Every finding on record at Good Samaritan Society - Waconia and Westview Acre

Based on interview, observation, and document review the facility failed to provide adequate supervision creating a likelihood for potential serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement on [DATE] and wore a Wander Guard bracelet (security device that prevents alerts staff if a resident at risk of wandering attempts to leaving a designated area) and eloped from the facility on [DATE]. The immediate jeopardy began on [DATE], when R1 exited the facility front door at 12:54 a.m., then was found by a community member lying in the parking lot of an apartment building. The facility identified R1 was missing when a county sheriff came to the facility at 2:56 a.m., showed R1's photo to staff, and staff discovered R1 was not in his bed. The facility administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 5:38 p.m. The deficient practice corrected on [DATE], prior to the start of the survey and was therefore past non-compliance. Findings include: A Vulnerable Adult Maltreatment Report dated [DATE], reported by a community member, indicated emergency medical services (EMS) was called to an apartment complex located a block away from the facility by a resident of the apartment complex. The resident noticed a person [R1] lying on the ground outside the building, who had wandered unnoticed by the facility staff. [R1] had a diagnosis of dementia and was supposed to be checked every two hours. Staff were unaware R1 was missing until notified by a [NAME] County deputy after R1 was taken to the emergency room. An Incident Report Summary dated [DATE] at 4:49 am., indicated on [DATE] staff was alerted by police [R1] was found on the ground in a parking lot, and was taken to a hospital to be examined, and police came to the facility to confirm it was [R1] who they found. [R1's] most recent Wander Guard assessment on [DATE], indicated [R1] was not an elopement risk. On [DATE], [R1] was deemed cognitively intact. [R1's] diagnoses included Lewy body dementia (a progressive neurodegenerative disease in the brain that causes decline in thinking, movement, memory, and mood) with psychotic disturbance and diabetes with neuropathy (nerve damage caused by long-term high blood glucose leading to pain, numbness, and tingling). R1's Nursing admission assessment dated [DATE], indicated R1 was admitted with a history of falls, diabetes, weakness, and was alert and oriented to person, but not oriented to place, time, or situation. R1 was slow to respond to questions, had poor word recall and increased confusion and forgetfulness, but was not at risk for elopement. Learning barriers included cognitive status and cues were required. R1's orders dated [DATE], instructed staff to administer quetiapine fumarate (antipsychotic medication) 25 milligrams (mg), give 25 mg by mouth at bedtime for repeated episodes of anxiety. The order was discontinued [DATE]. R1's care plan with initiation/edit dates indicated: [DATE]- a self-care deficit with ambulation, required assistance of one staff, with a gait belt and walker for safe ambulation [DATE]- high risk for falls [DATE]- potential for elopement, Wander Guard used to alert staff to resident's movements [DATE]- impaired cognitive function as evidenced by forgetfulness, poor recall, and impaired cognition [DATE]- behavior problems related to Lewy Body dementia: psychosis (collection of symptoms which disrupt a person's thoughts and perceptions, making it difficult to distinguish what is real from what is not), anxiety, hallucinations, and delusions. R1's Elopement Risk assessment dated [DATE], identified R1 had a caregiver or staff change, had a change in normal behavior, and had no learning barriers. R1 was deemed not at risk for elopement. The assessment lacked indication R1 was admitted within the last month, had a history of elopement from home, had increased confusion and forgetfulness, diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on [DATE]. R1's Elopement Risk assessment dated [DATE] identified R1 was admitted within the previous month, had a caregiver or staff change, had a diagnosis of dementia, R1 should not leave the facility unattended, and a Wander Guard was placed to alert staff of R1's movements. R1 was deemed an elopement risk and a care plan related to elopement was initiated. The assessment lacked indication R1 had a history of elopement from home, had a diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on [DATE]. R1's provider orders dated [DATE] instructed staff to place a Wander Guard to R1's right wrist, check placement every shift, and check functionality daily. R1's nursing orders dated [DATE], instructed staff to place a Wander Guard to R1's right wrist, check placement every shift, and check functionality daily. The nursing order was discontinued [DATE]. The provider order was not discontinued. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE] with intact cognition, diagnoses that included dementia and diabetes, and had no wandering behavior in the 7-day look-back period. R1's progress notes dated [DATE] at 2:30 p.m., indicated R1's Wander Guard was found in the trash. The nurse manager was aware and indicated R1 no longer needed the Wander Guard. R1's medical record lacked indication an Elopement Risk Assessment was completed to make the determination the Wander Guard was no longer needed. R1's progress notes dated [DATE] at 5:23 p.m., indicated R1 returned from the hospital at 5:05 p.m., the Wander Guard was not re-implemented, and staff should perform more frequent checks overnight. R1's Elopement Risk assessment dated [DATE], indicated R1 was admitted in the prior month, had no diagnoses related to elopement risk, had no learning barriers, and was not at risk for elopement. The assessment lacked indication R1 had a history of elopement from home, had a caregiver or staff change after he had returned from the hospital the day prior, had a diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on [DATE]. The assessment lacked indication R1's care plan was reviewed at the time of the assessment. R1's progress note dated [DATE] at 2:37 p.m., indicated during rounds the nurse practitioner added a diagnosis of Lewy Body dementia to R1's clinical record and diagnoses of major depression and psychosis. The medical record lacked indication R1 was reassessed for Elopement Risk after the addition of the diagnoses. R1's quarterly MDS dated [DATE], indicated intact cognition, diagnoses included dementia, diabetes, and depression, and had no wandering behavior during the 7-day look-back period. R1's Elopement Risk assessment dated [DATE], indicated resident had no history of elopement attempts in the past, no diagnoses related to elopement risk, and indicated R1 was not at risk of elopement. The assessment lacked indication if R1 had a history of elopement from home, had a diagnosis of dementia with psychosis and depression and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on [DATE]. The assessment lacked indication R1's care plan was reviewed at the time of the assessment. R1's progress notes indicated the following: [DATE] at 2:42 p.m., during a care conference R1 indicated he was having hallucinations of roaches and people. R1 had fallen that morning. [DATE] at 10:05 a.m., R1 was alert and oriented with forgetfulness. [DATE] at 3:41 p.m., R1's wife called the facility twice to ensure R1 was being checked on because R1 was really confused and didn't know he was in the facility, or what town he resided in. [DATE] at 5:53 p.m., R1 had frequent delusions, was suspicious of others, and had verbal disruptions. R1 had anxiety and nervousness that impaired his quality of life and was taking antipsychotic, antidepressant, and antianxiety medications. [DATE] at 5:50 a.m., the sheriff came to the facility and reported R1 was found in a parking lot nearby, appeared to have fallen but no injury was noted, and was transported to the emergency room. R1 was last checked and changed for incontinence on [DATE] at 11:30 p.m. Will place Wander Guard on resident when he returns from the emergency room. Review of the weather on [DATE] between 12:00 a.m. and 1:00 a.m. from the Weather Channel at https://weather.com, revealed the temperature in Waconia was approximately 43-45 degrees Fahrenheit. A photo of R1, provided by the administrator from camera footage, revealed R1 left the facility on [DATE] at 12:54 a.m. R1 left out the front door wearing a short-sleeved shirt, shorts, and tennis shoes, and was walking with a walker. R1's progress notes dated [DATE] at 5:50 a.m., indicated at 2:50 a.m., the sheriff came to the facility and reported the resident was found in a nearby parking lot and appeared to have fallen. The sheriff noted no injuries and R1 was transported by ambulance to an emergency room for evaluation. R1 was last checked and changed by staff on [DATE] at 11:30 p.m. R1's Elopement Evaluation dated [DATE] at 1:23 p.m., indicated R1 had a history of elopement or attempt while at home and while at the facility. R1 had an elopement score of 2 which indicated a risk for elopement. R1's orders dated [DATE], instructed staff to place a Wander Guard to R1's left ankle and to check placement every shift, and function daily. During an interview on [DATE] at 4:53 p.m., the nursing assistant (NA)-A stated he was not aware R1's Wander Guard was removed shortly after admission but acknowledged he knew R1 should have been checked every two hours but was not on the night of [DATE], into [DATE]. NA-A stated he was working on the night of [DATE], and checked on R1 when R1 activated his call light on [DATE] at around 11:00 p.m. Then, NA-A returned to the desk to watch for call lights. Within a few minutes, R1's neighbor activated his call light. When NA-A walked past R1's room, on his way to answer call light, he could see R1's feet. NA-A thought R1 must have left the unit after that. NA-A stated there were a lot of call lights to answer that night and he didn't get back to R1. The sheriff came to alert staff R1 was gone, and NA-A acknowledged he did not see R1 leave the unit. NA-A stated he was supposed to check R1 every two hours and had not. During an interview on [DATE] at 8:22 a.m., licensed practical nurse (LPN)-A stated around 11:00 p.m., on [DATE] NA-A checked on R1. R1 returned to his recliner after NA-A was finished assisting him. Staff were supposed to check on R1 every two hours to assist with repositioning but had not that night. LPN-A stated he was not aware R1 was missing until the sheriff came to the facility. During an interview on [DATE] at 11:03 a.m., family member (FM)-A stated she was made aware, after R1 left the facility, R1 fell and was on the ground for over an hour. R1 was found by a community member. FM-A stated before R1 admitted to the facility, he left their home during winter months, It was just like [R1] to do it. FM-A put an alarm on the door so she would be notified if R1 attempted to leave again. FM-A stated R1 walked with a walker and sometimes used a wheelchair. During an interview on [DATE] at 11:46 a.m., R1 stated he experienced hallucinations since he was fifteen years old and was sleepwalking since he was in the military. R1 thought he was sleepwalking in the facility, and this was the reason he left the facility, on the night of [DATE]. R1 recalled, when he walked away from the facility, it was cold and he was wearing shorts and a short-sleeved shirt. He got far from the facility and was tired of walking so he laid on the pavement in a parking lot. R1 thought he laid in the parking lot for about an hour and half, someone saw him and asked him what he was doing, then called the police. R1 was taken to the hospital. R1 stated he could sign in and out of the facility and was allowed to be out until 10:00 p.m. Staff were supposed to check on him every two hours but didn't that night. During an interview on [DATE] at 12:12 p.m., registered nurse (RN)-B stated, to determine if R1 had a history of elopement prior to admission, the facility staff should have asked R1's family about any history or elopement. RN-B did not know if staff asked this question, but thought if they had, it would have been included on the assessment. The RN-B stated on each of R1's Elopement Risk assessments dementia with psychosis and anxiety should have been acknowledged but were not. Further, RN-B stated she knew R1 had a history of wandering after asking R1's wife. RN-B stated she knew R1 was at risk of elopement and had previously had a Wander Guard; R1 was at risk but the facility indicated he was not. If R1's forms had been completely accurate, R1 would have been assessed to be at risk for elopement. The RN-B stated she does assess a resident's medications when completing the Elopement Risk Assessment and knew R1's quetiapine was prescribed for anxiety but acknowledged when she completed some of R1's Elopement Risk Assessments, she failed to indicate R1 had anxiety. During an interview on [DATE] at 12:35 p.m., RN-A stated upon admission, R1's wife indicated R1 had a lot of trauma in his life and was having increased confusion. R1's wife was worried about R1 when she was sleeping because he would get up and wander around the house. RN-A stated based on the information from R1's wife, the elopement risk form should have indicated R1 had a fear of abandonment, sleep disturbance, and anxiety. Further, RN-A stated each of R1's Elopement Risk Assessments should have indicated a risk for elopement with care planned interventions. RN-A acknowledged only the assessments on [DATE], and [DATE], indicated a risk for elopement. RN-A indicated R1 was deemed at risk on [DATE] when R1 returned from a visit at home and got lost going to his room on 2nd floor but instead went to 3rd floor. RN-A stated when R1's Wander Guard was found in the garbage; the interdisciplinary team discussed the event but did not perform an assessment to determine if R1 had changes in his condition and no longer needed the Wander Guard. RN-A stated a new elopement risk assessment should have been completed before the decision was made to not replace the Wander Guard. Further, RN-A stated the team should have performed a new Elopement Risk Assessment after the nurse practitioner added diagnoses of depression, Lewy Body dementia, and psychosis to R1's diagnoses list. RN-A stated she was informed by the administrator when R1 left the facility he was wearing shorts and a T-Shirt and left around midnight. R1 was supposed to be checked by staff every two hours but he was not. R1 could have died outside, it was cold, and he was not dressed appropriately for the weather. R1's fall could have resulted broken a hip. '[R1] should have had a Wander Guard all along. During an interview on [DATE] at 1:24 p.m., the administrator stated per video, on [DATE] at 12:47 a.m., R1 walked out of his room, at 12:48 a.m., R1 went down the elevator, and at 12:54 a.m., walked out the front door. The police reported to the administrator, a call was made to the police department on [DATE] at 2:43 a.m. The officer pulled up to the facility at 2:56 a.m. Staff did not know R1 was gone. Staff indicated NA-A last assisted R1 on [DATE] at 10:58 p.m. R1's care plan indicated R1 was supposed to be checked every two hours. Administrator stated it was hard to say what could have happened to R1, but the mind goes to anything, but thankfully nothing bad happened. During an interview on [DATE] at 1:55 p.m., the director of nursing (DON) stated R1 had a care planned intervention to be turned and repositioned and toileted every two hours. That task was not completed during the night, and the staff had not checked on R1 until the sheriff came to the facility. The facility identified the elopement assessment completed after R1 removed his Wander Guard was not immediately completed, and R1 was having increased delusions and hallucinations. When staff found R1's Wander Guard in the garbage on [DATE], staff should have assessed how it was removed, had a conversation about putting it back on, and discussed it with his family. To know R1's history of wandering prior to admission, staff would have to interview the family. During an interview on [DATE] at 4:08 p.m., the nurse practitioner (NP)-A stated R1 had a history of Lewy Body dementia and did not have the physical or mental capacity to be outside on his own, which was why R1 required 24-hour care. The Elopement policy dated [DATE], indicated all Skilled Nurse Facility residents would be assessed for risk of elopement through the pre-admission and/or admission process and as needed. The Elopement Risk assessment will be completed for all resident with the quarterly, annual, and significant change MDS assessments and triggered as needed when elopement risk is identified like in change of condition, exhibiting a new mood or behavior, or attempt to elope. The past non-compliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected [DATE], after the facility implemented a systemic plan that included the following actions: Upon returning to the facility R1 was assessed for injuries, depression, supervision needs, cognitive status, and safety interventions. Staff requested an evaluation by the Associated Clinic of Psychology for R1. R1's Elopement Risk was reassessed, and a Wander Guard was placed on R1. Nursing assistant NA-A and LPN-A were suspended, given written warnings for corrective action, and prior to returning to the facility to work were retrained on rounding and supervision of residents. RN-A was suspended, given a written warning for not performing accurate and comprehensive assessments, and prior to returning to her role, was retrained on how to complete an accurate comprehensive Elopement Risk Assessment. A facility-wide reassessment of all residents' elopement risk was performed; care plans were adjusted accordingly. Staff education was initiated for all nursing staff on [DATE] for elopement risk identification, resident supervision and monitoring, timely implementation of care plan interventions, the Wander Guard process and monitoring, and the expectations of reporting and response of elopement. Ongoing audits and monitoring plans were developed [DATE] to ensure ongoing compliance.

