Every finding on record at Good Samaritan Society - Windom

Based on interview and document review, the facility failed to ensure the infection preventionist provided the Quality Assurance Performance Improvement (QAPI) members with employee surveillance and illness data during monthly meetings. This had the potential to affect all 56 residents. TBReview of RN-A's employee file identified she had a hire date of 8/13/25. On 8/13/25, RN-A completed a baseline screening questionnaire and was given a first step TB skin test (TBT) which was negative for TB exposure. On 8/26/25, RN-A was given her second TST, On 8/29/25, the TST site on RN-A's arm was reviewed by the tester and determined positive as it showed induration (thickened, raised skin). Employee file note entitled Regarding [name] TB testing identified an un-named staff noted:RN-A's 1st TST was negative.Second TST was reviewed at 48 and showed redness and induration. Staff waited until the 72-hour (8/29/25) timeframe and re-evaluated. On 8/29/25, the redness was improved, however, the induration remained so the plan was to send RN-A for a blood TB test and scheduled RN-A to be tested at the local clinic.On 9/2/25, staff were looking for the blood test results as it was routine for the clinic to fax over result documentation to the facility. No fax was received. The clinic was contacted. They had no record of RN-A being seen for testing. RN-A was called. She is in the building working on floor orientation. RN-A's lack of blood test results was discussed. RN-A stated to facility staff that the clinic did not draw blood on 8/29/25, as the [laboratory] courier was already gone for the day. RN-A was then scheduled to go back to the clinic by 3:00 p.m. on 9/2/25 for the blood test. She has been on the floor today interacting with staff and residents. She states she does not feel sick, but yet, does not feel comfortable being out there if there is a problem with her TB test. A plan was made to consult with the interim director of nursing (DON) (currently the DON), but the staff advised holding RN-A from [having] contact with residents until the test results came back. RN-A was noted to have agreed with the plan.On and unidentified later date, a note was made the staff consulted with the IDON and the administrator, and they would allow RN-A to remain on the floor for orientation while wearing a mask.On 9/5/2, staff noted they received a report of the TB blood test. It was positive for TB exposure. Staff noted the spoke with a physician, administrator, and Minnesota Department of Health nurse (TB specialist). Staff would hold off of work until after a physician exam and chest x-ray. An appointment was made for RN-A to be seen on 9/9/25 by a physician.On 9/12/25, the note identified RN-A's appointment was rescheduled to 9/15/25. Review of the 9/15/25, physician (MD)-A note regarding RN-A identified RN-A was seen on 9/15/25 via telemedicine consultation for evaluation of her positive TST and blood test. RN-A was evaluated on 9/9/25, by MD-B who noted in his exam RN-A's lung sounds were normal. RN-A also had a chest x-ray which showed RN-A had latent TB (infected with TB bacteria, but do not have active TB disease). RN-A was offered treatment but declined at that time. RN-A was not contagious and was able to return to work without restriction. Review of the 4/17/25, Clinical Overview of Latent Tuberculosis Infection, located at https://www.cdc.gov/tb/hcp/clinical-overview/latent-tuberculosis-infection.html, identified People with latent TB infection are infected with TB bacteria, but they do not have TB disease. However, if these bacteria become active and multiply, latent TB infection can develop into TB disease. Treating people with latent TB infection substantially reduces the risk that latent TB infection will progress to TB disease. Once active, TB can be spread from person to person through the air. People with latent TB infection should be treated to prevent the development of TB disease. Short-course latent TB infection treatments are effective, safe, and have higher completion rates than treatment regimens. Further review of the note entitled Regarding [name] TB testing identified on 9/15/25, staff noted RN-A had been seen as noted in the above physician note. Staff spoke to RN-A about treatment, and she was noted to be considering it. No further documentation was made on the note. Review of the Absence/[NAME] Report forms identified there were no ill call-ins from RN-A from September 2025 through January 2026. Further review of RN-A's employee file identified there was no signed education provided to RN-A about signs and symptoms of active TB, nor any mention of mitigating measures or exclusions to work required if RN-A showed signs or symptoms of active TB or her acknowledgement of any education having been provided. The facility infection preventionist was terminated from employment 9/9/26 and was unable to be interviewed. Review of the facility's 5/7/25, TB risk assessment identified the facility risk was low. The DON and infection preventionist (IP) were responsible for TB infection control (IC) in the facility. The IC committee members listed were the DON, the IP, RN case managers, along with the dietary and the activities directors. There was no indication another risk assessment had been completed after RN-A was identified to have latent TB to see if the facility's risk would remain low. Review of the infection control surveillance data identified RN-A was not listed on any surveillance as being monitored. Review of the IC Safety Meeting November 2025 minutes, presented to Quality Assurance Performance Improvement (QAPI) committee identified there was a section for:Employee health. There were no recorded illnesses for October 2025.TB. One new hire (RN-A) with a positive TB was noted. It was documented that RN-A was not taking medication treatment, but a sign/symptom screening was to be done every year while they worked at the facility. It was not identified in the meeting notes if the facility would ensure RN-A would be seen by a physician and prevented from working if she showed new evidence of signs or symptoms of active disease, or if the facility planned to send RN-A for annual evaluation and chest x-ray by a physician to identify the continued absence of active disease. Interview and document review on 2/12/26 at 11:22 am., with regional nurse consultant (RNC)-A, who was also the interim infection preventionist identified she was unaware of RN-A's latent TB diagnosis or that RN-A was allowed to work before given medical clearance from a physician. RNC-A reviewed the Regarding [name] TB testing note and agreed the facility needed heightened surveillance and mitigation measures in place for RN-A if she became symptomatic with signs or symptoms of active TB (fever, night sweats, weight loss, loss of appetite, sense of illness or loss of energy). Further interview on 2/12/26 at 11:46 a.m., with RNC-A and the administrator identified RN-A was to receive yearly chest x-rays and physician exams, however, they agreed, there was no enhanced surveillance of RN-A that was identified in the infection control surveillance documentation, that staff were to be aware of active TB symptoms, or that RN-A had received education to those symptoms and not report to work if that should occur and seek medical evaluation by a physician. RNC-A and the administrator identified they felt RN-A declined treatment due to expense. Both RNC-A and the administrator were unaware of the Minnesota Tuberculosis Medication Program that served to eliminate financial barriers to medication for the treatment of latent TB infection (LTBI) or active TB disease for state residents. Both the RNC-A and administrator identified they would work with RN-A to assist her with treatment accessibility, and would work on implementing heightened mitigation measures and surveillance for RN-A. Review of the 6/1/25, Tuberculosis Control Plan and Screening policy identified prior to or upon hire, all staff were to be screened and tested for TB. Employees with newly identified positive TST or blood tests would be required to be evaluated by a medical provider to rule out active TB. Employees were to be instructed about signs and symptoms of TB and reporting requirements to the IP or designee. Employees with untreated latent TB were to receive yearly symptom screening to detect evidence of active TB and to re-evaluate to risks and benefits of treatment. An employee with suspected or confirmed TB was not to be allowed on the facility until the employee had been confirmed to be non-contagious by a physician. Employees with symptoms were to be evaluated promptly for TB and not return to work until active TB was excluded by a physician and written documentation from that physician was required. EMPLOYEE SURVEILLANCE and RETURN TO WORK Review of employee Absence/[NAME] Report forms identified the form listed:Employee name.Date of absence.Reason for absence.Comments.Recorded by.Date recorded.A section for If absence was an illnessDate of return to work.Signature of nurse verifying the employee was cleared for work.There was no indication on the forms of which nursing staff were trained and able to sign the form to ensure employees were appropriate to return to work (RTW), kept out of work for an appropriate timeframe, or what professional standards the facility followed to ensure staff followed specific guidelines ensure transmission of potential infectious disease did not occur. Review of the October 2025 through January 2026 Absence/[NAME] forms identified in:October 2025, 25 of 26 staff call-ins were due to staff or family illness with illnesses varying with gastrointestinal illnesses (stomach flu, nausea, vomiting, diarrhea) , respiratory illnesses, etc.November 2025, 6 of 23 staff call-ins were due to staff illnesses such as diarrhea, not feeling well, personal sick or sick, heading to the emergency room (ER)December 2025, 22 of 28 staff call-ins were reported for staff illnesses of stomach flu, sick, fevers, diarrhea, and nausea and/or vomiting.January 2026, of 23 of 28 staff call-ins were related to staff or family illness of flu, sore throats, body aches, stomach aches, nausea, diarrhea, vomiting, flu, and one with a child with Respiratory Syncytial Virus (RSV) (highly contagious respiratory disease) and one with Strep throat (bacterial infection of the throat easily spread).None of the forms identified what date an employee was allowed to RTW, if any trained nursing staff had made that determination, or what criteria was used to determine the appropriateness of RTW. or what staff had identified they were appropriate to return to work. Review of the IC Safety Meeting minutes, presented to Quality Assurance Performance Improvement (QAPI) committee identified there was a section for Employee Health each month. In:November 2025's meeting, there were no recorded illnesses of staff reported. The action plan noted they would review staff illnesses at the next meeting.Decembers 2025's meeting, there was no recorded illnesses of staff reported. The action plan remained that the committee would review staff illnesses at the next meeting. Interview on 2/12/26 at approximately 1:30 p.m., with RNC-A identified she agreed staff were not appropriately screened for their appropriateness to return to work and the forms lacked critical information on what criteria were to be used. There was no other employee surveillance data they were aware of from the previous IP who was terminated on 2/9/26. Review of the November 2025, and December 2025 QAPI meeting minutes identified there was no information on employee surveillance brought forth to QAPI from the Infection Control Committee Meetings. Review of the 11/18/25, Infection Prevention and Control Program policy identified the facility was to have a system of surveillance for employees to report signs, symptoms and diagnosed illnesses that may present a risk to residents, employees, and other individuals. Education to employees was to occur as appropriate. Review of the 9/30/25, Surveillance policy identified appropriate surveillance of residents was identified, however, there was no mention on the inclusion of employee illnesses, the collection of that data, or how the facility was to ensure employees returned to work appropriately after an illness using professional standards to mitigate potential spread of infection by employees.

Based on observation, interview, and document review, the facility failed to ensure there was appropriate surveillance and subsequent mitigation efforts and education identified for 1 of 1 staff (registered nurse (RN)-A) who was found to be positive for Tuberculosis (TB) during routine pre-employment testing. Additionally, the facility failed to ensure employees were cleared to return to work (RTW) after illness using professional standards and appropriately surveilled for illness, for 4 of 4 months (October 2025 through January 2026) reviewed. The facility also failed to ensure 3 of 3 whirlpool tubs were cleaned and disinfected according to manufacturer's guidelines and failed to ensure 1 of 1 nebulizer (inhaled medication) treatment devices were cleaned, rinsed, and left to air dry after each medication administration. These deficient practices had the potential to affect all 56 residents or other staff and visitors in the facility.Findings include: TBReview of RN-A's employee file identified she had a hire date of 8/13/25. On 8/13/25, RN-A completed a baseline screening questionnaire and was given a first step TB skin test (TBT) which was negative for TB exposure. On 8/26/25, RN-A was given her second TST, On 8/29/25, the TST site on RN-A's arm was reviewed by the tester and determined positive as it showed induration (thickened, raised skin). Employee file note entitled Regarding [name] TB testing identified an un-named staff noted:RN-A's 1st TST was negative.Second TST was reviewed at 48 and showed redness and induration. Staff waited until the 72-hour (8/29/25) timeframe and re-evaluated. On 8/29/25, the redness was improved, however, the induration remained so the plan was to send RN-A for a blood TB test and scheduled RN-A to be tested at the local clinic.On 9/2/25, staff were looking for the blood test results as it was routine for the clinic to fax over result documentation to the facility. No fax was received. The clinic was contacted. They had no record of RN-A being seen for testing. RN-A was called. She is in the building working on floor orientation. RN-A's lack of blood test results was discussed. RN-A stated to facility staff that the clinic did not draw blood on 8/29/25, as the [laboratory] courier was already gone for the day. RN-A was then scheduled to go back to the clinic by 3:00 p.m. on 9/2/25 for the blood test. She has been on the floor today interacting with staff and residents. She states she does not feel sick, but yet, does not feel comfortable being out there if there is a problem with her TB test. A plan was made to consult with the interim director of nursing (DON) (currently the DON), but the staff advised holding RN-A from [having] contact with residents until the test results came back. RN-A was noted to have agreed with the plan.On and unidentified later date, a note was made the staff consulted with the IDON and the administrator, and they would allow RN-A to remain on the floor for orientation while wearing a mask.On 9/5/2, staff noted they received a report of the TB blood test. It was positive for TB exposure. Staff noted the spoke with a physician, administrator, and Minnesota Department of Health nurse (TB specialist). Staff would hold off of work until after a physician exam and chest x-ray. An appointment was made for RN-A to be seen on 9/9/25 by a physician.On 9/12/25, the note identified RN-A's appointment was rescheduled to 9/15/25. Review of the 9/15/25, physician (MD)-A note regarding RN-A identified RN-A was seen on 9/15/25 via telemedicine consultation for evaluation of her positive TST and blood test. RN-A was evaluated on 9/9/25, by MD-B who noted in his exam RN-A's lung sounds were normal. RN-A also had a chest x-ray which showed RN-A had latent TB (infected with TB bacteria, but do not have active TB disease). RN-A was offered treatment but declined at that time. RN-A was not contagious and was able to return to work without restriction. Review of the 4/17/25, Clinical Overview of Latent Tuberculosis Infection, located at https://www.cdc.gov/tb/hcp/clinical-overview/latent-tuberculosis-infection.html, identified People with latent TB infection are infected with TB bacteria, but they do not have TB disease. However, if these bacteria become active and multiply, latent TB infection can develop into TB disease. Treating people with latent TB infection substantially reduces the risk that latent TB infection will progress to TB disease. Once active, TB can be spread from person to person through the air. People with latent TB infection should be treated to prevent the development of TB disease. Short-course latent TB infection treatments are effective, safe, and have higher completion rates than treatment regimens. Further review of the note entitled Regarding [name] TB testing identified on 9/15/25, staff noted RN-A had been seen as noted in the above physician note. Staff spoke to RN-A about treatment, and she was noted to be considering it. No further documentation was made on the note. Review of the Absence/[NAME] Report forms identified there were no ill call-ins from RN-A from September 2025 through January 2026. Further review of RN-A's employee file identified there was no signed education provided to RN-A about signs and symptoms of active TB, nor any mention of mitigating measures or exclusions to work required if RN-A showed signs or symptoms of active TB or her acknowledgement of any education having been provided. The facility infection preventionist was terminated from employment 9/9/26 and was unable to be interviewed. Review of the facility's 5/7/25, TB risk assessment identified the facility risk was low. The DON and infection preventionist (IP) were responsible for TB infection control (IC) in the facility. The IC committee members listed were the DON, the IP, RN case managers, along with the dietary and the activities directors. There was no indication another risk assessment had been completed after RN-A was identified to have latent TB to see if the facility's risk would remain low. Review of the infection control surveillance data identified RN-A was not listed on any surveillance as being monitored. Review of the IC Safety Meeting November 2025 minutes, presented to Quality Assurance Performance Improvement (QAPI) committee identified there was a section for:Employee health. There were no recorded illnesses for October 2025.TB. One new hire (RN-A) with a positive TB was noted. It was documented that RN-A was not taking medication treatment, but a sign/symptom screening was to be done every year while they worked at the facility. It was not identified in the meeting notes if the facility would ensure RN-A would be seen by a physician and prevented from working if she showed new evidence of signs or symptoms of active disease, or if the facility planned to send RN-A for annual evaluation and chest x-ray by a physician to identify the continued absence of active disease. Interview and document review on 2/12/26 at 11:22 am., with regional nurse consultant (RNC)-A, who was also the interim infection preventionist identified she was unaware of RN-A's latent TB diagnosis or that RN-A was allowed to work before given medical clearance from a physician. RNC-A reviewed the Regarding [name] TB testing note and agreed the facility needed heightened surveillance and mitigation measures in place for RN-A if she became symptomatic with signs or symptoms of active TB (fever, night sweats, weight loss, loss of appetite, sense of illness or loss of energy). Further interview on 2/12/26 at 11:46 a.m., with RNC-A and the administrator identified RN-A was to receive yearly chest x-rays and physician exams, however, they agreed, there was no enhanced surveillance of RN-A that was identified in the infection control surveillance documentation, that staff were to be aware of active TB symptoms, or that RN-A had received education to those symptoms and not report to work if that should occur and seek medical evaluation by a physician. RNC-A and the administrator identified they felt RN-A declined treatment due to expense. Both RNC-A and the administrator were unaware of the Minnesota Tuberculosis Medication Program that served to eliminate financial barriers to medication for the treatment of latent TB infection (LTBI) or active TB disease for state residents. Both the RNC-A and administrator identified they would work with RN-A to assist her with treatment accessibility, and would work on implementing heightened mitigation measures and surveillance for RN-A. Review of the 6/1/25, Tuberculosis Control Plan and Screening policy identified prior to or upon hire, all staff were to be screened and tested for TB. Employees with newly identified positive TST or blood tests would be required to be evaluated by a medical provider to rule out active TB. Employees were to be instructed about signs and symptoms of TB and reporting requirements to the IP or designee. Employees with untreated latent TB were to receive yearly symptom screening to detect evidence of active TB and to re-evaluate to risks and benefits of treatment. An employee with suspected or confirmed TB was not to be allowed on the facility until the employee had been confirmed to be non-contagious by a physician. Employees with symptoms were to be evaluated promptly for TB and not return to work until active TB was excluded by a physician and written documentation from that physician was required. EMPLOYEE SURVEILLANCE and RETURN TO WORK Review of employee Absence/[NAME] Report forms identified the form listed:Employee name.Date of absence.Reason for absence.Comments.Recorded by.Date recorded.A section for If absence was an illnessDate of return to work.Signature of nurse verifying the employee was cleared for work.There was no indication on the forms of which nursing staff were trained and able to sign the form to ensure employees were appropriate to return to work (RTW), kept out of work for an appropriate timeframe, or what professional standards the facility followed to ensure staff followed specific guidelines ensure transmission of potential infectious disease did not occur. Review of the October 2025 through January 2026 Absence/[NAME] forms identified in:October 2025, 25 of 26 staff call-ins were due to staff or family illness with illnesses varying with gastrointestinal illnesses (stomach flu, nausea, vomiting, diarrhea) , respiratory illnesses, etc.November 2025, 6 of 23 staff call-ins were due to staff illnesses such as diarrhea, not feeling well, personal sick or sick, heading to the emergency room (ER)December 2025, 22 of 28 staff call-ins were reported for staff illnesses of stomach flu, sick, fevers, diarrhea, and nausea and/or vomiting.January 2026, of 23 of 28 staff call-ins were related to staff or family illness of flu, sore throats, body aches, stomach aches, nausea, diarrhea, vomiting, flu, and one with a child with Respiratory Syncytial Virus (RSV) (highly contagious respiratory disease) and one with Strep throat (bacterial infection of the throat easily spread).None of the forms identified what date an employee was allowed to RTW, if any trained nursing staff had made that determination, or what criteria was used to determine the appropriateness of RTW. or what staff had identified they were appropriate to return to work. Review of the IC Safety Meeting minutes, presented to Quality Assurance Performance Improvement (QAPI) committee identified there was a section for Employee Health each month. In:November 2025's meeting, there were no recorded illnesses of staff reported. The action plan noted they would review staff illnesses at the next meeting.Decembers 2025's meeting, there was no recorded illnesses of staff reported. The action plan remained that the committee would review staff illnesses at the next meeting. Interview on 2/12/26 at approximately 1:30 p.m., with RNC-A identified she agreed staff were not appropriately screened for their appropriateness to return to work and the forms lacked critical information on what criteria were to be used. There was no other employee surveillance data they were aware of from the previous IP who was terminated on 2/9/26. Review of the November 2025, and December 2025 QAPI meeting minutes identified there was no information on employee surveillance brought forth to QAPI from the Infection Control Committee Meetings. Review of the 11/18/25, Infection Prevention and Control Program policy identified the facility was to have a system of surveillance for employees to report signs, symptoms and diagnosed illnesses that may present a risk to residents, employees, and other individuals. Education to employees was to occur as appropriate. Review of the 9/30/25, Surveillance policy identified appropriate surveillance of residents was identified, however, there was no mention on the inclusion of employee illnesses, the collection of that data, or how the facility was to ensure employees returned to work appropriately after an illness using professional standards to mitigate potential spread of infection by employees. WHIRLPOOL TUB CLEANING Observation, interview, and document review on 2/10/26, of bath aide (BA)-F in the 400-wing tub room identified the facility had Cascade brand whirlpool jetted tubs. BA-F proceeded to fill the bottom of the tub well with a disinfectant mix connected to the tub from the manufacturer's container for approximately 2 gallons of disinfectant mix. BA-F scrubbed the walls and bottom and chair of the whirlpool tub for 3 minutes then released the water and rinsed the rub. BA-F then engaged the whirlpool jets to blow out and remaining disinfectant from the jets. BA-F stated she had worked at the facility for 30 years. She noted instructions for the process were on the wall. BA-F then opened the side of the whirlpool tub to show the disinfectant and verified on the manufacturer's instructions of the disinfectant; there was a wet-contact time of 10 minutes that was required to ensure appropriate disinfection would occur. BA-F was unaware of the instructions on the bottle and pointed to typed up instructions on the wall. Those instructions were posted in all 3 of the whirlpool tub rooms. All 56 residents were bathed and/or showered in one of the three whirlpool tubs (one for each wing) and that process posted was completed after each resident bath. Interview on 2/10/26 at 12:45 with BA-G in the south hall tub room identified she followed the same posted instructions as above and verified the instructions lacked the disinfectant note portion for there to be a wet-contact time of 10 minutes to ensure disinfection. Review of the undated, Bath Cleaning After Every Bath posted instructions identified staff were to:Close and lock the tub door.Rinse the tub using the sprayer.Put the drain in the tub.Press and hold the disinfectant button on the left side of the tub.Release the button when staff saw cleaning solution coming out of all jets and there was 1.5 to 2 gallons of disinfectant solution in the tub.Use the scrub brush to thoroughly scrub all interior surfaces of the tub with the solution.Remove the drain plug.Rinse the interior surfaces thoroughly.Press and hold the rinse button until clear water ran from the jets.Finish rinsing the tub interior.Start the air blower for all jets and allow to run for 30-45 seconds to push all the water out.Unlock the tub door and leave it slightly open.There were no posted instructions that included the [NAME] disinfectant criteria for appropriate disinfection using a 10-minute wet-contact time in any of the 3 whirlpool tub rooms. Interview on 2/10/26 at 12:56 p.m., with the DON identified she would expect staff to follow the disinfectant instructions on allowing a 10-minute wet-contact time for appropriate disinfection to occur. Review of the current, Cascade [NAME] Operation and Daily Maintenance Instructions, located at https://www.pennerbathing.com/wp-content/uploads/2020/12/Alcove-Tub-operation-manual-360750A.pdf, identified the tub instructions were the same as above, however, it was noted for staff to clean and disinfect the tub after every bath with [NAME] Cleaner/Disinfectant. [NAME] Cleaner/Disinfectant was a special non-abrasive cleaning and disinfecting solution and was the only cleaning solution designed and recommended for use with the Cascade Tub. Review of the current, [NAME] Bathing Spas Disinfection Quick Guide, located at https://express.adobe.com/page/dGLlnlGnBbk3E/, Step 4, identified for staff to allow the disinfectant to remain in contact for 10 minutes. All other instructions were the same and followed Cascade instructions. NEBULIZER ADMINISTRATION Observation on 2/10/26 at 4:50 p.m., of licensed practical nurse (LPN)-A identified she proceeded to administer a nebulizer treatment to R43. LPN-A went to the countertop in R43's room, and retrieved his nebulizer that was intact and assembled on the counter. LPN-A then opened the nebulizer medication cup (residue was noted to be inside the cup), poured in R43's medication, connected to the nebulizing machine and administered his medication. LPN-A stated staff were to disassemble the medication cup and mouthpiece after each medication administration, clean and rinse them out and leave on the counter to air-dry. LPN-A stated she should have either rinsed and cleaned his medication cup and mouthpiece or gathered new nebulizer supplies before she administered R43 his medication. She agreed not cleaning and rinsing the mouthpiece and cup had the potential to cause a respiratory infection for residents when they were not cleaned and rinsed after each use. Interview on 2/10/26 at approximately 5:00 p.m., with the DON identified she expected staff to clean and rinse nebulizers after each administration. Review of the 12/10/25 Nebulizer policy identified following medication administration, staff were to disconnect the nebulizer parts (mask/mouthpiece and cup) and wash them in warm soapy water and rinse thoroughly, set on a paper towel, and let air-dry.

