:29 p.m., nursing assistant (NA)-C walked past R21's room and did not look in R21's room. NA-C came back approximately 1:30 p.m., to answer R21's ringing telephone. NA-C handed R21 the phone and R21 answered the phone but stated no one is there. NA-C covered R21 with a blanket and he grabbed at her. At this time, the director of nursing, (DON), walked past and entered registered nurse (RN)-A's office. NA-C then covered R21 up with a blue blanket and R21 made inappropriate comments to NA-C and attempted to reach out and grab her. NA-C redirected his behavior and left the room leaving the door open. During an observation on 1/28/25 between 1:44 p.m. and 1:48 p.m., R21 was lying in bed and remained covered with a blanket and the door was open. During an observation on 1/28/25 at 1:51 p.m., trained medication aide, (TMA)-A walked by R21's room, R21 had removed his blanket and unfastened his brief on the left side. TMA-A closed the door without talking to resident or going inside. During interview on 1/28/25 at 1:56 p.m., TMA-A stated R21 was at risk for falling, and the door should remain open for safety. TMA-A walked back to R21's door and confirmed with surveyor the door had been shut and remained shut during our interview outside R21's door. TMA-A opened the door during our interview. The brief was loosely on with no private areas visible for the staff and visitors in the hallway to see. TMA-A verified there was no curtain hanging to provide privacy. During observation on 1/28/25 at 2:12 p.m., TMA-A exited R21's room carrying a trash bag containing a tan brief and left the door open. R21 was covered with a blue blanket. During observation on 1/28/25 at 2:35 p.m., R21's door was open, and R21 was lying in bed, scratching left side of his hip. R21's pants were pushed to end of bed and the blanket was pushed aside. Health Unit Coordinator (HUC)-A came out of the office directly across from R21's room, looked into R21's room and introduced self to state surveyors then went back in the office. There were two staff and two visitors walking down the hall. During observation on 1/28/25 at 2:42 p.m., NA-C walked down the hallway and shut R21's door. At 2:45 p.m., NA-C returned to R21's room, went inside and closed the door behind her. NA-C opened the door and as she was leaving R21 was making inappropriate sexual comments and reached out asking for a rub down. R21 was covered with a blanket and NA-C closed the door. NA-C walked over to the nursing station and discussed the inappropriate comments and gestures to other NA's and began discussing dinner plans. At 2:59 p.m., R21 was moaning and could be heard from the hallway. During an interview on 1/29/25 8:42 a.m., the DON, verified R21's door should be open due to being at risk for falls. Further R21's door could be partially shut to provide as much privacy as possible, but safety was first. [NAME] Policy Resident Dignity-Rehab/Skilled, dated 12/11/24 and [NAME] Policy Falls Resource Packet-Rehab/Skilled 5/7/24.

Based on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R25) received assistance with shaving and nail care reviewed for activities of daily living (ADL). Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and a diagnosis of blindness. It further indicated R25 required supervision with personal hygiene. R25's physician's orders dated 1/24/25, indicated weekly skin assessment, please check skin and document findings in the skin observation V-3, chart vital signs, trim nails and obtain weight, offer to shave resident if he wishes, every day shift on Friday. R25's weekly skin observation dated 1/24/25, lacked documentation R25's nails were trimmed, he had been shaved, or that staff offered or he had refused. R25's care plan indicated R25 had an ADL self care performance deficit related to a history of cerebral vascular accident (CVA), blindness evidenced by a shuffling, slow gait, and required more help with ADLs. It further indicated an intervention for staff to provide assistance with bed mobility, transfers, eating, dressing, toilet use and personal hygiene. During observation and interview on 1/27/25 at 1:31 p.m., R25 was sitting in his recliner in his room. The fingernails on both hands were approximately a 1/2 an inch long and he had a few weeks worth of facial hair. R25 stated he wanted his fingernails to be trimmed and to be clean shaven. He wanted to keep his moustache. During observation and interview on 1/28/25 at 2:00 p.m., R25 was sitting in his recliner and his fingernails on both hands were approximately a 1/2 inch long and he stated he would like them cut. He also stated he wasn't clean shaven and would like to be. During interview on 1/29/25 at 6:40 a.m., nursing assistant (NA)-A stated NA's were responsible for trimming residents nails (who are not diabetic) and shaving resident's once a week on their bath day. There was no place to document it specifically, its just part of what they were supposed to do. If the resident refused, they should re-approach and let the nurse know. During interview on 1/29/25 at 6:46 a.m. NA-B stated NA's were responsible for shaving and trimming (non-diabetic) residents nails and shaving them once a week on bath day. There was no specific place to document and if the resident refused they should re-approach 3 times then let the nurse know. During interview on 1/29/25 at 9:05 a.m., licensensed practical nurse (LPN)-A verified R25's nails and facial hair were long (more 1-2 weeks growth). LPN-A also stated nursing assistants were responsible for trimming residents nails (non-diabetic) and shaving residents once a week on bath day. The nurses were responsible for documenting it had been completed and the NA's should let nurses know if a resident refuses. During interview on 1/30/25 2:35 p.m., the director of nursing (DON) stated NA's were responsible for trimming resident's nails and shaving them once a week on bath day. They should also be documenting if the task was completed and if the resident refused, they should also re-approach, let the nurse know, and document the refusal. A facility policy on ADL's dated 11/29/22, indicated the purpose of the policy was to provide residents with appropriate treatment and services to maintain or improve abilities in ADL for the well being of mind, body and soul

Based on observation, interview and record review the facility failed to ensure bruising was monitored for 1 of 1 residents (R14) reviewed for bruises. The facility further failed to ensure interventions for edema care were implemented for 1 of 1 residents (R17) reviewed for edema. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had moderate cognitive impairment and diagnoses of dementia and heart disease. Furthermore, R14 received an anticoagulation (AC, medication to thin the blood) daily. R14's provider order summary indicated R14 required the following: - on10/4/23, Eliquis (AC medication) 5 milligrams (mg) daily to prevent blood clots. - on 5/28/24, weekly skin assessment every evening shift on Sundays. -on 5/21/24, required monitoring due to AC use. Instructed staff to report to the provider blood in the urine or stools, severe headache, unusual bruising. R14's care plan revised 5/21/24, indicated R14 was on AC therapy and directed staff to monitor resident based on clinical standards related to AC use and easily bruising. R14's weekly skin assessment dated [DATE], indicated R14 was assessed for skin alterations including bruising, however lacked indication bruising was identified. R14's weekly skin assessment dated [DATE], indicated R14 was assessed for skin alterations including bruising, however lacked indication bruising was identified. R14's weekly skin assessment dated [DATE], indicated R14's skin alterations had resolved. R14's medical record lacked indication of when R14's bruising was identified and/or monitored. An observation on 1/27/25 at 2:58 p.m., R14 was sitting in their wheelchair. R14's left forearm had a purple quarter sized bruise. Below was a second purple bruise with yellowing in the middle. R14's right hand around the second knuckle had a dime size dark purple bruise. When interviewed on 1/28/25 at 1:10 p.m., nursing assistant (NA)-A verified R14's bruises and stated R14 had them for a while. R14 was on blood thinners and always had bruises on their hands and arms. NA-A wasn't sure how she always gets the bumps and bruises, but believed they were from hanging on to the grab bars tightly and bumping her arms with repositioning. When interviewed on 1/29/25 at 12:09 p.m., licensed practical nurse (LPN)-A stated if bruising was noticed on a resident, staff attempted to determine when it happened and how it happened. LPN-A stated monitoring if the bruising was significant or suspicious, more investigation and monitoring would occur. LPN-A further stated it was common for residents on blood thinners to have bruising on their hands and arms so there may not be any specific monitoring orders in place however the bruising would be documented on the weekly skin assessments. LPN-A verified R14 had bruising and stated it was not unusual for R14 to have multiple bruises from bumping their hands or arms during repositioning and transfers. LPN-A verified there was no specific monitoring, just the weekly observations and stated one bruise goes away and another one comes. When interviewed on 1/29/25 at 12:37 p.m., registered nurse (RN)- A stated all residents who are on AC medication have monitoring in place for bruising. RN-A further stated any bruising would also be noted on the weekly skin assessments. If bruising was noted during cares or in between the weekly assessments, a separate skin assessment would be completed. If the bruising was suspicious or very large the provider would be notified, and additional monitoring orders would be placed. RN-A stated R14 was prone to bruising on the hands or forearms as she was on an AC medication and often bumped the grab bars or the bedside table. RN-A wasn't aware if R14 had any bruising currently as the bruising comes and goes. RN-A further stated if they were not listed on the weekly skin assessment, R14 may have just gotten them and would expect an assessment done to document when they were identified. When interviewed on 1/30/25 at 1:51 p.m., the Director of Nursing (DON) expected staff to identify any bruising on the weekly skin assessments for routine monitoring. If the bruise was large or abnormal, additional investigation or monitoring would also be in place. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/24, directed staff to monitor bruising weekly and any changes and or progress toward healing should be documented on the skin observation assessment. 42586 R17's significant change Minimum Data Set (MDS) dated [DATE], indicated R17's cognition was unable to be assessed and diagnoses of congestive heart failure (CHF) and localized edema. It further indicated R17 required supervision with dressing. R17's physician's orders dated 3/23/23, indicated Tubi-grips (compression bandages) to bilateral lower legs, on in the morning, off at hour of sleep (HS), every day shift for edema. R17's care plan dated 11/9/22, lacked any indication of R17 wearing Tubi grips on bilateral lower extremities, potential for excess fluid, or edema related to CHF. R17's medication administration and treatment administration records (MAR/TAR) for the month of January 2025 lacked documentation R25's Tubi grips were being applied in the morning or removed in the evening. During observation on 1/27/25 at 6:02 p.m., R17 was sitting in the dining room waiting for dinner. He was wearing slippers and the legs of his sweat pants were bunched up approximately 2-3 inches in which his bare ankles/lower legs were visible and he was not wearing Tubi grips. During observation on 1/29/25 at 6:30 a.m., R17 was asleep in his recliner in his room. His legs were elevated on the foot rest and he was wearing bilateral Tubi grips. During observation and interview on 1/29/25 at 6:46 a.m. NA-B verified R17's Tubi grips were on and stated they should have been removed last night before he went to bed. NA- further stated NA's were responsible for applying R17's Tubi grips each morning and removing them in the evening. During interview on 1/29/25 at 9:05 a.m., licensed practical nurse (LPN)-A stated NA's were responsible for applying R17's Tubi grips in the morning and removing them at night when he goes to bed. They should also re-approach, let the nurse know, and document any refusals. During interview on 1/30/25 2:35 p.m., the director of nursing (DON) stated nursing staff were responsible for ensuring R17's Tubi grips were applied during the day and removed at night and to document the task was completed. They were also expected to document refusals and let the nurse know. A facility policy regarding monitoring for edema was received but didn't address the use of assistive devices such as compression socks, Tubi grips, etc.