Based on interview and document review, the facility failed to include complete and accurate information when assessing elopement risk for 1 of 3 residents (R1) reviewed for elopement. Findings include:R1's Elopement Risk assessment dated [DATE] identified R1 had a caregiver or staff change, had a change in normal behavior, and had no learning barriers. R1 was deemed not at risk for elopement. The assessment lacked indication R1 was admitted within the last month, had a history of elopement from home, had increased confusion and forgetfulness, diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on 11/26/25.R1's Elopement Risk assessment dated [DATE], identified R1 was admitted within the previous month, had a caregiver or staff change, had a diagnosis of dementia, R1 should not leave the facility unattended, and a Wander Guard was placed to alert staff of R1's movements. R1 was deemed an elopement risk and a care plan related to elopement was initiated. The assessment lacked indication R1 had a history of elopement from home, had a diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on 11/26/25. R1's provider orders dated 11/28/26, instructed staff to place a Wander Guard to R1's right wrist, check placement every shift, and check functionality daily. R1's nursing orders dated 11/28/26, instructed staff to place a Wander Guard to R1's right wrist, check placement every shift, and check functionality daily. The nursing order was discontinued 12/11/25. The provider order was not discontinued. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 admitted to the facility on [DATE], with intact cognition, diagnoses that included dementia and diabetes, and had no wandering behavior in the 7-day look-back period. R1's progress notes dated 12/5/25 at 2:30 p.m., indicated R1's Wander Guard was found in the trash. The nurse manager was aware and indicated R1 no longer needed the Wander Guard. The medical record lacked indication a new Elopement Risk Assessment was completed to make the determination the Wander Guard was no longer needed. R1's progress notes dated 12/10/25 at 5:23 p.m., indicated R1 returned from the hospital at 5:05 p.m., the Wander Guard was not re-implemented, and staff should perform more frequent checks overnight.R1's Elopement Risk assessment dated [DATE], indicated R1 was admitted in the prior month, had no diagnoses related to elopement risk, had no learning barriers, and was not at risk for elopement. The assessment lacked indication R1 had a history of elopement from home, had a caregiver or staff change after he had returned from the hospital the day prior, had a diagnosis of dementia with psychosis, and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on 11/26/25. The assessment lacked indication R1's care plan was reviewed at the time of the assessment. R1's Elopement Risk assessment dated [DATE] indicated resident had no history of elopement attempts in the past, no related diagnoses related to elopement risk and indicated R1 was not at risk of elopement. The assessment lacked indication of R1 had a history of elopement from home, had a diagnosis of dementia with psychosis and depression and had learning barriers related to his cognitive status as indicated in the admission Nursing Assessment on 11/26/25. The assessment lacked indication R1's care plan was reviewed at the time of the assessment. During an interview on 5/7/26 at 8:22 a.m., the licensed practical nurse (LPN)-A stated to accurately perform an elopement assessment staff observed behaviors, reviewed the resident's diagnoses, and reviewed the resident's medications for side effects that may affect behaviors. The LPN-A stated when residents are newly admitted , they may not want to be in the facility and may try to leave the facility to return home. During an interview on 5/7/26 at 12:12 p.m., the registered nurse (RN)-B stated to complete an Elopement Risk Assessment staff should ask family about elopement history, but didn't think that had been done for R1. If it had, then staff would have known R1 was at risk for elopement. The RN-B stated each prior Elopement Assessment for R1 should have indicated R1 had dementia but did not. R1 had anxiety, but was not indicated on the forms, and had dementia with psychosis, which was also not indicated. The RN-B stated she was aware of R1's history of wandering from asking R1's family. Further, the RN-B stated more than one check mark on an Elopement Assessment indicated a risk for elopement, and if the forms had been completed correctly, R1 would have always been a risk for elopement. Additionally, the RN-B stated when R1's Wander Guard was found in the garbage in November 2025, staff should have performed additional assessments prior to determining the Wander Guard was no longer needed. The RN-B stated the facility had a new elopement assessment form and had been trained in how to complete the form, but the assessment did not include mood, diagnoses, and medications that were assessed using the previous form. The RN-B stated if the resident had mood, diagnoses, or medications that were indicators a resident may elope, that data should be included in a progress note after completing the form, but could be missed if the form didn't prompt to review the medical record for the data. During an interview on 5/7/26 at 2:32 p.m., the LPN-B stated to complete an Elopement Risk Assessment, staff reviewed the resident's admission paperwork and read the resident's history to determine if the resident was at risk for elopement. Staff should ask the family if the resident was at risk for elopement, and review diagnoses, mood, and medications. The LPN-B stated the new form the facility used for elopement risk assessment did not include review of diagnoses, mood, and medications, and if not prompted for that data, the LPN-B stated she would not assess that data. During an interview on 5/7/26 at 12:35 p.m., RN-A acknowledged she completed R1's Elopement Risk Assessment on 11/28/25 and missed checking the boxes that indicated R1 had a history of wandering, fear of abandonment, sleep disturbance, and diagnoses of anxiety and depression based on R1's history. The RN-A stated each of R1's Elopement Risk Assessments should have indicated a risk for elopement and should have included care plan interventions on the forms. The RN-A acknowledged she also completed R1's Elopement Risk Assessment on 12/11/25, and missed data on that assessment as well. The RN-A stated after finding R1's Wander Guard in the garbage on 12/5/25, she should have completed a new Elopement Risk Assessment right away, but waited until 12/11/25, and then did not complete the assessment correctly to indicate R1 was at risk for elopement. Additionally, the RN-A stated R1's Elopement Risk Assessment completed 3/2/26, was completed incorrectly as well. The assessment lacked data for history of elopement, mood, and diagnoses, and should have indicated a risk for elopement. The RN-A stated R1 took only eight minutes to leave the facility on 5/1/26, and R1 was more mobile than staff thought, and R1 should have been wearing a Wander Guard throughout his stay at the facility. The RN-A stated the new assessment form used by the facility to assess for Elopement Risk did not include the same elements as the previous form, and did not consider diagnoses, medications, and mood, and stated the new assessment was not a comprehensive elopement assessment. During an interview on 5/7/26 at 1:55 p.m., the director of nursing (DON) stated R1's Elopement Risk Assessment on 11/28/25, was accurate in that it deemed R1 at risk for Elopement but lacked data including indicators for mood and diagnoses that indicate risk for elopement. The DON further acknowledged R1's Elopement Risk assessment dated [DATE], also lacked data that indicated R1 had a history of wandering, hallucinations, increased confusion, and data about mood and diagnoses, that would have indicated a risk for elopement. The DON stated when R1's Wander Guard was found in the garbage on 12/5/25, R1 should have been reassessed to determine if the Wander Guard was still needed but had not. Further, the DON stated the new form the facility used to assess elopement risk did not indicate to assess for medications, diagnoses, and mood, but should but had a box at the bottom of the form where nurses could enter that information. The DON stated he was concerned about the form, and had escalated his concern to the Regional Clinical Director, and Regional Operations Director, who were going to review the new form and escalate the concern to the management team, and had not yet made a determination about the use of the new form. The Elopement policy dated 4/7/25, indicated all Skilled Nurse Facility residents would be assessed for risk of elopement through the pre-admission and/or admission process and as needed. The Elopement Risk assessment will be completed for all residents with the quarterly, annual, and significant change MDS assessments and triggered as needed when elopement risk is identified like in change of condition, exhibiting a new mood or behavior, or attempt to elope.

Based on record review and interview, the facility failed to develop and implement comprehensive, person-centered care plans that included all identified needs and appropriate interventions for 4 of 18 residents (R10, R25, R72, and R88) reviewed for care planning.Findings include:R10R10's admission Minimum Data Set (MDS), dated [DATE], identified R10 had intact cognition and required assistance with all activities of daily living (ADLs). R10's diagnoses included anxiety disorder (excessive worry), depression (persistent sadness), PTSD (post-traumatic stress disorder; stress after trauma), and mild cognitive impairment of unknown etiology (early memory/thinking changes with unclear cause). Review of R10's comprehensive care plan, print date of 3/26/26, failed to include person-centered interventions related to R10's trauma history, including approaches to minimize triggers, promote emotional safety, or individualized care preferences. During interview on 3/26/26 at 9:55 a.m., the Director of Nursing (DON) and Social Services Designee (SSD) confirmed R10 had a known trauma history; however, this had not been incorporated into the care plan with personalized, resident-specific information. R25R25's admission MDS, dated [DATE], identified R25 had moderate cognitive impairment and required assistance with all ADLs. R25's diagnoses included non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), muscle weakness (reduced strength), abnormalities of gait and mobility (difficulty walking), hypertension (high blood pressure), arthritis (joint inflammation causing pain), and insomnia (difficulty sleeping). Review of R25's comprehensive care plan, print date of 3/26/26, revealed no interventions addressing edema management, including but not limited to monitoring, limb elevation or use of compression stockings During interview on 3/25/26 at 3:40 p.m., Registered Nurse (RN)-B reviewed the medical record and stated R25 had non-pitting edema in the right and left lower extremities. RN-B confirmed edema was not included on R25's care plan. During interview on 3/26/26 at 10:46 a.m., the DON stated edema should have been included on the care plan so it was clearly identified to staff and safe care could be provided. R72R72's admission MDS, dated [DATE], identified R72 had intact cognition and required assistance with ADLs. R72's diagnoses included urinary tract infections (infection in the urinary system), viral hepatitis (inflammation of the liver caused by a virus), enterocolitis due to Clostridium difficile (inflammation of the intestines caused by a bacterial infection leading to diarrhea), Sjogren syndrome with vasculitis (an autoimmune disorder causing dry eyes/mouth and inflammation of blood vessels), vasculitis limited to the skin (inflammation of blood vessels affecting only the skin), and retention of urine (inability to fully empty the bladder). The MDS indicated the resident had a Stage 1 pressure ulcer (early skin injury with non-blanchable redness). Review of R72's comprehensive care plan, print date of 3/26/26, failed to include Enhanced Barrier Precautions (EBP) interventions, including use of gown and gloves for high-contact care activities, availability of personal protective equipment (PPE), or appropriate signage. During interview on 3/25/26 at 4:01 p.m., the DON confirmed R72 was on EBP; however, this had not been included in the care plan. R88R88's admission MDS, dated [DATE], identified R88 had intact cognition and required assistance with ADLs. R88's diagnoses included dependence on renal dialysis (requires routine dialysis treatment to perform kidney function), chronic kidney disease stage 5 (severe kidney failure where the kidneys no longer function adequately), and presence of other vascular implants and grafts (surgically placed devices or vessels used to support blood flow, often for dialysis access). Review of R88's comprehensive care plan, print date of 3/26/26, failed to include EBP interventions, including use of gown and gloves for high-contact care activities, availability of PPE, or appropriate signage. During interview on 3/25/26 at 3:55 p.m., the Director of Nursing (DON) confirmed R88 was on EBP; however, this had not been included in the care plan. A facility care plan policy was requested but was not received.

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect by continuing use of a Wander Guard device in a manner that caused ongoing distress and failed to attempt alternative placement to reduce discomfort for 1 of 3 residents reviewed for dignity (R25).Findings include:R25's admission Minimum Data Set (MDS), dated [DATE], identified R25 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R25's diagnoses included non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), muscle weakness (reduced strength), abnormalities of gait and mobility (difficulty walking), hypertension (high blood pressure), arthritis (joint inflammation causing pain), and insomnia (difficulty sleeping). During observation on 03/23/2026 at 2:44 p.m., R25 was observed with a Wander Guard applied to the left wrist. R25 stated, I have to have this on so I don't go anywhere. I have gone outside once before, but it's not like I can go anywhere. During observation on 03/24/2026 at 12:59 p.m., R25 was observed sitting in the dining room eating ice cream. R25 stated it was not going well because they won't let me leave and I have this 'stupid thing on my wrist.' The Wander Guard remained in place on the left wrist. During observation on 03/24/2026 at 3:26 p.m., R25 was observed waiting outside the elevator, then entered the elevator and traveled to the third floor. During observation on 03/24/2026 at 3:33 p.m., R25 returned to the second floor and self-propelled around the main living room area. R25 approached the surveyor, grabbed the Wander Guard, and stated, I still have this thing on, they won't let me leave. During observation on 03/24/2026 at 6:48 p.m., R25 was observed in the living room area talking with two nursing assistants while self-propelling. The Wander Guard remained on the left wrist. During observation on 03/25/2026 at 8:33 a.m., R25 was observed sitting in the dining room reading a newspaper. R25 stated breakfast was good and warm. The Wander Guard remained in place on the left wrist. During observation on 03/25/2026 at 3:13 p.m., R25 was observed sitting outside the elevator waiting to go downstairs. The Wander Guard remained on the left wrist. R25 grabbed the device, shook it, and stated, They won't let me go home and I still have this stupid thing on. Review of R25's medical record and care plan lacked evidence the facility assessed or addressed the resident's ongoing distress related to the Wander Guard. There was no documentation indicating alternative placement options or less intrusive interventions were considered or implemented. During an interview on 03/25/2026 at 3:18 p.m., Nursing Assistant (NA)-C stated R25 did not like the Wander Guard, frequently verbalized wanting it removed, and was constantly fidgeting with the device. During an interview on 03/25/2026 at 3:19 p.m., Registered Nurse (RN)-A stated the Wander Guard really bugs him and confirmed R25 frequently asked for it to be removed. During an interview on 03/25/2026 at 3:40 p.m., RN Case Manager (RN)-B stated Wander Guards could be placed on the wrist or ankle and should be monitored for proper placement and effectiveness. During an interview on 03/26/2026 at 10:46 a.m., the Director of Nursing (DON) stated Wander Guard placement should be individualized and should not cause distress to the resident. The DON acknowledged that if the device was causing distress, it could be a dignity concern and alternative placement, such as the ankle, should have been attempted. The facility's Resident Dignity policy, dated 12/18/25, indicated the facility would promote care for residents in a manner that maintained or enhanced each resident's dignity and respect.

Based on record review and interview, the facility failed to conduct the initial and quarterly care conferences for 1 of 18 residents (R60) reviewed for care conferences.Findings include:R60's annual Minimum Data Set (MDS) dated [DATE], indicated R60 was admitted on [DATE], cognitively intact, and had the following diagnoses: peripheral vascular disease (poor circulation in the limbs), benign prostatic hypertrophy (enlarged prostrate), renal insufficiency, hyperlipidemia (elevated level of fat in the blood stream), and depression.R60's medical record lacked evidence a care conference was offered or conducted since admission.On 3/25/26 at 8:03 a.m., the administrator confirmed the facility had no record of any care conferences being conducted for R60.On 3/26/26 at 9:55 a.m., the social work designee (SW)-A and the director of nursing (DON) stated care conferences were organized by the social worker in cooperation with the MDS coordinator and should have been conducted within 3 days of admission, quarterly, with a significant change, or at family request. SW-A and the DON confirmed R60 had not had any care conferences and stated they were missed during a staff change over. SW-A stated the importance of conducting care conferences were to ensure the residents received what they needed and their family members/representatives provided input into their care. The DON stated they expected the initial care conference to have been conducted within 3 days of admission and then quarterly, with a significant change or at family request. The DON stated the importance of completing care conferences was to have clear communication and collaboration with the families.The facility Comprehensive Care plan and Care Conferences Policy last reviewed 12/29/25, indicated the facility will establish a baseline care plan and provide the resident and/or representative with a written summary of the care plan, and document the meeting occurred with the resident and representative and any significant discussion that occurred.

Based on record review and interviews, the facility failed to provide quarterly statements to 1 of 1 resident (R36) reviewed for personal funds. Findings include:R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 admitted [DATE], cognitively intact, and had the following diagnoses: heart failure, hypertension (high blood pressure), renal insufficiency, diabetes, and schizophrenia.On 3/23/26 at 1:20 p.m., R36 stated the facility was responsible for management of their money, but they had no idea what was going on with the account and the facility received their statements.On 3/26/26 at 12:12 p.m., the business office manager (BOM) stated they received monthly statements at R36's request and then met with the resident to explain and provide the documents to them. Additionally, the BOM confirmed they had no documentation to confirm conversations or explanations occurred.R36's medical record lacked evidence of agreement or statements were provided or explained to R36.On 3/26/26 at 12:50 p.m., administrator stated they expected personal fund account summaries were provided per regulations. It was important to provide documents to residents and document all conversations regarding accounts. Residents needed to be informed of account balances and facility needed documentation to refer back to.The facility Resident Trust Account Policy last revised 5/23/24, indicated as fiduciary of resident funds the location must hold, safeguard, manage, and account for the funds as well as ensure they are handled in accordance with state and federal regulation.

Based on interview and document review, facility failed to contact provider for 1 of 2 residents (R82) who expressed a plan to discharge against medical advice (AMA).R82's care plan dated 1/9/26, indicated R82 wished to return home in community pending therapy outcomes. Interventions included facility to make arrangements with required community resources to support independence post-discharge for example home care, physical and/or occupational therapy. R82 required assistance with dressing, transfers, ambulation, bathing and toile use.R82's face sheet undated, indicated R82 had diagnoses which included diabetes, dizziness, anxiety, chronic pain, muscle weakness, falls, abnormal gait and mobility, need for assistance with personal care. Care conference progress note dated 1/26/26, at 11:35 indicated therapy planned to end 1/28/26, therapy recommended assisted living facility for medication management, eating and cognitive concerns on living at home. R82's friends expressed concerns regarding R82's living conditions. R82 expressed desire to return home with county services. Facility explained if R82 did not admit to assisted living facility (AL) or home with extra services R82 would be considered discharged AMA and facility would not assist with setting up home services. Facility expressed to R82 if stayed in facility while after therapy ended to arrange either an AL or home services R82 may need to privately pay for extra days to enable facility to plan. R82 had expressed continued desire to discharge home. R82 was given a Notice of Medicare Non-Coverage (NOMNC) 1/26/26, at the care conference. Progress note dated 1/21/26, at 2:45 p.m. indicated R82 informed facility staff there were people coming to take him home. Staff explained to R82 if he left AMA they would not be able to set up services or send prescriptions for medications, R82 stated understanding and agreed to stay until 1/28/26 then discharge. Progress note dated 1/28/26, at 12:10 p.m. indicated R82's daughter was notified of R82's decision, R82 discharged from the facility with all personal belongings. R82's electronic medical record (EMR) lacked documentation R82's provider was contacted regarding R82's plan to discharge, in addition R82's EMR lacked documentation facility attempted to facilitate a planned discharge. R82's EMR lacked documentation provider was notified R82 discharged AMA. During interview on 3/26/26, at 10:56 a.m. Social worker (SW)- A stated R82 was educated regarding the risks and benefits of discharge AMA versus discharge to AL or home with services. SW-A stated R82 was adamant was going to discharge to home. When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated they attempted to convince R82 to remain in facility to allow them to contact the provider regarding desire to discharge to home. DON stated facility goal when a resident expressed they intended to discharge even if AMA was to contact the provider to attempt to facilitate a safe discharge for the resident rather than they discharge AMA with no assistance to obtain services or orders for medications. DON reviewed R82's EMR, DON noted facility was made aware on 1/26/26, R82 intended to discharge, however DON was unable to locate documentation provider had been informed, no attempt had been made to facilitate a safe planned discharge for R82. Facility Discharge and Transfer Rehab/Skilled, Therapy and Rehab policy dated 1/15/26, indicated discharge home facility would obtain an order from the physician for discharge to home with medications, arrange community resources and referrals, and coordinate a discharge plan with interdisciplinary team and resident. In addition, the policy indicated discharge AMA facility was to inform the physician of the situation.