Based on interview and document review the facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 3 of 3 (R13, R24, R40) sampled resident when they ended their Medicare Part A skilled services with days remaining.Findings include: R13's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R13's services ended on 9/16/25. There was a handwritten note dated 9/11/25 on the CMS-10123 form that the wife had been called and notified that the skilled services would end on 9/16/25. R13 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R13 would choose to continue with the skilled services on his own. R24's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R24's services ended on 8/22/25. There was a handwritten note dated 8/20/25 on the CMS-10123 form that the resident had been notified that the skilled services would end on 8/22/25. R24 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R24 would choose to continue with the skilled services on his own. R40's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R40's services ended on 12/15/25. There was a handwritten note dated 12/10/25 on the CMS-10123 form that the wife had been called and notified that the skilled services would end on 12/15/25. R40 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R40 would choose to continue with the skilled services on his own. Interview on 2/12/26 at 1:00 p.m., with the director of nursing (DON) identified she was responsible for providing the beneficiary notices when a resident discharged from skilled services. She was unaware that she needed to provide the CMS-10055 form. She confirmed she had not provided the CMS-10055 form with the estimated cost to continue if the resident would choose to do so.

Based on interview and document review, the facility staff failed to report allegations of potential abuse timely to the facility management for 3 of 3 residents (R7, R26, and R39) sampled. Findings include: Review of the 11/24/25 reports to the State Agency identified three individual reports were received identifying:R7 no longer wanted nursing assistant (NA)-C to assist because NA-C was too rough when providing cares, and disregarded R7's complaints of discomfort and pain.On 11/16/26, NA-C was rough during cares with R39, was unorganized, did not respond to call lights of certain residents, did not knock on resident doors before entering a resident's room, slammed doors and continued to assist residents who did not want NA-C's help.On 11/15/25, NA-C did not respect R26's privacy when providing cares and would leave her exposed during cares. R26's had requested to speak to the nurse twice, and NA-C just wanted R26 to tell her what she needed verses going to get the nurse for R26. R7's 12/19/25 quarterly Minimum Data Set (MDS) assessment identified she was admitted in October 2025, her cognition was moderately impaired, she was dependent on staff to complete daily activities, and she had a diagnosis of vascular disease, renal failure, diabetes, arthritis, asthma, and depression. Interview on 2/10/26 at 5:25 p.m., with R7 stated the staff here are really good to me, I have no complaints. R39's 1/16/26, accepted comprehensive Minimum Data Set (MDS) assessment identified R39's cognition was moderately impaired, and she was dependent on staff to assist with cares. R39 took a daily antidepressant and had diagnoses of depression, diabetes, and hemiplegia. Interview on 2/11/26 at 7:37 a.m., with R39 identified that there had been no staff that had ever treated her rough however, they did go fast at times as they were always in a hurry. She identified there was one staff member who took longer to answer her call light, but she worked slowly with everything. She denied any staff being rough with her during cares or being disrespectful to her.R26's accepted 12/27/25, quarterly Minimum Data Set (MDS) assessment identified R26's cognition was intact. She required staff assistance with care. R26 took an antipsychotic, antianxiety, and antidepressant. She had diagnoses of anxiety, depression, hypertension, and diabetes.Interview on 2/11/26 at 9:00 a.m., with R26 identified that she did have a concern with a staff leaving her exposed during cares. She reported she told him that it bothered her, and he has been good now about covering her up as much as possible during cares, and she had no further concerns with him. She denied any other staffing concerns and stated she was not shy and had no problems expressing concerns. Interview on 2/11/26 at 10:07 a.m., with licensed practical nurse (LPN)-A identified that NA-C started at the facility around November, after working at the facility for about a month, residents started reporting to LPN-A that NA-C was rough when providing cares, does not knock on the door before entering, and slams the door when she leaves the room. When residents complained, LPN-A gathered written statements from them and slid the information under the director of nursing door. She received an email from the director of nursing saying she would take care of it. Interview on 2/11/26 at 2:13 p.m., with the director of nursing identified when she arrived at the facility on 11/19/15, she found a report related to resident care concerns that had been slid under her office door. She interviewed some residents and the staff member that was being reported. She asked them specifically if they felt safe and they said they did. She did not interview any of the staff that made the reports. We reached out to our leadership team because the report did not point to any abuse or neglect. Review of the 11/18/25, Formal Complaint letter provided to the director of nurses (DON) from LPN-A identified LPN-A noted various concerns that had been reported to her with the statements from residents and staff attached that identified: On 11/16/25, R39 signed a statement written by an unknown source that identified concerns regarding NA-C of not taking advice from residents, being rough when handling clients/residents and was unorganized.R10 wrote in an undated note that NA-C slammed doors and was rude. Various staff between 11/16/25 and 11/18/25, identified concerns regarding NA-C for not knocking on resident doors prior to entering, not providing privacy, avoiding cares for certain residents, turning up resident oxygen to 5 liters when resident had not been on oxygen for a while, being bossy and passive aggressive with coworkers. Interview on 2/12/26 at 11:00 a.m., with trained medication aide (TMA)-A identified if a resident made a complaint that someone was rough with them, she would report that right away to the case manager and if the case manager was not there, she would report that to the director of nursing. Interview on 2/12/26 at 4:22 p.m., with the administrator identified that on 11/19/25, the director of nursing (DON) had received a report under her office door from licensed practical nurse (LPN)-A, regarding concern related to NA-C being rough while providing cares. At the time neither the administrator nor the DON had identified one of the allegations received by LPN-A that was signed by a resident had been reported to LPN-A on 11/16/25. LPN-A did not report this allegation of potential abuse until the Formal Complaint was given to the DON 3 days later on 11/19/25, when the DON arrived at work that morning. Interview on 2/12/26 at 4:43 p.m., with medication aid (TMA)-B identified they had received reports from R26 (date known) that NA-C was rough when providing cares. TMA-B reports they left a note at the nurse's desk but does not recall who was working at the time. They have received training on abuse reporting and stated we are supposed to report to our direct supervisor unless the complaint involves the direct supervisor. In that case they would report to the administrator. Review of 4/7/25, Abuse and Neglect policy identified allegations of mistreatment, neglect, exploitation or abuse would be reported immediately to the administrator, but not later than two hours after the allegation was made. If administrator was unavailable staff were to report to the director of nursing or the supervisor of social services. The designated individuals had the authority to intervene in any situation to protect residents, including removing any individuals from the location to protect residents. If there was an allegation of abuse from an employee to a resident, the employee would be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation.

Based on interview and document review, the facility failed to thoroughly investigate allegations of potential abuse for 3 of 3 (R7, R26, R39) sample residents. Findings include: Review of the 11/24/25 reports to the State Agency identified three individual reports were received identifying:R7 no longer wanted nursing assistant (NA)-C to assist because NA-C was too rough when providing cares, and disregarded R7's complaints of discomfort and pain.On 11/16/26, NA-C was rough during cares with R39, was unorganized, did not respond to call lights of certain residents, did not knock on resident doors before entering a resident's room, slammed doors and continued to assist residents who did not want NA-C's help.On 11/15/25, NA-C did not respect R26's privacy when providing cares and would leave her exposed during cares. R26's had requested to speak to the nurse twice, and NA-C just wanted R26 to tell her what she needed verses going to get the nurse for R26. R7's 12/19/25 quarterly Minimum Data Set (MDS) assessment identified she was admitted in October 2025, her cognition was moderately impaired, she was dependent on staff to complete daily activities, and she had a diagnosis of vascular disease, renal failure, diabetes, arthritis, asthma, and depression.Interview on 2/10/26 at 5:25 p.m., with R7 stated the staff here are really good to me, I have no complaints. R39's 1/16/26, accepted comprehensive Minimum Data Set (MDS) assessment identified R39's cognition was moderately impaired, and she was dependent on staff to assist with cares. R39 took a daily antidepressant and had diagnoses of depression, diabetes, and hemiplegia. Interview on 2/11/26 at 7:37 a.m., with R39 identified that there had been no staff that had ever treated her rough however, they did go fast at times as they were always in a hurry. She identified there was one staff member who took longer to answer her call light, but she worked slowly with everything. She denied any staff being rough with her during cares or being disrespectful to her.R26's accepted 12/27/25, quarterly Minimum Data Set (MDS) assessment identified R26's cognition was intact. She required staff assistance with care. R26 took an antipsychotic, antianxiety, and antidepressant. She had diagnoses of anxiety, depression, hypertension, and diabetes.Interview on 2/11/26 at 9:00 a.m., with R26 identified that she did have a concern with a staff leaving her exposed during cares. She reported she told him that it bothered her, and he has been good now about covering her up as much as possible during cares, and she had no further concerns with him. She denied any other staffing concerns and stated she was not shy and had no problems expressing concerns. Interview on 2/11/26 at 10:07 a.m., with licensed practical nurse (LPN)-A identified that NA-C started at the facility around November, after working at the facility for about a month, residents started reporting to LPN-A that NA-C was rough when providing cares, does not knock on the door before entering, and slams the door when she leaves the room. When residents complained, LPN-A gathered written statements from them and slid the information under the director of nursing door. She received an email from the director of nursing saying she would take care of it. Interview on 2/11/26 at 2:13 p.m., with the director of nursing identified when she arrived at the facility on 11/19/15, she found a report related to resident care concerns that had been slid under her office door. She interviewed some residents and the staff member that was being reported. She asked those residents specifically if they felt safe, and they said they did. She did not interview any of the staff that made the reports. The DON stated she reached out to the corporate leadership team for direction because the report in her opinion did not point to any abuse or neglect. The DON did not elaborate on direction received. Interview on 2/11/26 at 2:20 p.m., with registered nurse consultant (RNC)-A identified after reviewing the Formal Complaint letter and seeing that the staff pointed out a potential relationship between the DON and the staff identified in the complaint, it would have been better if someone other than the DON completed the investigation. Review of the 11/18/25, Formal Complaint letter provided to the director of nurses (DON) from LPN-A identified LPN-A noted, I am writing this letter to bring to your attention the various complaints expressed by staff and resident regarding NA-C. Over the past month, I have had a total of five residents express dissatisfaction with the care provided on numerous occasions. This ongoing dilemma has significantly impacted and continues to affect the quality of care provided to our residents, as well as other CNAs, who often feel as though they must do double the work. In creating this letter, the intention is not to berate the individual but to advocate for the residents and staff, who have personally brought to my attention the actions and behaviors that have been carried out. I would be more than happy to visit with you in person, if needed. Most of us are aware of the work history between you, the named individual, and other staff members; however, it is my goal to see that this situation is resolved in an unbiased manner. Included with the Formal Complaint letter was statement from residents and staff as follows:On 11/16/25, R39 signed a statement written by an unknown source that identified concerns regarding NA-C of not taking advice from residents, being rough when handling clients/residents and was unorganized.R10 wrote in an undated note that NA-C slammed doors and was rude.Various staff between 11/16/25 and 11/18/25, identified concerns regarding NA-C for not knocking on resident doors prior to entering, not providing privacy, avoiding cares for certain residents, turning up a resident's oxygen to 5 liters when the resident had not been on oxygen for a while, and being bossy and passive aggressive with coworkers. Review of the facility investigation identified it was completed by the DON on 11/19/25, with interviews with R7, R10, R26, and R39, who reported to the DON they felt safe at the facility, felt safe with the people who cared for them, and denied that anyone ever verbally or physically abused them. Also, on 11/19/25, the DON spoke to NA-C via phone and her notes identified she explained she had received some complaints from residents about door slamming, privacy concerns, and not listening to residents. The DON investigative notes identified quotes from NA-C of [I] don't have any problems with the employees.only here on PRN basis.not working with them every day so [I] don't know them real well. NA-C expressed it was hard when there were only two staff on the floor. The DON noted she explained to NA-C to be aware of these items, and she would be circling back with the residents in a couple of weeks to see if things were better. The DON's investigation documentation failed to identify:The DON addressed the allegation of rough handling of residents during cares with NA-C.Additional staff were interviewed.Other residents were interviewed who were not identified in the complaint.Late reporting occurred from LPN-A to management after becoming aware on 11/16/25, related to allegations of potential abuse. Interview on 2/12/26 at 11:00 a.m., with trained medication aide (TMA)-A identified if a resident made a complaint that someone was rough with them, she would report that right away to the case manager. If the case manager was not there, she would report that to the director of nursing. Interview on 2/12/26 at 4:22 p.m., with the administrator identified that on 11/19/25, the director of nursing (DON) had received a report under her office door from licensed practical nurse (LPN)-A, regarding concern related to NA-C being rough while providing cares. By the time she had learned the details of the letter that morning on 11/19/25, the DON had reported she had addressed the issues and found it to be nothing. Interview on 2/12/26 at 4:43 p.m., with medication aid (TMA)-B identified they had received reports from R26 that NA-C was rough when providing cares (unknown date). TMA-B reports staff left a note at the nurse's desk but had not recalled who was working at the time. TMA-B received training on abuse reporting and stated We are supposed to report to our direct supervisor unless the complaint involves the direct supervisor. In that case they would report to the administrator. Review of the 4/7/25, Abuse and Neglect policy identified the facilities investigation may include interviewing employees, residents or other witnesses to the event. The facility was to interview all involved (employees, residents and family) individually. The investigation should be documented. The facility will have evidence that all alleged or suspected violations were thoroughly investigated and would prevent further potential abuse while the investigation was in progress.