Based on observation, interview, and document review, the facility failed to fully assess and implement fall prevention interventions for 2 of 2 residents (R21, R187) reviewed for falls. Findings include: R21: R21's Optional State Assessment (OSA) dated 1/5/25, indicated moderate cognitive impairment, did not have delusions or hallucinations, did not reject care, had other behavioral symptoms not directed toward others 1 to 3 days, required extensive assist with bed mobility, eating, and toileting and was dependent on staff for transfers. R21's Admission Minimum Data Set (MDS) dated [DATE], indicated R21 was frequently incontinent of urine and always incontinent of bowels, had fallen in the month prior to admission, had fallen once since admission with no injuries. R21's Medical Diagnosis form undated, indicated the following diagnoses: acute on chronic systolic heart failure, muscle weakness, unspecified dementia, and Parkinson's disease. R21's care area assessment (CAA) dated 1/5/25, indicated R21 had an actual falls risk and would be addressed on the care plan. The assessment further indicated falls put R21 at risk for injuries like fractures or head injuries that could result in rehospitalization , further functional and cognitive decline, disability and even death and a referral to other disciplines was warranted including the provider, therapy, and nursing to help design and implement patient specific interventions and strategies like improving balance and strength to reduce the risk of falls. R21's care plan dated 12/31/24, indicated R21 had an actual fall on 12/31/24, and had the following interventions: staff to offer to help resident lay down in bed after meals when tired (1/25/24), educate resident and family about safety reminders and what to do if a fall occurs, educate resident and family and IDT as to the causes of falls, remind resident not to bend over to pick up dropped items, encourage use of grabber or to ask for assistance, modify environment to maximize safety, call light in reach, tap call light placed for easier access for resident due to dementia, night light used to maximize resident safety, ensure and provide a safe environment moved closer to the nursing station on 12/31/24 to increase observation, leave the door ajar to avoid isolation, 1/20/24 cues and reminders to resident to wait for assistance and not self-transfer. 1/21NP review of falls with labs ordered, signage placed on bathroom door to remind resident to have staff assist to the bathroom, review bowel and bladder continence status and establish and or review toileting plan based on resident's needs. 1/20/25 toileting, check and change upon arising, before and after meals, bedtime and as needed. 1/30/25 wheelchair in locked position beside bed. R21's Kardex dated 1/28/25, indicated encourage and monitor independent interests, assist with resources as needed, turn on the TV, R21 liked to watch channels 37, 47, or cop shows, and action movies. Invite and remind resident of scheduled activities, assisting to and from locations as needed, and responds well to redirection. Attempts to self-transfer back to bed after meals, staff to offer to help resident lay down in bed after meals when tired 1/25/24. Provide a safe environment, move closer to the nursing station to increase observation, leave the door ajar to avoid isolation. 1/20/24 cues and reminders to resident to wait for assistance and not self-transfer, signage placed on bathroom door to remind resident to have staff assist to the bathroom. Place the call light in reach, use a night light, remind resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. R21's Falls Tool form dated 12/31/24 at 8:39 a.m., indicated R21 had one or more falls between 3 to 12 months ago, took two risk factor medications, had moderately impaired cognition, and risk factors included cognitive status, restlessness, confusion, poor memory, impulsive, and under the heading, Action Plan indicated, Refer to therapy. R21's Falls Tool form dated 1/20/25 at 6:26 a.m., indicated R21 took two risk factor medications, appeared severely affected psychologically, had risk factors including, mobility and transfers related to impaired balance, and cognitive status problems of reduced insight. Under the heading, Action Plan was undocumented. R21's Falls Tool dated 1/21/25 at 12:32 a.m., indicated R21 was at high risk for falling, had one or more falls in the last three months, took two risk factor medications, appeared severely affected psychologically, had severe cognitive impairment, had restlessness, reduced insight, delirium, confusion, poor memory, was impulsive, withdrawn, disorientated, had difficulty following instructions and had sleep problems, used equipment unsafely, forgot to use equipment, had medical problems, and continence problems, multiple falls during a shift and under the heading, Action Plan was undocumented and under the heading, Multiple Falls indicated the care plan was updated to include the wheelchair had anti roll-back brakes applied. R21's Group and Self-Directed Activities 30 day look back form from 1/29/25, indicated no data was found for activities, community, creative, educational/cognitive, physical, sensory stimulation, social, and spiritual activities. R21's one to one Activities 30 day look back form from 1/29/25, indicated R21 had eye contact, and a social activity on 12/31/24. Further, the forms lacked documentation R21 had any spiritual, sensory, physical, educational/cognitive, creative, or community activities. No additional activities were documented. R21's Risk Management Report dated 1/20/25 at 6:17 a.m., indicated R21 was on the floor in the bathroom. R21 stated he was getting up and fell . R21 was assessed for injury and moved back to bed by Hoyer lift. He was not transferred to the hospital. Under the heading, Predisposing Situation Factors not applicable was documented, no medications identified as factors. IDT reviewed the incident on 1/20/25. R21's Risk Management Report dated 1/20/25 at 11:44 p.m., indicated R21 fell in the bathroom and was found between the sink and the toilet lying on his back. His right pointer finger had a 1 cm x 2 cm cut that was bleeding when staff found him. A bruise formed on the back of his head. The fall could not be described by R21. Paramedics were called and assessed R21 and was not transferred to the hospital. Under the heading, Injury Type no injuries observed at time of incident was documented. Under the heading, Predisposing Situation Factors other, unable to determine if resident was using a device at time of fall, and no medications were documented as factors to the fall. The risk management document does not identify resident had a fall within the past 24 hours, R21's had fallen at 6:17 a.m. and IDT reviewed the incident on 1/21/25. R21's Risk Management Report dated 1/25/25 at 10:01 a.m., indicated R21 was found on the floor next to his bed with his head against the nightstand. Under the heading, Injuries Observed at Time of Incident Other and back of head were documented. The note documented on 1/25/25 stated R21 was trying to self-transfer to bed from wheelchair. IDT reviewed the incident on 1/28/25. R21's progress notes dated 12/31/24 at 11:15 a.m., indicated R21 arrived back to the facility from the emergency room . R21's progress notes dated 12/31/24 at 11:34 a.m., indicated the after-visit summary was due to a fall and the CT and x-rays showed no broken bones. Progress notes from 12/31/24, lacked information regarding R21's fall. R21's progress notes dated 1/3/25 at 2:56 p.m., indicated an MDS review and was at high risk for falling with one fall with no injury since admission, poor safety awareness, impulsive, attempts to self-transfer out of bed and was moved closer to the nursing station and a night light was placed in R21's room. R21's progress notes dated 1/20/25 at 6:24 a.m., indicated staff saw R21 on the floor and had apparently tried to get up by himself and fell . R21's progress notes dated 1/20/25 at 8:45 p.m., indicated R21 was found on the floor in the bathroom between the sink and toilet and 911 was called. R21's progress notes dated 1/21/25 at 4:16 p.m., indicated the nurse practitioner was updated earlier regarding R21's two falls. There was no other documentation on 1/21/25, regarding the falls in the progress notes. R21's progress notes dated 1/25/25 at 9:59 a.m., indicated R21 was found sitting on the floor next to the bed with the head against the nightstand and was attempting to get back to bed from the wheelchair when R21 fell . R21's progress notes dated 1/25/25 at 10:01 a.m., indicated the care plan was updated with new falls intervention to offer to help to lie down after meals when tired. During interview on 1/27/25 at 5:25 p.m., family member (FM)-A stated R21 had three falls and went to the hospital for one of the falls. During observation on 1/27/25 at 6:33 p.m., care plan indicated to assist to bed after meals and R21 was up in the chair. During observation on 1/28/25 at 8:48 a.m., R21 was up in his wheelchair and appeared to be asleep at the nursing station. During interview and observation on 1/28/25 at 1:29 p.m., nursing assistant (NA)- C stated they looked to the Kardex on the computer to know what cares a resident required. She added R21 fell all the time and now they locked the wheelchair next to the bed and lower the bed, tied the call light to the bed and stated sometimes closed the door to resident's room., She stated, R21 was at risk for falling and they were trying to find a low bed because R21's bed did not go all the way to the floor. NA-C verified R21 did not have a grabber and stated she thought the facility took it away because R21 was falling. NA-C verified no Kardex was hanging in the room. During observation on 1/28/25 at 1:51 p.m., trained medication aid (TMA)-A shut R21's door and did not go inside the room. At 1:56 p.m., R21's door remained closed. During interview and observation on 1/28/25 at 1:56 p.m., TMA-A stated they checked the care plan and residents at risk for falling had an arm band, needed the call light close and the bed needed to be down. TMA-A confirmed the door was closed and that she walked by and closed the door. During observation on 1/28/25 at 2:12 p.m., staff set a new grabber on R21's bed side table. During observation on 1/29/25 at 7:15 a.m., R21's call light was on the night table across but out of reach no grabber. During interview on 1/29/25 at 8:42 a.m., director of nursing stated nursing assistants and nurses are expected to use the Kardex and for residents at risk for falls the Kardex should be posted in the resident's room. R21's door should be opened, the call light within reach, checked, and changed every couple hour, wheelchair locked and near bed. She confirmed that NA-C was told on 1/28/2025 to place a new grabber in R21's room and does not believe the grabbers work as this is an intervention implemented by therapy, not nursing. She is looking into a low bed for R21 and identified interventions that could be implemented in the care plan like increased time at activities, and stated R21 is just bored and restless. R187: R187's admission MDS in progress dated 1/26/25, indicated moderate cognitive impairment. R187's Medical Diagnosis form indicated the following diagnoses: traumatic ischemia of muscle, cystitis, and chronic kidney disease stage 3. R187's Nursing Admit Data Collection form, dated 1/22/2025 at 3:15 p.m., indicated the resident was admitted from the hospital for fall, traumatic, rhabdomyolysis. Physical and occupational therapy is recommended. R187's Orders form indicated the following orders: 1/22/25, trazodone (an antidepressant) 50 mg tablet, give 0.5 tablet by mouth at bedtime for trouble sleeping. 1/22/25, buspirone (an anxiolytic) 10 mg tablet, give 1 tablet by mouth two times a day for major depressive disorder. 1/22/25, mirtazapine (an antidepressant) 30 mg tablet give 1 tablet by mouth at bedtime for major depressive disorder. 1/22/25, tramadol (an opioid) 25 mg tablet, give 0.5 tablet by mouth every 4 hours as needed for pain. Pain: 4-6. Must chart effectiveness and give 1 tablet by mouth every 4 hours as needed for pain. Pain: 7-10. Must chart effectiveness. 1/23/25, escitalopram oxalate (an antidepressant) oral tablet 5 mg give 1 tablet by mouth one time a day for major depressive disorder. 