Based on record review and interview, the facility failed to ensure a discharge summary (recapitulation of stay) was completed for 1 of 1 resident (R80) reviewed for hospitalization who did not return to the facility and for 1 of 1 resident (R82) reviewed for transfer and discharge. Findings include: R80's admission Minimum Data Set (MDS), dated [DATE], identified R80 had intact cognition and required some assistance with activities of daily living (ADLs). R80's diagnoses included other gram-negative sepsis, hypertension, urinary tract infection, diabetes mellitus, non-Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), gross hematuria, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, unspecified hydronephrosis, hydrocele, right testicular pain, long-term use of insulin, and a personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of R80's progress notes indicated R80 was transferred from the facility to the hospital on 2/12/26, for fluid retention. Further review of the progress notes revealed R80 did not return to the facility following hospitalization and was considered discharged as of 2/13/26, when the family released the bed hold. Review of R80's electronic medical record (EMR) showed no evidence a discharge summary (recapitulation of stay) had been completed, including a summary of the resident's status at discharge or a post-discharge plan of care. During an interview on 3/25/26 at 10:18 a.m., the Director of Nursing (DON) stated the facility normally completed a discharge summary (recapitulation of stay) when a resident was discharged . The DON confirmed a discharge summary had not been completed for R80 and indicated it should have been, as the facility was expected to complete one for all residents upon discharge. The DON explained the discharge summary was important because it outlined the care provided during the resident's stay. She further stated the document was printed and sent to the physician for review and signature, at which time the physician could add additional comments. R82's care plan dated 1/9/26, indicated R82 wished to return home in community pending therapy outcomes. Interventions included facility to make arrangements with required community resources to support independence post-discharge for example home care, physical and/or occupational therapy. R82 required assistance with dressing, transfers, ambulation, bathing and toile use. R82's face sheet undated, indicated R82 had diagnoses which included diabetes, dizziness, anxiety, chronic pain, muscle weakness, falls, abnormal gait and mobility, need for assistance with personal care. Review of R82's progress notes from 1/6/26 to 1/28/26, identified the following: -1/21/26, at 2:45 p.m. indicated R82 informed facility staff there were people coming to take him home. Staff explained to R82 if he left AMA they would not be able to set up services or send prescriptions for medications, R82 stated understanding and agreed to stay until 1/28/26 then discharge -1/26/26, at 11:35 a.m. R82 informed facility during care conference he was going to discharge home on 1/28/26. - 1/28/26, at 12:10 p.m. R82 left the facility home by taxi with all belongings. R82's EMR lacked a discharge summary for R82's stay. During interview on 3/25/26, at 3:04 p.m. Director of nursing (DON) reviewed R82's EMR, indicated was unable to locate a discharge summary for R82. DON was unsure why there was discharge summary. Facility Discharge and Transfer – Rehab/Skilled, Therapy and Rehab policy dated 1/15/26, indicated when a resident discharge from the facility a discharge summary would be completed.

Based on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 2 of 18 residents (R10 and R11) reviewed for care planning.Findings include:R10R10's admission Minimum Data Set (MDS) dated [DATE] identified R10 had intact cognition and required assistance with all activities of daily living (ADLs). R10's diagnoses included encounter for other orthopedic aftercare (follow-up care after bone/joint treatment), GERD (acid reflux), diabetes mellitus (high blood sugar), hyperlipidemia (high cholesterol), arthritis (joint inflammation), osteoporosis (weak/brittle bones), anxiety disorder (excessive worry), depression (persistent sadness), PTSD (post-traumatic stress disorder; stress after trauma), rotator cuff tear/rupture of the right shoulder (tear of shoulder tendons), hereditary ataxia (genetic condition causing poor coordination), demyelinating disease of the central nervous system (damage to nerve covering affecting signals), chondromalacia of the right shoulder (cartilage damage in the shoulder), bicipital tendinitis (inflammation of the biceps tendon), and mild cognitive impairment of unknown etiology (early memory/thinking changes with unclear cause). Review of R10's electronic medical record (EMR) indicated R10 was admitted to the facility on [DATE]. Further review of R10's EMR revealed a baseline care plan had not been initiated or completed within 48 hours of admission. The ADL baseline care plan was first documented on 2/17/26, greater than 48 hours after admission. R11R11's quarterly MDS dated [DATE] identified R11 had intact cognition and required assistance with ADLs. R11's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder causing changes in thinking, movement, and behavior), non-Alzheimer's dementia (decline in memory and thinking not caused by Alzheimer's disease), and depression (persistent sadness or loss of interest). The MDS indicated R11 received antipsychotic medication. Review of R11's EMR indicated R11 was admitted to the facility on [DATE]. Further review of R11's EMR revealed a baseline care plan had not been initiated or completed within 48 hours of admission. The ADL baseline care plan was first documented on 12/1/25, greater than 48 hours after admission. During interview on 3/25/26 at 3:25 p.m., registered nurse case manager (RN)-B indicated baseline care plans included areas such as transfer status, high-risk ( black box) medication warnings, medications, fall risk, behaviors, pain, risk for pressure ulcers, psychotropic medication use, and presence of a feeding tube. RN-B stated baseline care plans should be completed within 24-48 hours of admission. RN-B confirmed R11's ADL interventions were not initiated until 12/1/25. During interview on 3/25/26 at 4:07 p.m., the Director of Nursing (DON) indicated care plans were expected to be initiated upon admission, with assessments set up to automatically populate the care plan. The DON stated the RN manager or herself would follow up or complete the care plan, with an expectation for completion within 48 hours so staff were aware of how to provide care. The DON further stated, at a minimum, fall and ADL interventions should be in place within that timeframe. The DON confirmed R11's ADL interventions were initiated on 12/1/25, which was beyond the required 48-hour timeframe. During interview on 3/26/26 at 11:31 a.m., the DON provided consistent information regarding care plan initiation and expectations for completion within 48 hours of admission, including implementation of fall and ADL interventions. The DON confirmed R10's ADL interventions were initiated on 2/17/26, which was beyond the required 48-hour timeframe. The facility Care Plan policy was requested but was not received

Based on observation, interview, and record review, the facility failed to revise a comprehensive, person-centered care plan to reflect a change in mobility status for 1 of 1 resident (R25) reviewed for care planning related to wheelchair use.Findings include:R25's admission Minimum Data Set (MDS), dated [DATE], identified R25 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R25's diagnoses included non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), muscle weakness (reduced strength), abnormalities of gait and mobility (difficulty walking), hypertension (high blood pressure), arthritis (joint inflammation causing pain), and insomnia (difficulty sleeping). Review of R25's comprehensive care plan, with a print date of 3/26/26, indicated R25 required assistance of one staff with a front wheeled walker for mobility. During the following observations, no use of a front wheeled walker was observed:3/24/26 at 3:26 p.m., R25 was observed sitting outside the elevator in his wheelchair and was self-propelling via wheelchair to and from various locations within the facility.3/24/26 at 6:48 p.m., R25 was observed self-propelling via wheelchair to and from various locations on the second-floor unit.3/25/26 at 8:33 a.m., R25 was observed self-propelling via wheelchair to and from various locations on the second-floor unit.3/25/26 at 3:13 p.m., R25 was observed sitting outside the elevator in his wheelchair and was self-propelling via wheelchair to and from various locations within the facility. Further review of R25's electronic medical record (EMR) lacked evidence the care plan had been revised to reflect R25's current use of a wheelchair for mobility assistance. During interview on 3/25/26 at 3:40 p.m., registered nurse care manager (RN)-B stated the wheelchair use had not been reflected in R25's care plan and should have been revised. During interview on 3/26/26 at 10:46 a.m., the director of nursing (DON) confirmed wheelchair use for R25's mobility had not been revised in the care plan and should have been, to ensure the care plan was clearly identified for staff to provide safe care. A facility care plan policy was requested but was not received.

Based on observation, interview and document review, the facility failed to ensure shaving was offered or provided for 1 of 1 residents (R15) reviewed for assistance with activities of daily living (ADLs).R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairments and required staff assistance with ADLs. R15's diagnoses included diabetes, Parkinson's disease, dementia, anxiety and chronic pain. R15's care plan revised 3/7/26, indicated R15 had a self-care deficit related to Parkinson's disease with interventions that included resident required assistance from one staff for bathing, dressing and personal hygiene. On 3/23/26, at 11:25 a.m. observed R15 to have gray hairs on chin, above upper lip and below lower lip, about an inch in length. During follow-up observations on 3/24/26, at 12:37 p.m., 3/24/26, at 3:48 p.m., 3/24/26, at 6:55 p.m., 3/25/26, at 8:29 a.m., 3/25/26, at 4:15 p.m. and 3/26/26, at 7:16 a.m. R15 continued to have long gray hair on chin, above upper lip and below lower lip, about an inch in length. During interview on 3/26/26, at 10:18 a.m. family member (FM)-A stated they had asked the facility to shave R15, FM-A further stated R15 would be very bothered if she knew she had long hairs on her face. FM-A stated I don't know why they don't remove the hairs for her, I would think they could easily do that for her, she has a electric razor in her drawer. When interviewed on 3/26/26, at 10:32 a.m. nursing assistant (NA)-A stated R15 did not refuse cares, if a resident was unable to request to be shaved the resident should then be shaved when they start to look scruffy. When interviewed on 3/26/26, at 10:36 a.m. trained medication aide (TMA)-A stated R15 was cooperative with cares, TMA-A stated she had noticed R15 had long hair on her chin but had not shaved her this morning. TMA-A observed R15 with surveyor and stated R15 did look like she should have been shaved before now for R15's dignity When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated the expectation was both men and women should be shaved when there was hair/whiskers that had grown for their comfort and dignity. Facility Activities of Daily Living - R/S, LTC policy dated 12/10/26, indicated ADLs are those necessary tasks conducted in the normal course of a resident's daily life that included general personal, daily hygiene/grooming: care of hair, hands, face, shaving, applying makeup, skin, nail and oral care.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice by not following provider-ordered edema management interventions, including assistance with application and removal of compression stockings, and by inaccurately documenting care on the Treatment Administration Record (TAR) for 1 of 3 residents (R25) reviewed for edema management.Findings include:R25's admission Minimum Data Set (MDS), dated [DATE], identified R25 had moderate cognitive impairment and required assistance with all activities of daily living (ADLs). R25's diagnoses included non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), muscle weakness (reduced strength), abnormalities of gait and mobility (difficulty walking), hypertension (high blood pressure), arthritis (joint inflammation causing pain), and insomnia (difficulty sleeping). Review of R25's physician orders, dated 3/4/26, indicated an order for staff to apply compression (TEDS) stockings in the morning and remove them in the evening for edema management. Review of the Treatment Administration Record (TAR) from 3/1/26 through 3/26/26 indicated staff documented the application and removal of compression stockings as completed, as ordered. During observation and interview on 3/23/26 at 3:07 p.m., R25 was observed seated in his wheelchair without compression stockings in place. Observation of R25's lower extremities revealed he was wearing regular socks that were causing indentations around his lower extremities. R25 stated staff had not consistently assisted with applying the compression stockings, and he had been wearing regular socks for the past several weeks. During observation on 3/24/26 at 12:59 p.m., R25 was observed seated in his wheelchair in the dining room without compression stockings in place. Observation of his lower extremities revealed he was wearing regular socks that were causing indentations. During observation on 3/25/26 at 8:33 a.m., R25 was observed seated in his wheelchair in the living room area without compression stockings in place. Observation of his lower extremities revealed he was wearing regular socks that were causing indentations. During interview on 3/25/26 at 3:18 p.m., Nursing Assistant (NA)-C stated she was not aware R25 had compression stockings that he should have been wearing during the day. During interview on 3/25/26 at 3:19 p.m., Registered Nurse (RN)-A stated R25 had an order for compression stockings to be applied in the morning and removed at bedtime. RN-A stated R25 did not refuse compression stockings. RN-A confirmed R25 did not have compression stockings on at that time and was wearing regular socks. RN-A confirmed the TAR indicated the compression stockings were applied and removed as ordered and acknowledged the documentation was not accurate when the stockings were not in place. During interview on 3/25/26 at 3:40 p.m., the Registered Nurse Care Manager (RN)-B stated she had not been aware of R25's edema. RN-B reviewed R25's electronic medical record (EMR) and stated R25 had non-pitting edema in the right and left lower extremities and should have been wearing compression stockings. RN-B indicated she would have expected R25 to wear them, as there was an order in place, and stated they were important to help manage his edema. RN-B confirmed staff had been documenting on the TAR that the compression stockings were applied and removed as ordered. During interview on 3/26/26 at 10:46 a.m., the Director of Nursing (DON) stated compression stockings should have had an order to be applied in the morning and removed at night and that this intervention should have been care planned. The DON stated staff were expected to assist R25 with application and removal. The DON further indicated compression stockings were important to help manage edema, promote circulation, and reduce the risk of blood clots. The DON also stated staff were expected not to document care that was not completed, as doing so would be false documentation. A facility policy regarding compression stocking application, documentation, and care planning was requested but was not received.