Based on interview and document review, the facility failed to ensure 1 of 14 sampled resident (R26) code status was accurately reflected in all parts of the medical record. Findings include: R26's current face sheet identified she was admitted to the facility in [DATE] with diagnoses of obstructive sleep apnea (absence of breathing while asleep), asthma, chronic kidney disease, a history of multiple surgeries on her back and abdomen, diabetes, anxiety, history of shortness of breath, edema (swelling from fluid retention), arthritis in her bones, and a history scoliosis and other curvatures in her back. R26's quarterly, Minimum Data Set, accepted on [DATE], identified R26 had intact cognition and had no behaviors noted. R26 required the use of a wheelchair and required either extensive assistance or was dependent upon staff for most Activities of Daily Living such as toileting, dressing, and bathing. Observation on [DATE] at 6:22 p.m., of R26's electronic medical record identified on the main screen for R26's electronic medical record (EMR) (at the top in the banner section), R26 was listed as a FULL CODE (all resuscitative measures performed in an emergency). R26's [DATE], Minnesota Health Care Directive identified R26 was her own person but had designated family to act on her behalf with her wishes if R26 was unable to make decisions about her life or care. R26 gave the following instructions about her health care surrounding her values and beliefs, what she did and did not want to do, medical treatments, concerns, fears, etc When my heart no longer circulates my blood, I do not want CPR [cardiopulmonary resuscitation]. I do not want to be on a ventilator. I do not want hemodialysis unless I am coherent and able to decide for myself. I want pain control even that may affect my breathing or circulation. R26 signed the agreement under witness of a Notary Public. R26's [DATE], Care Conference note identified R26 and a family member were in attendance. Staff noted R26 had a physician's order on file for CPR and R26 commented on wanting to update her code status. R26 was given a copy of a blank POLST (Physician Orders Life Saving Treatment) to review. Review of R26's progress notes made no mention of any follow-up after the care conference to identify staff had ensured an updated POLST was obtained, or if staff had checked her current Healthcare Advanced Directive from 2024 that was on file and verified with R26 for accuracy in coordination with her wishes. Interview and document review, on [DATE] at 6:32 p.m., with registered nurse (RN)-C identified when verifying code status, staff look in the EMR but also have a paper copy in a book to reference. The book had a screen shot of the EMR record indicating the incorrect FULL CODE status. The book contained no POLSTs or original physicians' order regarding each resident's code status. Interview on [DATE] at 7:13 p.m., with the social worker (SW) identified he was responsible to check residents' code status, and the Director of nursing (DON) was responsible to ensure the EMR was accurate in the EMR. He indicated R26 was currently a FULL CODE but had recently wanted to change that. He was not aware of the status of her decision. Either he or the DON would assist a resident with updating a POLST, and an RN or care leader would be responsible for getting the code status changed. Interview on [DATE] at 7:24 p.m. with R26 identified at the last care conference ([DATE]), R26 told staff she wanted to change her code status discussed in care conferences from CPR to Do Not Resuscitate (DNR). Staff gave her a new POLST to fill out that day. R26 thought she had given it to a staff nurse to put in her medical record. R26 did not want CPR. R26 was unaware the current electronic medical record entry still identified her as a Full Code (CPR). Interview on [DATE] at 7:53 p.m. with the DON and the corporate consultant identified she agreedR26's POLST and EMR inconsistencies should have been addressed and followed up on after care conference in [DATE]. The EMR should have been updated and the physician contacted. The DON and RNC-B noted they would check all other 55 residents' EMR for accuracy. No other errors or inconsistencies were noted. Review of the [DATE] Advanced Directive including CPR and Automated External Defibrillator policy identified if a cardiac arrest were to occur, CPR must be initiated unless the resident had a valid DNR order on file or a valid Advanced Directive on file. Advanced Directives were to be reviewed with residents and or health care decision-makers at each care plan (conference) meeting to ensure no changes were needed. If a resident informs a staff member, he or she had changed their decision, the resident's wishes for different measures were to be followed and the physician contacted for updated orders. In an emergency, the method to identify code status that was most expedient to determine code status was to be used.

Based on interview and document review the facility failed to identify target behaviors or symptoms for psychoactive medication for 3 of 5 (R3, R7, R26) sampled residents for monitoring. Findings include: R26's accepted 12/27/25, quarterly Minimum Data Set (MDS) assessment identified R26's cognition was intact. She required staff assistance with care. R26 took an antipsychotic, antianxiety, and antidepressant medications. R26 had diagnoses of anxiety and depression. R26's care plan identified she was on medication with FDA boxed warning or warnings of adverse consequences related to major depressive disorder and anxiety. The facility would consult with the pharmacy and health care provider to consider dosage reduction when clinically appropriate. R26 had a depression diagnosis, and the facility would attempt non-pharmacological interventions. R26 enjoyed playing games on her ipad, she enjoyed visits from the companion dogs. R26 used psychopharmacological medications (Seroquel an anti-psychotic medication, duloxetine an anti-depressant medication, and buspirone an anti-anxiety medication) related to anxiety and depression. The care plan identified that a dosage reduction was not clinically appropriate and had been documented as contraindicated on 10/7/24. WAH Behavior Health provider prescribed the medications. The care plan had no mention of target behaviors or symptoms related to the psychoactive medications that R26 took to monitor for effectiveness. Review of the 10/7/24, Certified Nurse Practitioner (NP) specialty in Psychiatry encounter visits notes identified, that R26 had Seroquel increased to 200 milligrams (mg) at bedtime, her duloxetine (Cymbalta) 60 mg twice a day and her buspirone 15 mg in morning and buspirone 30 mg at bedtime would continue. The NP notes had diagnosis listed for each medication. The physician note identified R26 had denied feeling depressed, had paranoia or delusional thoughts and denied any mania however, it was unsure if those were R26's target behaviors or symptoms that all the medication were ordered to treat or not. There was no mention that a dose reduction was contraindicated with a rationale. Review of R26's 2/10/26, printed Order Summary Report identified buspirone HCI 15 mg twice a day for anxiety and mood related to anxiety disorder. Duloxetine HCI 60 mg every day for depressed mood related to major depressive disorder. Seroquel 200 mg at bedtime for major depressive disorder. The orders had no mention of monitoring for side effects of the medication and no mention of target behaviors or symptoms that the medications were ordered to treat. Interview on 2/10/26 at 4:35 p.m., with director of nursing (DON) identified that the facility monitored residents that took psychoactive medication by watching the residents each shift. If a resident was noted to have increased anxiety or stayed in their room and that was not normal, that would be something that she would report to the physician. She was unable to identify specific behaviors or symptoms they monitored R26 for. Interview on 2/10/26 at 4:41 p.m., with registered nurse consultant (RNC)-A identified target behaviors should be identified on the care plan and the nursing assistant Kardex for monitoring of symptoms. RN-C identified the facility was working on reviewing each care plan related to a recent survey where it was identified that the care plans did not reflect the resident's status. The facility had been focusing on reviewing the residents with wounds as that was what the recent survey was about. She confirmed that the facility had not reviewed any care plans to ensure target behaviors or symptoms were identified and would imagine there are care plans with no target behaviors identified. The expectation was that the facility would identify target behaviors or symptoms for each psychoactive medication and that those target behaviors would be monitored for effectiveness of the medication. Review of the 12/9/25, Psychotropic Medications policy identified each resident's medication must have an indication for use and adequate monitoring. The facility behavior committee would ensure that the resident's care plan was up to date and reflect non-pharmacological intervention to be used and the symptoms the medication was treating. A facility RN would complete an antipsychotic medication assessment and abnormal involuntary movement scale assessment for any antipsychotic medication ordered. Throughout the use of psychotropic medication, the facility would document the resident mood and behavior to monitor the effectiveness of the medication on the behavior. The facility would also monitor side effects of medications and notify the physician if side effects occur or worsen. The facility reduction committee would review the need for psychotropic medications every 3 months and document the rationale to continue the medication. The committee would further monitor the resident target symptoms and the effect of the medication. R3's 12/27/25, quarterly Minimum Data Set (MDS) assessment identified he admitted to the facility in December of 2024. His cognition was moderately impaired, and he had diagnoses of Alzheimer's Disease, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). R3's current undated care plan identified he has a diagnosis of anxiety, depression, and PTSD. The goal was for R3 to remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. The facility staff were to offer companionship visits, invite him to social activities, engage in life review, offer opportunities to express feeling/suggestions/concerns, and receive dog visits. The care plan made no mention of target behaviors that staff should monitor for to determine if the intervention or medications used were effective in treating R3's mental illness. R3's February 2026, medication administration record (MAR) identified he was administered citalopram hydrobromide (antidepressant medication) 10 milligrams (mg) daily for PTSD, anxiety, and mood disorder due to a known physiological condition with depressive features. The MAR made no mention that staff should monitor R3 for target behaviors to determine if the medications he was being administered were effective. R7's 12/19/25 quarterly Minimum Data Set (MDS) assessment identified she was admitted in October 2025, her cognition was moderately impaired, and she had a diagnosis of depression. R7's current, undated care plan identified she has a diagnosis of depression. Staff were to consult with pharmacy, and health care provider to consider dosage reduction when clinically appropriate, monitor conditions based on clinical practice guidelines or clinical standards of practice for the medications she is taking, and attempt non-medication approaches (visits with pastor, staff, or reading kindle). The care plan made no mention staff should be monitoring target behaviors to identify if the medication or treatment was effective for R7. R7's February 2026, MAR identified she was administered citalopram (anti-depressant) 20 mg daily in the morning related to a diagnosis of major depressive disorder. The MAR made no mention that staff should be monitoring for target behaviors to determine if the mediations she was being administered were effective. Interview on 2/12/26 at 3:00 p.m., with the director of nursing identified the target behaviors should be indicated on the resident's care plan or the administration record; however, she was not sure if that had been completed for all residents with behaviors or residents who were taking psychotropic medications. She is aware they have some issues with care plans not being complete and/or updated with the correct information, but they are working on it. She would expect staff to add the target behaviors to the care plan so that licensed nurses and nursing assistants can access the information.

Based on interview and document review the facility failed to notify the ombudsman of a discharge for 2 of 2 (R6, R61) sampled residents.Findings include: R61's 12/19/25, accepted discharge Minimum Data Set (MDS) identified an unplanned discharge return not anticipated. R61 had discharged on 12/15/25 and returned home. R61's 12/15/25, progress note identified that R61 had discharged home with family against medical advice. Interview on 2/12/26 at 3:00 p.m., with social service designee (SSD) identified that she had just clarified discharge reporting with the ombudsman on 2/11/26, as she was unsure of the process. She reported that the licensed social worker (LSW) had not reported R61's or R6's unplanned discharge from the facility to the ombudsman. She further identified she had not reported the discharges to the ombudsman either. She identified that neither she nor the LSW were aware of reporting all discharges including an unplanned discharge or discharge against medical advice. R6's 11/21/25, discharge Minimum Data Set (MDS) assessment identified she discharged to the hospital on [DATE]. R6's transfer form identified she was sent to the hospital emergency department for evaluation following a fall on 11/13/25. R6's 11/21/25, hospital discharge summary identified she was admitted to the hospital on [DATE] for hip repair surgery. She remained in the hospital for 7 days and was discharged to a long-term care facility on 11/21/25. Review of 1/15/26, Discharge and Transfer policy identified when a discharge or transfer occurred that information would be documented in the resident's medical record. The Office of the State Long-Term Care Ombudsman must be notified of a transfer or discharge with the location of the discharge or transfer.

Based on interview and document review, the facility failed to complete and submitted a timely quarterly Minimum Data Set (MDS) assessment for 1 of 1 (R56) resident reviewed.Findings include: R56's 2/12/26, printed admission Record identified that R56 had been admitted to the facility at the end of September 2025. R56's MDS section in Point Click Care (PCC), the facilities electronic medical record identified that R56's last MDS was completed with an Assessment Reference Date (ARD) of 9/26/25 as an MDS admission/5-day assessment. There had been no other MDS's initiated or started under the MDS section of the facilities PCC electronic medical record. Interview on 2/12/26 at 9:07 a.m., with registered nurse (RN)-B identified that she was responsible for completing and submitting the MDS assessments. She revealed that PCC did not automatically calculate R56's MDS schedule and she had missed completing a quarterly assessment for R56. She confirmed that the quarterly MDS should have been completed in December of 2025. Interview on 2/12/26 at 3:21 p.m., with the senior clinical reimbursement specialist for the facility identified that R56 had a missed quarter assessment. Review of 10/27/25, MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument) policy identified that the facilities PCC system automatically calculated the MDS schedules. Centers for Medicare & Medicaid Services (CMS) mandates MDS transmission no later than completion date plus 14 calendar days, the facility completes weekly transmission of MDS data. The policy referred to the RAI manual for guidance not reflected in the policy. There was no identification of time requirements for completing the various MDS assessments. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025, identified quarterly MDS assessment would be conducted every 92 days and submitted within 14 days of completion.

Based on interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PAS) level I was completed accurately for 1 of 1 resident (R3) reviewed for PASARR. Findings include: R3's 1/2/25, comprehensive Minimum Data Set (MDS) assessment identified he was admitted to the facility in December of 2024, his cognition was moderately impaired, and he had diagnoses of anxiety, depression, and post-traumatic stress disorder (PTSD). R3's diagnosis report identified he had a diagnosis of PTSD, insomnia due to other mental illness condition, anxiety disorder, and mood disorder due to known physiological condition with depressive features upon admission. R3's 12/18/24, initial pre-admission screen (PAS) completed by the facility and submitted to Senior LinkAge indicated that R3 had no major mental health disorders diagnosable as listed in the diagnostic and statistical manual of mental disorders (DSM). R3 did not meet the criteria for mental illness (MI) however, final determination would be made by Senior LinkAge Line. Interview on 2/11/26 at 8:41 a.m., with the facilities registered nurse consultant (RNC) reviewed R3's PAS and identified he had PTSD that should have been noted on the PAS. She would expect the facility to complete a more thorough assessment and ensure the pre-admission screen be completed correctly to ensure residents receive appropriate care. Review of the facility provided 12/29/25 Pre-admission Screening and Resident Review (PASARR) policy identified All prospective residents will be screened for possible serious mental disorders or intellectual disabilities and related conditions. The initial pre-screening is referred to as PASARR Level I. A positive Level 1 screen necessitates an in-depth evaluation of the individual, known as PASARR Level II, conducted by the state-designated authority prior to admission.

Based on interview and document review, the facility failed to have an integrated care plan to coordinate and delineate what services hospice was to provide and what services the facility was to provide, to ensure oversight and services would be provided for 1 of 1 sampled resident (R5) reviewed for hospice care.Findings include: R5's 2/6/26, quarterly Minimum Data Set (MDS) identified R5 had severe cognitive impairment and was dependent on staff to assist with his cares. R5 had a condition or chronic disease that may result in life expectancy of less than 6 months and was currently receiving hospice services. R5's hospice care plan identified the hospice NA would perform or assist with duties as directed. The hospice aid would apply lotion, assist with incontinent cares, dressing, and shampoo and haircare. The hospice aid would clean and tidy R5's room and report to the registered nurse with any questions or concerns. The hospice staff would effectively collaborate with facility/agency staff or providers. The collaboration with the facility staff would include discussion of the plan of care and discussion of a schedule and with an invite to the agency interdisciplinary group. R5's 11/19/25, care plan identified a terminal prognosis related to end stage dementia and cardiovascular disease as evidence by requiring hospice care. R5 would have support from the hospice provider. Hospice visits from a registered nurse and a nursing assistant would be twice a week or more often as needed. The social worker was to come 1-2 times a month or as needed. The facility staff would encourage support systems from family and friends. There was no mention of what services hospices would provide to R5 to ensure coordination of care. Interview on 2/10/26 at 12:44 p.m., with trained medication aide (TMA) identified that the hospice nurse would complete wound care when she was here. She was unsure if the hospice aid did any type of care with R5. She had only observed the hospice aid sitting and visiting with R5. Hospice did have a schedule in the hospice book at the nurse's station, and the hospice staff typically came to see R5 on Monday and Thursdays. Interview on 2/12/26 at 10:45 a.m., with nursing assistant (NA)-M identified that hospice staff came to the facility and typically just sat with R5. The facility staff completed all his cares. She revealed she reviewed the Kardex for directions on how or what cares to provide to R5 and was unaware of the hospice care plan. Interview on 2/12/26 3:15 p.m., with the director of nursing (DON) identified she was unaware that the facility care plan needed to have more information other than the hospice provider's name and phone number. The hospice provider typically provided their own care plan and the facility kept that in a book at the nurse's station. She confirmed there was no mention in the facility care plan of what type of cares or services hospice would provide as was identified in the hospice care plan. Review of the 4/8/24, hospice agreement identified coordinated plan of care meant the plan of care for a resident would clearly delineate what services to be provided by hospice and the facility, based on assessments, and the residents current medical, physical, psychological, and social needs. The facility will immediately notify hospice with a significant change in the residents' physical, mental, emotional, or social status. If clinical complications appear or a need to transfer the hospice resident from the facility for any condition, or the resident dies.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R1) who had impaired hearing was provided hearing aids daily. Findings include: R1's 10/29/25 comprehensive Minimum Data Set (MDS) assessment identified hearing and cognition are moderately impaired. R1's current, undated care plan identified he has impaired thought process and decision making related to the aging process and he would be able to communicate basic needs on a daily basis. R1 would need assistance with all decision making and staff were to ask him yes or no questions in order to determine his needs. R1 had a communication problem related to his hearing deficit. Staff were to ensure and document hearing aids are both in place during the day and removed at bedtime. R1's care plan did not identify a behavior of refusing hearing aids nor did it identify what staff should do if R1 refused his hearing aids. R1's December 2025 through February 2026, Treatment Administration Record (TAR) identified an order for staff to insert hearing aids at 7:00 a.m., daily and remove them at 8:00 p.m., daily. Staff were to irrigate ears as needed. Staff had signed off on the TAR that R1 had refused his hearing aids all but 5 of 73 days. R1's TAR did not identify that staff had completed a treatment to irrigate his ears at any time during this period. Observation and interview on 2/9/26 at 2:59 p.m., R1 had a difficult time hearing and identified he had hearing aids, but they were in the office. He said if he wants them, he must ask staff for them. Observation and interview on 2/11/26 at 9:45, am identified R1 did not have his hearing aids placed. R1 identified he was having difficulty hearing and stated his ears needed to be cleaned. R1 identified staff had not offered him his hearing aids. Observation and interview on 2/12/26 at 8:59 a.m., identified R1 did not have his hearing aids and had already eaten breakfast. He identified when he has asked for his hearing aids or when he has complained that his ears need cleaning, staff say they will come back but they do not return with his hearing aids or come back to clean his ears. Observation and interview on 2/12/26 at 9:04 a.m., with the medication aid (TMA)-A stated, he refuses his hearing aids everyday. She identified that when R1 refuses she marks the treatment administration record (TAR) to note refusal and write a progress note. TMA-A retrieved the hearing aids from her cart and went into R1's room. She asked R1 if he would like his hearing aids in. He responded yes and told the TMA his ears needed to be cleaned. The TMA inserted the hearing aids and left the room. Review of the facility provided 12/1/25, Hearing Services, Hearing Device Care policy identified if a resident is unable to handle his/her hearing aids, the staff needs to develop a plan for the insertion of the hearing aid in the morning and the removal in the evening for safe keeping. Staff should check ear canals periodically for was buildup and document findings.