1/22/25, diphenhydramine hcl (an antihistamine) 50 mg capsule, give 1 capsule by mouth as needed for skin reaction if consuming shrimp. D/C Date 1/24/25 R187's Pharmacy New Admit Review was electronically sent to the DON, physician, and nurse practitioner on 1/23/25 at 7:08 p.m., indicated recommendations to update directions for diphenhydramine and lidocaine. The pharmacist recommended once R187 was settled consider decreasing the doses or discontinuing some of the five psychoactive medications prescribed. Noting she doesn't have any mental diagnoses under the tab. R187's care plan dated 1/22/25, indicated R187 was on medications with an FDA black boxed warning or warnings of adverse consequences related to atrial fibrillation, migraine, depression, hypertension, pain, and trouble sleeping. Interventions included to refer to the boxed warnings in the orders or eMAR, or medication reference of choice for mirtazapine, escitalopram, tramadol, and trazodone. R187's care plan dated 1/23/25, indicated R187 had an activity of daily living (ADL) deficit due to cystitis, fall, rhabdomyolysis and required limited assist of one staff with a walker and gait belt for ambulating short distances in the room. Further, R187 required limited assist to use the toilet and transferred with limited assist of one using a walker and gait belt. R187's care plan revised 1/28/25, indicated R187 had actual falls due to rhabdomyolysis, history of traumatic brain injury, deconditioning, gait and balance problems, and a history of falls and had the following interventions: educate resident and family about safety reminders and what to do if a fall occurs, educate the resident, family, and IDT of the cause of the fall, educate and instruct the resident and family on the safe use of assistive devices, 1/28/25 keep the walker within reach, remind to cue resident to call for assistance, remind resident not to bend over to pick up dropped items, encourage use of grabber or to ask for assistance, modify the environment to maximize safety, call light should be in reach, 1/28/25 offer toileting assistance upon arising, before and after meals, bedtime and as needed. R187's Falls Tool form dated 1/22/25 at 6:28 p.m., indicated R187 had recent falls, took two or more risk factor meds such as sedatives, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives, hypnotics. Under the heading, Risk Factor-Psychological (Anxiety, Depression, Decreased Cooperation, Decreased Insight or Decreased Judgement especially related to mobility) indicated, Does not appear to have any of these. Further, the risk factor check list and intervention plan had check boxes that were checked for mobility and transfers, changes in mobility related to muscle weakness or strength, impaired balance or coordination, cognitive status, poor memory, medical problems included check boxes for changes in medication, high risk medications, changes in condition, and under the heading, Action Plan included check boxes to refer to therapy, restorative nursing, provider or practitioner, obtain a pharmacy consult, refer to the registered dietician, and update the care plan. The only box checked was to update the care plan. R187's Fall Scene Huddle Worksheet dated 1/28/25, at 6:45 p.m., indicated anticoagulant, antidepressant, cardiovascular were given in the past eight hours. R187 was found on the floor, had attempted to ambulate and self-transferred, used walker and lost balance. Last toileted at 5:30 p.m. and complained of back pain with movement. R187's Falls Tool form dated 1/28/25 at 8:56 p.m., and saved on 1/29/25 at 12:05 p.m., indicated there were no fall risk factors indicated, no risks factor checklists or interventions; no action plans were identified. R187's dispatch health imaging final report dated 1/30/25 at 12:59 p.m., indicated thoracic spine two views, there are no prior examinations for comparison. There is diffuse bony demineralization and kyphosis. There is a compression deformity of a midthoracic vertebral body of uncertain age. This is probably T7. There is a diffuse degenerative disc disease throughout the thoracic spine. Compression, midthoracic vertebral body compression fracture of uncertain age. Fax was received at 1/30/25 at 12:16 p.m. and certified nurse practitioner notified 1/30/25 at 12:30 p.m. R187's progress notes dated 1/22/25 at 5:38 p.m., indicated R187 had traumatic rhabdomyolysis of the right shoulder and arm and had not fallen prior to this one. R187's progress notes dated 1/24/25 at 9:18 a.m., indicated R187 had a recent fall at home and R187's PHQ-9 score was a 1 out of 27, indicating minimal depression. R187's progress notes dated 1/27/25 at 8:43 p.m., indicated R187 forgot to take her medications at times and the assisted living facility set up R187's medications and R187 scored low on cognitive assessments. R187's progress notes dated 1/29/25 at 9:18 a.m., indicated R187 had a fall and would get an x-ray. The notes lacked information when R187 fell , how R187 fell , what R187 was doing at the time of the fall, or any type of fall assessment. R187's progress notes dated 1/29/25 at 12:54 p.m., indicated the nurse practitioner was updated R187's son requested x-rays because R187 fell and had pain. R187's progress notes dated 1/30/25 at 12:41 p.m., indicated the nurse practitioner was at the facility and reviewed the x ray results. No other information was documented. R187's Potential Clinically Significant Medication Issues form dated 1/24/25 at 9:14 a.m., indicated a drug regimen review did not find issues of a potentially clinically significant medication issue. Additionally, check boxes indicating the date and time the prescriber was contacted was undocumented. R187's Interim Medication Regimen Review dated 1/28/25 and signed by admitting physician indicated physician orders reviewed with high-risk monitoring recommendations for anticoagulant and tramadol. R187's Risk Management Report from 1/28/25 at 9:20 p.m., stated the resident was found on the floor after trying to open the door. Assessed by registered nurse (RN)-A and recommended two certified nursing assistants to use the Hoyer lift to get R187 off the floor. Under the heading, Predisposing Situation Factors, not applicable was documented and no documentation of psychopharmacological medications. IDT reviewed incident on 1/29/2025. R187's Mar/Tar indicated on 1/29/25 amlodipine was given for hypertension, escitalopram oxalate was given for major depressive disorder, lisinopril for hypertension, melatonin for insomnia, mirtazapine for major depressive disorder, trazadone HCL for sleep, buspirone twice for major depressive disorder, carvedilol twice for atrial fibrillation, divalproex sodium twice for migraine, apixaban twice for atrial fibrillation, acetaminophen once for pain, tramadol three times for pain. R187's was referred to therapy due to a fall on 1/18/25 at home. R187's occupational therapy (OT) report dated 1/23/25 through 2/21/25 indicated, a baseline assessment was completed on 1/23/25. R187 demonstrated good rehab potential as evidenced by ability to follow one-step directions, able to make needs known, active participation in skilled treatment, motivated to a participate, motivated to return to prior level of living, strong family support and supportive caregivers/staff. R187 was assessed for activities of daily living (ADL's) and needed substantial to maximal assistance for toileting hygiene, shower/bathe, putting on/taking off footwear. Set up assistance for eating and oral hygiene. Supervision for upper body dressing and partial assistance for lower body assistance. R187 transferred with supervision or touching assistance, ambulated 10 feet with touching assistance, toilet transferred with supervision or touching assistance, partial assistance with bed mobility. R187 was able to sit up unsupported for 30 seconds with feet flat on floor and no back support. Ability to communicate wants and needs. Followed one step directions. Modified decision making. Therapy noted, patient presents with impairments in balance, mobility, strength, follow through, planning and problem solving resulting in limitations and/or participations restrictions in the areas of general tasks and demands, mobility and selfcare which requires skilled OT services to maximize independence with ADLs to facilitate ability to live in environment with least amount of supervision and assistance. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for falls and further decline in function. R187 attended OT on 1/23/25, 1/24/25, and 1/27/25. OT notes for 1/28/25 and 1/30/25 indicated resident was not able to participate in therapy due to fall on 1/28/25. R187's physical therapy (PT) report dated 1/23/25 through 2/21/25 indicated resident demonstrates good rehab potential as evidenced by high prior level of functions, motivated to participate, motivated to return not prior level of living and stable medical condition. R187 attended PT on 1/23/25, 1/24/25 and 1/28/25. PT notes for 1/29/25 and 1/30/25 indicated resident was not able to participate in therapy due to fall on 1/28/25. During observation on 1/27/25, at 2:28 p.m., no grabber or call light in reach. During observation on 1/27/25 at 6:10 p.m., call light pressed for R187 to check response time. At 6:12 p.m. staff did not respond to call light but did deliver meal tray. At 6:14 p.m. through 6:17 p.m. the call light remained on in the resident's room, but the marquee in the hallway closest to the resident's room was not displaying room ten and had a black screen. However, the marque near the nursing station on the opposite end did have Room ten scrolling on the marquee. During observation on 1/28/25 at 8:26 a.m., R187 was in her recliner, had vomited and attempted to use remote for lift chair to sit up. Call light was out of reach, assisted R187 with call light and she stated she was ready to go back to bed. Notified nursing assistant (NA)-D that resident vomited. The marquee near room ten was on. During observation on 1/29/25 at 11:57 a.m., verified with nursing assistant (NA)-C there was no grabber in R187's room. During an interview on 1/30/25 at 9:11 a.m., with registered nurse, (RN)-C, stated that she was not working at the time R187 fell , but neurological assessments are checked for three days following a fall. During observation on 1/30/25 at 9:30 a.m., dispatch health imaging arrived for imaging. The nurse practitioner was notified at 1/30/25 at 12:30 p.m. of the results. During an interview on 1/30/25 at 9:32 a.m., with registered nurse, (RN)-A, stated the floor nurse was on break when R187 fell . I assessed R187 and she was doing fine so the aids got her up using the lift. The fall assessment would be completed once the floor nurse returned from break. Verified with RN-A no progress note was entered regarding the initial fall assessment when R187 was on the floor. Licensed practical nurse (LPN)-B must have called R187's son because he is aware of the fall and inquired if this would change discharge planning. During a phone interview on 1/30/25 at 11:00 a.m. with LPN-B, stated she works for Focus One agency and has been trained for falls at this facility. LPN-B was on break during the fall. RN-A assessed R187, and LPN-B contacted the family. LPN-B completed the fall scene huddle worksheet and falls management checklist. LPN-B confirmed that RN-A assessed R187. Vital signs were entered in the medical chart at 1/29/25 at 4:15 p.m. and again 1/30/25 7:12 a.m. During interview on 1/30/25 at 12:31 p.m., pharmacist stated admission medications are reviewed within three days. If issues are identified the review will be completed immediately. The pharmacist looked for medication duplicates, same class of medications and any information that doesn't look right. The pharmacist stated, the current process is to email the DON, nurse practitioner and physician with recommendations. Red is used to identify a nursing task and black is used to identify a physician task. The nurse practitioner looked at medication orders and the DON looked for accuracy in the eMAR. This system has been used since he started reviewing at this facility. The pharmacist did review R187's medications and emailed the DON, nurse practitioner, and physician with recommendations on 1/23/25 at 7:08 p.m. The pharmacist stated in his email, she takes 5 psychoactive meds. I'm not sure if she was in the hospital for a fall because she has [NAME] appointments. Once she is settled, consider decreasing the doses or discontinuing some of them. She doesn't have any mental diagnoses under that tab. The pharmacist stated that taking all five of these psychoactive medications could have potential incompatibilities, fall risk, clarity issues and since she did not have a mental diagnosis the facility should review the medications and that was his recommendation. During interview on 1/30/25 at 1:03 p.m., with the minimum data set (MDS) coordinator, registered nurse (RN)-D, stated she is aware of the process the pharmacist uses when reviewing new admission medications, but could not find an email forwarded by the DON, Nurse Practitioner, or Physician to her regarding the recommendations and was not on the original email sent by the pharmacist regarding R187's medication review. RN-D stated she usually receives gradual dose reductions (GDR's) from the pharmacist or DON. RN-A and the HUC will also work on transcribing orders, but confirmed an RN would always double check the HUC's work. RN-D verified that the MDS for R187 is not completed, but she did confirm she marked NO for assessments needed for medications and crossed off the NO during this interview. RN-D stated, the MDS system will flag the new file if there is a black box warning for medications or duplicate medications but isn't aware if the system will identify five drugs in the same class. RN-D agreed that in this case the pharmacist recommendations have not been completed. During interview on 1/30/25 at 1:28 p.m., the DON stated the nurse practitioner did not respond back to the pharmacist email regarding the recommendations for R187's psychoactive medications. The expectation is that if it is a nursing error or fix, she will take care of it. RN-D could also make this change. The DON confirmed there is no system in place for duplicate or multi-class medications dispensed to residents and that nursing would have to use critical thinking skills for dispensed medications. The DON confirmed in this situation the floor nurses should have recognized that R187 was receiving five psychoactive medications in addition to identified as a fall risk. The DON stated what should have happened was the nurse practitioner reviews the discharge summaries from the hospital and if R187 was on medications prior to the hospitalization then these are considered home meds, and the provider will not change the order. The DON thinks R187 came to the facility on these medications, the review was sent to the pharmacist, and she is not sure what happened here. When asked what did happen, the DON said survey stress, documentation from the nurse that day should have been better and then the completed fall tool would have been reviewed earlier. The DON verified the nurse practitioner did sign off on the review from the pharmacist but did not make the recommended changes. At the next pharmacy review meeting the DON will suggest another layer of review to be added to this system. During interview on 1/30/25 at 1:36 p.m., RN-A stated there is no treatment needed for R187's fall that occurred on 1/29/25. R187's injured back will need to heal itself and to talk to the DON for more information. At 1:38 p.m., the DON stated R187 sustained an L4 and mid thoracic compression fracture of uncertain aging. Reviewed [NAME] Policy Falls Resource Packet Rehab/Skilled dated 5/7/24.