Based on observation, interview, and record review the facility failed to ensure ongoing monitoring of pressure ulcers for 2 of 4 residents (R2 and R15) reviewed for pressure ulcers. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. F686 Based on observation, interview, and record review the facility failed to ensure ongoing monitoring of pressure ulcers for 3 of 4 residents (R2, R15 and R 72) reviewed for pressure ulcers. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) guidelines dated 2016, identified a pressure ulcer as, . localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. These are then staged according to the following criteria: - Stage I Pressure Injury: Non-blanchable erythema (redness) of intact skin. - Stage II Pressure Injury: Partial-thickness skin loss with exposed dermis. - Stage III Pressure Injury: Full-thickness skin loss, Adipose (fat) is visible, and rolled wound edges are often present - Stage IV Pressure Injury: Full-thickness skin and tissue loss, Exposed bone, tendon, ligament, cartilage, or muscle. - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. The extent of damage cannot be confirmed because it is covered by slough (contains yellowish or white, soft, stringy dead tissue that acts as a barrier to healing) or eschar ( thick, dry black or brown layer of dead tissue). -Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. R2 R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact and was dependent on staff for activities of daily living (ADLs). R2's diagnoses included: hemiplegia ( weakness, numbness or reduced muscle strength on one side of the body) and hemiparesis (inability to move muscles on one side of the body) following a stroke, pressure ulcers, anemia, muscle weakness and protein-calorie malnutrition. R2's pressure ulcer/injury care area assessment (CAA) dated 11/9/25, indicated R2 was admitted with a stage II pressure ulcer to the coccyx. R2's care plan revised 3/5/26, indicated R2 had actual impairment to skin related to immobility, R2 had an unstageable pressure ulcer to sacral/coccyx/ bilateral intergluteal cleft region with interventions that included: staff to monitor location, size and treatment of skin injury. Report abnormalities, failure to heal, s/s of infection, maceration, etc. to health care provider. Weekly skin observation by licensed nurse. Review of R2's EMR wound documentation identified:On 11/3/25, sacrum wound measured 6.5 centimeters (cm) x 6.5cm x no depth Partial loss of skin, blanchable, 100% granulation tissue, tender to touch, scant bleeding.The next documented measurements was obtained a month later on 12/3/25, indicated sacrum/coccyx recently resolved stage 2 pressure ulcer sacral area is fragile resolved no open area all moisture-associated skin damage (MASD).On 12/13/25, right buttock wound measured 7.5cm x 3.5cm x no depth documented 10% eschar.On 12/18/25, Sacrum/coccyx/bilateral intragluteal cleft suspected deep tissue injury (SDIT) measured 9.0cm x 8.4cm x 0.2cm with 20%on granulation 80% slough worsening with unstageable condition at this time.On 12/23/25, Sacrum/coccyx/bilateral intragluteal cleft SDIT measured 8.4cm x 8.2cm x0.2cm with 20% granulation 80% slough.The next documented measurements were completed 36 days later on 1/28/26, coccyx wound measured 5.6cm x 3.0cm x 0.3cm with 40% granulation 60% slough.On 2/5/26, right intergluteal cleft 7.0cm x 2.2cm x 0.3cm with 80% granulation 20% slough.On 2/18/26, sacrum stage 3 measured 5.5cm x 1.7cm x 0.4cm with 80% granulation 20% slough.On 2/19/26, sacrum 5.0cmx2.5cmx0.3cm with Full thickness skin loss on the buttocks, no drainage, white fat tissue at the base, and non-blanchable.On 2/26/26, sacrum 5.0cm x 1.6cm x 0.4cm with 70% granulation 30% slough minimum serosanguineousOn 3/5/26, unstageable wound pressure ulcer spanning coccyx and bilateral intragluteal cleft (vertical groove between buttocks) 2.7cm x 2.7cm x 0.4cm undermining (tissue under wound edges erode creating a shelf or pocket beneath skin) at 6:00 0.8cm length, 70% granulation 30% slough, surrounding skin macerated (wet, white, waterlogged tissue).On 3/12/26, unstageable wound pressure ulcer spanning coccyx and bilateral intragluteal cleft measured 3.2cmx0.8cmx1.2cm.On 3/20/26, unstageable wound pressure ulcer spanning coccyx and bilateral intragluteal cleft measured 2.5cm x 1.3cm x 0.7cm with 90% granulation 10% slough. Wound edges not attached appear as a cliff, surrounding skin macerated with induration (localized hardening/firming around wound typically caused by inflammation, infection, or chronic cellular immune response). During interview on 3/25/26, at 1:29 p.m. licensed practical nurse (LPN)-A stated R2's wound improved from what it had looked like, had been double the size it currently was and was no longer dark purple in color. When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated the expectation was all wounds would be measured and documented on weekly. DON stated she expected the nurses/nurse managers to take ownership with their wounds. DON reviewed R2's EMR, stated unable pull data that is not in the chart. R15 R15's quarterly MDS dated [DATE], indicated R15 had severe cognitive impairment and required assistance with ADLSs. R15's diagnoses included: cellulits of right lower limb, pressure ulcer right heels stage 3, pressure ulcer left heel stage 3, diabetes, Parkinson's disease, dementia, hypertension, anxiety and chronic pain. R15's pressure ulcer/injury CAA dated 12/15/25, indicated R15 had pressure ulcers on her right and left heel that she was admitted with hospital documentation listing them as stage 2. Per hospital record Right heel is chronic with poor healing. right heel 1cm x 1.3cm x 0.2cm and Left heel 0.5 0cmx 0.3cm x 0.2cm. R15's care plan revised 3/8/26, indicated R15 had stage 3 pressure ulcer to right and left heels present on admission with interventions that included staff apply foam heel protectors when R15 in bed and assess/record/monitor wound healing. Report improvements and declines to the health care provider. Review of R15's EMR wound documentation identified:On 12/3/25, left heel stag 3 measured 1.5cmx0.4cmx0.2cm with100% slough, right heel stage 3 measured 1.3cmx1.1cmx0.2cm with 90%granulation and 10% slough.On 12/12/25, left heel stage 3, measured 0.9cmx0.4cmx0.2cm with 100% slough. right heel stage 3 measured 1.4cmx0.9cmx0.2cm with 90% granulation and 10% slough.The next documented measurements were completed 47 days later on 1/28/26, right heel stage 3 measured 0.5cmx0.3cmx0.2cm with 100% granulation, left heel stage 3 measured 0.2cmx0.2cmx0.2cm with 100% granulation.On 2/4/26, left heel stage 3 was documented as 0cmx0cmx0cm with100% epithelial. right heel stage 3 measured 0.8cmx0.5cmx0.1cm with 100% epithial wound bed.On 2/12/26, right heel 1cm x 1cm x 0cm scabbed. left heel scabbed 1.5cm x 1.5cm x 0cm.On 2/18/26, right heel 0.1cm x 0.2cm x 0.1cm 100% granulation. left heel 0.9cm x 0.4cm x 0cm 100% slough.The next documented measurements were completed 15 days later on 3/5/26, left heel stage 3 pressure ulcer scab covered measured as 0cmx0cmx0cm. Right heel stage 3 pressure ulcer 1cmx0.5cmx0cm scab covered.On 3/12/26, left heel stage 3 pressure ulcer measured 0.5cmx0.3cmx0.1cm, right heel stage 3 pressure ulcer measured 1cmx0.5cmx0.1cm.On 3/19/26, left heel stage 3 measured 0.5cmx0.3cmx0.1cm, right heel stage 3 measured 1cmx0.5cmx0.1cm. When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated the expectation was all wounds would be measured and documented on weekly. DON stated she expected the nurses/nurse managers to take ownership with their wounds. DON reviewed R15's EMR, stated unable pull data that is not in the chart. Facility Pressure Ulcer/Wound Care Resource Packet-Rehab/Skilled policy stated 12/8/25, indicated wound RN assessment is required at least every seven days and as needed when skin integrity is impaired or open area is present.

Based on record review and interview, the facility failed to ensure effective communication of necessary clinical information to the dialysis center for 1 of 1 resident (R88) reviewed for dialysis services.Findings include:R88's admission Minimum Data Set (MDS), dated [DATE], identified R88 had intact cognition and required assistance with activities of daily living (ADLs). R88's diagnoses included dependence on renal dialysis (requires routine dialysis treatment to perform kidney function), chronic kidney disease stage 5 (severe kidney failure where the kidneys no longer function adequately), and presence of other vascular implants and grafts (surgically placed devices or vessels used to support blood flow, often for dialysis access). Review of R88's electronic medical record (EMR) indicated R88 received routine dialysis treatments at an external dialysis center on a scheduled basis (Mondays, Wednesdays, and Fridays). Review of facility documentation, including dialysis communication forms and transfer records from 3/18/26 to 3/25/26, revealed the facility failed to send required clinical information with R88 to the dialysis center. Missing or incomplete information included, but was not limited to, vital signs, current medication list, recent changes in condition, weights, and/or physician orders. During interview on 3/24/26 at 12:13 p.m., R88 stated she went to an offsite dialysis center and reported the facility did not send any paperwork or communication form with her to her dialysis appointments. During interview on 3/25/26 at 3:55 p.m., the Director of Nursing (DON) confirmed the expectation that communication forms should accompany the resident to each dialysis appointment to ensure continuity of care. The DON acknowledged the facility did not consistently ensure this information was provided. A call to the Fresenius Dialysis Center was placed on 3/27/26 at 8:04 a.m.; a message was left, and no return call was received. The facility was requested to provide a policy regarding communication with outside providers, including dialysis centers; however, the facility did not provide the requested policy.

Based on record review and interview, the facility failed to ensure a trauma-informed care approach was implemented by not completing a trauma assessment upon admission for 1 of 1 resident (R10) reviewed for trauma-informed care.Findings include:R10R10's admission Minimum Data Set (MDS), dated [DATE], identified R10 had intact cognition and required assistance with activities of daily living (ADLs). R10's diagnoses included post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing a traumatic event), anxiety disorder (excessive worry), and depression (persistent feelings of sadness). Review of R10's electronic medical record (EMR) lacked evidence a trauma assessment was completed upon admission to identify past trauma, triggers, or individualized care needs related to trauma history. Review of R10's comprehensive care plan, print date 3/26/26, did not include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional safety. During interview on 3/26/26 at 9:55 a.m., the Director of Nursing (DON) and Social Services Designee (SSD) confirmed R10 had a known history of PTSD; however, no trauma assessment had been completed at the time of admission. The DON and SSD further confirmed trauma-informed interventions had not been developed or implemented for R10. The facility's Trauma-Informed Care policy, dated 12/31/25, indicated the facility would provide trauma-informed care and avoid re-traumatizing residents. The policy further indicated staff would ensure residents who experienced trauma received culturally competent, trauma-informed care in accordance with professional standards of practice, accounting for residents' experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization. The policy indicated a trauma assessment was required within five days of admission for all new residents and as needed. The trauma assessment was to be completed by Social Services while interviewing the resident and/or representative. During the interview, staff were to focus on understanding the resident's experience (what happened to the resident) rather than attempting to correct behaviors. The policy further indicated staff were to document how trauma was currently affecting the resident.

Based on record review and interview, the facility failed to act upon consultant pharmacist recommendations in a timely manner related to completion of an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 3 residents (R11) reviewed for unnecessary medications.Findings include:R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder causing changes in thinking, movement, and behavior), non-Alzheimer's dementia (decline in memory and thinking not caused by Alzheimer's disease), and depression (persistent sadness or loss of interest). The MDS indicated R11 received antipsychotic medication. R11's physician order summary report, dated 3/4/26, included an order for Quetiapine (an antipsychotic medication used to treat mood and thought disorders) 25 milligrams (mg) to be administered at bedtime for repeated episodes of anxiety. Review of the consultant pharmacist's monthly medication regimen review (MMR), dated 12/18/25, identified a recommendation for completion of an AIMS assessment to monitor for potential side effects related to antipsychotic medication use. Subsequent MMRs, dated 1/14/26, 2/13/26, and 3/6/26, reiterated the same recommendation. Review of R11's electronic medical record (EMR) revealed no evidence that an AIMS assessment had been completed following the pharmacist's recommendation. Further review showed the recommendation remained unaddressed as of 3/20/26. During an interview on 3/20/26 at 10:15 a.m., the director of nursing (DON) confirmed the consultant pharmacist (CP) recommended completion of an AIMS assessment and acknowledged the facility had not completed the assessment or followed up on the recommendation in a timely manner. During an interview on 3/25/26 at 1:45 p.m., DON stated when MMRs were received, she divided the recommendations between two registered nurse case managers and forwarded provider-related recommendations to the providers. During an interview on 3/25/26 at 3:25 p.m., registered nurse case manager (RN-B) stated the DON printed the pharmacist recommendations and distributed them to the nurse managers, where they were placed in a drawer for follow-up. RN-B stated the nurse manager was responsible for completing the AIMS assessment and that recommendations should be followed up as soon as possible, including consideration of gradual dose reduction (GDR) and monitoring for adverse medication reactions. RN-B confirmed the AIMS assessment had not been completed. During an interview on 3/25/26 at 4:07 p.m., the DON stated MMR recommendations were expected to be completed prior to the next consultant pharmacist visit. The DON stated the recommendation had been assigned to the RN case manager; however, for unknown reasons, it was not completed. The DON further stated the recommendation was important as it related to monitoring the resident's medication and potential adverse effects. During an interview on 3/26/26 at 2:18 p.m., the Consultant Pharmacist (CP) stated the expectation was for facilities to respond to recommendations within the first month and no later than 60 days. The CP stated there had been no response to the recommendation in December, January, or February and reported the lack of follow-up may have been related to turnover in the DON position, resulting in the recommendation not being addressed. Review of the facility policy titled Medication: Drug Regimen Review, dated 12/1/25, indicated drug regimen review included identifying and preventing clinically significant medication issues. The policy further indicated the consultant pharmacist would complete a written report noting any irregularities, which would be provided to the DON, and the facility must ensure recommendations were acted upon and documented within 30 calendar days.

Based on observation, interview, and record review, the facility failed to establish and implement an infection prevention and control program to prevent the spread of infection by not initiating Enhanced Barrier Precautions (EBP) per Centers for Disease Control (CDC) guidance. when indicated and failing to ensure staff followed EBP during resident care for 3 of 6 residents reviewed for infection control (R11, R46, and R88).Findings include: Review of CDC guidelines dated 8/12/22, identified EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. CDC guidelines updated 6/28/24 identified examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs)), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. R11R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder causing changes in thinking, movement, and behavior), non-Alzheimer's dementia (decline in memory and thinking not caused by Alzheimer's disease), and depression (persistent sadness or loss of interest). The MDS also identified R11 had a stage 2 pressure ulcer. Review of R11's electronic medical record (EMR) identified the presence of a wound requiring ongoing care. Further review of the comprehensive care plan, with a print date of 3/26/26, and physician orders, dated 3/4/26, indicated an order for EBP precautions and wound orders to cleanse with wound cleanser and apply mepilex every other day to the pressure ulcer, and EBP interventions were included in the care plan. However, there was no evidence of implementation, including no documentation of staff use of gown and gloves for high-contact care and no placement of appropriate signage or personal protective equipment (PPE) outside of R11's room. During observations on 3/24/26 at 4:57 p.m. and 3/25/26 at 8:46 a.m., there was no appropriate signage or PPE placed outside R11's room to indicate the resident was on precautions. During interview on 3/25/26 at 3:07 p.m., Nursing Assistant (NA)-D stated she would know if a resident was on precautions based on signage posted outside the resident's room, stating, I just look before I walk in the room. NA-D confirmed R11 was not on EBP precautions, as there was no signage posted outside the room. During interview on 3/25/26 at 3:25 p.m., the registered nurse case manager (RN-B) stated the facility maintained signage on resident doors and a printed list identifying residents on precautions. RN-B indicated the care plan included an EBP section and confirmed R11 was being followed by the wound nurse practitioner (NP) and that the wound was healing; however, R11 should have been on EBP precautions and was included on the facility's EBP list. RN-B accompanied the surveyor to R11's room and confirmed EBP precautions were not in place. RN-B further stated EBP was important to protect staff and residents from infection. R46R46's admission MDS, dated [DATE], identified R46 had intact cognition and required assistance with all ADLs. R46's diagnoses included sepsis due to E. coli (a serious bloodstream infection caused by bacteria), renal failure (impaired kidney function), obstructive uropathy (blockage of urine flow), urinary tract infections (infection in the urinary system), and presence of urogenital implants (devices placed in the urinary or reproductive system). The MDS also indicated R46 had an indwelling catheter (a tube inserted into the bladder to drain urine). Review of R46's care plan, with a print date of 3/26/26, indicated the resident was on EBP precautions due to the presence of the indwelling catheter, including interventions for staff to use a gown and gloves during high-contact resident care. During observation on 3/23/26 at 3:20 p.m., NA-C and an orientee were observed providing direct care to R46, including assisting with toileting, peri-care, and transferring, without donning a gown and/or gloves in accordance with EBP requirements. No PPE was observed in use during the care interaction. During interview on 3/23/26 at 3:43 p.m., NA-C stated she was not sure if R46 was on precautions because she did not normally work on that floor. NA-C stated she believed the resident was on EBP precautions due to having a catheter and that staff were to wear gloves and a gown whenever assisting with care. NA-C confirmed she and the orientee did not wear a gown or gloves when assisting R46 and should have. During interview on 3/25/26 at 3:38 p.m., RN-B stated staff were expected to wear a gown and gloves whenever they anticipated coming into contact with the resident. During interview on 3/25/26 at 3:55 p.m., the DON confirmed staff were expected to follow EBP precautions, including use of gown and gloves for high-contact care, and acknowledged the observed care was not provided in accordance with facility policy. R88R88's admission MDS, dated [DATE], identified R88 had intact cognition and required assistance with ADLs. R88's diagnoses included dependence on renal dialysis (requires routine dialysis treatment to perform kidney function), chronic kidney disease stage 5 (severe kidney failure where the kidneys no longer function adequately), and presence of other vascular implants and grafts (surgically placed devices or vessels used to support blood flow, often for dialysis access). Review of R88's EMR identified the presence of a dialysis shunt. Further review of the comprehensive care plan, with a print date of 3/26/26, and physician orders, dated 3/18/26, failed to include initiation of EBP precautions related to the presence of the dialysis shunt. There was no documentation indicating assessment for EBP implementation, use of gown and gloves for high-contact care, or placement of appropriate signage and PPE outside of R88's room. During observations on 3/23/26 at 11:12 a.m., 3/24/26 at 4:59 p.m., and 3/25/26 at 2:53 p.m., there was no appropriate signage or PPE placed outside R88's room to indicate the resident was on precautions. During interview on 3/25/26 at 3:55 p.m., the director of nursing (DON) stated R88 should have been on EBP precautions due to the presence of a tunneled catheter. She indicated there should have been signage outside the door and EBP supplies available in a cupboard outside the room. The DON stated it was important to prevent infection transmission to the resident and to staff and confirmed gloves and a gown should be worn during care. The facility Standard, Enhanced Barrier, and Transmission-Based Precautions policy, dated 7/7/25, indicated Enhanced Barrier Precautions (EBP) were implemented to reduce the transmission of multidrug-resistant organisms (MDROs) for residents who were infected or colonized with a CDC-targeted or epidemiologically significant MDRO, or when additional precautions were warranted. The policy indicated EBP were used for residents with chronic wounds (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomies), regardless of known MDRO status. The policy indicated staff were to wear a gown and gloves during high-contact resident care activities, including transfers, dressing, bathing, hygiene care, toileting, linen changes, wound care, and care or use of indwelling medical devices. The policy indicated EBP were intended to remain in place for the duration of the resident's stay; however, for residents with a wound or indwelling medical device only, precautions could be discontinued if the wound resolved or the device was removed