Based on observation, interview, and document review, the facility failed to have signage posted outside the door for 1 of 1 medication room (South) identifying oxygen canisters were stored within. Findings include: Observation on 2/10/26 at 4:32 p.m., of the South medication room with licensed practical nurse (LPN)-A identified a cupboard to the far right of the door, with a pullout drawer containing 3 canisters of oxygen (O2). The canisters were held in place in individual holders inside the cabinet. Upon inspection, the outside of the medication room did not have signage posted notifying staff oxygen was being stored in the medication room. LPN-A normally did not work on that wing and was unaware of the oxygen being stored there. Interview on 2/10/26 at 5:44 p.m., with the director of nursing identified she agreed when O2 was stored in a room, signage should be placed on the outside of the room, identifying O2 was being stored within. Review of the 7/30/25, Oxygen Administration, Safety, Mask Types policy identified its purpose was to store O2 in a safe manner. All appropriate signage was to be displayed according to federal, state, and local laws. O2 was noted to be dangerous. Staff were to avoid use of flammable materials (oils, greases, alcohol-based products). O2 cannisters were to be stored on a clean, controlled area. There was no mention of O2 signage placement outside of rooms that contained oxygen within the policy. Review of the current, National Fire Prevention Association (NFPA) 99, published 2012, section 11.3.4.1, identified for storage of oxygen, a precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

Based on observation, interview, and document review, the facility failed to ensure controlled narcotic medication awaiting destruction were easily reconciled in 1 of 3 med rooms (South) to prevent potential diversion.Findings include: Observation and interview with licensed practical nurse (LPN)-A in the South medication room identified a locked cupboard that contained medication awaiting destruction. Of those medications, the following controlled/narcotic blister-pack medication had been discontinued, but were not noted on any list to verify the medications were tracked and secured from potential diversion:R26 had 4 tablets of tramadol (pain), each 50 milligram (mg) awaiting destruction. R17 had 12 tablets of tramadol, each 50 mg dose awaiting destruction.R24 had 5 tablets of lorazepam (anti-anxiety), each 0.5 mg awaiting destruction.R7 had 1 tablet of preglabin (anti-convulsant) at 150 mg.R17 had 30 tablets of lorazepam, each 0.5 mg awaiting destruction.R2 had 9 tablets of Xanax (anti-anxiety), 0.5 mg each and another blister pack of Xanax 0.5 mg with 10 tablets remaining awaiting destruction.LPN-A noted she normally had not worked on the South wing, but stated the facility kept all controlled medication awaiting destruction in the locked cabinet. Nursing staff had access to the key. The facility practice was to store medications awaiting destruction in that locked cabinet within the locked medication room. Staff would wait for the director of nursing (DON) to destroy medications. Staff would not keep track of the medications once in the cabinet in order to be able to easily reconcile those medications to prevent potential diversion from being easily recognized. Interview on 2/10/26 at 5:44 p.m., with the DON identified she was aware the narcotics were stored in the cabinet awaiting destruction and verified the medications were no longer tracked for easy reconciliation of potential diversion. A policy for medication storage was requested but not received prior to the end of the survey.

Based on interview and document review, the facility failed to ensure pharmacist consultant recommendations were acted upon for 1 of 5 sampled resident (R26).Findings include: R26's accepted 12/27/25, quarterly Minimum Data Set (MDS) assessment identified R26's cognition was intact. She required moderate to total assistance from staff for Activities of Daily Living (ADL'S). R26 took an antipsychotic, antianxiety, and antidepressant medications. R26's current undated, care plan identified she was on medication with warnings of adverse consequences related to major depressive disorder and anxiety. R26 used psychopharmacological medications Seroquel (an anti-psychotic), duloxetine (an anti-depressant), buspirone (an anti-anxiety) related to anxiety and depression. R26's 2/10/26, printed Order Summary Report identified that R26 took quetiapine fumarate (Seroquel) an antipsychotic medication daily. R26's 1/28/26, pharmacist recommendation identified for nursing to complete an abnormal involuntary movement scale (AIMS) assessment. The AIMS assessment was a tool to detect and monitor the severity of tardive dyskinesia (TD) in residents taking antipsychotic medication. R26's electronic medical record identified under the assessment section the last AIMS assessment had been completed on 5/9/25. Interview on 2/11/26 at 10:50 a.m., with director of nursing (DON) identified she was responsible to ensure that the pharmacy recommendations were acted upon. She confirmed the 1/28/26, pharmacy recommendation for the facility nursing staff to complete an AIMS assessment did not get done. She identified the last AIMS assessment was completed on 5/9/25 eight months ago and should be completed every six months. Review of the 10/9/25, Psychotropic Medication policy identified a registered nurse must complete an AIMS assessment for each resident prescribed an antipsychotic medication. The AIMS assessment was to be completed every 6 months. Any changes in the AIMS assessment, the facility would notify the family/representative and physician with the notification documented in the resident's medical record.

Based on observation, interview, and document review, the facility failed to ensure the overall medication error rate was below 5% for 2 of 25 observations resulting in an 8% medication error rate.Findings include: Observation on 2/10/26 at 11:54 p.m., with licensed practical nurse (LPN)-B identified she went to administer 1 tablet of Baclofen (muscle relaxant) 10 milligrams (mg) and 1 tablet of spironolactone (diuretic) 25 mg, inside of a medication cup to R47 who was reported to be in her room. LPN-B knocked on R47's room door. R47 was not inside her room, so LPN-B left the medication cup containing the medications on R47's dresser drawer just inside her room and shut the door. LPN-B stated R47 was able to self-administer her medications, so she would leave them there for her to take them later. LPN-B then returned to the medication cart and finished the medication pass identifying and marked the medication had been administered in the electronic medical record (PCC). Interview on 2/10/26 at 5:44 p.m. with the director of nursing identified staff were not to leave medications unattended inside of a resident room or mark the medications administered. Review of the 4/8/25, Medication Administration Including Scheduling and Medication Aides policy identified medications were to be administered according to the Six Rights of medication administration [right patient, right medication, right dose, right route, right time, and right documentation]. In the section of self-administration, the policy noted staff were to be aware of medications kept in the room. There was no mention staff should ensure security of those medications in the policy.