Based on observation, interview and document review, the facility failed to assess for and implement appropriate interventions to decrease the risk for falls for 4 of 4 residents (R189, R7, R29, R24) reviewed for falls. This failure led to actual harm for R189 when R189 obtained a right ankle fracture after a fall. Findings include: R189 R189's admission MDS dated [DATE], indicated R189 was admitted to the facility on [DATE], at risk for falls and had a fall with injury prior to admission. Further indicated, diagnosis of open reduction internal fixation (ORIF) of the left femur. R189's cognitive loss/dementia CAA dated 9/2/23, indicated R189 had confusion, disorientation, and forgetfulness and requires frequent reorientation, reassurance, and reminders to help make sense of things. The CAA lacked any interventions. R189's fall CAA dated 9/2/23, indicated R189 was at risk for falls related to being unable to ambulate without staff assistance due to unsteadiness, fall history within the last month prior to admission, and a fall after admission. R189's care plan dated 8/30/23, lacked any evidence of a fall care plan, fall history or any interventions to decrease the risk for falls. Further, the care plan lacked any evidence of what R189's ADL self care performance deficit was related to and had no interventions. R189's kardex dated 8/30/23, lacked any evidence of R189's fall risk status or interventions to prevent falls. Further, lacked evidence on how to assist R189 during transfers or ambulation. R189's fall assessment dated [DATE], indicated R189 was high risk for falls however, lacked evidence of an action plan to prevent/decrease the risk of falls. The facility Risk Management report dated 9/2/23 at 6:45 a.m., indicated R189 was found sitting on the floor of the bathroom. The report lacked any evidence of an assessment, root cause analysis, or any interventions implemented to prevent further falls. The report further indicated the physician wasn't notified regarding the incident until 1:34 p.m. R189's progress noted dated 8/30/23 at 2:30 p.m., indicated R189 was able to ambulate to the bathroom with walker and contact guard assistance from staff. R189's progress noted dated 8/31/23 at 1:09 a.m., inidcated R189 was limited assistance with ambulating to the bathroom with a walker and assist of one staff. R189's progress note dated 9/2/23 at 3:34 p.m., indicated R189 was found sitting on the floor of the bathroom with redness noted to right lower leg. R189's progress note dated 9/2/23 at 11:29 p.m., indicated R189 was unable to bear weight and the right ankle was examined at 8:00 p.m. The on-call provider was notified and an order was given to send R189 to the emergency room to obtain x-rays. The progress note further indicated emergency medical services (EMS) stated to the nurse R189's right ankle was broken. R189's progress note dated 9/3/23 at 1:44 a.m., indicated R189 was admitted to Lakeview hospital with a right broken ankle. During an interview on 04/18/24 at 2:41p.m., emergency medical technician (EMT) stated ,we were called between 10:00 p.m. and 12:00 a.m. to transport a resident with a possible infection however, when we arrived noted an obvious deformity to the residents' right leg, the leg was swollen twice the size, and purple in color. During an interview on 04/19/24 at 9:29 a.m., licensed practical nurse (LPN)-A stated R189 was found on the floor in the bathroom and complaining of pain to her legs. No immediate intervention was put into place to prevent further falls. R7 R7significant change Minimum Data Set (MDS) dated [DATE], indicated R7 had mild cognitive impairment, was at risk for falls related to impaired mobility and psychotropic medication use, and no history of falls. Further, the MDS indicated R7 was unable to walk in room [ROOM NUMBER] feet and required moderate assist for transfers and toileting. R7's fall Care Area Assessment (CAA) dated 1/16/24, indicated R7 was at high risk for falls due to psychoactive medication use. Lacked evidence of a history of falls. R7's care plan revised date 3/5/24, indicated R7 was at risk for falls related to impaired mobility, history of falls, and psychoactive medication use. Interventions included: remind resident not to bend over or to ask for assistance. As a result of falls on 2/2/24 and 2/5/24 the resident received education to call for assist to prevent falls. The care plan lacked evidence of any new potential effective interventions for the falls on 2/1/24 and 2/5/24 to prevent further falls. The care plan lacked evidence of the falls on 2/4/24 and 4/12/24 or any interventions implemented to prevent any further falls. R7's order summary dated 4/22/24, indicated R7 had orders for Aspirin Enteric Coated (EC) 81 milligrams (mg) one tablet one time a day and Plavix 75mg one tablet one time a day, which both medications can increase risk for bleeding. Further, R7's order summary indicated R7 had an order for Bupropion HCL Extended Release (ER) 24 hour 150mg (medication used for major depression) one tablet one time a day, which has a side effect of dizziness. Trazodone 50mg (medication used for insomnia) one tablet one time a day, which has side effects of weakness and tiredness. Quetiapine Fumarate 150mg (medication used to treat mental/mood conditions) one tablet one time daily, which has side effect of orthostatic hypotension (a sudden drop in blood pressure when someone stands up). Buprpion HCL ER, Trazodone, and Quetiapine Fumarate can increase the risk for falls. R7's admission record printed 4/22/24, included diagnosis of osteoarthritis, osteomyelitis, and muscle weakness. These diagnosis places the resident at increase risk for falls and/or injuries due to a fall. Fall 2/1/24 R7's progress note dated 2/1/24 at 6:40 p.m., indicated R7 was in room, standing with her walker with no assistance. The staff entered the room however, R7 began to fall and staff were unable to break the fall. A request was made for the facility Risk Management for the incident on 2/1/24 however, did not receive. The care plan lacked evidence of any new potential effective interventions for the falls on 2/1/24. Fall 2/4/24 R7's progress note dated 2/4/24 at 3:47 p.m., indicated R7 was found in room with recliner in the up most position with R7's buttocks half on the recliner and half off the recliner. The nursing assistant was unable to help R7 into the recliner and had to lower R7 to the floor after attempting to use the stand lift to adjust R7 back into the recliner. The progress note lacked evidence of an immediate intervention to prevent further falls. A request was made for the facility Risk Management for the incident on 2/4/24, however, did not receive. The care plan lacked evidence of the fall on 2/4/24 or any interventions implemented to prevent any further falls from the recliner. Fall 2/5/24 R7's progress note dated 2/5/24 at 10:15 a.m., indicated R7 was found on floor next to her recliner. R7 stated she was trying to get into the wheelchair from the recliner. The progress note lacked evidence of an immediate intervention to prevent further falls. R7's fall assessment dated [DATE], indicated R7 was at risk for falls and lacked evidence of any interventions put into place to prevent further falls. The facility Risk Management dated 2/5/24, indicated R7 was found on the floor. R7 stated she was trying to get into her wheelchair from the recliner and just slipped and fell . The report lacked any evidence of intervention put into place to prevent further falls. Fall 4/12/24 R7's progress note dated 4/12/24 at 3:43 p.m. indicated R7 was found on floor laying on her back close to her recliner and the recliner was at the highest position with the wheelchair next to the recliner.The progress note lacked evidence of an immediate intervention to prevent further falls. The facility Risk Management dated 4/12/24, indicated R7 was found on the floor laying on her back closer to the recliner with the recliner at the highest position. The report lacked any evidence of new intervention to prevent further falls. The care plan lacked evidence of the falls on 4/12/24 or any interventions implemented to prevent any further falls. During an interview on 4/22/24 at 3:55 p.m., the nurse practitioner (NP) stated any further falls for R7 could lead to serious injury/harm without new interventions implemented due to R7's history of falls with injury, her diagnosis, and medication usage. Further stated, any resident in a long-term care facility was at risk for serious injury from repeated falls. R29 R29's quarterly MDS dated [DATE], indicated R29 had moderatecognitive impairment, was at risk for falls due to one fall since admission, and was unable to walk 10 feet in room without moderate assistance. R29's fall CAA dated 10/20/23, indicated R29 was at risk for falls related to impaired mobility, incontinence, and psychoactive therapy. Interventions included interdisciplinary team (IDT) to monitor resident and update care plan as needed, staff to ensure to toilet resident in a timely manner, keep resident safe and injury free, and monitor for effectiveness of psychoactive medications. R29's care plan revised on 3/12/24, indicated R29 was at risk for falls related to history of repeated falls as evidence by unsteady gait. The care plan lacked any evidence of new interventions for the 4/15/24 fall. R29's fall assessment on 4/15/24, indicated R29 was high risk for falls however, lacked evidence of any interventions put into place to prevent further falls. The facility Risk Management dated 4/15/24 at 7:00 a.m., indicated R29 was found on the floor at the foot of his bed. R29 stated he was trying to get some pants and just fell . The report lacked evidence of any new interventions to prevent further falls. R29's progress note dated 4/15/24 at 7:30 a.m., indicated R29 was found on the floor at the foot of his bed. The progress note lacked evidence of an immediate intervention to prevent further falls. 44647 R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure, atrial fibrillation, vascular disease, and weakness. R24 required assistance of a walker and wheelchair for mobility and for rolling left to right in bed. Furthermore R24's MDS indicated R24 required and had a recent fall with injury. R24's fall CAA dated 1/8/24, indicated R4 was at risk for falls and fall related injuries due to antidepressant, opioids, and diuretic medication use. R24's nursing progress notes indicated: -on 3/27/24 at 7:20 a.m., R24 was found sitting on the floor next to the bed in between the bed and the window. R24 stated they had rolled over in bed to turn off alarm clock and just fell out of bed. R24 was assessed for injury. R24 was on blood thinners and hit their head. R24 had a rape sized bump on left side of forehead, bleeding on face between lip and nostril, a large skin tear to right arm, and swelling and bruising to left knee. R24 sent to emergency room for evaluation. -on 3/27/34 at 11:30 p.m., R24 returned from the emergency room with diagnoses of closed head injury, traumatic hematoma, skin tear to right arm and facial laceration. R24's fall incident report dated 3/27/24, indicated R24 had rolled out of bed when attempting to shut off alarm clock. R24 was sent to emergency room due to hitting head and on blood thinners. R24's report further indicated no injuries were observed at time of incident and R24 was alert and orientated. R24's fall incident lacked any root cause or care plan interventions placed. R24's interdisciplinary team (IDT) follow up note dated 4/1/24, indicated IDT reviewed the incident and education was provided to R24 to ask for help if they were not able to reach alarm clock. R24's physical devices and/or Restraint Evaluation dated 4/4/24, indicated grab bars were requested from resident and family to assist with safe bed mobility. Assessment concluded bars did not restrict movement and education provided to patient and family. R24's care plan revised on 4/9/24, indicated R24 had an actual fall with serious injury related to poor balance and coordination. Interventions included educate and instruct resident and family on safe use of assistive devices, educate resident not to bend over and pick up dropped items and use grabber or ask for assistance. Furthermore, R24's care plan indicated the use of grab/assist bars on bed related to fall risk and instructed staff to educate resident and family risks and benefits, any concerns with use of the bars. R24's Kardex dated 4/17/24, directed staff to ensure resident was wearing appropriate footwear when ambulating or mobilizing wheelchair and encourage resident not to bend over to pick up items- encourage use of grabber or ask for assistance. An observation on 4/18/24 at 2:00 p.m., R24 was laying in bed with the head of bed elevated. On R24's left was a bedside table located in-between the bed and wall with window. On the bedside table was R24's alarm clock. The bedside table was located by the head of the bed and for R24 to reach the alarm, they would need to reach over their left shoulder behind them. R24's bed had a grab bar on R24's right side, but not one on the left side where the alarm clock and bedside table were. R24's reacher was noted to be out of reach and standing next to a dresser to the right of R24. When interviewed on 4/18/24 at 2:00 p.m., R24 stated she was trying to turn off the alarm clock and just fell out of bed. R24 stated it happened so fast, she wasn't sure what she hit or how she landed. R24 stated she would like to use the alarm clock but was too scared and she didn't want to roll out of bed again. R24 stated after the fall, the bars were put up, but that job never got completed .they only put on one side, and that bar is loose. R24 took a hold of the grab bar that was placed on right side and shook it. The bar was very loose. R24 stated staff were aware and wasn't sure if the bar was going to be fixed or why the other side was not placed. R24 stated she still had bumps and bruising from the fall and pulled her hair back to show a lump that appeared to be scabbed over on the left forehead and her left knee which still had a lump and was a dark purplish color. When interviewed on 4/28/24 at 2:18 p.m., NA-A was aware of R24 rolling out of bed and stated R24 was bleeding from their face. NA-A stated R24 was independent and was not a fall risk. R24 wasn't considered a fall risk as she was able to transfer independently, get dressed, and was able to get herself out for meals. NA-A further stated they were not sure how to know which residents were considered a fall risk and stated residents who have a lot of falls and have touch call lights would be considered a fall risk. NA-A further stated the grab bar was placed to help R24 getting out of bed. NA-A thought they were placed on both sides. When interviewed on 4/18/24 at 2:31 p.m., LPN-C stated R24 rolled out of bed when trying to turn off the alarm clock. R24 had not had prior falls to this and R24 and family requested grab bars to be placed to help assist with bed mobility and reaching for the alarm clock. LPN-C further stated there wasn't any specific side or not but thought there were two on the bed. When interviewed on 4/19/24 at 9:59 a.m., maintenance personal stated when nursing staff complete the assessment for safety, a work order was placed for grab bars. Grab bars were checked quarterly during room checks. The maintenance personal further stated R24's loose bar was replaced as there was a suction part that was no longer functioning. A follow up interview on 4/22/24 at 9:59 a.m., maintenance personal verified the work order for R24's grab bars indicated for both sides. Maintenance personal explained he had only the right one available to place. The bars and beds were no longer manufactured so new ones were not able to be ordered. There wasn't a left side available to put on and nursing staff on that day were told and said it was ok. When interviewed on 4/22/24 at 2:08 p.m., the Director of nursing (DON) stated the care plan, Kardex, and wing assignment sheets were how staff knew what residents were at risk for falls and what interventions were needed. The Kardex and assignment sheets could be updated by any of the nurses when there was a change. DON expected staff to be aware of residents at risk for falls. DON further stated all falls were reviewed in the daily IDT meetings and if new interventions were needed, the care plan and Kardex was updated. DON wasn't sure why only one rail was placed and thought it may have been placed only on the side R24 got out of bed. DON expected fall interventions to be in place for residents. During an interview on 4/19/24 at 11:11 a.m., nursing assistant (NA)-B stated had been working at the facility for about a month. NA-B knew residents were a fall risk by fall risk being posted on residents' doors or in their rooms, for example on bathroom doors. NA-B further stated residents who were at risk for falls wore a wristband or wore a band around their ankle. NA-B stated residents' charts stated if they were at risk for falls, and NA-B was not aware of any residents who were a fall risk on the hallway being worked. NA-B stated when a resident fell , the staff kept the resident on the floor until the nurse could get the resident's vitals and make sure the resident was okay. Staff assisted the resident back into bed if they were okay or called the hospital if they were not okay. NA-B stated had education regarding falls and fall prevention during nursing assistant certification but doesn't recall any fall or fall prevention education from the facility. After completing medical record review and review of the resident rooms, noted several residents on NA-B assignment were at risk for falls including R24. During an interview on 04/19/24 at 9:46 a.m., director of nursing (DON) stated when a resident falls the staff should put an immediate intervention in place after an assessment of the fall and then IDT would review and change the intervention and update the care plan if appropriate. Further, the DON stated the staff should follow the fall policy. The facility Fall Prevention and Management policy dated 4/2/24, indicated proactive approach before a fall occurs: 1. On admission or readmission, review the applicable documents and additional admit information documentation for fall risk factors. 2. Complete the Falls Tool UDA for fall screening and identifying fall risk factors. 3. Care Plan the appropriate interventions, including personalizing all specify areas. 4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-hour report, care plan, and kardex, daily stand-up meeting, and/or Fall Committee meetings. 5. Communicate any identified environmental changes and/or referral needs. Procedure for a fallen resident: - A nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident. - Notify the physician and resident representative of the incident. - After the initial documentation of the incident in the incident report this will be done in the progress note (PN) - Incident. Document the physician's comments in the medical record. - Communicate that a fall has occurred during shift change and daily stand-up meetings. - Review and update the Care Plan with any changes/new interventions. - Continue to monitor condition and the effectiveness of the interventions.