Based on observation, interview, and document review, the facility failed to maintain resident supervision and safety to prevent accidents for 1 of 1 resident (R2) who was at a high risk for elopement, left the facility unsupervised, and was found across the street in another assisted living (AL) parking lot. This resulted in an immediate Jeopardy (IJ) situation for R2. The IJ began on 7/18/25, when R2 was admitted to the facility and was identified to be a high risk for falls and elopement but the facility failed to implement safety measures and increased supervision resulting in an elopement from the facility on 7/19/25, when R2 wandered onto the elevator; walked through the attached assisted living, crossed the parking lot, crossed a busy street, and was found by police in the parking lot across the street from the facility. The IJ was removed on 7/19/25, and the deficient practice corrected on 7/19/25, prior to the start of the survey and was therefore issued at Past Noncompliance.Findings include: R2's admission Record identified R2 was admitted to the facility on [DATE] at 2:15 p.m. The Minimum Data Set (MDS) was not completed yet due to R2's recent admission date of 7/18/25. R2's Diagnoses List identified diagnoses of Alzheimer's disease and dementia. R2's Brief Interview for Mental Status dated 7/18/25, indicated R2 had severe cognitive impairment. R2's admission elopement assessment dated [DATE] at 8:00 p.m., identified R2 was at high risk for elopement related to R2's recent admission, caregiver change, disorientation to place, increased confusion and forgetfulness, recent room change, not understanding what is being said, inability to communicate needs, advanced dementia, wandering, and loss of self-control. In addition, the assessment identified diagnoses of Alzheimer's disease, dementia, and anxiety disorder and were risk factors for elopement. Interventions identified were to attempt non-pharmacological interventions and minimize potential of resident behavior problems by modifying environmental factors and daily routine. R2's Fall Risk assessment dated [DATE], indicated R2 was at a high risk for falls related to one or more falls in past three months, medications, severely impaired cognitive status, restlessness, delirium, confusion, poor memory, history of depression, disorientation, difficulty following instructions, restlessness, and poor sleep pattern. R1's Care plan initiated 7/18/25, did not identify R2 as an elopement risk or identify safety interventions to prevent or mitigate the risk of elopement until after R2's elopement on 7/19/25. R2's care plan did not identify the risk for falls or fall interventions until 7/19/25. R2's admission progress note on 7/18/25 at 2:15 p.m., identified R2 was admitted following hospitalization for mental status changes, left sided weakness, confusion, impaired speech, nasal fracture, periorbital (around the eyes) bruising due to a fall. R2's facility Progress Notes dated 7/18/25 at 11:17 p.m., identified R2 required assist of one staff with all cares and standby assist with a walker. The progress note indicated R2 was a high fall risk due to cognitive issues, a high risk of elopement, and needed to be monitored at all times. R2's Health Status progress note on 7/19/25 at 11:16 p.m., noted R2 eloped from the facility at 4:10-4:15 p.m. when staff noticed he was no longer in his room. Police officer found R2 wandering across the street at another AL facility. After the elopement, staff placed a wanderguard on R2 and implemented frequent checks. During observation on 7/23/25 at 12:20 p.m., R2 was seated at a table in the common area with his spouse. Wanderguard noted on his wrist. During an interview on 7/23/25 at 2:25 p.m., registered nurse (RN)-A identified she was the nurse that admitted R2 to the facility on a Friday afternoon (7/18/25). RN-A indicated on 7/18/25, R2 followed his wife down the facility elevators to the first floor exit doors. Staff responded and brought him back to the third floor and determined he was at high risk for elopement at that time. RN-A stated she did not apply a wanderguard because she did not know where the wanderguard bracelets were kept or how to activate them. RN-A further indicated the nurse managers usually applied them and stated she informed nurse manager (NM)-A that R2 was at risk for elopement and needed a wanderguard however, understood that NM-A had to leave and would apply one the next Monday (7/21/25), when she returned. RN-A indicated she wrote a progress note and passed the information to the next shift. RN-A confirmed a waderguard had not been placed on R2 on 7/18/25. During an interview on 7/23/25 at 2:50 p.m., RN-C indicated the nurse managers applied the wanderguard and he had not been trained on activating the wanderguard until after R2 eloped from the facility on 7/19/25. During an interview on 7/23/25 at 4:00 p.m., the director of nursing (DON) stated she was notified by phone on 7/19/25, about R2's elopement when staff were unable to locate R2 in the facility. The police found him in the parking lot across the street from the facility at approximately 5:25 p.m. The DON stated a dietary aide saw R2 get on the elevator on 7/19/25, however, thought he was a visitor. R2 was identified as an elopement risk upon admission [DATE]), however, RN-A misinterpreted what NM-A said and did not place a wanderguard on R2 or inform NM-A that she was not aware of the policy and procedure on wanderguard application and activation. In addition, 15-minute checks were not implemented. During an observation of the route on 7/23/25 at 4:15 p.m., the DON stated the camera footage identified the route R2 had taken and the timeline of events on 7/19/25. R2 entered the third-floor elevators at approximated 4:10-4:15 p.m.; exited the elevators on first floor to the facility lobby, bypassed the main entrance and continued down the hallway to the attached assisted living (AL) hallway; exited the main entrance of the AL; entered the AL parking lot; crossed the approximate 1/4 block long parking lot; crossed a busy street shared with a medical center and had a blind curve a short distance away. R2 was found by police in the parking lot of the AL across the street at approximately 5:20 - 5:25 p.m. During an interview on 7/23/25 at 4:50 p.m., NM-A indicated RN-A notified her on 7/18/25, that R2 was actively exit seeking and needed a wanderguard. RN-A asked NM-A to apply one and NM-A stated she had to leave and offered to come back if needed. NM-A stated she was not aware RN-A did not know how to apply the wanderguard nor did RN-A ask NM-A to return and apply one. NM-A assumed RN-A had applied a wanderguard to R2 on 7/18/25, and was notified by the DON on 7/19/25, that R2 had eloped from the facility and did not have a wanderguard on. NM-A indicated a wanderguard was immediately placed on R2 when he returned to the facility on 7/19/25. NM-A stated that wanderguard policies, procedures, and instructions were not part of the nurse's orientation however, it had been added after R2's elopement. During an interview on 7/24/25 at 9:47 a.m., dietary aide (DA)-A stated she was working the evening of 7/19/25, when she noticed a unknown man (later identified as R2) waddling down the hallway to the elevator without a walker or wheelchair. DA-A indicated she thought it was a visitor so did not think more about it until she overheard the nursing staff at approximately 4:20 p.m. saying that R2 was missing. DA-A stated she did not know that there was a new resident in the facility until that time. During an interview on 7/24/25 at 10:16 a.m., RN-B identified she was working on 7/19/25, when R2 eloped. RN-B indicated she was informed by RN-A that R2 had wandered off third floor for 1/2 hour the day prior (7/18/25), had not placed a wanderguard on R2 because NM-A would place the wanderguard on Monday (7/21/25). RN-B stated she may have seen R2 in the hallway however, was not sure because she did not know what he looked like. RN-B confirmed increased safety checks had not been implemented on R2 prio to his elopement. RN-B confirmed she had not placed a wanderguard on R2 because she did not know where they were kept and that placing a wanderguard on a resident was the nurse manager's responsibility. RN-B identified she was notified at approximately 4:15 p.m. on 7/19/25, that R2 was not in his room and searched the facility. When they were unable to find R2, she notified the DON, administrator, family, and police at approximately 5:00 p.m. R2 was located by the police across the street from the AL in the parking lot and returned to the facility at 5:30 p.m. During an interview on 7/24/25 at 11:10 a.m., nursing assistant (NA)-A indicated she worked the day of R2's admission and knew he was at risk for elopement because he went down the elevator in his wheelchair independently. NA-A confirmed a wanderguard had not been placed on R2 and that increased safety checks had not been implemented. NA-A stated NAs did not know how to apply wanderguards however, received education after R2's elopement. During an interview on 7/24/25 at 11:25 a.m., NA-B indicated she was working on 7/19/25, had not been informed R2 was an elopement risk when she received report. NA-B noted R2 had some of his personal items outside his room as if he were packing to leave and another resident told her that R2 was going to leave. NA-B checked on R2 at 4:15 p.m., and noted he was not in his room. NA-B notified the nurse, and they began to search for him and stated they did not know what he looked like at that time. Facility policy titled, Elopements dated 4/7/25, defined elopement as a resident who needed supervision left the premises or a safe area without authorization and/or any necessary supervision to do so. The policy indicated the skilled nursing facility (SNF) would be responsible for maintaining a system that clearly defined the mechanisms and procedures for monitoring residents at risk for elopement. These include identifying, evaluating, and analyzing environmental hazards and risks; and implementing, monitoring, and modifying interventions as needed. All SNF residents would be assessed for risk of elopement through pre-admission and/or admission process and as needed. Each SNF location would put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. The past-noncompliance immediate jeopardy began on 7/18/25, and was removed on 7/19/25, when the facility implemented a systemic plan to ensure all residents were safe. The following actions were implemented prior on 7/19/25; R2 had a wanderguard immediately placed on his wrist when he returned; all residents were re-assessed for elopement risk; all door access points and exit doors were checked for functionality; implemented 15-minute checks on all residents at risk for elopement until the door access points were fully functional on 7/21/25; re-education all nursing staff on wanderguard policies and procedures to include step-by-step instructions for placement and set-up; all elopement risks photos were update and distributed throughout the facility; and missing person drills were conducted.

Based on record review, staff interviews, and policy review, the facility failed to ensure that medications were accurately identified and dispensed upon discharge, resulting in one resident (R214) being sent home with another resident's (R221) medications. This failure led to R214 ingesting medications not prescribed to her. This resulted in actual harm when R214 required emergency medical intervention and hospitalization due to hypotension (low blood pressure). Findings include: R214's discharge Minimum Data Set (MDS) dated [DATE], indicated R214 had intact cognition, and had diagnoses of hypertension (high blood pressure), atrial fibrillation (irregular heartbeat that originates in the heart's upper chambers), anemia (low red blood cells) and depression. R214 was admitted to the transitional care unit (TCU) for rehab, on 3/14/25, following hospitalization with a primary diagnosis of hypertension with shortness of breath. R214's Discharge or Therapeutic Leave Medication List assessment dated [DATE], lacked a verified of medication reconciliation. Assessment identified the form of education that was provided to resident at time of discharge was paper handouts with no verbal education indicated. Hospital records dated 3/31/25, confirmed R214 had fallen four times in the last four days with one fall causing acute facial trauma which required sutures. Records also indicated R214 was experiencing orthostatic hypotension (drop in blood pressure with change in position) that was likely contributing to her falls. R214 was readmitted to the facility's TCU for rehab, on 4/4/25, following hospitalization from 3/31/25 to 4/4/25 with a primary diagnosis of orthostatic hypotension. R214's Discharge summary, dated [DATE], lacked verification of medication reconciliation and listing of current medications. Clinic visit note, dated 4/22/25, indicated orthostatic hypotension, [R214's] blood pressure readings have remained soft, with a recent measurement of 102/76. It was discovered that she was mistakenly given another patient's medication upon TCU discharge [3/27/25], including lisinopril 20 mg, which is a blood pressure-lowering agent. This error may have contributed to her second hospitalization [3/31/25-4/4/25] (med pack of lisinopril she was taking was dated late February) and may have contributed to her falls. She has been advised to discontinue the use of lisinopril immediately. A follow-up with Good Samaritan will be conducted to address this medication error. Blood work will be ordered today to monitor her kidney function and potassium levels. R221's electronic medication record (EMR) indicated R221 prescribed Lisinopril was not available from 3/29/25 to 4/2/25. During interview on 5/20/25 at 12:13 p.m., registered nurse (RN)-D from R214's primary care provider's office stated R214 came to clinic for a follow up appointment and brought all her medications with her for the provider to review. R214 stated she was taking all medications that she brought with her. RN-D stated there were two medications (Lisinopril and Atorvastatin) with R221's name on them. These medications were kept and destroyed in the clinic. RN-D stated R214 reported a couple incidents of being dizzy and falling at home since second discharge from the facility. RN-D stated R214 ingested approximately 11 doses of incorrect medications at home, resulting in low blood pressure that led to R214 falling four times in four days while at home, prompting an emergency department visit on 3/31/25 and hospitalization. During interview on 5/27/25 at 11:26 a.m., FM-B stated medications which did not belong to R214 were sent with her after being discharged on 3/27/25 with one medication that lowered blood pressure. FM-B stated R214 thought the other resident's name on the label of medications was the name of the ordering provider and did not think anything of it and assumed she was supposed to take the medications as they were sent home with her. FM-B stated R214 had intact cognition with no memory concerns. FM-B confirmed R214 had taken the incorrect medication that was sent home by facility after the first discharge and also after the second discharge. During interview on 5/27/25 at 11:37 a.m., RN-A stated the nurse manager (NM) obtained orders from the provider for discharge. NM then put together information in a discharge folder with information regarding other services to be provided in the home if applicable. RN-A stated the discharging nurse would notify the resident of any upcoming appointments which was also included in their discharge folder. Any medications in the facility, belonging to the resident, were sent with the resident and a fax was sent to the resident's preferred pharmacy with a seven-day order for all medications. RN-A stated the list of medications was placed in discharge folder. During interview on 5/27/25 at 11:42 a.m., RN-E stated R214's clinic called and informed her R214 had brought medications into her clinic appointment that were not prescribed to R214. RN-E stated medications were prescribed for R221. RN-E believed the medications were sent with R214 during discharge on [DATE]. RN-E notified the nurse manager immediately. RN-E stated when a resident discharged from the facility, she followed the facility's discharge checklists and sent all ordered medications with the resident. Attempts to contact R214 were unsuccessful. During interview on 5/27/25 at 3:46 p.m., RN-A stated she would expect the discharging nurse to go through each and every medication and ensure each medication was prescribed for the correct patient and was the correct medication and reviewed with the resident at time of discharge. RN-A stated the discharge medication list was placed in the discharge folder with the current medications and the last time medications was taken. During interview on 5/27/25 at 5:59 p.m., medical director (MD) stated she was not made aware of this situation. MD stated she would expect that each medication is reviewed with the current medication orders and also reviewed with the resident at the time of discharge and the medication list should be printed for the resident. MD stated medications are sent home with the resident at the time of discharge. The facility Discharge and Transfer policy, dated 3/28/25, indicated the charge nurse or designated individual will: a. Complete a progress note - discharge b. Obtain an order from the physician for discharge to home with medications. c. Complete the Discharge or Therapeutic Leave Medication List UDA. d. Complete Miscellaneous Information section of the admission Record. e. Complete and review any relevant portions of the PN - Teaching - Resident/Family. f. Complete the Discharge Summary.