Based on observation, interview, and document review the facility failed to identify, comprehensively assess, monitor, and develop interventions to prevent/mitigate the risk of pressure ulcer development and/or deterioration for 4 of 4 residents (R1, R2, R3, R5). The facility's failure resulted in Immediate Jeopardy (IJ) for R1 when the facility failed to prevent and manage impaired skin integrity that progressed to bone and soft tissue infections which required hospitalization for treatment and management.The IJ began on 12/31/25 after R1's existing buttock wound(s) were documented as black and blue tissue to the buttocks, with ongoing inconsistent identification of skin integrity and without completion of comprehensive wound assessments, physician notification, or implementation of effective treatment and pressure-relieving interventions to prevent further deterioration. The Administrator, director of nursing (DON), regional clinical services director, senior director, and clinical care lead registered nurse (CCLRN)-B were notified of the IJ on 1/22/26 at 1:34 p.m. The IJ was removed on 1/27/26 at 1:58 p.m., but non-compliance remained at the lower scope and severity level E, which indicated no actual harm, with the potential for more than minimal harm that is not immediate jeopardy. R1R1's face sheet dated 1/20/26, identified R1 admitted with diagnoses of paraplegia (paralysis of legs and lower body), pressure ulcer of right heel (diagnosis added 8/11/25), type 2 diabetes, and obesity. On 1/13/26, diagnoses of pressure ulcer of other site, pressure ulcer of unspecified, pressure ulcer of left buttock were included.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairments, no rejection of care, had an indwelling catheter and ostomy, had impairment on both sides of lower extremities, dependent for lower body care, maximum assistance to roll left and right, and dependent to transfer from surfaces. R1 was at risk of developing pressure ulcers/injuries but did not have any pressure ulcers and no open lesions. Treatments included pressure-reducing devices for chair and bed. R1 was not on a turning and reposition program, no nutrition or hydration interventions, and no dressing or treatments to feet.R1's Nursing Admit/Re-admit Data Collection dated 7/24/25, identified R1 had a right heel wound. Despite the instructions on the form that directed .staging to be completed by an RN [registered nurse].Important Note: include the type of skin observation (blanchable or non-blanchable), size, color, odor or discharge in the description., there was no further information documented. R1's care plan dated 7/25/25, did not identify a skin integrity focus nor identified R1 had a wound on his right heel. The care plan identified R1 required extensive assistance of one staff to turn from side to side. R1 was able to assist by using the grab bars located on both sides of the bed. Dependent on two staff to transfer between surfaces using the mechanical lift.R1's Skin Observation dated 7/31/25, identified R1 had a bath and skin check was completed. The evaluation had no mention of the right heel wound as identified on 7/24/25.In review of R1's record between 7/24/25 through 8/3/25, the care plan was not revised to identify the heel wound and not revised until 8/4/25 with new pressure relieving interventions to prevent deterioration and new wound development. R1's progress note dated 8/1/25, identified R1 was transferred to the hospital. R1's care plan dated 8/4/25, identified R1 had potential for pressure ulcer development related to dehydration, disease process, history of ulcers, and immobility. Interventions directed staff to position oxygen and indwelling urinary catheter tubing appropriately; Provide pressure redistributing mattress on bed and cushion on manual wheelchair; and notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care.R1's progress note dated 8/11/25, identified R1 returned from hospital. R1's Nursing Admit/Re-admit Data Collection dated 8/11/25, had the same instructions for documenting the wound as previous assessment dated [DATE]. The assessment identified R1 had right heel wound with a description of dried blood area size of nickel, and sacrum slightly red. These areas were not measured, staged, or the surrounding skin condition identified. Despite the identification of new impaired skin integrity on R1's sacrum and the existing heel wound, there was no indication R1's care plan was revised with new pressure relieving/prevention interventions to address R1's sacral redness.R1's Treatment Administration Record (TAR) dated 8/11/25, identified for the nurse to acknowledge every shift: heel lift boots while in bed for heel protection and pressure reduction. Assess bony prominences, turn and reposition every 2 hours, protect skin and keep clean and dry, moisture barrier for incontinence, use lift pad.R1's RN Wound assessment dated [DATE], identified right heel unstageable pressure ulcer. There is a 1.5-centimeter (cm) x 1.5 cm eschar (dry, dark scab) wound that was present on readmission. Surrounding skin is slightly pink. Mepilex applied to wound and off-loading boots to both feet. Referral made to local wound center. The wound assessment did not address the red sacrum identified on the 8/11/25 assessment and there was no indication the care plan was updated to reflect the off-loading boots until 10/30/25 (however updated on TAR 8/11/25).R1's Wound Clinic Visit Report dated 8/19/25, identified the wound on R1's right heel as stage 3 pressure ulcer. Wound measured 1.0 cm x 1.2 cm x 0.2 cm depth. No tunneling or undermining (pocket or shelf beneath skin) noted. Small amount of serosanguineous drainage noted. Wound margin is distinct with the outline attached to wound base. No granulation (new tissue growth) within the wound bed. A large amount (67-100%) of necrotic tissue within the wound bed including eschar and adherent slough. No probe to bone. The wound was debrided (removal of dead, infected, or damaged tissue) of eschar tissue and was not tolerated well. New wound measurements were 1.0 cm x 1.2 cm x 0.3 cm depth. Treatment included cleanse with normal saline, apply Iodosorb ointment to wound bed, avoid getting on surrounding skin. Cover with gauze sponge and tape. Prevalon boot at ALL times. Other non-wound condition instructions included buttocks looks okay, no need for Mepilex unless there is a concern, than may apply. In review of R1's record, despite the direction for R1 to have Prevalon boot (brand of off-loading boot) there was no indication the care plan was revised until 10/30/25 (however was on the TAR 8/11/26).Review of R1's wound clinic notes in conjunction with RN Wound Assessments and Skin Observations between 8/20/25 through 9/3/25, did not identify any impaired skin integrity to R1's buttocks/sacral/coccyx regions and or perineal areas.R1's progress note dated 9/4/25, identified R1 had a new pressure sore to his right buttock. R1 had been refusing staff to get up in his chair at mealtimes per therapy. Explained the risks of not repositioning but R1 continued to refuse. Faxed physician regarding new pressure sore found on R1's right buttock. R1's record did not include a comprehensive assessment of R1's pressure ulcer to right buttock.R1's Wound Clinic Visit Report dated 9/10/25, identified the stage 3 pressure ulcer to right heel. Measured 0.8 cm x 0.4 cm x 0.2 cm depth. New orders for Santyl ointment in wound bed. R1 had new concerns of an ulceration to the urinary meatus (opening of the urethra) from his catheter. R1 reported he had reconstructive surgery to the area and had chronic issues with erosion (loss of epithelial tissue) of the glans (tip of penis) as a result of long-term catheter use. This wound was classified as stage 3 pressure ulcer at 3 o'clock. Measured 1.5 cm x 0.7 cm x 0.1 cm depth. Medium amount of serous (watery discharge) noted. Wound margin is flat and intact. No granulation within the wound bed and small amount of necrotic tissue within the wound bed. Noted R1's incontinent brief was causing serious tension to the catheter that led to the breakdown. Repositioned the device that holds the catheter in place at the leg to the right leg. Brief removed in order to avoid further irritation to the skin and silicon barrier cream twice daily. In review of R1's record there was no indication the care plan was revised to identify the presence of the new ulcer on the urinary meatus nor revised to address interventions pertaining to the urinary catheter placement and incontinent garment usage.R1's Skin Observation dated 9/12/25, indicated new wound development; left buttock-open area with current treatment of a Mepilex to area and right buttock open area with current treatment as barrier cream to area. In review of R1's record there was no indication these areas were comprehensively assessed nor evident a comprehensive assessment was completed for a turning and repositioning program, nor the care plan was revised with pressure relieving/prevention measures.R1's wound clinic notes, RN Wound Assessments and Skin Observations records were reviewed between 9/10/25 through 11/7/25. The Wound Clinic notes during this period identified on 9/10/25 a new wound on R1's urinary meatus stage 3 pressure ulcer which was comprehensively assessed and was documented as healed on 9/25/25; associated interventions for this wound included avoidance of briefs and use of undergarment pads only, which was recommended on 9/18/25 and reiterated on 10/2/25, at which time R1 was documented as wearing a brief despite prior recommendations. The left and right buttock skin impairments identified on Skin Observation form on 9/12/25 were not addressed by the wound clinic until 10/17/25, when the wound clinic determined the presence of partial thickness shearing injury; the shearing injury was subsequently documented as healed on 10/24/25. The right heel pressure ulcer was comprehensively assessed by the wound clinic beginning 9/18/25, with ongoing monitoring and treatment recommendations including strict offloading, and was documented as healed on 11/7/25. In contrast, the facility's RN Wound Assessments, progress notes, and Skin Observations did not include ongoing comprehensive assessments of R1's buttock wounds identified on 9/4/25 and 9/12/25 nor identify the urinary meatus pressure ulcer prior to wound clinic identification on 9/10/25 and reflected inconsistent wound identification with variable assessment details.R1's quarterly Braden Scale for Predicting Pressure Score Risk dated 10/30/25, identified R1 was at moderate risk for pressure ulcers. The assessment included an intervention guide, for moderate risk which suggested interventions of: frequent turning with a planned schedule, use foam wedges for thirty degree lateral positioning, pressure reduction support surfaces, maximal remobilization, protect heels, manage moisture, manage nutrition, manage friction and shear*if other major risk factors present, advance to next level of risk. Also included were interventions to manage moisture, nutrition, friction and shear, and other general care issues.R1's care plan dated 10/30/25, was revised to include use of heel boots/protective boots while in bed and received diabetic nutritional supplements twice daily for wound healing. The care plan did not address the wound clinic's directions for prevention/minimization of re-current pressure injuries pertaining to the urinary catheter nor address interventions to prevention/minimization the risk of re-current shearing injuries to buttocks until 11/20/25.R1's Wound Clinic Visit Report dated 11/7/25, identified R1 was discharged from wound center today.R1's Skin Observation dated 11/11/25, identified no skin conditions observed.R1's interdisciplinary team (IDT) progress note dated 11/12/25, identified IDT met to review resident status. Followed by outside wound care services (sic-discharged on 11/7/25). R1 is to be up in chair for about two hours around mealtimes, compliant, often refuses. Diabetic boost taken for wound healing. New wounds seen on bottom and back, he can reposition himself but does not, a lot of the time. Monitoring these wounds. He needs much re-education on why these two new wounds are not healing (lack of repositioning, not getting out of bed.) mepilex on. these wounds are worsening. Using skin barrier to these areas. It is felt the buttock wound is due to the shearing, not pressure. He also has a wound on the penis where the catheter comes out. Silicone cream being used and ABD pads.In review of R1's IDT progress notes from 9/30/25-1/14/26, the information and word structure remained almost identical. According to the Wound Clinic notes R1's buttock wounds were healed on 10/24/25 and based on the R1's skin records after 10/25/24 that identified coccyx wound/buttock skin impairment it could not be ascertained if the IDT notes were redundant since 9/30/25 or the wounds on and after 11/12/25 were new wounds. R1's IDT progress note dated 11/18/25, was verbatim from progress note on 11/12/25 with no new information identified. R1's progress note dated 11/18/25, identified R1 would not get out of bed this shift, nor would he take a bath.R1's Skin Observation dated 11/20/25, identified shearing on left and right buttocks. No comprehensive assessment and/or additional information was included. R1's care plan dated 11/20/25, identified R1 had shearing on his left and right buttock and is at risk for skin breakdown and shearing related to immobilization/chairbound/bedbound and used the total lift sling evidenced by open shearing areas on both left and right buttock. Interventions included to keep skin clean and dry. Use skin barrier cream to buttocks daily and protect these areas with a dressing when open and draining. High risk for skin injury-use caution during transfers when using the sling being cautious to not quickly and forcefully place the sling under R1. Monitor for signs of shearing. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to health care provider.R1's faxed request to physician dated 11/21/25, identified FYI: R1 continued to have some shearing on buttocks off and on due to resident not wearing a brief as this causes other issues with skin breakdown in groin and penial area. Will continue to apply skin barrier cream to bottom when appropriate or cover with a coccyx mepilex if area is more open and drainage. Physician responded OK.R1's faxed request to physician dated 11/25/25, identified R1 was more depressed and refused to get out of bed which caused increased skin breakdown and open sores on his buttocks. Physician response was to get a psych consult. There was no indication R1's care plan was revised that addressed R1's refusals or repositioning program.R1's IDT progress note dated 11/26/25, was verbatim when compared to IDT progress notes dated 11/12/25 and 11/18/25 which included R1 is to be up in chair for about two hours around mealtimes, compliant, often refusesDuring an interview on 1/22/26 at 8:51 a.m., NA-D stated a resident could refuse cares three times before they told the nurse. NA-D had worked with R1 since admission and R1 rarely refused cares. When R1 refused care, NA-D would go back later and R1 would always accept the cares offered.R1's record was reviewed which included Skin Observations, Wound Data Collections, and progress notes between 11/8/25 through 12/30/26. The skin observations identified inconsistent identification of the presence and location of wound (coccyx vs right and/or left buttocks) with no comprehensive assessment of the impaired skin integrity when identified. Skin Observation dated 12/5/25 identified pressure sore to coccyx, Observation on 12/12/26 identified no skin impairments, Observations dated 12/19/25, 12/29/25, and 12/30/25 described wound(s) on buttocks as shearing.R1's Wound Data Collections between 12/12/25 and 12/26/25 identified the area of impaired skin integrity was on R1's coccyx and/or coccyx/sacrum but not buttocks as described in the Skin Observations. Wound Data collections during this period were not comprehensive as none of these assessments included measurements nor included type of wound present. Examples from the record included:R1's Wound Data Collection dated 12/12/25, identified coccyx. Dressing present and intact. No drainage on the dressing.R1's Wound Data Collection dated 12/16/25, identified wound location coccyx and the site was sacrum. Protective cream applied after shower. Dressing present and intact. No drainage on dressing. R1's physician note dated 12/19/25, had no mention of shearing injury or other wounds.R1's IDT progress note dated 12/24/25, was verbatim compared to IDT progress notes dated 11/12/25 and 11/18/25, and 11/26/25 with no new information added. R1's nursing order dated 12/25/25-12/30/25, identified clean buttock area with soap and water or wet wipes. Apply a thin layer of zinc oxide to both buttock areas and cover each buttock with an ABD pad and secure the outer edge with tape daily.R1's Wound Data Collection dated 12/27/25, identified coccyx. Dressing present and intact. No drainage on dressing. Pink skin around dressing. Cleansed with wound cleanser, applied ABD pad, secured with tape.R1's Wound Data Collection dated 12/29/25, identified a new wound on R1's left lateral foot that measured 1.2 cm x 1.0 cm x 0.1 cm depth. [NAME] in color. Applied skin prep and covered with Mepilex. No other information was included.R1's Skin Observation dated 12/29/25, identified left and right buttock shearing. Cleansed area and covered with ABD pads secured with tape. Applied zinc oxide to reddened areas that were not open.R1's Skin Observation dated 12/30/25, right and left buttock shearing. Mepilex and ABD to areas.R1's Wound Data Collection dated 12/30/25, identified left buttock has shearing to area, right buttock has darkened area with redness surrounding it. Applied skin prep and covered with mepilex.R1's Skin Observation dated 12/31/25, identified right buttock shearing, left buttock shearing-black and blue tissue noted, left lateral foot-dried calloused area. Covered with ABD pads and secured with tape. Applied iodine to left lateral foot. In review of R1's records between 12/5/25 through 12/31/25, it was not evident the physician was notified of new wounds nor changes to treatment orders. Additionally, between 12/27/25 through 12/31/25 there was no indication R1's right and left buttock wounds and left lateral heel were comprehensively assessed. Nursing order dated 12/31/25-1/8/26 directed clean buttock area with soap and water or wet wipes. Cover each buttock with ABD pad and secure outer edges with tape. Apply zinc oxide to other areas that are red but not open daily. Skin Observations dated 1/2/26, 1/3/26, and 1/6/26 reflected variable identification of skin integrity. On 1/2/26, no skin conditions were observed. On 1/3/26, a small dark pressure area measuring 1.0 cm x 1.0 cm was identified on the left heel/lateral area, and skin prep and Mepilex were applied. On 1/6/26, no additional skin concerns were identified, and documentation noted ongoing daily treatment to the buttocks.During an interview on 1/20/26 at 2:40 p.m. with NA-C and NA-B present, nursing assistant (NA)-C stated R1 had the wounds on his buttocks prior to September. The buttocks had gotten progressively worse from the size of a nickel to the size of a quarter. NA-C was unable to articulate a time frame, for when the buttocks looked worse, but it was somewhere from two weeks to a month and a half ago. NA-B stated R1 refused to turn and reposition however, if staff re-approached when he refused to get out of bed that seemed to work. R1 would sometimes pull the wedge cushion out that helped him stay on his side when in bed. If R1 went to his recliner or wheelchair he would want to go back to bed after about 20 minutes.R1's Wound Data Collection dated 1/7/26, initial data collection for left buttock wound, type of wound was not included. The wound measured 8.0 cm x 6.0 cm x 0.2 cm depth. Drainage present with a presence of possible complications described as eschar and slough present. Wound bed was 25% slough and 75% eschar. Minimum sanguineous drainage with no odor present. Wound edges were macerated and erythematous. Cleansed area with soap and water, covered with hydrofera blue, ABD pads secured with tape.R1's Wound Data Collection dated 1/7/26, initial data collection for right buttock wound, type of wound was not included. The wound measured 6.0 cm x 4.0 cm x 0.2 cm depth. Drainage present with a presence of possible complications described as eschar and slough present. Wound bed was 60% slough and 35% eschar. Moderate sanguineous drainage with no odor present. Wound margins were macerated and erythematous. Cleansed area with soap and water, covered with hydrofera blue, ABD pads secured with tape.R1's progress note dated 1/7/26 at 9:30 p.m., identified R1 stated he was not feeling like himself. Stated he was having chest/heart pain but mostly felt his heart hurt. Nitro administered and pain was 8/10 to begin and 2/10 after nitro given.R1's progress note dated 1/8/26 at 10:12 a.m., identified physician was notified for R1 having heart hurting and pain going down back on left side. Had good results from nitro the evening before. Verbal order to go to emergency department. At 12:55 p.m., returned from emergency room with no changes made to medications after electrocardiogram and x-ray obtained.During an interview on 1/20/26 at 2:46 p.m., RN-B stated she last worked with R1 on 1/7/26 and 1/8/26. When she changed the dressing on 1/8/26, there was not an odor to the wound, but had felt there had been an odor prior. The wound was red, moist, and the skin around was pink. There was an additional small wound just below the one that was the original pressure ulcer on the left side. RN-B informed clinical care lead RN (CCLRN)-B the left buttock was worse, it had spread and was bleeding; the right buttock was only reddened skin. RN-B did not work again until after R1 had been sent to the wound clinic on 1/13/26. On 1/21/26 at 10:09 a.m., RN-B stated CCLRN-B would always measure the wounds, sometimes do the wound care, notify the physician, and put the orders in the computer. Nurses would follow what the computer directed for orders. CCLRN-B was always the first person RN-B would go to with wound concerns as she was a wound care nurse prior to working at the facility. RN-B reviewed documentation on R1's skin for December and January and noted the wounds had not been measured until 1/7/26.R1's progress note dated 1/12/26 at 6:06 p.m., identified R1 complained of nausea. At 10:55 p.m., nausea was better but now complaints of headache. Medicated with as needed Tylenol. Has two appointments in the morning.R1's progress note dated 1/13/26 at 1:08 p.m., identified wound clinic called and stated they sent R1 to the emergency department with fever, chills, and R1 would most likely be admitted .During a phone interview on 1/20/26 at 1:41 p.m., certified wound nurse practitioner (CWNP)-A stated she knew R1 well and had followed his wound care from 8/19/25-11/7/25, when all wounds were healed. Wound clinic received a referral on 1/12/26 for pressure ulcer right lateral foot, left and right buttock pressure ulcers from facility. On 1/13/25, R1 came to the wound clinic. The wounds were classified as unstageable on right lateral foot, unstageable pressure ulcer to the gluteus, and stage 3 left ischium. The gluteus was very advanced and infected, so wound clinic sent R1 to the emergency department. CWNP-A saw R1 inpatient at the hospital from [DATE]-[DATE] and debrided the wound daily. The wound was to the bone when CWNP-A last saw it on 1/17/26. R1 was diagnosed with osteomyelitis, cellulitis, and soft tissue infection. Emergency department was suspicious of one but unable to officially diagnose until after MRI and MRI showed it went to the bone. R1 could die from these infections.R1's care plan was revised on 1/16/26 after R1 was admitted to the hospital on [DATE]. The care plan identified R1 often refused repositioning and refused to get out of bed. Interventions included to educate R1/family of the possible outcomes of not complying with repositioning. Attempt non-pharmacological interventions including re-approach and report to nurse if refused a second time.During an interview on 1/22/26 at 10:42 am LPN-A stated R1 moved in bed with staff help. R1 was able to help by turning a little bit on his top half but he needed assistance of two people to get him on his side and staff performed most of the work. R1 was not on a turning and repositioning schedule, and staff would do cares in the morning and evening. Staff encouraged R1 to move to his recliner for meals but he would refuse a lot. Nurses were to chart when he refused.R1's hospital History and Physical records dated 1/17/26, indicated R1 was admitted to the hospital on [DATE] for a sacral decubitus ulcer and osteomyelitis of pelvis. MRI of pelvis with and without contrast was completed and showed osteomyelitis of the proximal coccygeal segment (bone infection near the tailbone) with likely anteriorly dislocated middle coccygeal segment (section tail bone shifted forward-can happen with long standing pressure, infection, or tissue breakdown in the area). Cellulitis within right pelvic sidewall and right medial buttocks (infection in nearby soft tissues of the pelvis and buttock area). R1 reported his girlfriend noticed the wound on approximately 1/10/26 and according to documentation facility had noted a sacral wound for approximately two weeks. R1 reported a couple of wounds to his heels which he had previously received treatment. There is a 2.5 cm x 2.5 cm lesion on lateral aspect of right foot with no significant erythema or discharge. Records indicated on 1/20/26 R1 remained in the hospital for ongoing treatment. During a phone interview on 1/20/26 at 1:47 p.m. family member (FM)-A stated the facility had yet to tell her that R1 had a wound on his buttocks. FM-A found out about the wound after a text message was sent from R1's visitor, who discovered the severity of the wound, while assisting R1 with cares a week prior to R1 being sent to the wound clinic. R1 remained in the hospital with cellulitis and osteomyelitis, he had debridement's, a wound vacuum to his buttock, possible sepsis and kidney failure. R1 could die it is an avoidable wound they didn't tend to.During a follow-up interview on 1/22/26 at 10:05 a.m., CCLRN-B stated shearing was not a form of pressure. Interventions for R1 were in the care plan, but R1 refused to get out of bed. He was supposed to be up for meals. R1 could reposition himself and turn himself side to side in bed. R1 had a pressure-relieving mattress but if he wanted something that had more pressure relief, like an air mattress, it was up to R1 to contact the social worker or his case manager. Staff would reposition R1 to the wheelchair or recliner and that would distribute pressure in a different area. CCLRN-B had instructed R1 to move and get off his bottom various times. Pressure would be distributed to a different area if he got up in his wheelchair or recliner (did not articulate how long R1 could sit) and did not stay in his bed. R1 did go to a psychiatrist appointment in December 2025, but no interventions or suggestions for the care plan to help R1 with not refusing cares were discussed. R1's bottom was black and blue, always looked discolored and darker, and then it would heal. That was always something that was monitored. If skin was breaking down, a Mepilex would be appropriate but the facility did not have a large enough Mepilex, possibly related to payor concerns, so an ABD pad was used. Sometimes the mepilex and/or ABD were used just to protect the skin on his bottom. Nursing staff would always look for signs and symptoms of infection but CCLRN-B was unable to find documentation to that effect. CCLRN-B stated it would depend on the injury or what it looked like, she would monitor for a day or two, add orders in the medical record based off her experience from working at the wound clinic for three years. Typically, would communicate with physician when a wound changed and most of the time the physician would give a referral for the wound clinic. CCLRN-B acknowledged cleansing the buttock wounds with soap and water or wet wipes was not a standing order, but was unable to articulate the clinical rationale, physician authorization, or evidence-based standard supporting this practice. CCLRN-B stated she began the treatment of using hydrofera blue on R1's buttocks prior to getting orders from a physician.R1's hospital After Visit Summary dated 1/23/26, identified new orders for Intravenous medications ceftriaxone 50 milliliters every 24 hours, and daptomycin 600 milligrams for bone and joint infection; metronidazole 500 milligrams three times a day by mouth for osteomyelitis.During an observation and interview on 1/23/26 at 2:41 p.m., R1 returned to the facility from hospital around noon. R1 stated the facility had not provided education prior to hospitalization on the risks of not repositioning. They about killed me; I have never been that sick. R1 would like an air mattress on the bed but the facility told R1 an air mattress would make the wounds worse. R1 was positioned on his back in bed, and two wedge cushions were lying in the recliner. R1 had heel boots on bilateral heels and stated there was a wedge under his back. R1 stated he was supposed to be turned every two hours, and it had been past two hours. R1 would turn on his side if the staff came and helped him. R1 did not say if he ever refused position changes.During an observation on 1/26/26 at 9:02 a.m., R1 was sitting in a recliner in his room. Heel boots in place and air mattress on bed.During an interview on 1/26/26 at 10:15 a.m., RN-B could not find orders in R1's medical record to change R1's dressings, even though R1 returned to the facility on 1/23/26. RN-B alerted DON, RN-D, and DON-B. During an interview on 1/26/26 at 10:43 a.m., R1 was in bed, laying on his back. R1 stated staff had not done anything with his heels all weekend. Staff put the air mattress on his bed on 1/25/26 and staff would only put the wedges in if he told them too.During an observation and interview on 1/26/26 at 10:58 a.m., CCLRN-B and DON-B went to R1's room to complete dressing changes. CCLRN-B stated the left lateral foot wound had been a blister prior to hospitalization, was pretty much healed, looks really good, slightly open and was not a pressure ulcer, but a diabetic wound. DON-B identified the area as partial thickness, barely open, pink, healthy tissue, slightly pink around wound with some edema, raised but that could be the bone that was raised. CCLRN-B painted the entire wound and surrounding tissue with betadine and stated the wound was not open on 1/23/26 when assessed. CCLRN-B stated the left heel was blanchable, normal pink colored skin. DON-B advised CCLRN-B to follow the current wound treatment order and update the physician on progress. Toenails on left foot were observed pressing into adjacent toes, creating indentations in the skin. Upon inquiry, CCLRN-B stated she was unaware of these skin conditions until identified during the observation. Gauze was placed between the toes to relieve pressure and CCLRN-B stated she would trim the toenails later. CCLRN-B stated prior to hospitalization the area on the right lateral side of the foot was a blister. DON-B stated the area was large, circular and dark colored inside and questioned if it was an unstageable pressure ulcer. DON-B stated it should be labeled as unstageable so the floor nurses would keep a better eye on it. DON-B did not see any blanching and that would be the other red flag for the area. CCLRN-B stated that was the weird thing, he got both of the blisters while wearing his heel boots. Measured the darkened area at 1.5 cm x 2.5 cm and noted a small open area at the top of the blister that measured 0.3 cm x 0.2 cm x 0.1 cm depth. CCLRN-B observed the right heel and stated it was blanchable, pink in color, and appeared healed. DON-B observed the right heel and stated it should be staged as a suspected deep tissue injury as it was slightly blue in color and

Based on interview and record review the facility failed to update the care plan for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include:R1's face sheet dated 1/20/26, identified R1 admitted with diagnoses of paraplegia (paralysis of legs and lower body), pressure ulcer of right heel (diagnosis added 8/11/25), type 2 diabetes, and obesity. On 1/13/26, diagnoses of pressure ulcer of other site, pressure ulcer of unspecified, pressure ulcer of left buttock were included.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairments, no rejection of care, had an indwelling catheter and ostomy, had impairment on both sides of lower extremities, dependent for lower body care, maximum assistance to roll left and right, and dependent to transfer from surfaces. R1 was at risk of developing pressure ulcers/injuries but did not have any pressure ulcers and no open lesions. Treatments included pressure-reducing devices for chair and bed. R1 was not on a turning and reposition program, no nutrition or hydration interventions, and no dressing or treatments to feet.R1's Nursing Admit/Re-admit Data Collection dated 7/24/25, identified R1 had a right heel wound. Despite the instructions on the form that directed .staging to be completed by an RN [registered nurse].Important Note: include the type of skin observation (blanchable or non-blanchable), size, color, odor or discharge in the description., there was no further information documented. R1's care plan dated 7/25/25, did not identify a skin integrity focus nor identified R1 had a wound on his right heel. The care plan identified R1 required extensive assistance of one staff to turn from side to side. R1 was able to assist by using the grab bars located on both sides of the bed. Dependent on two staff to transfer between surfaces using the mechanical lift.R1's care plan dated 8/4/25, identified R1 had potential for pressure ulcer development related to dehydration, disease process, history of ulcers, and immobility. Interventions directed staff to avoid positioning on oxygen and indwelling urinary catheter tubing; Provide pressure redistributing mattress on bed and cushion on manual wheelchair; and Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care.R1's RN Wound assessment dated [DATE], identified right heel unstageable pressure ulcer. The wound assessment did not address the red sacrum identified on the 8/11/25 assessment and there was no indication the care plan was updated to reflect the off-loading boots until 10/30/25. (however, updated on TAR 8/11/25).R1's progress note dated 9/4/25, identified R1 had a new pressure sore to his right buttock. R1 had been refusing staff to get up in his chair at mealtimes per therapy. Explained the risks of not repositioning but R1 continued to refuse.R1's Wound Clinic Visit Report dated 9/10/25, identified the stage 3 pressure ulcer to right heel. R1 had new concerns of an ulceration to the urinary meatus (opening of the urethra) from his catheter. R1 reported he had reconstructive surgery to the area and had chronic issues with erosion (loss of epithelial tissue) of the glans (tip of penis) as a result of long-term catheter use. This wound was classified as stage 3 pressure ulcer at 3 o'clock. Noted R1's incontinent brief was causing serious tension to the catheter that led to the breakdown. Repositioned the device that holds the catheter in place at the leg to the right leg. Brief removed in order to avoid further irritation to the skin and silicon barrier cream twice daily. In review of R1's record there was no indication the care plan was revised to identify the presence of the new ulcer on the urinary meatus nor revised to address interventions pertaining to the urinary catheter placement and incontinent garment usage.R1's care plan dated 10/30/25, was revised to include use of heel boots/protective boots while in bed and received diabetic nutritional supplements twice daily for wound healing. The care plan did not address the wound clinic's directions for prevention/minimization of re-current pressure injuries pertaining to the urinary catheter nor address interventions to prevention/minimization the risk of re-current shearing injuries to buttocks until 11/20/25.During an interview on 1/22/26 at 12:14 p.m., director of nursing (DON) stated she expected the care plan to be followed and RN nurse leaders to update the care plan quarterly and with changes.

Based on observation, interview, and record review the facility failed to provide dignity 2 of 3 residents (R5, R6) who were reviewed for dignity. Findings include:R5's face sheet dated 1/20/26, identified diagnoses of Alzheimer's, and dementia.R5's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment, no behaviors, used a walker and wheelchair; needed moderate assistance with dressing upper and lower body, independent to roll side to side, touching assistance to transfer locations.R5's care plan dated 10/27/25, identified self-care deficits. Interventions included R5 could not walk, used mechanical lift for transfers, and required 1-2 staff to assist with toileting needs.R5's progress note dated 1/2/26, identified hospice nurse visited and placed a urinary catheter.During an observation and interview on 1/20/26 at 8:23 a.m., R5 was in his recliner chair. R5's urinary catheter collection bag was hanging on a garbage can next to recliner without a dignity cover. Registered nurse (RN)-A was in room and stated urinecollection bags need to be covered, facility uses dignity bags. I don't like that it is on a trash can either. RN-A provided education to nursing assistant (NA)-A that urine collection bags cannot hang from garbage cans and a dignity bag must be provided to R5.During an observation and interview on 1/22/26 at 9:00 a.m., R5 was lying in bed. catheter bag was on floor in wash basin with no dignity cover. Licensed practical nurse (LPN)-B stated R5 was supposed to have a cover on his catheter bag. LPN-B went to R5's closet, pulled out a dignity bag, applied to R5's urine collection bag.During an interview on 1/20/26 at 1:18 p.m., NA-A stated urine collection bags should be covered for dignity, same thing for hanging them on trash cans, if someone would walk by they could see the urine in the bag.During an interview on 1/20/26 at 10:44 a.m., clinical care lead registered nurse (CCLRN)-A stated urine collection bags should be covered for dignity and should not hang off garbage cans, there is a pocket on the other side of the recliner where it could have gone.R6R6's face sheet dated 1/20/26, identified diagnoses of anxiety disorder.R6's care plan dated 1/12/26, identified self-care deficits that required two staff for bed mobility.During an observation on 1/20/26 at 8:05 a.m., NA-B exited R6's without shutting the door and the privacy curtain drawn leaving R6 sitting on the edge of the bed with a brief on, secured around waist, and her pants pulled down to her knees while NA-C and NA-G provided support to keep R6 in the seated position. R6 was yelling help! During an interview on 1/20/26 at 10:34 a.m., NA-C and NA-G stated R6's door should have been shut when she was sitting on the edge of her bed in a brief and pants at her knees.During an interview on 1/22/26 at 12:14 p.m., director of nursing (DON) stated she expected the door to be shut during cares. Sometimes, the door does not shut unless slammed and was unsure if the NA's would have been able to get the curtain shut when performing cares on R6. DON expected covers on catheter bags. The facility purchased a bunch recently. DON was not sure if staff thought they were disposable, but they should not be thrown out unless ripped.The facility policy Resident Dignity revised 12/18/25, identified the IDT will assist all staff members in maintaining the dignity of every resident.