Based on observation, interview, and document review, the facility failed to ensure frozen and refrigerated food items were properly stored, labeled, and dated and disposed of after expiration date. Furthermore, the facility failed to ensure the ice machine and air vents were clean and sanitary. This deficient practice had the potential to affect all 39 residents who receive food from the kitchen. Findings include: Food Storage During the initial kitchen observation on 4/15/24, at 12:46 p.m., the walk-in freezer contained the following: -a Ziplock bag labeled corn beef hash dated 2/11/24. The contents of the bag were brown meat with crystals of ice that had formed on the meat and the inside of the bag. -a Ziplock bag labeled turkey dated 4/12/24. The contents of the bag were white meat with crystals of ice that had formed on the meat and the inside of the bag. -Two plastic tub containers labeled potato salad with a date of 3/20/24 and 3/12 -a plastic tub that stated seafood salad dated 3/22. -four foil containers with foil tops had no label to identify contents, but had a date of 3/20. The walk-in refrigerator contained the following: - a container of [NAME] strawberries. The strawberries contained a greenish black fuzzy substaines -a container of Sysco ham soup base had a label that stated opened on 1/21 and lacked a use by date. -a container of Sysco chicken-based soup had an open date of 1/6 and lacked a use by date. -a white container of cucumber salad had no open date or use by date. -a tray of brownies on a plate was sitting on a cart with no label or date on when they were made. When interviewed on 4/15/24 at 1:08 p.m., the dietary supervisor stated food storage was on a first in first out basis. So, items that are the oldest should be used first but wasn't sure of the system in the facility as they were helping from a sister facility. DS verified the frozen meat appeared to not be good any longer and wasn't sure if the date was when it was put in the freezer. The potato salads and seafood salad were regular menu items and DS stated those were homemade items and were not normally items to be frozen and they should be thrown out. DS had no idea what was in the foil pans and stated they needed to be thrown out. The DS verified the mold on the strawberries, containers of soup base, and cucumber salad. DS was not sure when the salad was made or the trays of deserts, but most likely should be thrown. DS stated currently there was no dietary manager (DM) and since coming to help at the facility DS was trying to figure out the ordering process and menus. DS stated the previous DM saved everything, which was not always a good thing as items get old. DS acknowledged there was not a good process for dating, labeling, and storing food. This was something DS needed to get in place. Clean vents A kitchen cleaning schedule was requested however was not provided. An observation on 4/17/24 at 7:11 a.m., DS was prepping for breakfast. Over the kitchen prep area were two air vents on the ceiling. The vents had large grey clumps of dust in the grates. Across from the vents were clean pitchers, plates, and trays. DS verified the grey clumps of dust and verified the air was blowing out of the vents. When interviewed on 4/17/24 at 7:30 a.m., DS stated there was no cleaning schedule for the kitchen. DS stated since coming to help, they had been trying to get the kitchen cleaned better but it was challenging with working both places and not having a lot of help. DS stated there was work to be done to ensure there was a more streamlined process as almost all the staff was new. Ice Machiene A facility document titled Work History Report dated 1/2024-3/2024, indicated ice machine inspection and cleaning was completed on 1/31/24 and 2/29/24. An observation on 4/17/24 at 8:13 a.m., the ice/water machine for resident use was in the dining room. On the spouts where ice and water were obtained, there were large amounts of crusty white substance on the tray and around both the water and ice spigots. The sides of the tray also had crusty white substance on it that ran down onto the cooler located under the machine. When interviewed on 4/18/24 at 11:50 a.m., the maintenance personal stated there were 2 ice machines, but only one for resident use. The ice/water machines were cleaned quarterly. The log indicated a cleaning was done in January for the ice/water machine in the dining room and were required to be cleaned quarterly. The resident ice/water machine was due to be cleaned this month. Maintenance personal stated the white substance was hard water and calcium build up and it happened quickly. They attempted to try to clean it more often if there was time, but it just builds up quickly and doesn't get cleaned until the next quarter. When interviewed on 4/22/24 at 1:39 p.m., the administrator, stated he expected food to be dated and stored properly and there shouldn't be moldy items. Furthermore, staff were expected to follow the cleaning schedule for the kitchen and ice/water machines. If items needed to be cleaned more often, it should be completed. This was all important for sanitary and safe food for the residents. A facility policy titled Food Supply Storage revised 5/11/23, directed staff to ensure foods that have been opened or prepared were placed in an enclosed container, dated, labeled, and stored properly. Furthermore, leftovers or food items prepared for service that were not served were stored for use within 7 days. A facility policy titled Cleaning Schedule- Food and Nutrition Services revised 11/27/2023, directed staff post written daily, weekly and monthly cleaning assignments in the kitchen areas. Furthermore, the policy directed daily inspections of ceilings daily for dust and cobwebs, and for walls and vents to schedule a cleaning every 6 months. A facility policy titled Ice Machine Use and Maintenance dated 12/11/23, directed staff to clean, descale, and change filters according to the water/ice machine's manufacture recommendations. Furthermore, the policy indicated to adjust the frequency based upon use and conditions related to the machine (location, quality of water, etc.

Based on observation, interview, and record review the facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services. This had the potential to affect all 39 residents who reside in the facility. Findings include: The facility's undated list of hires did not include a dietary manager (DM). An undated facility document titled Annual and New Hire Education Dietary indicated all dietary staff had required training titled Basics of Food Safety in Long Term Care Facilities and IDDSI training for safe swallowing. Dietary aide (DA)-A's new hire education dated 4/18/24, lacked indication DA-A had completed the required training for dietary staff titled Basics of Food Safety in Long Term Care Facilities and IDDSI training for safe swallowing. An observation on 4/16/24 at 8:06 a.m., residents were being served breakfast in the dining room. There was no daily menu posted in the dining room. DA-A was serving up cold cereal, yogurt, and toast. DA-A stated there was no cook this morning due to an ill call. DA-A stated she was on her own until 9:00 a.m., and she isn't a cook so breakfast was toast and cereal. DA-A stated she wasn't sure what breakfast was supposed to be. When interviewed on 4/15/24 at 12:50 p.m., cook-A stated they were working late to help with dishwashing as there wasn't enough staff. When interviewed on 4/15/24 at 1:08 p.m., dietary supervisor (DS) stated they had been coming to work at the facility for about a month to help as there was not a dietary manager (DM). DS was also working as a supervisor at a sister facility. When starting here, DS stated there was not a good process for labeling and dating foods or for ordering what was needed. DS stated he wanted to get some processes in place for ordering what was needed for menu items, labeling, and dating foods, and a kitchen cleaning schedule. DS stated he was working in the facility almost every day and stated there just was not enough staff or time to work on the needed processes. DS stated everyone was just trying to do their best with what they have. A follow up interview on 4/19/24 at 8:34 p.m., DA-A stated she had not had any education related to food service when hired and had initially started as a housekeeper. DA-A started working as a DA due to being short staffed in the kitchen. DA-A further stated she did not train with anyone and just jumped in as the help was needed. A follow up interview on 4/19/24 at 9:06 a.m., DS stated he was aware of no cook on 4/16/24 but was scheduled at the other facility. DS stated if he came here, then no cook would be over there, so there was not a good solution. DS was not aware of the training DA-A received as DS was not here when DA-A was hired. DA-A was hired prior to DS starting at the facility and was initially a housekeeper and switched to kitchen a week or so ago. Furthermore, DS stated he tried to train as best they can and wasn't aware of any checklist or sign off, just what staff were assigned to in the online training. When interviewed on 4/22/24 at 1:39 p.m., the administrator expected any general education for dietary staff would come from the supervisor. The administrator further stated any further education would depend on the employee and their experience. A policy on kitchen training and requirements was requested however was not received.

Based on observation, interview, and record review the facility failed to ensure the facility's walk-in freezer was maintained to ensure water drippings and ice build up would not impact frozen food storage. This had the potential to impact all 39 residents who reside in the facility. Findings include: During the initial kitchen observation on 4/15/24 at 12:46 p.m., the walk-in freezer was observed. Inside the freezer, near the top, at the far end were two fans. The right one was in motion while the left one was not moving due to a large ice dam inside the fan. In the fan blades and grate the large ice dam extended from the fan down all three shelves to the floor of the freezer. The ice dam appeared to be frozen water that had dripped down and frozen as it went down, as it gotten smaller as it went down. As it extended down the shelves, the ice had frozen on to several unopened boxes located on the back three shelves. When interviewed on 4/15/24 at 1:08 p.m., the dietary supervisor (DS) verified the ice dam and stated it had been there since he started at the facility a few weeks ago. DS stated it was something to do with the fan and wasn't sure how long it had been that way. DS further stated maintenance had been aware, but nothing had gotten fixed yet. DS verified the boxed items on the back shelves and was not sure if it impacted the items inside. When interviewed on 4/18/24 at 11:50 p.m., the maintenance personal stated he was made aware of the ice dam in the freezer a week or so ago and wasn't sure how long it had been there. Maintenance personal further stated he had been working on trying to chip it away, but it just kept building up. Maintenance personal further stated they had some help from another facility yesterday and were able to get the ice dam cleaned out and determine what the problem was. A temporary fix was now in place until the needed part arrived. When interviewed on 4/22/24 at 1:39 p.m., the administrator had not been aware of the ice dam in the freezer and expected all equipment in the kitchen to be in good working condition. If something wasn't working, it should be followed up on in a timely manner. A policy for maintaining equipment was requested however was not received.