Based on interview and document review the facility failed to assure that 1 of 3 residents (R213) reviewed for pressure ulcers received care and services to prevent occurrence of newly developed pressure ulcer. This failure resulted in actual harm to R213 when the facility failed to follow R213's care plan resulting in the development of a deep tissue injury (a type of pressure injury where the underlying tissue is damaged, but the skin may appear intact. It's characterized by a localized discoloration, often purple or maroon, and may have a blood-filled blister. deep tissue injury can develop into a larger, open wound, but it's initially a localized injury). Although noncompliance was present at the time of the event, the facility implemented appropriate corrective action prior to the survey resulting in a finding of past-noncompliance for R213. Findings include: A Facility Reported Incident (FRI) was submitted to the State Agency (SA) on 5/4/25 at 12:12 p.m., (approximately 12 hours after facility staff discovered incident occurred) which identified R213 had been placed on a bedpan by nursing assistant (NA)-C at about 1:30 p.m. on 5/3/25. NA-C failed to return to R213 and did not report to NA-D that R213 was on the bedpan at change of shift. NA-D reported she had asked R213 how she was doing, brought R213 food and fluids and repositioned in bed, however, NA-D failed to check/change R213 during her shift. At about 12:00 a.m. on 5/4/25, registered nurse (RN)-C checked R213 for toileting needs, found R213 still had bedpan underneath her. R213 developed a deep tissue injury due to the bedpan being in place for eleven and a half hours. R213's admission Minimum Data Set (MDS) dated [DATE], identified R213 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADL's). Diagnoses included depression, anxiety, radiation sickness, lung cancer, breast cancer, thyrotoxicosis (a condition where there is too much thyroid hormone in the body), muscle weakness, metabolic encephalopathy (a condition where a change in brain function, like confusion or decreased consciousness, is caused by an underlying metabolic or chemical imbalance in the body), diabetes and acute kidney failure. R213's care plan revised 5/4/25, indicated R213 had potential to develop pressure sores related to impaired mobility and incontinence with an intervention instructing staff to reposition R213 from side to side when in bed every two to three hours and as needed (PRN). The care plan also indicated R213 had an ADL self-care deficit related to weakness, recent bladder infection (UTI), recent cancer treatment and need for staff assistance with all ADL's. ALD interventions included bed-mobility assistance of two staff with positioning up in bed and turning from side to side, toileting assistance of one to two staff with sit to stand lift, large harness to use toilet, resident incontinent or urine and directed staff to anticipate toileting needs/check/change/toilet R213 PRN. Resident Kardex dated 5/6/25, indicated R213 required assistance of one to two staff to turn and repositioning side to side when in bed every two to three hours and PRN. R123 required assistance of one to two staff with standing lift, used large harness when toileted. Resident was incontinent or urine, wore large briefs. Staff were directed to check/change/toilet R213 PRN. Staff were directed to anticipate toileting needs. A facility wound assessment dated [DATE] at 12:54 p.m., indicated R213 had a suspected deep tissue injury to buttock. Area described as red in color, warm to the touch, and was non-blanchable (discoloration or redness that does not fade or turn white when pressed). A facility wound data collection assessment dated [DATE] at 2:47 p.m., identified R213 had an area on left lower lateral (outer) buttock that measured 1.25 centimeters (cm) by 0.6 cm was red, warm and inflamed. On left upper lateral buttock there was an area measured as 0.8 cm by 0.4 cm was red and warm to touch. On left upper medial (closer to center) buttock deep tissue injury measured at 1.5 cm by 1 cm red and warm to the touch. On right buttock a vertical deep tissue injury measured 24 cm by 2 cm that was non-blanchable red and purple in color, warm to touch with induration (hardening or thickening of the skin). Left buttock had vertical deep tissue injury measured at 26 cm by 4 cm, area was non-blanchable red and purple in color, was warm to the touch, with induration of skin. Progress note dated 5/4/25 at 7:42 p.m., indicated R213 was sent to the hospital due to change in mental status, was not alert and was very lethargic (sluggish, lack energy, drowsy, and decreased mental status). Hospital note dated 5/5/25, wound assessment indicated R213 appeared to have been left on a bedpan or similar device. The deep tissue pressure injury evolved into a stage two pressure injury (partial-thickness skin loss with the epidermis (top layer) and dermis (underneath layer) affected) in 3 areas. Deep tissue pressure injuries can continue to progress even when the pressure is relieved as the damage is already done. induration noted on both sides of injury. On 5/12/25, deep tissue injury was purple, top left area developed eschar (layer of dead tissue typically black in color.) When interviewed on 5/22/2025 at 2:10 p.m., NA-D stated had worked with R213 one other time two weeks prior, at that time R213 was fully responsive and communicated her needs. NA-D stated she had assumed R213 would utilize her call light and express her needs independently. NA-D stated they had not been informed there were any changes in R213's status, R213 had not communicated any needs when NA-D was in the room nor did R213 inform staff she was on the bedpan. When interviewed on 5/27/25 at 10:05 a.m., nurse manager (RN)-A stated she had been in the building morning of 5/4/25, had been informed by RN-C of the incident, went to R213 observed stage one pressure sore (the initial stage of skin breakdown caused by prolonged pressure on a specific area of the body) on R213's buttocks in the outline of the bedpan. RN-A stated had expected the area would progress to a deep tissue injury. RN-A stated R213 used the bed pan or was incontinent, refused to get out of bed to use the bathroom. RN-A reviewed R213's care plan, verified R213's care plan did not identify R213 used the bed pan, care plan stated R213 was incontinent of urine, wore a brief, staff were directed to check and change R213. RN-A stated did not appear R213 was aware there was a bed pan under her buttocks, R213 had not been herself on 5/3/25, was more fatigued. RN-A had spoken with the involved staff, NA-D had not seen a bed pan under R213, NA-C had fastened brief in place with the bedpan inside the brief. Although the facility failed to ensure R213 received care and services to prevent newly developed pressure ulcers, the facility had immediately assessed R213's skin, and the two NA's were suspended from work. The facility assessed other residents in the facility who used a bedpan or other alternative toileting devices and/or required assistance by staff to be turned and repositioned in bed, the facility completed audits for those identified residents. The facility gave corrective action to NA-C and NA-D, the facility educated nursing staff on what ADL's included, how to read and understand a resident care plan/kardex, how provided cares were documented, how incorrect documentation was avoided, and what neglect of a resident included. The facilities corrective action was verified during the onsite survey on 5/27/25, as having been implemented as of 5/6/25, therefore this deficiency is being cited as Past Non-compliance.

Based on observation, interview and document review, the facility failed to follow requirements to ensure safe use of a bed rail assist device resulting in a resident's neck becoming wedged between the assist bar and mattress while the rest of his body slid off the bed onto the floor preventing his ability to breathe for 1 of 4 residents (R1) reviewed for entrapment risk. This resulted in an immediate jeopardy (IJ) for R1. In addition, the facility failed to reduce the risk of bedrail entrapment when they did not attempt to use alternatives, ensure correct installation and maintenance, review risks and benefits, ensure bed dimensions were appropriate, and follow the manufacturers instructions resulting in the potential for harm for 57 of the 68 residents who utilized a bedrail assist bar for mobility. The immediate jeopardy began on 6/14/23, when R1 was found by family to have fallen off his bed with his neck and shoulder caught between the mattress and the assist bar while his bottom was on the floor. As a result R1 was having difficulty breathing. The IJ was identified on 6/27/23. The administrator, director of nursing (DON), regional clinical services director, administrator and senior director, and vice president of operations were notified of the immediate jeopardy at 5:49 p.m. on 6/27/23. The immediate jeopardy was removed on 6/28/23, but noncompliance remained at the lower scope and severity of a D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Food and Drug Administration (FDA) guidelines (Recommendations for Health Care Providers about Bed Rails) updated 2/27/23, provides the following guidance: Any decision regarding adult portable bed rail use or removal should be made based on the individual patient or resident assessments. If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. To learn more about the patient or resident assessment, see the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities and Home Care Settings. Before you install bed rails: Make sure the individual is an appropriate candidate for bed rails. Bed rails should not be used as a substitute for proper monitoring, especially for people at high risk for entrapment such as those with cognitive impairment. Follow the recommendations in the ASTM F3186-17: Standard Specification for Adult Portable Bed Rails and Related Products for home care facilities and long term care facilities. Only use bed rails that conform with ASTM F3186-17. Follow the recommendations in the FDA guidance Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for health care facilities and the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities and Home Care Settings. Be aware that not all bed rails, mattresses, and bed frames are interchangeable and not all bed rails fit all beds. Check with each manufacturer to make sure the bed rails, mattress, and bed frame are compatible, because most bed rails and mattresses are purchased separately from the bed frame. Bed rails should be selected and placed to discourage climbing over rails to get in and out of bed, which could lead to injury or death from falls. Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails The FDA guidelines (Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment 2006, pp. 10-24) identified key body parts at risk for life-threatening entrapment the head, neck, and chest in the seven zones of a hospital bed system, focusing on the most common zones for risk of entrapment zones 1-4. Zone 1 - within the rail is any open space with the perimeter of the rail. Recommended space be less than 4 3/4 inches representing head breadth. Zone 2 - under the rail, between the rail supports or next to a single rail support. This space is the gap under the rail between a mattress compressed by the weight of a patient's head and the bottom edge of the rail at the location between the rail supports or next to a single rail support. Recommended space limit for entrapment in this space is less than 4 3/4 inches. Zone 3 - between the rail and the mattress. The space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment. Recommended space between the area between the inside surface of the rail and compressed mattress should be of less than 4 3/4 inches. Zone 4 - under the rail at the ends of the rail. This space poses a risk for entrapment of a patient's neck. In this space, a gap forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of the rail. Recommended dimension for this zone measure both less than 60 mm in size and greater than 60 degrees in angle. Zone 5, 6, and 7 are identified as potential for entrapment with the least reporting. Zone 5 is the area between the split of bedrails, zone 6 is the between the end of rail and the side edge of the head or footboard, and zone 7 is between the head of footboard at the end of the mattress. Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. (2006). Retrieved from https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM072729.pdf During observation on 6/22/23 at 2:45 p.m., the facility assist bar was in the shape of a walking cane. The top part of the cane measured six inches before bending downward at an angle creating a 7-inch curved C shaped open space. Per the FDA, Zone 1 should measure 4 3/4 inches or less. The top of the assist bar measured 14 inches above the bed frame and 23 1/2 inches from the floor. During observation and interview on 6/27/23 at 12:32 pm., the DON and administrator demonstrated how R1 was found on 6/14/23. The DON stated he fell out of bed when his feet and the bolster slid off the foot of the bed pulling the rest of his body down to the floor. She added R1 had his back up against the side of the bed sitting on the bolster and floor. She stated R1's head was between the mattress and assist bar and she was able to untangle him. She added his neck was not entrapped by the assist bar, and she did not view the incident as an entrapment. When asked for a copy of her interviews with the staff involved during the incident, the DON stated she was sure she documented the interviews and would have to find them. R1's Admission Record indicated R1 admitted to the facility on [DATE] with multiple diagnosis including cerebral arthrosclerosis, dementia, heart disease, dysphagia, anxiety, and adult failure to thrive. R1 was receiving hospice care. R1's MD Orders dated 3/20/23, identified an order for alternating pressure mattress (APM) to prevent pressure ulcers, and an assist device to aid with bed mobility. R1's Physical Device and/or Restraint Evaluation and Review form dated 3/21/23 indicated it was recommended/reviewed the device of an assist/grab bar for R1 for participation in bed mobility and identified the potential resident safety risks were evaluated and reviewed with R1 to include potential entrapment, accident hazards, potential negative outcomes, a Federal Drug Administration (FDA) brochure and policy packet, and R1 had cognitive learning barriers related to the educational material provided but was able to verbalize understanding. The box for family or other individuals who received education was not checked. The boxes for alternatives that have been attempted before the use of assist/grab bars were not checked. The boxes for care planning the use of physical devices were not checked. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, anxiety, and received hospice care for a terminal disease. In addition, he required extensive assistance from two nursing staff for bed mobility. R1's progress note dated 6/14/23, indicated R1 fell off his bed at 4:16 p.m. when his family member (FM)-A yelled from R1's room, Help he is choking. R1 was found in a seated position on the floor facing the right where his neck and shoulder was caught between the mattress and the assist bar. In addition, R1 was tangled up in his sheets. FM-A was holding onto his right shoulder when the nurse was able to reposition him away from the assist bar. R1's nurse practitioner (NP) notification text dated 6/14/23 at 5:42 p.m. from the DON stated R1 fell out of bed and his head was caught on the assist bar. She added, Could have been bad! R1's progress note dated 6/15/23 indicated an incident meeting from fall on 6/14/23. The facility incident description indicated R1 was found sitting on the floor next to the bed with his head on the bed and his neck on the bedrail, tangled in his bedding, and wife in the room kneeling beside him holding his right shoulder. Contributing factors indicated R1 had severe cognitive impairment, can be restless with attempts to get out of bed. The facility plan was to implement new fall interventions for a high/low bed, safety sided mattress, floor mat, and soft touch call light. R1's NP-A visit dated 6/16/23, identified R1 was seen for an acute follow up related to neck pain. The note indicated R1 suffered a fall a couple days earlier out of his bed, where his head remained on the bed by the assist bar and his bottom was on the floor. R1 was confused and pointed towards his neck while appearing to be in pain. An order was placed for an ice pack four times a day to his neck and morphine 2.5 milligrams (mg) every hour as needed for pain and shortness of breath. R1's Physical Device and/or Restraint Evaluation and Review form dated 6/16/23 indicated R1's use of an assist/grab bar and bolsters cushion be discontinued for use because R1 did not use the grab bars for mobility and his head was hung up on the grab bar. There was no injury but a risk for injury. In addition, the air mattress with the bolsters cushions was also discounted due the R1's risk to slid off. The recommendation was for R1 to have a concave mattress to prevent him from sliding out of bed, a high/low bed to prevent injuries from falls out of bed. The concave mattress and high/low bed with its risk and benefits was reviewed with R1's representatives with no barriers to learning. The boxes of care planning were initiated. Email correspondence dated 6/26/23 at 11:31 a.m. with Hill-Rom representative (R)-A included Hill-Rom Siderail, Assist Bar, and Headrail Upgrade Kits Operation & Maintenance Manual dated 1/04 indicated new upgrades available to the bed assist devices in response to changing needs in health care. In addition, a Warning alert for owners to keep this manual with their existing service manual listing failure to do so could result in patient injury. Email correspondence dated 6/26/23 at 5:05 p.m. Hill-Rom technician (T)-A included Resident LTC Bed Brochure dated 12/6/17, indicated the special options available for this bed. The assist bar used at the facility was shown on the brochure installed at the foot of the bed and the open C space faced the foot of the bed. During interview on 6/22/23 at 1:16 pm. FM-A stated she found her husband sitting on the floor next to his bed, and his head was caught on the assist bar. She added he was a big guy, and she was unable to pull his neck away from the bar so he could breathe. She ran into the hall yelling, Help, help he is choking. She stated R1 was unable to communicate, and he was frightened. She added R1 was very restless and always trying to get out of bed or his wheelchair prior to his admission to the facility. She was afraid he would fall out of bed and told the facility staff about her concern when he was admitted to the facility. Now the facility provided a high-low bed capable of lowering to a few inches off the floor. In addition, the facility placed a thick fall mat next to the bed to catch him if he fell out of bed again. During interview on 6/26/23 at 9:05 a.m. the administrator stated the only bed operation and maintenance manual they could find was the Resident LTC Bed Service Manual for P870 model from Hill-ROM. The manual was originally issued on 12/1/1996. She stated the manual did not include the assist bars operator instructions or maintenance requirements for use. During interview on 6/26/23 at 11:11 a.m. Hill-Rom representative (R)-A stated the assist bars open C space should face the foot of the bed to prevent an entrapment. He said the facility would have installed the assist bars and must have placed them incorrectly facing the front of the bed. He added the facility could remove the assist bars and place them on the opposite side. During interview on 6/26/23, at 1:00 p.m. facility maintenance (M)-A stated the facility beds were the Resident LTC Bed from Hill-Rom model number P970, showing R1's bed now located at the facility garage. The assist bars were attached to the bed frame. The assist bar was capable of locking in the up position for use or stored in a locked position along the bed frame when not in use. He stated the assist bar came with the bed, and it was welded in place to be the frame preventing it from being switched to the other side of the bed so the open C area would face the foot of the bed. M-A confirmed he annually inspected each bed at the facility by shaking the bed to identify loose bolts and looking for frayed cords. During interview on 6/26/23, at 1:17 p.m. with M-A, R-A and the administrator, R-A said the assist bars were an accessory to the bed and would not have come installed. The facility must have installed the bars on the wrong side of the bed. He said all they would have to do was remove two bolts to remove and reinstall them on the other side of the bed. He reiterated the assist bars C space open must face the foot of the bed for safety. During interview on 6/26/23 at 3:00 p.m. the physical therapist (PT)-A stated one of his responsibilities included an assist bar evaluation for all the facility's residents upon admission, and after a change in condition. PT-A stated the assist bar is shaped like a cane, and the opening facing the head of the bed could be a potential risk for entrapment. PT-A stated prior to R1's falling out of bed he did not see the risk but now he could. PT-A stated he had no formal training on different assist devices for a nursing home bed, I just make sure it's on the bed appropriately and make sure the resident can use it. During interview on 6/26/23 at 3:35 p.m. the director of nursing (DON) stated what happened to R1 on 6/14/23, was not a case of entrapment because his neck was not caught in the assist bar's C shaped opening, and he was never choking. In addition, the shape and position of the assist bar did not pose a risk to any of their residents. She had worked at the facility for [AGE] years, and the assist bars on the beds had not changed. On 6/14/23, after R1's fall she arrived at the incident and found him sitting on the floor. She completed a head-to-toe skin evaluation and did not find any bruising or redness. She stated even though she did not feel there was an entrapment risk, she switched R1's bed to a high low bed because she did not want it to happen again. During interview on 6/26/23 at 5:00 p.m. Hill-Rom T-A stated the bed was manufactured with four side rails. As the bed became popular for nursing home use, the assist bar was developed for use. Later, after FDA regulations and changing guidance the original assist bar had too big of an opening and the company developed a conversation kit to eliminate the spacing created by the device. During interview on 6/27/23 at 2:01 p.m. administrator and senior director (SD)-A stated she spoke with T-B at Hill-Rom who told her the assist bars could face in any direction. During interview on 6/27/23 at 2:33 p.m. the DON confirmed R1's Physical Device and/or Restraint Evaluation and Review dated 3/21/23, did not include the requirements to try alternative approaches before using an assist bar, complete a risk verse benefits assessment and because R1 had severe cognitive impairment he was unable to give informed consent. In addition, she stated the nursing staff failed to update R1's bed mobility limitations and he was approved to use an assist bar in his care plan. R1's family did not receive the required Federal Drug Administration (FDA) brochure and policy resource packet. She stated after the 6/14/23 fall, she exchanged R1's bed with low-high bed and a fall mat next to his bed to prevent R1 from being trapped and choked again. She added after a fall the facility holds an incident meeting, fall review to determine the cause of the fall and any new practice to prevent future falls. She stated the incident meeting and fall review was held for the 6/11/23 fall but not for the 6/14/23 fall because they did not have time to do so. During interview on 6/27/23 at 4:42 p.m. spoke with Hill-Rom T-B regarding his conversation with SD-A. He stated he did not tell SD-A the assist bars could face in any direction. He said during the conversation he told her several times there was a left and a right assist bar and when placed correctly on the bed the open C space would face towards the foot of the bed. He even showed them the Resident LTC Bed Brochure picture of an assist bar facing the foot of the bed. T-B was unable to find the part number P00070848 for the assist bar listed in the Hill-Rom Siderail, Assist Bar, and Headrail Upgrade Kits Operation & Maintenance Manual because it was now obsolete. During interview on 6/28/23 at 9:07 a.m. NP-A stated she was contacted by someone at the facility regarding R1's fall on 6/14/23. She was told he did not suffer any injury, but she was unable to visualize how it happened. She asked the staff to describe how his neck was caught on the assist bar, but the staff told her at that time he did not get his neck caught on the assist bar, but it could have. She was updated on 6/16/23 after R1 was showing signs of neck pain. She assessed him at that time and did not find any deficit while he performed different range of motion exercises. She questioned why he would need an assist bar since he was an extensive assistance with two staff for bed mobility. During interview on 6/28/23 at 9:40 a.m. RN-B stated on 6/14/23, she found R1 sitting on the floor and leaning to the right towards the assist bar with his right shoulder tucked between the assist bar and the mattress. R1's neck was lodged in the C shape space causing his skin to turn blue and slow down his ability to breathe normally. His wife was trying to push him up so he could breathe. She said R1 was a large man, and his body weight made it difficult to reposition his neck and right shoulder away from the assist bar. R1 was incontinent of urine at the time and had a history of trying to climb out of bed. During interview on 6/28/23 at 11:00 a.m. SD-A stated all of the assist bars were removed from all the beds and reinstalled on the appropriate side to face the foot of the bed. During group interview on 6/28/23 at 12:29 p.m. with the administrator, DON, SD-A, and the regional clinical director (CD)-A call was placed to discuss the assist bars with a Hill-Rom technician and obtain the required maintenance and service manual for the assist bar. T-B stated Hill-Rom no longer had any maintenance and service manuals for their assist bar. In addition, the up-grade assist bar information is now obsolete. He was unable to tell when or why it became obsolete. SD-A stated she called Hill-Rom the day before and they told her they could be installed either way. Informed SD-A, T-B was interviewed and he denied telling the facility the assist bars could be installed in any direction. The facility policy Bed Safety Including: Bed Rails, Side Rails, Assist Bars-Rehab/Skilled, Therapy & Rehab dated 9/6/22 identified an entrapment would be any event involving a resident being caught, trapped, or entangled in the space between the bed and the bar. Review alternative devices before installing an assist bar. Only suitable residents who can grab the assist bar independently or with nursing staff and used for bed mobility would receive one. In addition, a risk verse benefit assessment would be reviewed with the resident or family along with a signed consent. The immediate jeopardy that began on 6/14/23, was removed on 6/28/23, when the facility removal plan was verified by observation, interview, and record review. Noncompliance remained at a lower scope and severity level of 2, D-isolated because the facility needs to document steps taken for substantial compliance. -The facility reviewed its policy titled Bed Safety including Bed Rails, Side Rails, Assist Bars-Rehab/Skilled, Therapy & Rehab and found it current. -A system was initiated for bed inspections following the policy title Bed Safety. -Educated all licensed nurses on assessing the use of assist/grab bar device. -All 57 resident currently using assist/grab bars were reassessed based on the on the assessment criteria, which when appropriate the grab bars were removed from resident use and/or applied according to manufacturing instruction. -Resident care plans were updated to reflect the use of assist/grab bar device.