Based on interview and record review the facility failed to notify the physician and resident representative regarding changes to skin integrity and treatment orders for 1 of 3 residents (R1) reviewed for change in condition. Findings include:R1's face sheet dated 1/20/26, identified R1 admitted with diagnoses of paraplegia (paralysis of legs and lower body).R1's care plan dated 11/20/25, identified R1 had shearing on his left and right buttock and is at risk for skin breakdown and shearing related to immobilization/chairbound/bedbound and used the total lift sling evidenced by open shearing areas on both left and right buttock. Interventions included to keep skin clean and dry. Use skin barrier cream to buttocks daily and protect these areas with a dressing when open and draining. High risk for skin injury-use caution during transfers when using the sling being cautious to not quickly and forcefully place the sling under R1. Monitor for signs of shearing. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to health care provider.R1's faxed request to physician dated 11/21/25, identified FYI: R1 continued to have some shearing on buttocks off and on due to resident not wearing a brief as this causes other issues with skin breakdown in groin and penial area. Will continue to apply skin barrier cream to bottom when appropriate or cover with a coccyx mepilex if area is more open and drainage. Physician responded OK.R1's faxed request to physician dated 11/25/25, identified R1 was more depressed and refused to get out of bed which caused increased skin breakdown and open sores on his buttocks. Physician response was to get a psych consult. There was no indication R1's care plan was revised that addressed R1's refusals or repositioning program.R1's Wound Data Collections between 12/12/25 and 12/26/25 identified the area of impaired skin integrity was on R1's coccyx and/or coccyx/sacrum and not buttocks as described in the Skin Observations. Wound Data collections during this period were not comprehensive as none of these assessments included measurements nor included type of wound present. Examples from the record included: R1's Wound Data Collection dated 12/12/25, identified coccyx. Dressing present and intact. No drainage on the dressing. R1's Wound Data Collection dated 12/16/25, identified wound location coccyx and the site was sacrum. Protective cream applied after shower. Dressing present and intact. No drainage on dressing.R1's physician note dated 12/19/25, had no mention of shearing injury.R1's nursing order dated 12/25/25-12/30/25, identified clean buttock area with soap and water or wet wipes. Apply a thin layer of zinc oxide to both buttock areas and cover each buttock with an ABD pad and secure the outer edge with tape daily.R1's Wound Data Collection dated 12/30/25, identified left buttock has shearing to area, right buttock has darkened area with redness surrounding it. Applied skin prep and covered with mepilex.R1's Skin Observation dated 12/31/25, identified right buttock shearing, left buttock shearing-black and blue tissue noted, left lateral foot-dried calloused area. Covered with ABD pads and secured with tape. Applied iodine to left lateral foot.In review of R1's records between 12/5/25 through 12/31/25, it was not evident the physician was notified of new wounds nor changes to treatment orders. Additionally, between 12/27/25 through 12/31/25 there was no indication R1's right and left buttock wounds and left lateral heel were comprehensively assessed. During a phone interview on 1/20/26 at 1:47 p.m. family member (FM)-A [emergency contact] stated the facility had yet to tell her that R1 had a wound on his buttocks. FM-A found out about the wound after a text message was sent from R1's visitor, who discovered the severity of the wound, while assisting R1 with cares a week prior.During a phone interview on 1/20/26 at 1:41 p.m., certified wound nurse practitioner (CWNP)-A stated she knew R1 well and had followed his wound care from 8/19/25-11/7/25, when all wounds were healed. Wound clinic received a referral on 1/12/26 for pressure ulcer right lateral foot, left and right buttock pressure ulcers from facility. On 1/13/25, R1 came to the wound clinic.During an interview on 1/22/26 at 12:14 p.m. director of nursing (DON) stated the facility received a call from the clinic that FM-A was upset about R1's wound and that she had not been notified of the wounds. FM-A had found out about the wounds from R1's girlfriend. Facility records did not have FM-A listed as emergency contact. Nurses should notify physician with any changes of resident condition.The facility Notification of Change policy revise 12/12/25, identified the facility must immediately inform the resident, consult with physician and notify resident representative a need to alter treatment significantly-a need to discontinue or change an existing form of treatment or to commence a new form of treatment.

Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 3 residents (R1) who eloped from the facility into an unsafe area. This failure resulted in an immediate jeopardy (IJ) when R1 left through the facility's front door on 9/23/22 without staff knowledge, tipped his wheelchair off the curb and fell on his side onto the driveway. R1 sustained a minor injury of a scraped right knee and skin tear to his right elbow. The IJ (Immediate Jeopardy) began on 9/23/22, at 1:00 p.m. when R1 had fallen from his wheelchair (w/c) after having gone outside without staff knowledge into an unsafe area within feet of a steep decline which led directly to a river. The director of nursing (DON) and administrator were notified of the IJ on 9/29/22, at 5:04 p.m., which was identified as a J-ISOLATED. The IJ was removed on 9/30/22 at 3:20 p.m., but non-compliance remained at the lower scope and severity of D-ISOLATED, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of the 9/23/22 at 2:42 p.m., State Agency (SA) Report identified R1 went out the front entry door onto the sidewalk in his w/c where 2 unidentified visitors observed R1 fall to the side in his w/c and notified facility staff. Staff immediately responded and R1 was discovered to have received a scrapped right knee and skin tear on his right elbow. R1 reported he wanted to see his wife when asked where he had been going. A wander guard device was placed on R1's w/c upon his return to the facility. Review of the 9/28/22 at 6:54 p.m., 5-day SA report identified 9/23/22 as the first time R1 had attempted to leave the facility. R1 was able to move independently in his w/c and his normal pattern was to wheel around the facility many times during the day. It was reported R1 wheeled himself in the main hallways and sat in the reception area by the main entrance to visit with staff, watch the birds or take a nap. The report identified he often spoke of his wife but had not made any attempt to leave the facility to find her. Unidentified staff reported R1 had been observed passing by in the hall four times that morning and he had reported he was looking for his wife to visit. Unidentified staff attempted to redirect R1, and he had replied, I think she is coming back. There was no mention staff identified R1 required increased supervision to prevent his elopement out through the front door. Observation on 9/28/22, of the main entrance of the facility identified the main entrance door was covered with an overhang and the drive way curved to allow motor vehicles access to pick up and drop off residents in front of the entrance doors. To the left of the doors the sidewalk curved along the drive and immediately began sloping down out of the parking area to the street which had a steep decline that formed a T with a guardrail at the bottom of the slope. A steep hill was on the other side of the guardrail and dropped steeply to the river at the base of the hill. Had R1 not tipped over in his wheelchair, he could have reached the road, with the potential of his chair picking up speed on the slope and possible crashing into the guard rail and been injured or been thrown over the rail and down the steep hill. The main entrance area has the potential for heavy traffic which increased the risk for serious injury if a resident were to exit in front of an incoming or exiting vehicle. Review of video footage of the elopement on 9/23/22 with review beginning at 12:56 p.m. identified: 1) Camera #1 showed R1 propelling himself in his w/c past the unoccupied receptionist desk towards the front door. He stopped just shy of the door and appeared to watch an unidentified person enter and walk past him. At 12:57 p.m. R1 proceeded to the door, pushed open the first door into the entry, and proceeded to push open and exit the outer door onto the sidewalk area. He turned his chair to the left and went out of camera range. Staff and visitors were observed walking in the area, but no one indicated they were aware R1 had exited the building. At 12:59 p.m., a female visitor quickly entered through the doors and went to the reception area where she called for assistance. A second unidentified person entered through the main doors and went down the administrative hall to summon assistance. At 12:59 p.m. Nursing assistants (NA)-A and B were observed running from the office behind the reception desk and out the main door. Immediately following the administrator and Chaplin were observed responding to the summons and they exited out the front door. At 1:01 p.m., nurse aide (NA)-A was observed transporting R1 back into the building in his w/c and proceeded down the hall toward the 200-wing nursing station. 2) Camera #2 revealed at 12:58 p.m., R1 exited onto the sidewalk outside the main door, turned his w/c left (toward the driveway with the steep incline), appeared get his w/c wheel stuck on the curb and had some difficulty getting it loose and then R1 self-propelled out of camera view. At 1:01 p.m. R1 was transported back into building seated in his w/c by NA-A. R1's 6/2/22, quarterly Minimum Data Set (MDS) identified he had severe cognitive impairment and wandered. This continued in the 9/9/22, quarterly assessment which further identified he required extensive assistance of 1 staff for all activities of daily living (ADLs). R1 had identified behaviors of verbal and physical behavior directed toward others, wandering, and refusal of care. R1's diagnoses included progressive neurological conditions, Alzheimer's disease, and depression. Review of the medical record identified R1 had been admitted to the facility on [DATE], but no elopement assessment was completed until following the incident on 9/23/22. Review of R1's undated care plan failed to identify R1's behaviors of physical and verbal agitation, wandering through out the facility, and his lack of safety awareness with interventions to address the areas of concern due to his severe cognitive impairment. R1's progress notes revealed: 1) 4/15/22 at 3:56 p.m., R1 told staff, my wife [NAME] is coming to take me out for dinner. He attempted to leave by the front door. Staff returned him to the North end and provided reassurance he was to have his meal at the facility. 2) 4/27/22 at 1:44 p.m., R1 was noted to be upset, stating I don't know where [spouse] is .she is taking me home today. R1 was then noting to be wheeling himself up and down halls on North end of building. 3) 6/4/22 at 1:19 p.m. R1 became upset and wheeled himself to center desk asking, Where's my wife? Was told by staff she was not there right now and became upset yelling, don't' lie to me I know she is here, I just talked to her, continued to yell with same statements. 4) 6/6/22 at 9:21 p.m., staff noted R1 was very restless, kept trying to get out the doors, following staff and kept trying to find a door he could open. Staff would continue to monitor. 5) 6/9/22 at 9:37 p.m. R1 had been noted to be restless stopping everyone who passes by stating he was waiting to go home. R1 became easily annoyed when staff attempted to explain he needed to stay. 6) 7/6/22 at 11:43 a.m. R1 was noted as being physically aggressive that day, tried to kick and trip other residents, was hitting staff with cares and had been trying to elope. 7) 7/30/22 at 112:51 p.m. R1 was asking to go outside and had attempted to go out east door. (That door is an emergency exit which was alarmed). Staff heard the alarm and intervened. 8) 8/21/22 at 2:35 p.m., staff noted R1 was unable to be redirected. Staff noted they closed the doors so he could not go out. He attempted to open the locked doors and yelled he wanted out. Staff were finally able to convince him to go with staff member to North end by his room. 9) 9/3/22 at 2:23 p.m., staff noted R1 was confused and kept looking for his wife and car. Staff were unable to redirect. 10) 9/6/22 at 1:31 p.m. Resident restless this shift, stating, Where's my wife? She's taking me home today. R1 was noted to be going up and down halls in his w/c. Review of the progress notes identified R1 demonstrated exit seeking behavior beginning 4/15/22, but there was no comprehensive assessment, safety measures implemented, or a care plan updated until after the September 23, 2022, elopement incident. Interview on 9/28/22 at 11:27 a.m., with NA-A who reported she was in the office behind the receptionist desk when an unknown visitor rushed to the reception desk stating a nurse was needed outside right away. NA-A reported she had run outside and observed R1 lying on his side on the driveway with his w/c tipped on its side. When she approached R1, he was laughing and commented his wife would need to be told about this incident. NA-A reported R1 was attempting to get up and stated he needed help to get out of this situation. NA-B, the Chaplin and administrator had also responded and assisted R1 to stand and sit back in his w/c. A small amount of blood was noted on R1's right elbow, but he had on a long sleeve shirt, so the injury was not visible. R1 also had a scrape on his right knee that was observed as his pant leg was pulled up. The unidentified visitors left when staff arrived to assist R1, and NA-A reported she was not aware of their identity. R1 was transported to the 200-wing nursing station for assessment by registered nurse (RN)-A. NA-A revealed she was unsure how long it would have been before anyone would have noticed R1 was missing if he had not fallen and a visitor had not seen him. NA-A reported following the incident she had asked trained medication aide (TMA)-A if she was aware R1 had gone out the front doors and fallen and she was not aware he was gone. NA-A reported she was aware R1 had attempted to exit the building previously, and nursing staff had been alerted, but didn't recall when it had occurred or that any interventions that had been put into place. NA-A reported the application of the wander guard after the most recent incident was the first that any intervention had been put into place. NA-A reported she had received annual education on dementia, elopement, vulnerable adults, and reporting, but there had not been any review of policies or education provided following the incident with R1 on 9/23/22. Interview on 9/28/22 at 1:00 p.m. with TMA-A identified she had been working on 9/23/22 and was not aware R1 had exited the building until she had been informed when he was brought back inside, and a wander guard device was applied to his w/c. TMA-A reported R1 wandered through out the facility, and she was not always aware of where he was located. On 9/23/22 TMA-A reported she had been assisting with resident cares and thought it had been at least 20 minutes since she had last seen R1. She reported that when R1 was not seen for 15-20 minutes staff would usually go check to on his location, but she reported there were no scheduled safety checks or documentation to confirm checks had been completed. TMA-A reported R1 did have a history of wandering and would have verbal and physical behaviors toward others, but it was usually toward staff and staff redirected him if the behavior was toward another resident. TMA-A reported she was not aware if the care plan had interventions in place for R1's behaviors and safety and she would have to go and look. Interview on 9/28/22 at 12:29 p.m., with RN-A reported R1 was confused, wandered through out the facility looking for his wife, and stated his wife was coming to get him. She revealed staff were aware R1 wandered and liked to sit in the front lobby area, but she was not aware of any attempted exits from the facility. RN-A reported elopement assessments were supposed to be completed at the time of admission, quarterly and if there was a change in condition. She reported R1 did not receive an elopement assessment until following the incident on 9/23/22 and confirmed one should have been completed with the 6/2/22 quarterly assessment when his wandering behavior had been identified. RN-A also identified the care plan had not been updated to include R1's behaviors, wandering and and lack of safety awareness due to his severe cognitive impairment. RN-A confirmed the facility policy had not been followed for the completion of elopement assessments, his care plan had not been updated and that there had not been review of the policy or education provided to staff following the incident on 9/23/22. Interview on 9/29/22 at 10:50 a.m., with activity assistant (AA)-A reported R1 wandered frequently as he looked for his wife and would wheel self toward the doors, stating he needed to go home. She reported R1 was usually able to be redirected, but at times was difficult, insisting he was going home or going to get his car. Interview on 9/29/22 at 12:59 p.m., with the interim medical director identified his expectation for the facility was to complete elopement and fall assessments according to facility policies. If a concern was identified the facility should have implemented interventions to monitor and keep the resident safe. He identified it was concerning that R1 had been able to exit the facility and staff were not aware he was missing until he had fallen, and visitors returned to the facility to notify staff. He agreed the facility had failed to provide adequate supervision of R1 if he was able to exit through the main entrance without staff knowledge. Interview on 9/29/22 at 1:17 p.m., with RN-B identified on 8/21/22 she had been working on the South (200 wing) when R1 became agitated and was not able to be redirected from going to the front entry to wait for his wife. RN-B reported there was not staff in the entry area on weekends and as a safety measure she had closed the fire doors and R1 was not able to open them to access the area. RN-B reported R1 was usually able to be redirected but at times he became agitated and was difficult to redirect. RN-B reported R1 liked to go to the front lobby where he would visit with staff and visitors/residents, watch birds and TV, or sit and watch outside. RN-B reported R1's wandering behavior had initially been identified in the June 2022 quarterly assessment and an elopement assessment should have been completed in addition to the care plan updated at that time. Interview on 9/29/22 at 2:00 p.m., with the director of nursing (DON) and administrator identified their expectation for staff to follow the facility policy for completion of elopement and fall assessments with the care plan updated to reflect the areas of concern. They confirmed the policy had not been followed regarding completion of assessments, updating of the care plan and provision of education for review of the facility policy/procedure following the incident on 9/23/22. They further reported an elopement assessment including updating of the care plan should have been completed when elopement intent was identified in the June quarterly assessment. Review of the 1/12/22 policy Elopement-Rehab/Skilled: Identified all residents were to be assessed for the risk of elopement at the time of admission and with quarterly, annual, and significant change MDS assessments. The purpose was to identify residents at risk for elopement, have monitoring measures in place, and provide individualized interventions. The assessment was also to be completed as needed when an elopement risk was identified, and investigation completed to identify causes of elopement attempts with individualized interventions implemented. The IJ was removed on 9/30/22 at 3:20 p.m., when it could be verified by observation, staff interviews, and document review, the facility had reassessed R1 and all 9 other residents at risk for elopement. Interventions were developed and implemented, and staff were educated to those interventions.