Based on observation, interview and document review, the facility failed to follow standard precautions, contact precautions, droplet precautions, and perform evidence-based hand hygiene for GI symptomatic residents for 4 of 4 (R4, R24, R13, and R91) reviewed for infection control practices. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and had diagnoses of overactive bladder, kidney disease, diabetes, and muscle weakness. R4's Care Area Assessment (CAA) for functional abilities (self-care and mobility) dated 3/21/24, indicated R4 required assistance with activities of daily living (ADLs) and one or two staff assistance. R4's CAA for urinary incontinence and indwelling catheter dated 3/21/24, indicated R4 required assistance with toileting, had incontinence, and was at risk for developing UTIs. R4's care plan dated 4/28/21, indicated she had an ADL self-care deficit related to a history of UTIs and required extensive assistance of one with toilet use. Furthermore, the care plan identified R4's history of UTIs with a goal to remain free of UTI. R4's care plan listed interventions of monitoring, documenting, and reporting signs and symptoms of infection to the nurse and provider and encouraging fluid intake. During observation and interview on 4/17/24 between 7:20 a.m. and 7:44 a.m., nursing assistant (NA)-A entered R4's without performing hand hygiene. NA-A assisted R4 out of bed and into the bathroom. NA-A donned gloves and assisted R4 to stand up and pivot onto the toilet. NA-A assisted R4 with dressing her upper body, putting on deodorant, and cleaning her eyeglasses while NA-A continued to wear the same gloves. NA-A instructed R4 to use the grab bars to help herself stand up, and once R4 was standing upright, NA-A reached from behind and wiped R4's perineal (peri) area from back to front with disposable wipes. Then, reaching from the backside of R4's perineal area, NA-A wiped front to back. NA-A removed the gloves and disposed of the wipes and gloves in the garbage can, pulled up R4's pants, and did not perform hand hygiene. NA-A wheeled R4 in front of the sink to complete morning ADLs independently. When interviewed, NA-A verified no hand hygiene was performed prior to entering R4's room. NA-A stated it was important to clean from front to back and ensure any soap used was rinsed and ensure there was no feces for the prevention of UTIs. Additionally, NA-A stated, in reality, I should wash my hands coming into the room, before peri-cares, then do peri-cares with gloves, then remove gloves after peri-cares and wash my hands, and then wash my hands before leaving the room. NA-A stated it was difficult to perform peri-cares because R4 was standing awkwardly, but R4 had a bath later in the day. During interview on 4/17/24 at 7:50 a.m., R4 stated she recently had a UTI and was feeling fine. She denied symptoms of infection and acknowledged staff allowed her the opportunity to perform hand hygiene after bathroom use. During interview on 4/18/24 at 10:47 a.m., the infection preventionist (IP) stated staff were expected to perform hand hygiene before entering and exiting a resident room and before and after glove use to protect residents from infection. The IP stated staff should clean front to back for female residents during peri cares to prevent fungal skin infections and UTIs. During interview on 4/18/24 at 1:45 p.m., registered nurse (RN)-B stated when performing perineal cares on a female resident, staff were expected to wipe from front to back and use a clean side of a washcloth or wipe for each swipe. RN-B stated staff were expected to perform hand hygiene before cares, don gloves during cares, change gloves after perineal cares and perform hand hygiene before donning new gloves. During interview on 4/18/24 at 3:30 p.m., the director of nursing (DON) stated staff were expected to use standard precautions when providing cares for residents. Additionally, the DON stated the expectation was to perform hand hygiene upon entering and before leaving a resident's room and, for female residents during perineal cares, for staff to wipe from front to back. The DON stated the goal was to prevent infection and it would not be an acceptable practice to enter a resident's room without performing hand hygiene, nor would performing perineal cares by wiping back to front. 42586 Findings include: R91's admission Minimum Data Set (MDS) dated [DATE], indicated R91 had intact cognition and diagnoses of sepsis, chronic kidney disease (CKD), chronic respiratory failure with hypoxia, and urinary tract infection (UTI). It further indicated R91 required maximal assistance with toileting hygiene and was frequently incontinent of bowel. R91's care plan dated 4/4/24, indicated R91 had bowel incontinence related to Crohn's disease and Norovirus and an activities of daily living (ADL) self-care performance deficit related to incontinence cares with an intervention of R91 required extensive assistance of one staff dependent for hygiene with incontinent bowel movement. During observation on 4/17/24 at 9:00 a.m., nursing assistant (NA)-D used hand sanitizer, donned a gown, gloves, mask, and entered R91's room. NA-D then assisted R91 to use the bathroom and exited the room still wearing the same gloves, gown, and mask and went into the hallway outside R91's room. NA-D then removed her gown and gloves and threw them away in the bins in the hallway, used hand sanitizer, and walked down the hallway towards the nursing station. During an interview on 4/17/24 at 9:19 a.m., nursing assistant (NA)-D stated she was aware R91 was on gastrointestinal (GI) and contact precautions but wasn't sure why. NA-D further stated she had assisted R91 to use the bathroom and R91 had diarrhea so had also assisted her to clean up. NA-D verified she used hand sanitizer after removing her gloves and did not wash her hands with soap and water stating You should just use soap and water when you get the chance because we don't have time in between residents so hand sanitizer works the best. NA-D verifed there was a sign on R91's door indicating she was on GI and contact precautions and staff should wash their hands with soap and water when leaving the room. NA-D works with all the residents in the facility, not just on one unit. During interview on 4/17/24 at 1:44 p.m., LPN-A stated if a resident was on GI/contact precautions staff should wear a gown and gloves before entering the room. It was okay to use hand sanitizer when entering and exiting the room but you should alternate with washing your hands with soap and water if you can. During interview on 4/17/24 at 1:52 p.m., nurse manager registered nurse (RN)-B stated R91 was admitted with Norovirus and continued to have diarrhea so they put her on GI/contact precautions. RN-B stated these precautions required staff to wear a gown and gloves stating whatever the sign says. and that staff should be washing their hands with soap and water (not hand sanitizer) when leaving the room. 44647 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure, atrial fibrillation, vascular disease, and weakness. R24 required assistance of a walker and wheelchair for mobility and for rolling left to right in bed. Furthermore, R24 was continent of bowel and bladder and was assist of one to the bathroom. R24's nursing and provider order summary indicated: -on 4/15/24, R24 required a COVID-19, influenza, urine analysis, and stool sample for enteric pathogen -on 4/15/24, gastrointestinal (GI)/contact/respiratory/droplet isolation until labs return An observation on 4/15/24 at 2:32 p.m., R24's door was closed. Outside the door was an isolation cart and two white garbage cans. On top of the isolation cart was a bottle of hand sanitizer. On the wall above the isolation cart were two signs. One stated enhanced barrier droplet precautions and instructed staff to wear gown gloves, eyewear, and surgical mask upon entering and if completing an aerosol generating procedure a N95 mask was required. Below that sign was a sign that read contact precautions and directed staff to use GI precautions if loose stools or C-diff. When interviewed on 4/15/24 at 2:44 p.m., LPN-C stated R24 started having diarrhea, nausea, and fevers today. The provider was notified and labs for COVID-19, influenza were ordered, and a urine and stool sample needed to be collected and sent for testing. LPN-C stated TBP were started as R24 was having a COVID-19 test and stool testing for enteric pathogens. An observation on 4/15/24 at 6:26 p.m., nursing assistant (NA)-E exited R24's room with gown, gloves, eyewear, and surgical mask in place. NA-E removed their gown and with gloved hands lifted the garbage can lid and placed the gown inside. NA-E then removed gloves and lifted the garbage can lid and place them in there. NA-E then removed eyewear and placed on isolation cart before using the hand sanitizer on top of the cart to perform hand hygiene. NA-E had not worn an N-95 mask. Without using soap and water to wash hands, NA-E then knocked and entered room [ROOM NUMBER] to provide resident assistance. When interviewed on 4/15/24 at 6:40 p.m., NA-E stated R24 had an unknown droplet infection as well as weakness and diarrhea. NA-E stated R24's tests were pending. NA-E verified the isolation signs outside of R24's room. The top one stated enhanced droplet precautions and verified just a surgical mask was ok. NA-E further stated if R24's COVID test returned positive then a N95 mask was needed, but test had not come back yet. NA-E verified the contact isolation sign outside R24's room directed to use GI precautions with loose stools. NA-E stated that indicated to use gown and gloves when entering the room. NA-E further stated washing hands with soap and water was always the best to do, but hand sanitizer was ok to use as well, even with GI precautions. An observation on 4/16/24 at 8:10a.m., laboratory technician (LT)-A was observed exiting R24's room with gown, gloves, eyewear, and N-95 mask in place. LT-A removed gloves and placed in the garbage can outside of the room. LT-A then removed N-95 mask and eyewear and placed into garbage. LT-A used hand sanitizer located on the isolation cart outside of R24's room and walked down the hallway and entered room [ROOM NUMBER]. When interviewed on 4/16/24 at 8:27 a.m., LT-A stated R24 had a blood draw and that was why she was in R24's room. R24 had a COVID-19 test pending and was aware R24 was having loose stools. LT-A further stated that was why R24 was on TBP. LT-A stated there was nothing different with isolation or hand hygiene for GI symptoms and acknowledged washing with soap and water was best, but you just use what you have so sometimes it was just hand sanitizer. An observation on 4/16/24 at 2:13 p.m., the enhanced barrier for droplet sign that was outside R24's room was removed. The orange contact isolation sign remained. When interviewed on 4/17/24 at 1:34 p.m., LPN-F stated they were not sure what was going on with R24 and was confused about why they are on TBP. In morning report, LPN-A was told R24's tests were negative and so TBP were removed. LPN-F had not been using any TBP all morning until an order was placed for enteric precautions an hour or so ago. LPN-F verified the signs, cart, and garbage bins outside of R24's room and stated I just didn't pay attention to them as I was told tests came back negative. LPN-F further verified GI precautions included gown, gloves and handwashing with soap and water. When interviewed on 4/17/24 at 1:44 p.m., the Director of Nursing (DON) stated residents with GI symptoms were placed on enteric precautions. Enteric precautions were contact precautions where hand washing with soap and water was expected. DON was aware of R91's norovirus and further stated they were admitted with it. DON was not aware of any other residents with GI symptoms except R24 and there were no trends in GI illness. DON stated staff were expected to complete handwashing when residents were in GI/contact TBP. If testing for infectious process was in place, the residents were treated as if they have the infection until a test was resulted. DON would also expect residents with pending COVID-19 tests to be in full droplet precautions and not in enhanced barrier precautions as staff were required to use precautions as if the resident had the infection until the test proved otherwise. R7significant change Minimum Data Set (MDS) dated [DATE], indicated R7 had mild cognitive impairment. An observation on 4/18/24 at 8:44 p.m., housekeeper (H)-A was cleaning R13's room. H-A swept the floors with a sweeper to the doorway and then took a broom and dustpan to sweep up and placed the dirt in the garbage on the housekeeping cart. Without hand hygiene, H-A then went to the clean linen room and took a towel and went back into R13's room and placed the towel in the bathroom. Without hand hygiene, H-A exited room and again went to the clean linen room and obtained sheets and brought back into R13's room. H-A proceeded to make R13's bed. At 8:59 a.m., H-A exited R13's room with no gloves and no hand hygiene was carrying R13's dirty bedspread that contained brown/tan substance on it that appeared to be bowl movement. The bedspread was not bagged but freely hanging in the open. The bedspread was brought to the soiled utility room and placed in a bin. Without hand hygiene, H-A left the soiled utility room and went to the clean linen room to obtain a clean bed spread and returned to R13's room to finish making the bed. After completing the bed, without hand hygiene, exited R13's room carrying a folded sheet and brought it back to the clean linen room. H-A then went to the cart and without hand hygiene placed a glove on the right hand only, obtained a wet washcloth from the cart and proceeded to clean high touch areas of R13's room. H-A then went back to the cart and placed washcloth in dirty linen bag attached to housekeeping cart and with same gloved hand took the toilet brush and went to clean the toilet. After completion, brought the brush back to place in the cart removed one glove and performed hand hygiene and entered room [ROOM NUMBER]'s room to clean. When interviewed on 4/18/24 at 9:35 a.m., H-A verified they only had one glove on and did not perform hand hygiene with each exit of R13's room or when exiting the soiled utility room. H-A stated they try to clean up the resident rooms and bring extra linens that were not used back to the clean linen. H-A had not been told that is not ok to do. H-A further acknowledged R13's bedspread had bowel movement on it and should have had gloves on and placed it in a bag before bringing to the soiled utility room. When interviewed on 4/18/24 at 11:50 a.m., housekeeping supervisor stated generally any linens were not touched by housekeepers unless turning over a room for discharge. HS expected staff to be wearing gloves when entering and exiting the room as well as when handling any soiled linens or towels. HS stated extra linens should not be brought out of resident rooms and placed back in storage as they were already placed on resident surfaces. All these things helped to prevent any spread of germs/bacteria. During interview on 4/18/24 at 10:47 a.m., the infection preventionist (IP) stated if a resident tested positive for something, staff were notified immediately to place the resident on isolation precautions and the resident's provider would be updated for further guidance regarding any type of outbreak testing. The IP stated enhanced barrier precautions (EBP) were initiated for residents with chronic wounds, pressure ulcers, surgical wounds and incisions, and catheterization. When asked when transmission based precautions (TBP) would be intitated for a resident, the IP stated, when they have a diagnosis. The IP was unsure what type of standing precautions could be implemented for the facility if a resident had gastrointestinal (GI) symptoms, such as diarrhea, and stated, I'm not aware of any standing orders for this facility for precautions, but for the other facility and during our regional infection preventionist call, the expectation is the resident be placed on contact or droplet or ehanced barrier precautions until we can rule that out. If a resident was GI precautions, the IP stated staff were expected to wear gloves, gown, and a mask for all direct cares with the resident. The IP stated handwashing should be done whenever going in and out of the resident's room to prevent cross contamination, and handwashing should be done if staff are providing cares with the resident. The IP stated hand sanitizer would be appropriate if staff are, going in and out of the room to just verbally speak to the resident. A facility policy titled Activities of Daily Living - Rehabilitation/Skilled Care and Long Term Care (R/S, LTC), dated 11/29/22, indicated any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. Furthermore, the policy indicated ADLs are those necessary tasks conducted in the normal course of a resident's daily life and included toileting, transferring on and off the toilet, use of bedpan, urinal or commode, cleansing after elimination, changing any protective pads, and adjusting clothing after toileting. A facility policy titled Standard and Transmission Based Precautions revised 4/2/24, indicated: -standard precautions were used to protect residents from all recognized and unrecognized sources of infection, blood, and bodily fluids. Standard precautions include hand hygiene and personal protective equipment (PPE) such as glove use. The policy directed all staff to use standard precautions with all residents when cleaning equipment or handling of potentially soiled items and entering/exiting rooms. -enhanced barrier precautions were used for residents with wounds or indwelling medical devices. Enhanced barrier was used only during high contact cares that involve close physical contact with the resident. -contact precautions will be used in addition to residents with a known or suspected infection or evidence of syndromes that represent an increased risk for contact transmission. Contact GI precautions should be used when GI illness was suspected. -droplet precautions will be used in addition to residents with a known or suspected infection with organisms transmitted by droplets generated by sneezing, coughing, or talking.