Based on interview and document review, the facility failed to follow the manufacturer's guidelines and provide the required maintenance on mechanical lifts resulting in harm to 1 of 1 resident (R1) reviewed for accidents. R1 had been assessed to transfer with an assistance of one staff and a sit to stand lift. R1 sustained actual harm during a transfer using the sit to stand lift when the lift broke and R1 fell on the ground. R1 sustained a cervical fracture (broken neck) as a result of the fall. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action by 5/8/20, resulting in a finding of past noncompliance harm for R1. Findings: R1's face sheet dated 5/14/20, indicated R1 had [DIAGNOSES REDACTED]. R1's quarterly minimum data set ((MDS) dated [DATE], indicated R1 had moderate cognitive impairment. R1's sit-stand-walk collection tool dated 3/2/20, identified R1 required a sit to stand lift with assistance of one staff with transfers. Record review of the EZ Way lift service manual dated 10/3/13, indicated checking the mounting bolts of the [MEDICATION NAME] (the part that moves on the lift) top and bottom, paying particular attention to top bolt hole for elongation. It further indicated the manufacturer suggested these components should be scheduled for inspection at intervals not greater than one month. R1's progress note dated 5/6/20, identified that R1 was being transferred with EZ Way lift when the sit to stand lift broke which resulted in R1 falling. As a result of the fall, a progress note dated 5/7/20, identified R1 sustained a cervical fracture (broken neck). On 5/14/20, at 8:58 a.m. during an interview with the environmental services director (ESD), the ESD indicated the part of the lift that broke was called the [MEDICATION NAME] pole. ESD explained that maintenance staff complete a monthly inspection on the lifts and the service manual mentions routine maintenance on that specific part. On 5/14/20, at 10:33 a.m. the environmental services director said the facility purchased all new lifts because upon inspection (following the incident on 5/6/20) they found 10 of the 12 lifts to have had wear at the [MEDICATION NAME]. On 5/14/20, at 10:39 a.m. the maintenance technician (MT)-B demonstrated an inspection on the EZ Way lift and pointed to all the parts that were inspected each month. MT-B did not indicate that he inspected the [MEDICATION NAME]. MT-B stated prior to the incident that took place, I had not been checking the [MEDICATION NAME] and had never been taught to do so. Although the facility failed to follow the manufacturer's guidelines and provide appropriate maintenance on the sit to stand lifts on 5/6/20, the facility was able to verify corrective action had occurred, including removing all sit to stand lifts from the floor on 5/6/20, purchasing new lifts on 5/8/20, and retraining maintenance staff on 4/7/20. The facility completed an investigation timely, and the interdisciplinary team had reviewed the incident which the team identified as isolated. The corrective action was verified as completed 5/8/20, during the onsite survey 5/14/20. Therefore, this deficient practice is being cited at Past Noncompliance.

Based on observation, interviews and document review, the facility failed to complete a comprehensive bladder assessment for 1 of 2 residents (R1) admitted with an indwelling Foley catheter and failed to ensure medical necessity for the continued use of an indwelling Foley catheter. This practice resulted in actual harm to R1 who displayed complications of bleeding from head of penis, leakage and penile swelling resulting in a partial circumcision. Further R1 had multiple visits to the emergency department and multiple [DIAGNOSES REDACTED]. Findings include: R1's 14 day Minimum Data Set assessment dated [DATE], indicated he was severely cognitively impaired and required extensive assistance from two staff for bed mobility, transfers and toileting. The MDS indicated R1 had an indwelling Foley catheter and was occasionally incontinent of bowel. R1's care plan dated 7/30/19, identified the use of an indwelling Foley catheter and directed staff to monitor /record/report to health care provider signs and symptoms of UTI, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine in color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills and altered mental status. The care plan further directed catheter care every shift, good perineal cares- especially penis and foreskin cares every shift and as needed, and to report unusual observations/conditions to the nurse. Recent catheter trauma, foreskin care. Review of R1's hospital Interagency Transfer Form - Notes dated 7/13/19, [MEDICAL CONDITION] due to bacteremia. The notes indicated [MEDICAL CONDITION] potentially contributing to [MEDICAL CONDITION]. Review of facility Progress Notes, hospital notes and clinic visit notes indicated the following: 7/16/19, R1 was hospitalized due to confusion and [MEDICAL CONDITION] had an indwelling Foley catheter in place. No skin issues except a skin tear on his back. 7/26/19, A lump was discovered on the underside of R1's penis. Staff continue to monitor. 7/30/19, Lump on penis is small and small amount of firmness to lump. 7/30/10, R1's daughter stated his water pill made his condition decline because he wouldn't eat or drink due to concern of going to the bathroom and the catheter had lessened this worry for him and helped him to sleep at night. 8/1/19, R1 found during the night pulling on his catheter. Catheter draining with some blood noted in urine. 8/2/19, R1's Foley catheter to be replaced in hopes of improving flow of fluids. 8/2/19, Catheter changed due to blood in urine. 8/3/19, R1 complained of pain in his penis, possibly due to pulling his catheter out on night shift. On 8/5/19, a clinic visit note indicated R1 indicated R1 was seen in the clinic by his physician for a follow up visit. The note indicated Has had a catheter placed at the request of family as well noting he has always been very upset about his inability to maintain continence and this was problem for him getting up repeatedly in the middle of the night. Family does understand the potential risk of complications including infection of this going forward. The note further indicated there had been discussion about the indwelling catheter which had resolved his anxiousness and increased urgency to urinate allowing him to participate more effectively in therapy, and there had been discussion associated with the increased risk of infection. The notes indicated the patient had verified awareness of these issues as well. The clinic note from the medical provider included, I discussed the possibility of transitioning to a condom catheter after a few weeks and using tamsulosin (a medication used to treat the symptoms of [MEDICAL CONDITIONS], enlarged prostate) prior to its discontinuation. 8/6/19, R1 currently with Foley catheter which family agreed to use due to previous incontinence and repeated attempts to get up to void. Physican stated R1 verbalized previous bladder infections and his concerns about it. 8/8/19, Facsimile was sent to clinic regarding R1's penile area. Staff documented an abnormal condition on underside of penis, where a lump was noted. 8/9/19, Lump on the underside of R1's penis increasing in size and now growing up the sides of the penis. 8/9/19, Writer looked at R1's penis and the foreskin was swollen and pulled away from the tip. Old catheter was removed and foreskin retracted somewhat and new catheter placed. Slight pain during treatment. 8/9/19, Note indicated, remove catheter, compress glands at tip of penis. (MONTH) take time but foreskin should then retract. (MONTH) send to emergency room (ER) if no improvement. 8/10/19, ER called with update, stated importance of fully retracting foreskin and cleansing area then be sure to pull back over. Also stated some skin tearing. Noted R1 was sent to ER after physican order, attempted to loosen foreskin first. This was accomplished previous evening, then worsened in the morning so was sent to ER. 8/10/19, R1 Pariphimosis (condition in which foreskin has retracted and cannot be returned to original condition) persisting. Foreskin pulled over per physican order last night, returned today. 8/10/19, R1 returned from ER, wife stated the swollen foreskin was due to not being pulled back after cleaning. Writer spoke to wife about R1 pulling on his catheter but wife stated that was not what caused it. Emergency Department (ED) note: On 8/10/19, R1 had [DIAGNOSES REDACTED]. R1 had a Foley catheter in place that was changed yesterday. Since then foreskin has been retracted and swelling. R1 came to the ED for penile swelling and discomfort. Foreskin was reduced back over the glans, however had difficulty maintaining a reduced position due to swelling. Ice pack placed with scrotal elevation. Physician spent quite a bit of time applying pressure to reduce [MEDICAL CONDITION] and was getting some success. But the physician was noticing the glans penis would still protrude and the problem did not completely go away. There was no urinary difficult at baseline. Discharge instructions were return if worse or new symptoms - especially increased swelling or pain of the penis or foreskin. It is extremely important to fully reduce the foreskin when it is retracted for hygiene cares. It is ok to put some topical [MEDICATION NAME] ointment on abraded areas of the foreskin as it heals. Foreskin was reduced back over the glans, however had difficulty maintain a reduced position due to swelling. Ice pack placed with scrotal elevation. ED note 8/11/19. R1 was seen in the ED for Pariphimosis and UTI. R1 was just seen 24 hours ago with Pariphimosis. R1 came back for recurrent Pariphimosis. A daughter noted that she had been checking on R1 throughout the evening and at 8 PM she noted that the foreskin was again retracted and stuck around the base of the glans. R1 denied pain, however over the last several hours the daughter noted some purulent discharge the indwelling Foley catheter at the meatus as well as inside the tube of the catheter bag. The physican attempted manual reduction of the Pariphimosis without success. A urology consulted and he would perform a dorsal slit. The urologist came in to see the resident and performed a dorsal slit. The urologist noted that the urethral discharge was normal especially with recent manipulation due to Pariphimosis reduction about 24 hours ago. The urologist recommended that R1 be [MEDICATION NAME] with Keflex to prevent skin infection related to dorsal slit, keep wound clean and dry. Apply [MEDICATION NAME] to wound 2 times a day and change dressing as needed. The urine analysis with greater than 200 white blood cells, 8-30 red blood cells, packed bacteria, and positive [MEDICATION NAME]. Concerning for UTI, but may also be due to colonization with chronic indwelling Foley. A urine culture was pending. Placed on [MEDICATION NAME] tablets 250 mg (milligrams) one tab by mouth twice a day for 7 days. 8/12/19, Circumcision site care completed per orders with intact sutures. Catheter intact and draining within normal limits. 8/13/19, Family concerned R1 was going to pull out his catheter and wanted it removed. Family planing to speak to nurse practitioner (NP). On 8/14/19, a clinic visit noted indicated R1 was seen in the clinic by his NP for follow up on circumcision as well as to address other family concerns. Last week resident developed Pariphimosis after multiple attempts to put foreskin back he ended up requiring dorsal slit. 8/14/19, R1's incision cleaned and [MEDICATION NAME] applied per order, mild swelling noted. Received new order for [MEDICATION NAME] and start [MEDICATION NAME]. On 8/19/19, clinic visit note indicated R1 had a follow up appointment with his physician in the clinic. R1 had a UTI and subsequently a staph infection in the urine and was switched to a different antibiotic. 8/19/19, Family reported concern about distended appearance of resident bladder. When leg bag was switched over to the night bag, urine started flowing consistently and writer scanned resident's bladder and found at most 49 milliliters (ml) of urine residual. 8/23/19, Writer washed R1's peri-area with warm soapy water and assessed. Writer applied [MEDICATION NAME] where sutures were. Writer noted scant amount of green discharge on residnet penis and brief. Writer noted some leaking of urine around Foley, checked all tubing and tightened. Passed on to the evening nurse to monitor for urine leaking around catheter, if so it may need to be replaced with a new one. 8/23/19, Family called wanting to check and see if catheter started flowing normally again, or what other interventions were required. Family continued to talk about how she was concerned staff needed to change it every two weeks instead of once a week. Writer encouraged family to keep it at once a month and try other options like flushing the catheter line to prevent sediment build up as a way to reduce chance of urinary tract infections. 8/23/19, R1 had episodes of agitation this evening on and off. Family was here most of the shift. At the beginning of the shift, family alerted writer to fact that catheter was leaking. On inspection urine was coming out of the tip of his penis around his catheter. R1 was also complaining of pain at the tip of his penis. Staff changed catheter and R1 tolerated catheter change ok but blood was coming out of the tip of his penis. R1 was very sensitive when tip was touched. Fluids were pushed this evening. Some small clots were seen in catheter tubing and urine was brown tinged. Once R1 started to increase fluids urine began to clear. Stitches were cleaned this evening. Some small clots were seen in cath tubing and urine was brown tinged. Once resident started to increase fluids, urine began to clear. Catheter appeared to be flowing without complications. Stitches were cleaned this evening and [MEDICATION NAME] applied. 8/24/19, R1 was restless in the beginning of the night shift, and after several attempts to have him fall asleep, Nursing assistants (NA) moved him to recliner. R1 got slightly combative and swung at N[NAME] Writer caught resident pulling at catheter through the shift and writer would tell him to stop and get his hands away from catheter. Around 5:00 a.m. NA came to tell writer that resident's brief had blood on it. Writer assessed R1's brief, catheter and penis. The on call physican said to put [MEDICATION NAME] on penis and to attempt to keep resident from pulling at catheter, and to monitor for clots in catheter. 8/24/19, R1's family member was very concerned about blood in urine. Family took resident to ER. Received call from ER that they will be admitting resident with [MEDICAL CONDITION] and ascites. 8/30/19, R1 was brought back from ER to facility by family via tunnel and escorted to his room via wheelchair. R1 was confused and was having hallucinations when writer was in room. R1 would take off his blanket and try to reach to ceiling to grab something. R1 had indwelling Foley catheter for comfort, per family. Resident urine is clear yellow and catheter was patent. R1 was being treated [MEDICATION NAME] possible UTI. 8/31/19, R1 had been tugging at his catheter and grabbing towards ceiling. 8/31/19, R1 confused and agitated, pulling at catheter, wringing hands. Resident was hallucinating, stated that the walls were on fire. 9/3/19, R1 required one on one supervision this shift. R1 was agitated and restless and continuously tried to get out of his geri (geriatric) chair. 9/4/19, Foley urine output was 1200 cc's (cubic centimeters). No expression of discomfort/pain observed. Penal swelling present, treatment done. 9/7/19, R1's incontinent pad was wet, catheter presumably bypassing, had 400 ml out at around 1:30 p.m. and was emptied prior at around 7:00 a.m. 9/8/19, R1's catheter was bypassing urine into pad, R1 continually pulled catheter. 9/9/19, R1 alert, confused during this shift, hallucinating (has been quite normal for his baseline) however, family was worried and wanted a urinalysis (UA) and urine culture (UC) done, order was given. The family transferred resident to the toilet and called this writer to inspect a new protrusion on his sacrum they had not seen before, it was about the size of a fist, no redness, warmth, or pain noted. This writer informed family she would update NP regarding this new lump. After family got him up from the toilet, they told writer they were going to ER to have it looked at. Resident's family took him to ER via tunnel at approximately 6:00 p.m. and R1 arrived back at facility around 8:00 p.m. with new orders for Cipro. 9/11/19, R1's Foley catheter was discontinued by the nurse practitioner and was successfully removed, 300 cc of clear, yellow urine was noted. R1 received penile care this shift as ordered, wound looks healed. 9/12/19, R1 voided well, had wet brief at 0000, 0200, and 0400 rounds. Post void residual (PVR): 0 ml. Multiple observations were made on 9/11/19, through 9/13/19 of R1 in the facility being attended by the family 24/7. R1 was able to feed himself during morning observations 9/12/19, without family present in the dining room. R1 was not able to coherently answer simple questions while eating. R1 had a Foley catheter that was draining amber urine. During morning observations on 9/12/19, a family member and NA had just finished showering R1. R1 was noted not to be in pain or restless. Registered Nurse (RN)- A was interviewed on 9/13/19, at 11:50 a.m and confirmed R1 was admitted from hospital on [DATE], with a blood infection, to second floor where she was the nurse manager. The nurse manager verified that the staff had not attempted to have the catheter assessed for medical necessity or potential removal. The NP was interviewed on 9/13/19 at 11:30 a.m., and confirmed that the multiple ER visits, partial circumcision, and UTIs may not have happened if the resident's Foley catheter had been appropriately assessed and removed. The NP further stated R1's family insisted on R1 having the catheter. In addition, the NP stated one of the resident's daughters had requested the Foley catheter remain in place when R1 went on hospice. The NP confirmed R1 lacked a medical [DIAGNOSES REDACTED]. The facility's Policy and Procedure for catheters, revised 1/18, included: A resident is not be be catheterized unless the clinical condition demonstrates that catheterization is necessary and is not to be used solely for nurse/physician convenience. Catheters will be inserted only with a physician's orders [REDACTED]. The SOM (State Operations Manual) F-Tag indicates that indwelling catheters must be medically necessary for the resident. The medical record must have documentation of attempts to remove indwelling catheters and the results of the attempts. It is recommended that removal be attempted at least two or three times during his/her stay before it can be determined that it is unsuccessful.