Based on observation, interview and document review, the facility failed to comprehensively assess, monitor and implement interventions for 1 of 1 resident (R1), who experienced a fall with injury. R1 sustained actual harm, a subdural hematoma and pelvic fracture resulting in a discomfort and a decline in mobility. Findings include: R1's admission record indicated the resident was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. Review of R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 as having a brief interview for mental status (BIMS) score of 7 (indicating R1 had moderately impaired cognition). The MDS indicated R1 was independent with bed mobility and transfers with set up assistance only. The MDS also indicated R1 was independent with ambulating in room with set up assistance and ambulated in the corridor with staff supervision, and a walker for ambulation. Further, the MDS indicated R1 was independent with toileting, and exhibited no impairment in range of motion (ROM) to the upper or lower extremities. During observation on 6/23/20, at 10:30 a.m. R1 was resting in bed. R1 was observed to be repositioned by staff while in bed. R1 offered no complaints during the care, but stated she wanted to go home. R1's left eyebrow was slightly swollen and bluish in color. Review of an incident report dated 6/17/20, at 5:00 a.m. indicated [REDACTED]. The report indicated R1 alerted staff she had fallen by yelling out loudly. R1 was found laying on her right side on the floor. The report indicated R1 stated she was attempting to go to the bathroom when she fell . R1 was incontinent and obtained a laceration to the outer left eyebrow that was swollen and bleeding. The laceration was identified a s measuring 3.0 centimeters (cm). Steri-strips and an ice pack were applied to control the bleeding, R1 complained of pain when touched. R1 had previously been independent with ambulating and toileting. The report further indicated R1 had no other injuries or complaints when assessed. Neurological checks were initiated. Review of R1's medical record included neurological checks on 6/17/20, at 5:30 a.m., 5:37 a.m., 6:05 a.m. and 9:13 a.m. 5:36 a.m. vital signs (VS) and neurological assessment (neuro) = within normal limits (WNL). Pain = 0 (pain scale of 1-10 meaning 1 mild and 10 severe). Eyebrow laceration oozing blood. Ice Pack applied. 5:37 a.m. VS and NA = WNL. Pain = 1 6:05 a.m. VS and NA= WNL. Pain=0. Slight oozing of blood from eyebrow laceration. 9:13 a.m. VS and NA = right leg and left leg weak. Pain =1. No action was taken when R1 was identified with weakness in the lower extremities with pain. The progress note indicated R1 was having difficulty standing and required extensive assistance to the toilet. A mechanical lift was required. The note also indicated R1's left eyebrow laceration continued to bleed and R1 was refusing to eat. There were no further VS or neuro checks completed after 9:13 a.m. when R1 exhibited signs of a change in condition. The medical record indicated R1 was given scheduled Tylenol at 7:39 a.m. There was no offer of pain medication at any other time. R1's post fall progress notes were reviewed for 6/17/20: At 6:04 a.m. an entry indicated R1 was resting in bed, denied complaints of pain and an ice pack was applied to the left side of the forehead. R1's laceration on the forehead was described in the notes as having 10 cm of blood from the area. At 7:39 a.m. an entry indicated R1 required assistance of a pivot transfer to wheelchair when assisted to the bathroom. The note further indicated R1 had no complaints. At 9:20 a.m. an entry indicated a fax was sent to the provider indicating R1 had a fall and obtained a 3.0 cm laceration on the left outer eyebrow. Steri-strips and an ice pack were applied with no other injuries noted. (There was no return fax from the provider verifying notification). At 9:24 a.m. an entry indicated R1 was attempting to get out of bed but required extensive assistance of staff to the toilet. R1's laceration on the left eyebrow was described as bleeding, and the note indicated a new pressure dressing was applied to control the bleeding. R1 refused breakfast when offered. The note further indicated R1 had trouble standing during assistance to the toilet and a standing lift was needed. At 10:36 a.m. an entry indicated R1 was scratching at the laceration on her left eyebrow and causing it to bleed more. At 11:53 a.m. an entry indicated R1's eyebrow laceration continued to bleed and new steri-strips and pressure dressings were applied. At 11:55 a.m. an entry note indicated there was increased bleeding from R1's laceration on the left eyebrow and another pressure dressing was applied due to saturation of blood. The note further indicated R1 had blood under her fingernails and may have been scratching at the laceration. At 12:20 p.m. an entry indicated R1 refused to eat dinner when offered. At 12:42 p.m. an entry indicated the laceration over R1's left eye continued to ooze blood and the eye was swollen shut. The facility's physician assistant (PA) was notified and indicated she would provide a house visit to assess the resident. At 1:03 p.m. an entry indicated the facility PA assessed R1 and ordered a transfer to the emergency department (ED) by ambulance for further evaluation of the head wound and left hip pain. At 2:24 p.m. an entry indicated a nurse from the ED informed the facility R1 was being transferred to the Mayo hospital in Mankato MN for further treatment, due R1 having a subdural hematoma and pelvic fracture. A summary of the progress notes indicated R1 had a change in condition at 9:24 a.m. when R1 had difficulty standing and required extensive assistance of staff to the toilet, requiring a mechanical lift. R1 had previously been independent with mobility. R1's laceration on the left eyebrow continued to bleed requiring continued pressure and the resident was refusing to eat. The medical record did not include a thorough evaluation/assessment of R1's decline in condition or weakness, nor did it include a pain assessment to include thorough monitoring of R1's left hip pain or control. Review of the PA visit progress note dated 6/17/20, at 1:00 p.m. indicated the PA was notified by facility staff R1 had fallen and had become more lethargic since the fall. The PA stated she was told by staff R1 was previously independent with mobility, but since the fall had been in bed and now required total assistance. The PA indicated she was informed R1 refused to eat or drink all day other than a sip of water taken with her medications at 9:00 a.m. on 6/17/20. The PA stated facility staff had further informed her they'd been unable to control the bleeding from R1s left eyebrow laceration after the fall, even when applying pressure. The PA also stated she was informed R1 had complained of nausea right after the fall, and stated the staff had reported they'd changed the pressure dressing to the resident's left eyebrow laceration 3-4 times throughout the day and could not obtain homeostasis. The PA indicated R1 had also reported left hip pain. Review of the 6/17/20 physical exam results by the PA, indicated R1 was identified to be lethargic and moaning in pain. R1 responded but did not open her eyes during the exam. The laceration on R1's left eyebrow was actively bleeding and swollen with an obvious hematoma formation. Finally the PA's note indicated R1 was to be transferred by ambulance to the ED for further evaluation. Review of an ED progress note dated 6/17/20, at 2:20 p.m. indicated R1 was examined after arrival to the ED. R1 continued to have bleeding from the facial laceration as well as moderate complaints of left hip pain. A computed tomography (CT) scan of the head was ordered with findings of an acute cerebral convexity subdural hematoma with periorbital soft tissue swelling. A CT scan of the pelvis was ordered with findings of an acute minimally displaced [MEDICAL CONDITION] pubic body. The ED progress note indicated R1 would be transferred to the Mayo hospital in Mankato MN for further evaluation and treatment. Review of a Mayo hospital discharge summary note dated 6/19/20, indicated R1's fractured pelvis and subdural hematoma were evaluated and it had been determined R1 was a high risk surgical candidate and therefore surgery was not recommended. R1's family chose comfort care measures only and R1 was discharged back to the nursing home facility with hospice care services During an interview on 6/23/20 at 11:45 a.m., case manager (CM)-A stated she provided care for R1 after the fall. CM-A stated she felt R1 was stable until around 11:30 a.m., when R1's eyebrow laceration continued to bleed. CM-A further stated she felt R1's condition had not changed enough to warrant notification of the provider until that time. CM-A stated, Although (R1's) laceration on the eyebrow continued to bleed, (R1's) neuro and VS were within normal limits even though a change in (R1's) mobility had been identified by a nursing assistant at 9:13 a.m CM-A confirmed R1 had been independent with mobility before the fall and at 9:13 a.m. on 6/17/20, R1 could not bear weight requiring a mechanical lift for transfers. CM-A also confirmed R1 had periods of left hip pain, but felt it was minimal. CM-A stated she'd only called the physician assistant (PA) because she thought R1's laceration needed stitches to stop further bleeding. During interview on 6/23/20 at 11:30 a.m., nursing assistant (NA)-A and NA-B stated they had both provided care for R1 on 6/17/20, after the fall. NA-A and NA-B stated R1 started to complain of left hip pain around 8:30 a.m. when repositioned in her bed. NA-A and NA-B said R1 was weak and required total assistance with all activities of daily living (ADL's) that included mobility. NA-A and NA-B confirmed R1 had been independent with mobility prior to the fall. NA-A and NA-B further indicated R1's laceration on the left eyebrow continued to swell and bleed through several pressure dressings throughout the morning. NA-A and NA-B further added R1 had been sleepier, refused to eat and stayed in bed all morning. NA-A and NA-B both stated they reported R1's changes in condition to CM-A when identified. According to interview with registered nurse (RN)-A on 6/23/20 at 2:45 p.m., RN-A confirmed she'd provided care for R1 at the time of the fall. RN-A stated she assessed R1 and did not identify any injuries other than a 3.0 cm laceration above the left eye, that was noted to be bleeding slightly. RN-A stated R1 denied complaints of pain when RN-A evaluated R1's extremities, adding that R1 was alert and she didn't note any change in cognition. RN-A further indicated a mechanical lift was used to transfer R1 back into bed per protocol. RN-A stated she was unsure whether R1 could bear any weight at that time because they did not attempt to have R1 bear any weight. When interviewed on 6/23/20 at 3:00 p.m., the facility's physician assistant (PA) confirmed the above documented dictated notes from the visit she made for R1 on 6/17/20. The PA stated when she examined R1 there was blood all over the resident's face, neck and upper body from the laceration on the left eyebrow, and the left eye was swollen shut. The PA stated there was a lot of bleeding from the laceration making it difficult to see the depth of the wound. The PA further indicated R1 was moaning in pain during attempts to sit her up in bed. The PA stated she assessed R1's extremities and the resident complained of left hip pain with range of motion (ROM). The PA further reported staff had informed her R1 had been more lethargic and weak, and the dressing on the eyebrow had required several dressing changes over the prior hour, due to increased bleeding and saturation of the dressings. The PA stated she should have been notified sooner when the resident's condition was noted to have changed. Changes that included not bearing weight and requiring a mechanical lift for transfers, pain in the left hip area, and the uncontrolled bleeding from the laceration on the left eyebrow were significant, and the PA stated earlier treatment could have prevented or decreased discomfort for R1. The director of nursing (DON) and administrator were interviewed on 6/24/20 at 1:00 p.m., and reviewed the record with the surveyor. They confirmed R1's condition had declined after the fall. The DON stated staff had not implemented the facility's policy/guidelines for monitoring neurological checks/assessments, nor had the staff completed the facility's change in condition checklist, or provide interventions to provide comfort for R1. The DON and administrator verified the medical provider should have been contacted to provide direction related to changes observed for the resident. The facility's procedure Neurological Evaluation revised 1/20, indicated staff were to complete a neurological evaluation when a resident had an unwitnessed fall, or following an event that results in a known or suspected head injury. The procedure included: Initiate and document a baseline neurological evaluation after the incident, notify the provider of the event and findings of the evaluation, obtain orders for subsequent neurological evaluations or other medical care, after the completion of the initial neurological evaluation with vital signs, continue with evaluations every 30 minutes for 4 times, then every 8 hours for 3 days or as directed by the provider. The policy further included: Evaluate and compare subsequent neurological evaluations to the initial baseline and previous evaluations and notify the provider of any neurological findings, which are a change from the baseline or previous evaluations. The facility's procedure for Change in Condition Evaluation revised 5/16/20, directed staff to complete a change in condition checklist to improve communication between nurses and the provider when nursing was monitoring a change in condition, and to enhance the nursing evaluation and documentation of a resident who has a change in condition. The procedure indicated the evaluation would provide a standard format to collect pertinent clinical data prior to contacting the provider when there was a change in condition.