Based on interview and record review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service. This had the potential to affect all 39 residents who resided in the facility. Findings include: The facility's undated list of hires did not include a DM. The interim dietary supervisor (DS)'s qualifications for a dietary manager was requested however was not received. When interviewed on 4/15/24 at 1:08 p.m., the DS stated there was not a DM currently employed at the facility. DS was a DS at a sister facility and was currently working both facilities. DS further stated there had been a lot of turnover in the kitchen staff and the facility was working on hiring. A follow up interview on 4/18/24 at 10:46 a.m., DS stated he had been at the facility for about a month trying to help. DS further stated he had food safety manager certificate, however, was not able to find it. When interviewed on 4/18/24, the RD stated they did not work full time at the facility and were on site twice weekly on Tuesdays and Thursdays. When interviewed on 4/22/24 at 1:39 p.m., the administrator verified there had not been a dietary director for a month or so and that was why DS was helping in the kitchen. The administrator further stated there was a new DM hired but was unsure of a start date as they were waiting on a background check.

Based on observation, interview and document review, the facility failed to follow care planned interventions to heal/prevent pressure ulcers for 2 of 2 residents (R6 and R29) reviewed for pressure ulcers. In addition, the facility failed to reassess R6's pressure ulcer, identify interventions, notify the provider and obtain treatment which caused actual harm when R6's healed pressure ulcer redeveloped. Findings include: R6's quarterly Minimum Data Set ((MDS) dated [DATE], did not include a Cognitive Patterns assessment. However, the prior MDS dated [DATE], indicated R6 had severe cognitive impairment. R6's MDS dated [DATE], indicated R6 required extensive assist for transfers and repositioning and was always incontinent of bowel and bladder. R6 was at risk for pressure ulcer development, had no current pressure ulcer(s) and was on a turning and repositioning program. R6's pressure ulcer Care Area Assessment (CAA) and dated 5/14/19, included, He is at risk for pressure ulcer development related to recent hospitalization with non surgical intervention of femur (leg bone) fracture, Alzheimer's dementia which may hinder his ability to identify pressure related discomfort, total dependence on staff for effective offloading (relieving pressure on a part of the body) and repositioning, high risk for friction and shear injury, and frequent incontinence, increase risk for pressure ulcer development. He is at risk for developing a terminal ulcer due his end stage diagnosis. No pressure related skin concerns at this time. R6's care plan, dated 8/28/19, included, The resident has frequent bladder incontinence and requires total assistance for toileting tasks. The goal was, Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Instructions to staff included, Total assist of two staff to provide incontinence care q (every) 2 hours and prn (as needed). R6's care plan, dated 8/28/19, included, The resident has an ADL (activities of daily living) self care performance deficit R/T (related to) Alzheimer's E/B (as evidenced by) need for assistance. The goal was, Resident will maintain current level of function in through the review date, staff were directed to, Turn side to side with A (assist) of 1-2. Turn and reposition q (every) two hour in alignment with incontinence cares. R6's care plan dated 8/28/19, included, The resident has the potential for pressure ulcer development R/T end stage hospice dx (diagnosis) and overall physical functional decline. With a goal of, Resident will have intact skin free of redness, blisters or discoloration by/through review date. Interventions included, Provide pressure relieving/reducing device on bed and/or chair to prevent skin breakdown, and, Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. R6's care plan did not address an existing pressure ulcer or history of pressure ulcer. R6's most current Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report dated 9/25/19, did not mention existence of any pressure ulcers. R6's progress note dated 10/10/19, at 3:18 p.m. included, Resident noted to have an open area on coccyx (upper portion of buttocks). Wound data collection done and wound nurse and NP (nurse practitioner) notified. Area cleansed and Duoderm (dressing) applied. R6's Wound Data Collection form dated 10/10/19, included a description of a coccyx wound measuring length of 1.0 cm (centimeter), width of 0.7 cm and depth not measured. The wound was described as, reddened and painful. R6's Medication Administration Record [REDACTED]. R6's most recent Food and Nutrition Data Collection Tool dated 10/17/19, and completed by the facility's registered dietitian (RD) noted no skin problem(s)/risk had been noted by nursing. R6's progress note dated 10/22/19, at 3:05 p.m. included, Resident's open area on Coccyx healed. There was no documentation of stage of wound, measurements, description of wound bed tissue or surrounding tissue, presence of drainage, or size of wound between, 10/10/19 and 10/22/19 in the progress notes. Nor was there evidence of an assessment or new interventions implemented in response to the new open area in this time frame. R6's Progress Note dated 11/3/19, at 11:22 p.m. indicated a recurrent coccyx wound. The note included, Open sore on coccyx, cleansed and applied zinc oxide spray. Will continue to monitor. There was no documentation of stage of wound, description of wound bed tissue or surrounding tissue, presence of drainage, or size of wound until R6 was seen by the wound care nurse, NP and Physician on 11/6/19. There was no documentation NP or physician were notified of reoccurrence of pressure ulcer until 11/6/19, 3 days later. R6's Wound Data Collection form dated 11/6/19, included the description of a coccyx wound measuring length of 1.7 cm, width of 1.7 cm and depth of 0.01 cm with a description of, Open area with beefy red wound bed. R6's Wound RN assessment dated [DATE], at 2:43 pm identified a stage II pressure area (Stage II pressure ulcers Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister.) R6's Medication Administration Record [REDACTED]. R6's nursing notes, dated from 10/4/19 to 11/6/19 from R6's hospice provider, did not mention the existence of a pressure ulcer until a note dated 11/6/19, that indicated the following; Per facility Dr requested, will order air mattress for R6 because pt (patient) has stage II pressure ulcer at coccyx. There was no documentation hospice had ever been notified of the original pressure ulcer from 10/10/19. R6's Braden Scale (a standardized tool for determining pressure ulcer risk) dated 11/1/19, gave R6 a score of 13 (moderate risk of pressure ulcers). R6 had slightly limited sensory perception, very moist skin, was chairfast and had probable inadequate nutrition. The form had an intervention guide which directed staff R6 needed: frequent turns, management of friction and shear, pressure reduction support surface, and nutrition management. No new/changed interventions were added to the care plan despite the pressure ulcer which had developed on 10/10/19. During continuous observation on 11/6/19, at 7:14 a.m. R6 was in his room, up in a Broda chair (reclining wheelchair) with a mechanical lift sling under him, watching television. At 7:19 a.m. R6 was moved to the dining room for breakfast. At 9:11 a.m. R6 was moved back to his room. At 9:13 a.m. nursing assistant (NA)-G and NA-H used an Ultra-Lift (mechanical full body lift) to lift R6 from his Broda chair and suspended him for four minutes with the lift sling (supportive fabric sling on the lift that suspends the patient) which was covering R6's coccyx area, this was the first time R6 had been moved from his chair during the observation. While suspended R6's clothes were cleaned off from breakfast and R6 returned to his Broda chair. R6 was still continuously observed and in the same position in his chair until 9:50 a.m. when NA-I and NA-J came into R6's room for cares and R6 was moved from his Broda chair to his bed. During cares R6 was noted to have an open area of skin on his coccyx. LPN-F assessed wound and stated, It was just noted last night that it was open again. When interviewed on 11/6/19, at 9:22 a.m. NA-G stated the facility offloaded or repositioned R6 every two hours. NA-G explained typically this was done either by using pillows to readjust or putting R6 into bed. NA-G reported she was told it was ok to offload R6 by suspending him in the sling. They had not used pillows to readjust his position since getting up in the chair this morning. R6 was last repositioned at 7:00 am on 11/6/19 for morning cares. NA-G did not know if all pressure was relieved to the coccyx while suspending in the sling. When interviewed on 11/6/19, at 10:54 a.m. nurse practitioner (NP)-E stated she just found out today R6 had a pressure ulcer. NP-E stated she would expect the nurse to notify the wound care nurse and she relied on the wound care nurse to notify her of a new wound or recurrent wound and stated she would expect to know about a new wound within a day or two. NP-E stated, I am not sure if a minute or two up in the air would be a lot of pressure relief, and explained R6 would need to have all pressure off of his wound to get pressure relief. When interviewed on 11/6/19, at 11:11 a.m. registered nurse and wound care nurse (RN)-H stated she found out about the condition (recurrent coccyx pressure ulcer) today and had not known there was a pressure ulcer at any other point during R6's admission. RN-H stated it was sufficient to offload if the patient was lifted in a sling if there was no pressure on the wound, meaning the wound was not covered by the sling. RN-H explained a nurse should have re-assessed R6 after the development of the pressure ulcer in October, including a thorough description of the wound, an assessment of why the pressure ulcer developed and to make changes to the care plan as needed. RN-H reported a comprehensive assessment did not occur after R6 developed the initial pressure ulcer in October. Typically she assessed new wounds and did weekly wound rounds. However, RN-H stated she was often busy working as a floor nurse on the transitional care unit and was not always available to assess wounds on the long term care unit. Nurses informed her of wounds in various ways including leaving notes, verbally or by sending an email. However, any nurse could assess wounds if she was not available. A Wound Data Collection Tool needed to be completed at least once every week for existing pressure ulcers, which was not done for R6. RN-H reviewed R6's care plan and confirmed it was not updated to include the pressure ulcer on R6's coccyx and no re-evaluation of the care plan had occurred despite the development of a pressure ulcer. Once a wound was healed, it should be noted on the care plan to inform staff the area remained vulnerable to pressure ulcer recurring. RN-H explained it was important to coordinate with hospice as hospice determined and provided the appropriate durable medical equipment such as pressure relief mattresses and cushions. Hospice had not been notified of the pressure ulcer until after its redevelopment. When interviewed on 11/6/19, at 11:58 a.m. physician, medical doctor (MD)-G indicated facility staff contacted (NP)-E with any changes if MD-G was not present in the building. MD-G was not aware of the development of a pressure ulcer on R6's coccyx in October. However had been notified on 11/6/19 about R6's current open area on coccyx. R6 was observed on 11/6/19, at 1:25 p.m. with NP-E, RN-H and MD-G for a dressing change and wound examination, the pressure ulcer was described by RN-H as a superficial wound, stage 2 pressure ulcer that measured 1.3 cm x 1.3 cm x 0.01 cm and described as painful. This assessment was agreed on by NP-E and MD-G. At this time NP-E and MD-G stated this was their first observation of a pressure ulcer on R6. When interviewed on 11/6/19, at 2:10 p.m. director of nursing (DON) stated the nurse practitioner should be notified of a new or recurrent wound within a day and a Wound Data Collection Tool should be completed the day a new or recurrent wound was identified by the nurse caring for the patient. A registered nurse should assess the resident after development of pressure ulcer. A nurse should complete Wound Data Collection Tool weekly with a thorough description of the wound. The wound should be included in the patient's care plan. The care plan should indicate what kind of wound it was and what the interventions were for the wound. DON demonstrated how when a wound was added to the care plan, the electronic care plan program prompted review of repositioning and offloading schedule. If the wound had healed, the care plan should indicate that R6 had the wound as the scar tissue that replaces the healed ulceration was always more susceptible to recurrence of a pressure ulcer going