Based on observation, interview and record review, the facility failed to implement care plan interventions and operate equipment safely to minimize the risk of falls for 1 of 4 residents (R1) with a risk of falls. This resulted in actual harm when (R1) sustained a left hip fracture when being lowered to the floor from an EZ stand lift. Findings include: R1's medical record was reviewed. R1 had [DIAGNOSES REDACTED]. R1 was dependent on staff to assist with activities of daily living. The care plan interventions for toileting at the time of the incident were 2 assist with total lift and large sling to the commode or bed for use of the bed pan. The facility's incident report and internal investigation of the incident, dated [DATE], were reviewed. They indicated a nursing assistant failed to check R1's care plan/Kardex and on [DATE] transferred R1 to the commode using the EZ stand and the assist of one. R1's [DATE] toileting care plan revision stated the total lift and 2 staff should have been used with R1's transfer to the commode. Prior to the incident, the nursing assistant also asked a co-worker, who had not checked the care plan/Kardex, how to transfer R1 to the commode. The co-worker provided incorrect information which the nursing assistant followed related to the transfer. The nursing assistant transferred R1 from the wheelchair to standing position with the EZ stand, and R1 suddenly lost strength in her left leg, needed to sit down and began to slip out of the EZ stand. R1 was assisted to bed by three staff and a mechanical lift was used. R1 complained of left leg pain and the on-call physician was contacted, and x-rays were performed that revealed a hip fracture. R1 was transferred to the ER for further care per the on-call physician's orders [REDACTED]. The facility policy titled Safe Resident Handling Program dated [DATE], indicated a total lift (also referred to as a mechanical lift or full lift) is to be used with residents who cannot sit upright on the side of the bed, do not have weight-bearing ability on at least one leg and cannot pull themselves to a standing position requiring full weight-bearing support. R1's death certificate was reviewed. It indicated R1 expired at the hospital on [DATE]. The immediate cause of death was listed as complications of a left femur fracture that resulted from a [DATE] fall. When interviewed in person on [DATE], administrative nurse (B) stated nursing assistant (E) was responsible for R1's fall and resulting injury, and nursing assistant (E) admitted her error. Nursing assistant (E) failed to read R 1's Kardex prior to transferring R1. A full lift should have been used, and 2 staff should have assisted with R 1's transfer to the commode instead of one staff person. The Kardex clearly stated how R 1 was to be transferred. Nursing assistant (E) transferred R1 with the EZ stand in error and following the incorrect advice of nursing assistant (H) who also failed to check the Kardex related to R1's transfer. Both (E) and (H) had received appropriate training related to transfers and checking the Kardex prior to transferring a resident. Nursing assistant (E) was immediately disciplined and placed on administrative leave following the incident. Nursing assistant (E) returned to work on [DATE] and was provided re-education related to transfers and the need to review the Kardex prior to transfers. Nursing assistant (H) received a written warning and was provided re-education related to transfers and the need to review the Kardex prior to transfers. In addition, re-education related to transfers and review of the Kardex was provided to all direct care nursing staff following the [DATE] incident. Re-education, follow-up and monitoring of staff related to the incident will continue on an ongoing basis. When interviewed by phone on [DATE], LPN (F) stated she was working with R 1 on the day of the incident. She verified that R 1 required an assist of 2 with toileting due to her left side weakness related to a prior stroke. She was summoned to R1's room by (H) and discovered nursing assistant (E) on the floor and R1 was on top of (E). R1 said her left leg became weak, and (E) lowered her to the floor. She stated the facility has provided re-education to staff related to lifts, transfer and use of the Kardex. When interviewed by phone on [DATE], nursing assistant (E) stated she was working with R1 on [DATE]. She stated she had worked with R1 on prior occasions. The resident could not walk but could bear weight on her right leg. R1 asked to be put on the commode, and (E) asked nursing assistant (H) how to transfer R1. Nursing assistant (H) told her to use the EZ stand and said R1 was an assist of 1. Nursing assistant (E) did not check R1's care plan/Kardex and verify how R1 was to be transferred. During the transfer, R1 said she had to sit down, and (E) tried to put a chair under her but was unsuccessful. Nursing assistant (E) lowered R 1 to the floor, and in the process, R1 fell on top of (E). Nursing assistant (E) said she made a mistake and should have used a full lift and assist of 2 staff with R 1. R1 said her left leg hurt following her fall. After the incident, (E) checked the Kardex and noted the Kardex clearly stated how R 1 was to be transferred and the number of staff needed to assist with the transfer. Nursing assistant (E) was provided re-education related to transfers and the Kardex and was allowed to return to work on [DATE].

Based on interview and document review, the facility failed to ensure emergency medical care, cardiopulmonary resuscitation (CPR) was provided in accordance with the resident's directives for 1 of 1 residents (R1), stopped breathing, and had no pulse. Staff started CPR but discontinued it when the resident's advanced directives were read incorrectly by a staff. The resident died at the facility. Findings include: R1's medical record was reviewed and indicated R1 was admitted to the facility's transitional care unit for short term rehabilitation on [DATE] after being hospitalized for [REDACTED]. The facility policy dated [DATE] title Cardiopulmonary Resuscitation (CPR) indicated that the facility had staff on duty at all times to provide CPR, that CPR was offered unless a do not resuscitate order was in place, or there were no obvious signs of clinical death. The policy indicated staff was certified by the American Heart Association and the American Red Cross and CPR was guidelines. An automatic external defibrillator (AED) and a backboard were observed [DATE] at 9 a.m. stored in an office on the same floor, on the long term care side. The admission nurse note dated [DATE] at 1:20 p.m. indicated that R1 was alert, oriented, and made her own decisions. The Provider Orders for Life Sustaining Treatment (POLST) was signed on admission by R1 and indicated R1 wanted staff to perform CPR. The POLST form dated [DATE] included R1's signature, the nurse, and the physician's signature. The goals of treatment sections (sections B and C) of the form were not completed to limit care when not in cardiopulmonary arrest. The electronic face sheet and Medication Administration Record [REDACTED]. When not in [MEDICAL CONDITION], follow orders in B and C. The progress note dated [DATE] documented a late entry for [DATE] by Licensed Practical Nurse (LPN- H), and indicated on arrival for the night shift LPN-H was told by LPN- J that R1 was going into [MEDICAL CONDITION]. LPN- H documented R1 was not breathing, had a rapid pulse, and CPR was initiated. A law enforcement officer arrived, and R1 was placed on the floor to continue CPR. The progress note indicated that LPN- J entered with papers and stated to stop CPR, that R1 did not need it. CPR was discontinued and R1 had no pulse or respirations, the emergency medical system (EMS) call was canceled. A second officer arrived and reviewed the POLST form and told staff CPR had been indicated. LPN-J did not have progress note documented for [DATE] for the change in condition. The investigative log (undated) filed by LPN-J indicated that R1 was unresponsive but breathing. She began a sternal rub and left the room to activate the emergency medical system (EMS) by calling 911. LPN-J was interviewed on [DATE] at 9:00 a.m. and stated that R1 had a fall at the beginning of the shift and she had monitored R1 several times during the shift for vital signs and injury from the fall. Late in the shift she had been called to R1's room by Registered Nurse (RN-G) because R1 was unresponsive. LPN-J assessed the vital signs and applied a sternal rub, R1 had gasping breathing and had a pulse at that time. LPN-J stated she left the room to call 911 and check the POLST status because she did not know if R1 wanted CPR done. LPN-J stated she did not send someone to get the automated external defibrillator (AED) and backboard to be used if CPR was initiated. She called 911 to activate the EMS. LPN-J stated she looked at the Medication Administration Record [REDACTED]. She was not sure about this and was looking in the electronic record for the POLST form when LPN-H arrived for the next shift and asked about a beeping noise, LPN-H went to R1's room. LPN-J stated she continued to get the POLST form, copied it, and stated she looked at the form and understood the form to note follow comfort cares written in section B and C. She stated she interpreted the POLST form to mean that R1 wanted comfort cares and CPR was not indicated. She said she went to R1's room and the staff were around R1 on the floor, she read the POLST to them and directed them not to do CPR. LPN-J said she did not know that CPR had been started and did not know why R1 was on the floor. She stated the officer and nurses looked at the POLST form and did not say anything. She stated she did not have training about the POLST form and had not used one before. She said she was told CPR had been started several minutes later by another officer that arrived. RN-G was interviewed [DATE] at 11:30 a.m. and stated that she had been with R1 on [DATE] at 11:00 p.m. when R1's level of consciousness changed and R1 was unresponsive and respirations were gasping. She notified LPN-J because she was a trainee and was not assigned resident care. She stated LPN-J assessed R1, increased the oxygen level being given, then left the room to activate the EMS by calling 911. She stated that LPN-J came back to the room and was asked if CPR was indicated and said refer to section B and C of POLST, RN-G said she was confused by this direction. A few minutes later RN-G felt CPR was indicated, she left the room for further direction, and LPN-H came down the hall went to R1 and began CPR. R1 was placed on the floor when an officer arrived to continue CPR. RN-G stated that LPN-J came into the room and said stop CPR, RN-G was handed the POLST but did not read the form and gave it to the officer.LPN-H was interviewed [DATE] at 1:20 p.m. and stated that she arrived on the unit for the night shift after receiving report on the long term care unit. She said the nurse on the long term care unit was not aware of a medical emergency on the transitional care unit. LPN-H stated that LPN-J was in the office at approximately 11 p.m. and did not initially report a medical emergency to LPN-H until asked what the beeping sounds were by LPN-H. LPN-H was told that R1 was going into [MEDICAL CONDITION], and she was checking the POLST. LPN-H stated she was surprised she had not been told immediately and the long term care nurse had not been notified. LPN-H stated she went to R1's room, assessed that R1 was not breathing and the pulse had dropped, she laid the bed flat and started CPR. She said that a law enforcement officer had responded, R1 was placed on the floor to continue CPR on a hard surface, R1 was assessed and had no pulse or breathing and CPR was to continue. She stated that LPN-J came into the room with the POLST form at that time and said CPR was not indicated. She stated CPR was discontinued at that time. The POLST form was not seen by her at that time. LPN-H stated that the usual process would be to immediately activate the EMS with a change in level of consciousness and breathing, to stay with the resident to assess and provide care, and have other staff get emergency equipment and AED. LPN-H stated the POLST information was available on the electronic medical record on the E-MAR, E-TAR, and face sheet. LPN-H stated R1's POLST form was very clear that CPR was indicated. LPN-H stated that the nurse should remain with the resident and direct the staff in the medical emergency process. Nursing Assistant (NA- E) was interviewed [DATE] at 2:00 p.m. and stated she was in the room with RN-G at 10:50 p.m. on [DATE] to care for R1. She stated R1 was not responsive that RN-G was doing a sternal rub and monitoring vital signs for R1. She stated that LPN-J left the room to call 911 and RN-G was not sure about the CPR status. She observed LPN-H come into the room and begin CPR chest compressions on the bed. R1 was lowered to the floor when an officer arrived, then LPN-J came into the room and told the others to stop CPR and waved the POLST form. NA-E stated that there did not seem to be anyone in charge of the medical emergency and communication was poor.The RN Nurse Manager (RN-B) was interviewed [DATE] at 11:15 a.m. and stated that the nurses are expected to have CPR certification, to direct emergency situations and to begin CPR when indicated. She said that the CPR status was documented on readily available computers and the nurse should ask other staff to help get the AED or assist with tasks, while they directed the CPR and have another nurse check the CPR status. The Director of Nursing (DON) was interviewed [DATE] at 3 p.m. and stated that the usual procedure for nurses in a CPR medical emergency was to bring the AED and back board to the room and to access the EMS by calling 911. He stated that the POLST information for CPR or do not resuscitate (DNR) were available to nurses and it was important to honor the choice of the resident. Review of the employee records indicated that LPN-J, LPN-H, and RN-G had current certification from the American Heart Association for CPR. Review of the American Heart Association training for healthcare professionals for basic life support dated 2015 indicated It is expected that Healthcare Professionals (HCPs) are trained in CPR and can effectively perform both compressions and ventilation. However, the priority for the provider, especially if acting alone, should still be to activate the emergency response system and to provide chest compressions. There may be circumstances that warrant a change of sequence, such as the availability of an AED that the provider can quickly retrieve and use. For witnessed adult [MEDICAL CONDITION] when an AED is immediately available, it is reasonable that the defibrillator be used as soon as possible.