forward. DON confirmed R6 was not assessed following the development of the coccyx wound in October. There was no documentation a nurse monitored R6's wound weekly or performed any wound care. R6's care plan was not updated to reflect development of a coccyx wound. When interviewed on 11/6/19, at 2:15 p.m. RN-H stated she was just reviewing her email and noticed she received an e-mail from LPN-F on 10/10/19 that notified her R6 had a new coccyx wound. RN-H stated she had not opened the e-mail until just then as she was behind on reviewing her emails. R6's Kardex, a guide used to direct nurse aides in resident care, dated 11/7/19, directed staff, Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. When interviewed on 11/7/19, at 8:32 a.m. the dietitian, (RD)-D stated she was not aware of R6's pressure ulcer. RD-D explained she needed to assess all residents with new or recurring pressure ulcers to ensure they had adequate meal, snack and protein intake. RD-D stated she was not sure about the process for finding out about a new wound. At 9:25 a.m. RD-D stated she normally found out about new wounds during morning report. RD-D was not sure how she would be informed of wounds if she was not at morning report as she worked part time, three days a week. When interviewed over the phone on 11/7/19, at 9:06 a.m. RN-J from hospice, indicated she was the nurse covering for the day for RN-K's hospice patients and she was not aware of a pressure ulcer on R6 and would have RN-K call back when she is working the next day. RN-K did not return the call. When interviewed on 11/7/19, at 10:20 a.m. the registered nurse and unit manager, (RN)-E, stated if a nurse found a new or recurrent pressure ulcer, a Wound Data Collection Tool and Wound Assessment Form should be completed and documented that day. It should then be documented as a high priority progress note and would be visible to RN-H and DON. RN-E stated the nurse should also send an email about the pressure ulcer to the wound care nurses, RN-H and DON. RN-H or DON should then assess the wound. When noting R6 had nothing documented on the wound between 10/10/19 and 10/22/19, RN-E stated, That is a problem. RN-E stated the care plan should have been updated to reflect the new wound and the recurrent wound. R6's care plan was not updated to reflect development and reoccurrence of a pressure ulcer. RN-E explained the hospice nurse should have been updated on the new wound, stating there was no documentation of hospice being informed until 11/6/19. RN-E stated R6's wife should have been informed of when the wound first occurred and when the wound reoccurred on 11/3/19. RN-E explained the nursing assistants were not trained to offload by suspending residents in a sling, as this did not fully offload the resident's area of pressure. Nursing assistants should fully offload and reposition R6 by laying him in bed, off his coccyx for at least five minutes, if he allowed. When interviewed on 11/7/19, at 1:12 p.m. Family Member (FM)-C stated she knew about the first pressure ulcer in (MONTH) but did not know about recurrent pressure ulcer. Even though R6 had developed a pressure ulcer on the coccyx on 10/10/19, and was healed on 10/22/19, the facility failed to re-assess interventions to prevent recurrence of the pressure ulcer or development of other pressure ulcers. The physician had not been notified and no treatments had been ordered until the wound recurred. R6 was harmed when the pressure ulcer recurred on 11/6/19. When observed on 11/7/19, the care plan was not followed to ensure pressure was relieved to the wound. The Tollos Ultra-lift 3510XH owner manual, dated 2014, and Tollos Combination Six Strap Slings specifications, undated, did not include any information on use of sling and lift for offloading pressure ulcers. A facility Procedure for Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements, last revised (MONTH) 2019, identified it was the procedure at the Good Samaritan Society the following need to occur. The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk UDA on all residents quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer. If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage on the Wound RN Assessment UDA (i.e., for a pressure ulcer, record the stage). Notify the physician/practitioner of the ulcer and the resident's condition to obtain orders for a treatment. Notify resident resident and/or family of the pressure ulcer, orders and planned interventions. Dietary is notified by an alert that occurs when the Wound Data Collection UDA is signed and locked. When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include the following: . An evaluation of the status of the dressing; if present . The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment UD[NAME] Progress towards healing and any modifications to the plan of care/treatments should be assessed and evaluated by the registered nurse. R29's significant change MDS dated [DATE], included severe cognitive impairment with [DIAGNOSES REDACTED]. R29 required extensive assistance with bed mobility and transfers, used a wheel chair, was at risk for pressure ulcers, but did not have a current pressure ulcer. R29's ADL (activities of daily living) care plan dated 7/26/19 included, resident requires total assist with turning in bed, and required a total body lift for transfers, staff were directed to check incontinent brief every 2 hours. R29's skin condition care plan dated 1/26/19, included a history of wounds and moisture associated skin damage and fragile skin. The goal was for R29 not to develop pressure ulcers or wounds though 12/7/19. Staff were instructed to keep skin clean and dry. R29's impaired physical mobility care plan directed staff to assist with turning and repositioning every 2.5-3 hours. R29 was observed during cares on 11/5/19, at 12:44 p.m. R29's incontinence brief was heavily saturated with urine and a small amount of stool. R29's buttocks and posterior upper thighs were red with deep creases and crevices from the incontinence brief. During continuous observation on 11/6/19, at 6:50 a.m. R29 was sitting in a wheel chair, at 7:20 a.m. R29 remained in wheel chair at the dining table. R29 remained sitting in the the wheel chair at the dining table until 9:20 a.m. when he was assisted to a different dining room for Bingo. R29 remained seated in the wheel chair at the activity until he was assisted to his room at 10:26 a.m. Throughout this observation no staff offered to assist him out of the wheel chair. At 10:26 registered nurse (RN)-B assisted R29 with cleansing and dressing a skin tear on his arm. RN-B left the room and R29 stated he would like to lie down. Call light was turned on for R29 and was answered by nursing assistant (NA)-A and NA-C at 10:51 a.m. At 10:54 a.m. NA-A and NA-C assisted R29 into bed utilizing a mechanical lift. R29's incontinence brief was removed and contained a small amount of urine and stool. Incontinence cares were completed. R29's buttocks had an approximate 18 inch by 12 inch dark red area with deep creases and crevices in the skin. NA-A and NA-C stated R29 had been assisted into the wheel chair at approximately 6:30 a.m. and they had not offered to check his incontinent brief or repositioned him since then. This was 4 hours and 24 minutes without being repositioned. When interviewed on 11/6/19, at 1:35 p.m. the director of nursing (DON) verified the staff should offer and provide cares according to the care plan. R29's plan directed a reposition every 2.5 - 3 hours. The DON stated, It should be close to that range. The facility policy titled Pressure Ulcer Practice Guidelines dated 9/16, indicated the purpose of the guideline was to provide current information on prevention and management for pressure ulcers. The guideline identified general instructions for staff to provide initial risk assessment as well as ongoing assessment, monitoring, and evaluation of skin break down. The guideline directed staff to manage exposure to moisture by checking for incontinence and to manage tissue load by implementing a resident-specific turning and positing program based upon an individualized assessment.

Based on interview and record review, the facility failed to provide adequate supervision for one of one resident, (R1), reviewed when R1 who required a covered cup for liquids was given hot soup in an uncovered cup. This resulted in a second degree burn to R1. Findings include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. R1's care plan dated 1/22/2017, indicated R1 needed finger foods and could eat independently after the meal was set up. It further indicated R1 was not able to express symptoms of distress (no grimacing) and staff were to monitor R1 for swallowing difficulties such as coughing and choking. R1's dining assessment dated [DATE], indicated R1 needed nectar thick liquids with a regular diet. R1's occupational therapy assessment indicated R1 needed adaptive devices for eating. R1's nursing progress note dated 2/28/2017, indicated a nursing assistant called RN-F to the table where R1 was seated. Both staff noted R1's head was tipped back, R1's eyes were open very wide and staring up in the direction of the ceiling. RN-F noticed R1's shirt had soup on it, so RN-F wiped it off. R1's staring episode ended about 3 minutes later. RN-F assessed R1 when R1 was changed for bed. RN-F noted a reddened area on R1's right inner arm from the armpit to the elbow and on the right side of R1's right breast. RN-F notified the provider who ordered cool damp cloths to be applied to the area. The facility food temperature record dated 2/28/2017, indicated the cream of broccoli soup served for the evening meal on 2/28/2017 and given to R1 had a temperature of 173 degrees Fahrenheit. R1's wound assessment completed by RN-E dated 3/1/2017, indicated R1 had a partial thickness wound with two blisters measured to be 2.5 centimeters (cm) by 4 cm and 3 cm by 3 cm on R1's right inner arm. The assessment indicated two additional blisters measured to be 2 cm by 3 cm and 1.5 cm by 1 cm on R1's right outer breast area. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's medication administration record (MAR) for the month of March 2017, indicated R1 received an acetaminophen suppository 650 mg for pain at 00:30 a.m. on 3/5/2017, an acetaminophen suppository 650 mg for pain at 04:30 a.m. on 3/5/2017, an acetaminophen suppository 650 mg for pain at 10:39 a.m. on 3/5/2017, an acetaminophen suppository 650 mg for pain at 3:48 a.m. on 3/5/2017, and an acetaminophen suppository 650 mg for pain at 9:20 p.m. on 3/5/2017. An interview was conducted with NA-A at 1:12 p.m. on 3/14/2017. NA-A stated R1 spilled food frequently so NA-A never gave R1 soup. NA-A stated the information for R1's meals was on the computer and included a covered cup and a divided plate. An interview was conducted with NA-B at 1:26 p.m. on 3/14/2017. NA-B stated R1 needed a double handled cup with a cover for liquids as R1 spilled a lot. NA-B stated the information was on the computer and on the diet card. An interview was conducted with RN-E at 2:26 p.m. on 3/14/2017. RN-E stated R1 needed a covered cup for liquids as R1 would pour out liquids and play with it. An interview was conducted with RN-F at 2:44 p.m. on 3/14/2017. RN-F stated R1 needed a two handled cup with a cover, and a divided plate. RN-F stated it was written on the dietary form. RN-F had been working on the day of the incident, but did not know who brought the soup to R1. An interview was conducted with NA-G at 3:05 p.m. on 3/14/2017. NA-G stated s/he worked with R1 the day of the burn, serving supper. NA-G stated R1 used a divided plate and a two handled cup with a lid. NA-G could not remember who brought R1's soup to the table. An interview was conducted with NP-H at 3:30 p.m. on 3/14/2017. NP-H stated R1 always had a cup with a cover on it as R1 would grab the cup and fling it up to R1's mouth. NP-H stated R1 had been declining for the last several years and staff had difficulty getting fluids into R1. NP-H stated R1 needed intravenous fluids after the burns due to dehydration. An interview was conducted with RN-I at 3:48 p.m. on 3/14/2017. RN-I stated s/he worked with R1 the day of the burn, but was unable to recall who gave R1 her soup that day. RN-I stated R1 only used a covered cup with two handles. An interview was conducted with NA-J at 2:17 p.m. on 5/17/2017. NA-J stated s/he worked with R1 the day of the burn. NA-J stated the soup was chunky and too thick for R1 to drink out of the covered cup, so the nurse (unidentified) left the cover off. NA-J stated the dietary aide looked at the diet card which indicated what the resident needed (regular, sippy cup, scoop plate, or special utensils) set it up and gave it to the staff to bring to the resident. The facility policy for dining room service dated 11/2016, indicated residents would be encouraged to eat as independently as possible and staff were to offer assistance as needed. It further indicated staff were to check for the resident's name and diet on the resident diet card, as well as provide special assistive eating devices per the plan of care.