Based on interview and document review, the facility failed to ensure signs and symptoms of urinary tract infection [MEDICAL CONDITION] were assessed, acted upon and treated in a timely manner for 1 of 3 residents (R51) reviewed for hospitalization . This resulted in actual harm for R51 who required hospitalization for UTI, and severe [MEDICAL CONDITION] (a high concentration of sodium in the blood). In addition, the facility failed to ensure a [MEDICAL CONDITION], skin tear, and bruising were monitored on a routine basis to ensure healing and intervention efficacy for 3 of 3 residents (R24, R51,R46) reviewed for non-pressure skin conditions. Findings include: R51's significant change Minimum Data Set assessment ((MDS) dated [DATE], indicated the resident had moderate cognitive impairment, was totally dependent on staff for assistance with transfers and locomotion on/off unit, and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated R51 was always incontinent of urine and frequently incontinent of bowel. The MDS and admission face sheet identified R51 with [DIAGNOSES REDACTED]. R51's care plan printed 6/28/19, indicated an ADL (activities of daily living) self care performance deficit R/T (related to) weakness and cognition E/B (evidenced by) inability to independently dress, groom, bathe and toilet self. Interventions included: EATING: set up/supervise. When interviewed on 6/25/19, at 11:50 a.m. family member (FM)-B, who had cared for R51 prior to admission to the nursing home, stated on 2/18/19, R51 exhibited symptoms of sniffling and developed a cough which was labored. FM-B stated she'd been told by nursing staff they were monitoring R51 and the resident's lungs were clear. However, FM-B reported in mid-March, she'd reported to nursing staff that R51 was exhibiting symptoms of a UTI as resident was declining and had a strong urine odor. FM-B stated she, 2 other family members, and facility therapy staff had reported their concerns to the nursing staff about the resident's declining condition, but felt their concerns had been dismissed. FM-B further stated on 3/18/19, R51 continued to decline in health and had a hard time swallowing and eating, and was holding her head to the side in pain. FM-B stated she'd emailed R51's social worker but never heard anything back. FM-B stated she had also talked with nursing staff and had asked them to have R51 checked for a UTI. FM-B stated she'd been told by nursing staff it took 2 days for the physician to get back to them. On 3/20/19, FM-C called FM-B and reported R51 had been coughing and choking, and couldn't catch her breath for 12 minutes.FM-B said FM-C had reported concerns about R51's health to nursing and had been advised, She will work it out. FM-B said on 3/23/19, FM-K had called stating he was worried about R51 as the resident was not eating, kept her head down and could barely stay awake. FM-B stated on 3/24/19, she'd visited R51 who was lying in her room with a washcloth on her forehead, unresponsive. That same afternoon, FM-B stated staff had called her reporting R51 was unresponsive and had asked what FM-B would like staff to do. FM-B said she'd advised the facility staff to transfer R51 to the emergency room so she could be treated. FM-B stated she'd been frustrated that staff hadn't requested the resident be checked for a UTI when FM-B had first requested they do so. FM-B said they could probably have avoided the decline in condition and hospitalization . When interviewed on 6/27/19, at 2:00 p.m. FM-C stated she'd noticed R51's decline in condition around the beginning of (MONTH) 2019. FM-C stated it was at least a couple weeks when R51 was declining until she went into the hospital, in addition she was also missing therapy sessions due to her decline in condition. FM-C stated by the time R51 went into the hospital her condition was really bad. FM-C stated during the time R51 was declining she'd also had a change in doctors and maybe that was part of the problem. FM-C stated she and the facility's therapists could see R51 was experiencing a decline while the resident was still on their case load. FM-C said there was a big change and you could tell something was wrong, stating different therapists would approach nursing and let them know our concerns, but it just didn't seem like they were doing anything. I think at the time she had a cough or cold and they were giving her medication for that. When they brought her in she was unresponsive. Prior to going in she was to the point where she couldn't feed herself; she was also having trouble swallowing. The biggest change was she was unable to feed herself or assist with eating; even when staff were feeding her her intake was low and she wasn't eating much, just looked sleepy. R51's ST (speech therapy) Daily Treatment Notes indicated: - 3/4/19, .Limited session time-wise as pt (patient) quickly tired across tasks . - 3/5/19, .Pt needed increased stimulation to remain alert . - 3/12/19, .Pt seems tired and confused .at noon meal - pt was being fed by staff when SLP (speech language pathologist) arrived - demonstrates increased coughing with decreased energy and alertness today - reported medical follow up to rule out infection. Addressed functional sequence at meal - open ended questions and choices - Pt did not seem excited about being fed, yet lacked ind (independent) and functional sequence for ind intake - needed cues to chew and swallow, which may have been multi factorial - processing - uncomfortable with the rate and style of prompts - as well as physiologic changes . - 3/14/19, .Pt. seems low affect with slow response time .pt is needing more assist - cause is not yet know- begin trial of NTL (nutrients to limit), although attn (attention) needs to be paid to adequate hydration. - 3/19/19, .Pt had reduced responsiveness today .cause of changes is unknown . R51's PT (physical therapy) Daily Treatment Notes indicated: - 3/6/19, Pt reports that she is doing better today after denying therapy earlier in the week due to not feeling well .Pt notes fatigue after stands, and denies exercises or riding bike today. - 3/7/19, Pt appears to be tired and sleepy, she states she has not been sleeping well at night .Family member is trying to work with nursing to get pt in to see a Dr (doctor) due to pt still very sleepy and not feeling the best. Pt demonstrated good upper body posture in stand frame today but did state fatigue after 5/6 min (minutes). - 3/8/19, .states she has been so tired and has not been sleeping well at night . - 3/11/19, .rest breaks between as pt fatigues and gets sleepy .attempted to see pt again in PM as pt wanted to rest, but pt was very tired and did not want to have any more therapy today. - 3/14/19, .Rest breaks between due to fatigue, cuing required throughout to keep pt alert and on task as she fatigues quickly .pt is hoping to get in to see a Dr soon to see what is going on as she has not been feeling her self for awhile, she conts (continues) to have a strong cough. - 3/15/19, Pt agrees to therapy today but states feeling tired and frustrated of not knowing why her cough won't go away and what is wrong .Pt is very fatigued today and has a difficult time keeping her eyes open when she is standing. Pt requires verbal cuing to improve posture and to push through LEs (lower extremities) to stand tall. Pt continues to be very fatigued and has deep cough after standing-discussed this with nursing staff to hopefully get appointment in to see her physician to help pt feel better and have more energy. When interviewed on 6/27/19, at 3:02 p.m. nursing assistant (NA)-A stated prior to R51 going into the hospital she became very tired and sleepy. R51 was also confused which was different for her. The resident also wasn't eating well and required more assistance with eating. Review of the nursing progress notes included the following: - 3/12/19, at 14:24 (2:24 p.m.) Family cancelled (sic) appt. with PCP (primary care physician) today,so sent fax updating on status. VS (vital signs) as previously charted with addition of B/P of 119/76. Cough is full sounding,but NP (non-productive). Has fatigue. Questioning any labs and also informed that needs order for PRN [MEDICATION NAME]. Also,needing diet texture change to pureed as is pocketing food and not chewing at meals. Called clinic to bring attention to fax - 3/12/19, at 19:35 (7:35 p.m.) B/G (blood glucose) was 229 mg/dL (milligrams per deciliter) before supper. Res. (resident) ate 100% of supper. Skin is moist and warm to the touch. Cont. with non-productive cough. Afebrile. Temp. 98.9. Res. was restless before meal time. She kept saying, Lets go. Come on. Lets go. Res. was toileted. Voided LG (large) incontinent. Urine is dark amber. Res. is now resting peacefully in bed. Nursing will cont. to monitor. - 3/13/19, at 08:00 (8:00 a.m.) (Family member first name) called to discuss status and reminded that family requested PCP appt. yesterday be cancelled (sic), but informed that faxed MD (medical doctor) and called clinic yesterday afternoon r/t (related to) status and have not heard back. Will follow up this am. (Family member first name) was satisfied and nursing will keep updated on new orders. Fax to physician dated 3/12/19 at 2:15 p.m. indicated: Has frequent full sounding, NP cough, LS (lung sounds) CTA (clear to auscultation) but diminished. No dyspnea (difficult or labored breathing). B/p (blood pressure) 119/76, TPR (temperature, pulse, respirations) 98.8 - 67 - 24, 02 sat (oxygen saturation) 97% RA (room air). Has increased (written as upward arrow) fatigue. - Need order for PRN [MEDICATION NAME] DM 10 ml po (by mouth) q (every) 4° (hours) ? Need any labs? - Need to change diet texture to pureed as pocketing food. Ok? The physician response dated 3/13/19 indicated: OK for above. The fax did not address the resident's dark amber urine or request that a urine sample be tested . - 3/13/19, at 09:44 (9:44 a.m.) Called clinic and reminded have not had reply r/t fax. They stated usually takes a couple of days.Reminded that had called prior to say that needs prompt reply as has URI (upper respiratory infection).She replied that will pass message along to return call. - 3/13/19, at 11:00 a.m. Fax received from (physician name) to change diet texture to pureed and may use PRN (as needed) [MEDICATION NAME] for cough. - 3/13/19, at 11:30 a.m. T.O. (telephone order) (physician name) that may draw CBC with diff (complete blood count with differential). - 3/13/19, at 13:19 (1:19 p.m.) Received results of CBC and WBC (white blood count) WNL (within normal limits). Results also sent to MD (medical doctor). - 3/13/19, at 13:22 (1:22 p.m.) Called (family member first name) and updated on lab results and MD's other orders - 3/13/19, at 18:25 (6:25 p.m.) Resident had difficulty at supper. Plate guard did not help her scoop up her food as the utensil she was using didn't have any food on it. She couldn't get it to her mouth as it just hung in her hand over her waist. Nurse tried to feed her bites and offered fluids. Then she picked up her plate and tried to put her face to the food. Nurse asked if she was hungry to which she stated no. Did take several bites of each food item and drank a small glass of juice. Eyes were shut the whole time. - 3/14/19, at 14:01 (2:01 p.m.) Message faxed to clinic asking for nectar thick liquids as noting increased cough with thin liquids. - 3/14/19, at 14:45 (2:45 p.m.) Continues to have occasional loose NP cough. T 98.8. Appetite greater than 76% today at both meals. Staff totally fed res. [MEDICATION NAME] PRN for cough. Requested to lie down and napped for approx. 30 min. this am and then was restless and assisted back up into w/c (wheelchair).Resting in recliner at present. No c/o pain. Usual scheduled Tylenol in am. Will continue to monitor. - 3/14/19, at 16:39 (4:39 p.m.) Called and spoke with daughter. Discussion about changing to local physician for continuity of care. Daughter would like to pursue (medical director). Will follow-up. - 3/14/19, at 17:38 (5:38 p.m.) Resident is not feeling well for past several days which has impacted her energy level and her participation level is down. There is a pending PCP appointment. At this time the therapy interruption is seen as temporary until feeling better again. Fax from physician received 3/18/19, at 8:52 indicated: Blood counts are normal for the most part. She may be hemoconcentrated (A decrease in plasma volume, which causes a simultaneous increase in the concentration of red blood cells and other commonly tested constituents of the blood.) from being slightly dehydrated though. (Related to CBC with diff laboratory results from 3/13/19). - 3/19/19, at 9:49 a.m. New plan of treatment will be for PT 2x/week as currently not feeling well which is affecting energy level/ability. Has been standing 3 minutes in the transfer bars. - 3/20/19, at 13:26 (1:26 p.m.) Message faxed to clinic that family requesting to check again for infection due to no energy, sleepy and occasionally talking nonsense. B/P 92/62, TPR 98.1-64-22, oxygen sat 94% RA. LS CTA. NP cough has decreased from frequently to occasional. Asking PCP if wants any labs or UA (urinalysis)? - 3/20/19, at 22:51 (10:51 p.m.) Family member alerted nurse that resident started coughing after eating, and moist sounding breathing. Nurse took resident to nurses station and cleaned out mouth, large amount of mucous. Afterwards resident was breathing easier and was able to cough up more mucous. was [MEDICATION NAME]. - 3/21/19, at 14:57 (2:57 p.m.) Called clinic and asked to have nurse return call. Res. has decreased energy,sleepy,decreased appetite,difficulty swallowing at meals,occasional NP cough diminished. B/P 137/82, TPR 99.7-74-28 and oxygen sat 95% RA. Questioning if needs eval (evaluation) at ER (emergency room ) since unable to make trip to PCP in Wgt. (Worthington)? - 3/21/19, at 15:01 (3:01 p.m.) Change in Condition (V4.1, V4.2) Change in condition, symptom or signs called about: Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Functional decline (worsening function and/or mobility)Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Functional decline (worsening function and/or mobility) This started on 03/20/2019 Medication changes in the past week: [MEDICATION NAME] for cough on 3-13-19 Vital signs: Most recent Blood Pressure: BP 137/82 - 3/21/2019 15:02 Position: Lying r/arm Most recent Pulse: P 74 - 3/21/2019 15:03 Pulse Type: Regular Most recent Respiration: R 28 - 3/21/2019 15:03 Most recent Temperature: T 99.7 - 3/21/2019 15:03 Route: Temporal Artery Most recent Weight: W 158.0 lb - 3/13/2019 07:45 Scale: Bath Scale Most recent O2 Sats: O2 95 % - 3/21/2019 15:04 Method: Room Air Most recent Blood Glucose: BS 275.0 - 3/21/2019 11:37 Abnormal lab/diagnostic tests: None to report Things that make the condition or symptom worse: starting to have temperature increase Things that make the condition or symptom better: none - 3/21/19, at 15:30 (3:30 p.m.) Fax received from (physician name) to recheck UA/UC (urinalysis, urine culture). - 3/22/19, at 10:36 a.m. Resident resting quietly in bed. Was down to dining room for breakfast. Was assisted to eat small amount of meal. Did let some food come out of mouth. Lethargic, but did respond when spoken too. Afebrile. - 3/22/19, at 10:36 a.m. Straight cath (catheterized) UA collected and sent to WAH (Windom Area Hospital) lab. - 3/22/19, at 21:51 (9:51 p.m.) Did receive faxed order from primary to started (sic) resident on [MEDICATION NAME] 100mg (milligrams) BID (twice a day) times 7 days. This was started this evening when it came up from pharmacy. She has had a very poor appetite this evening for evening meal, she would not swallow the food and liquids would just run out of resident's mouth. She did however consume about 85% of her arginad mixed with 120cc water prior to supper, after supper she drank 120cc of supplement and 200cc of water. Resident has voided times one this shift. She has remained afebrile, prior to evening meal temp was 98.6, and at 2100, 98.8, she does get 500mg Tylenol at bedtime. Family was here this evening, I did get to speak with grandson, informing him that resident was on antibiotic and I would encourage and assist with giving fluids to resident. - 3/23/19, at 2:33 a.m. Resident's face is flushed, took temp 98.8. Brown urine in brief. Is very difficult to get her to drink thickened liquids. Lets it run down side of mouth. Have not noted any side effects from new antibiotic series which started last eve. - 3/23/19, at 15:17 (3:17 p.m.) Has not eaten food today. Worked with her to get her to take her anti biotic at breakfast. Took a 180 cc orange juice. Has been afebrile all day. Has voided twice. Has been laid down between meals. - 3/23/19, at 21:24 (9:24 p.m.) Res. is lethargic. Is easily aroused tactually. VSS taken and recorded. Res. pockets food and does not swallow. Ref. (refused) supper. took medication in apple sauce. B/S 250mg/dL before supper and 239 mg/dL at HS. Res. urine is dark w/strong odor. Nursing will cont. to monitor all body systems for pot. (potential) comp.(complications). - 3/24/19 at 1:48 a.m. Change in condition, symptom or signs called about: Altered mental status Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Functional decline (worsening function and/or mobility) Unresponsiveness Other change in conditional mental status Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Functional decline (worsening function and/or mobility) Unresponsiveness Other change in conditionLethargy This started on 03/23/2019 Medication changes in the past week: [MEDICATION NAME] 100mg BID X 7 days Vital signs: Most recent Blood Pressure: BP 118/77 - 3/24/2019 14:20 Position: Lying r/arm Most recent Pulse: P 85 - 3/24/2019 14:21 Pulse Type: Regular Most recent Respiration: R 27 - 3/24/2019 14:21 Most recent Temperature: T 98.1 - 3/24/2019 14:21 Route: Temporal Artery Most recent Weight: W 158.0 lb - 3/13/2019 07:45 Scale: Bath Scale Most recent O2 Sats: O2 93 % - 3/24/2019 02:03 Method: Room Air Most recent Blood Glucose: BS 277 - 3/24/2019 11:30 Abnormal lab/diagnostic tests: Urinalysis Urine Culture Things that make the condition or symptom worse: no oral hydration Things that make the condition or symptom better: havingher take in fluieds (sic) - 3/24/19, at 8:46 a.m. Unable to get her to swallow this morning. No meds given. Let food run out of her mouth. - 3/24/19, at 11:51 a.m. afebrile. Will leave her in bed and reposition her Q2H (every 2 hours). Oral care being completed. Is not showing any signs of pain. Has voided once - 3/24/19, at 15:44 (3:44 p.m.) Family was updated on health status. Was consent needed? If so, document risk/benefits and decision: Yes. Consent was needed to have her sent in for evaluation as per (ER on-call physician name) orders. Family is aware of residents most recent change in health status and approved of res. to be seen at WAH. - 3/24/19, at 15:48 (3:48 p.m.) On call, (physician name) was called and notified of res. most recent change in health status. (Physician name) ordered res. to be sent in for evaluation. Family has been notified. - 3/24/19, at 16:04 (4:04 p.m.) Res. sent via ambulance to WAH (local hospital). - 3/24/19, at 20:09 (8:09 p.m.) WAH called to inform res. will be sent to Sanford Hospital in Sioux Falls, South Dakota. When interviewed on 6/28/19, at 9:51 a.m. the director of nursing (DON) stated when R51 was admitted to the facility the resident continued to see her primary care practitioner (PCP) in Worthington. The DON said when R51 resident started to decline, the family requested to switch to a local physician who would see R51 at the facility. The DON stated the process takes a while because their doctor wanted the process to go a certain way. When R51 got sick she was still doctoring with the PCP in Worthington but upon hospital return was now seeing a local doctor who is also the facility's medical director. The DON stated the resident had always sat at the assist table and some days were better than others as far as how much assistance was needed. The DON indicated they'd tried a lot of different approaches to try to keep the resident independent; such as having staff present to move food closer or to remind her to drink. DON didn't think R51 would let staff feed her necessarily. DON reviewed the nursing progress note from 3/13/19 at 1825 and confirmed the resident's actions were something out of the ordinary as far as the confusion. DON was unaware if therapy had communicated concerns about the resident and stated therapy staff would usually contact the case manager with concerns. DON further stated therapy staff may have reported concerns at the medicare meetings. Further, the DON stated the day R51 was hospitalized staff had tried to get a hold of the PCP and were unable to reach him. They then called the Worthington ER and were advised by the nurse to contact the MD on call and that's what they did. DON reported having to conduct a QI (quality indicator) report after every resident hospitalization . DON talked with the medical director and he solidified his process on how/when he could take on a new resident which would be at the resident's next 60 day med review. The DON stated residents needed to remain with their original PCP until that time and stated staff may have been waiting for the medical director to see R51 on his rounds as she was on the list. I think we even asked when he was on rounds if he would see her and he declined stating he would wait until her med review. The DON further stated the nursing staff felt they weren't receiving good response from the Worthington Clinic and were feeling caught. The DON confirmed there had probably been an indication R51 should have been evaluated by a physician sooner. Nursing had asked about sending the resident to the ER and didn't really follow up on that. Maybe if we had that could have prevented the hospitalization . DON confirmed R51 should have been evaluated sooner and further stated they could have contacted the physician on-call in Windom to report the resident's decline to get an order to transfer to the ER. When interviewed on 6/28/19, at 10:46 a.m. registered nurse case manager (RN)-B confirmed R51 had been seeing a PCP in Worthington prior to hospitalization on [DATE]. RN-B stated it was difficult getting ahold of the PCP and added there was some appointments that the family had canceled because they didn't want to pay for transportation. RN-B didn't remember therapy ever voicing concerns r/t the resident's decline and stated she kept the family apprised of R51's status. The resident's Hospitalist Admission History & Physical dated 3/24/19, was reviewed with assessment indicating:[MEDICAL CONDITION]: Unknown etiology concern is for a UTI but can't exclude meningitis as the patient is currently only able to open her eyes. UTI. Acute metabolic [MEDICAL CONDITION] (A broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.). Acute kidney injury, most likely due to hypovolemia (A decreased volume of circulating blood in the body.) [MEDICAL CONDITION] (a high concentration of sodium in the blood). R51 returned to the facility on [DATE]. When interviewed on 7/1/19, at 10:40 a.m. the medical director confirmed first seeing R51 on 4/9/19, and further confirmed the resident was discharged from the hospital on [DATE]. Medical director stated he would like to see new residents within 48 hours if they transition into the nursing home. If the resident already had a primary care provider that was giving care and at some point they wanted to switch their care to him, he would see them at their next 60-day review. Medical director confirmed he had not seen the resident prior to hospitalization in (MONTH) 2019, and further confirmed the resident was very ill by the time she admitted to the hospital per the ER notes. Medical director was unable to comment on the care/condition of the resident the weeks prior to hospitalization , as the resident was not under his care at that time. Medical director stated when residents are showing a decline and the physician needs to be notified nursing should be making a phone call to the physician rather than relying on a fax that may not be answered timely. The facility's policy, Notification of Change, dated (MONTH) (YEAR), included: A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: 2. A significant change in the resident's physical, mental or psychosocial status. Non-pressure skin Issues On 6/27/19, at 9:12 a.m. R51 was observed seated in wheelchair in her room. R51's right hand had a large purple bruise covering the top of the hand with a bruise also on the top of the right middle finger that radiated down to the 2nd knuckle. There was also a steri-strip across the top of R51's right middle finger. R51 stated when her hand gets banged up it bruises easily. When asked if the bruising was painful resident stated, It depends on what I'm doing. Review of R51's medical record did not include evidence related to assessment or monitoring of R51's right hand bruising or skin tear. When interviewed on 6/27/19, at 2:40 p.m. nursing assistant (NA)-B stated yesterday (6/26/19) when R51 returned from therapy she noticed there was blood running down the residents right hand. NA-B stated she alerted RN-E who then cleaned and dressed R51's right hand. NA-B further stated she'd asked R51 what happened and the resident wasn't sure. On 6/27/19, at 2:47 p.m. RN-A observed R51's right hand bruising and skin tear with the surveyor. RN-A stated this skin issue when first identified would be assessed by the nurse, treated, measured, and charted on in a progress note. The nurse assessing would also fill out a purple skin integrity sheet which was kept at the nursing desk to remind staff to monitor and chart on the area weekly until healed. RN-A checked the nurses desk and confirmed a skin integrity sheet had not been filled out for R51 r/t the bruising/skin tear. When interviewed on 6/27/19, at 2:51 p.m. case manager RN-B stated she thought R51's right hand skin bruising/tear had been charted on because originally RN-E had put a [MEDICATION NAME] on the area then changed it out to the steri strips; RN-B stated she would review R51's chart. When interviewed on 6/28/19, at 10:22 a.m. the DON stated when a new skin condition was identified the nurse should assess and complete either a wound data or skin observation UDA (user defined assessment). DON further confirmed with a skin tear the skin observation UDA should be completed. DON stated there was also a reminder sheet at the nurses desk r/t monitoring of the area. The nurse doing the initial assessment would also initiate the reminder form. DON confirmed the nurse who first identified R51's right hand bruising and skin tear should have completed a progress note and either completed the UDA skin observation or an incident report. On 6/24/19, at 3:30 p.m. R24 was observed in his room with a large purple bruise on the left wrist. When interviewed at at that time, R24 stated being unsure how the bruising had happened, and also stated he was awful touchy and skin was real thin. R24's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had intact cognition and required extensive assistance with bed mobility, transfer, locomotion on/off unit, dressing, toilet use and personal hygiene. R24's care plan printed 6/28/19, included: Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. WEEKLY SKIN INSPECTION BY NURSE. Review of R24's medical record did not include evidence related to assessment or monitoring of R24's left wrist bruising. On 6/25/19, at 9:44 a.m. RN-E was observed administering medication to R24 which included Biofreeze 4% gel to be applied to the residents left wrist three times a day. While RN-E was applying the Biofreeze to R24's left wrist she commented on the bruising and how it had extended around the wrist; RN-E did not measure the area. On 6/28/19, at 1:44 p.m. the DON observed R24's left wrist bruise with surveyor. DON confirmed she would expect nursing to perform a skin assessment on this size of a bruise including trying to figure out how it occurred and monitoring to assure it was getting better. R24's Skin Observation form dated 6/28/19 at 15:30 (3:30 p.m.) indicated: Discolored area at wrist level and above measuring 9 cm (centimeters) across the top of wrist and 8 cm at longest length, denies pain, states doesn't know how it happened. R46's [DIAGNOSES REDACTED]. R46's quarterly minimum data set ((MDS) dated [DATE] indicated there were no skin problems. R46's care plan revised 5/29/19, did not identify a skin intervention or monitoring of the lesion behind his left ear. Review of R46's skin assessments completed on bath day 6/17/19 and 6/24/19, did not identify the area behind the left ear. During an observation on 6/24/19 at 3:38 p.m. R46 was observed to have a cut behind the left ear approximately 1.5 inches long. The edges of the wound were separated, approximately 1/8 inch and the tissue surrounding the wound was reddened approcimately 1/8 inch. During interview/observation on 6/26/19 at 1:33 p.m., R46 was found sitting in his room, the nursing assistant (NA-C) indicated he was aware of the wound, and stated it has been there for a long time. The licensed practical nurse (LPN-C) entered the room and indicated the cut had been there since R36 admission on 11/7/18, it has always been reddened around the edges and the wound is not monitored, or documented on. During interview and observation on 6/27/19 at 10:55 a.m., the clinical nurse manager, registered nurse (RN-C) examined the skin behind his left ear. She confirmed this wound should be monitored, further RN-C indicated she would address the wound with the physician. During interview with the director of nursing on 6/28/19 she indicated she was made aware of the wound during the survey and it was her expectation that the wound be assessed and monitored for healing. The facility's 3/19 policy Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements included: A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk. The nursing assistant responsible for this will report any abnormal findings or skgns of skin impairment to the licensed nurse. The bruise, contusion, skin tear, abrasion should be monitored weekly and any changes and or progress toward healing should be documented on the skin observation user defined asessment and on the residents care plan.

Based on observation, interview and document review, the facility failed to provide care and services in a timely manner to ensure pain management was maintained for 1 of 3 residents (R16) who sustained an injury from a fall. R16 suffered harm, severe pain following the injury and was subsequently diagnosed with [REDACTED]. Findings include: R16's Admission Record face sheet identified R16 was admitted to the facility with [DIAGNOSES REDACTED]. R16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R16 had a Brief Interview for Mental Status score (BIMS) of 15 indicating intact cognition. The MDS also identified R16 needed supervision with one person physical assistance for transfers and walking in room and limited physical assistance of one with walking in hallway and toileting. R16 was identified as having no pain and no falls since prior assessment 2/23/18. R16's current care plan, last revised 6/18/18, identified R16 had an actual fall with minor injury R/T (related to) urinary tract infection [MEDICAL CONDITION] with weakness evidenced by 2 falls on 6/16/18. The goal was identified as resident will resume usual activities without further incident. Interventions included monitor/document/report PRN (as needed) times 72 hours to health care provider for s/s (signs/symptoms) pain, bruises and monitor for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. A care plan problem dated 6/20/18, identified the resident had acute pain/discomfort R/T right ankle fracture with surgical repair. An Incident Report dated 6/16/18, at 5:40 a.m. indicated staff had gone into R16's room when the resident had not put on her call light by 5:30 a.m. as was her usual routine. R16 was found sitting on the floor next to the bathroom door frame with her walker next to her. The Incident Report indicated R16 had reported she didn't know what had happened, but had complained of the left foot being tender to touch, but having no significant swelling compared to the other ankle. R16 was not able to bear any weight after assessing the ankle however, there was no bruising, and she was able to move the ankle back and forth, and up and down. Review of an Incident Report dated 6/16/18, at 7:25 a.m. indicated R16 had been assist to the bathroom by staff. The report indicated staff had wheeled R16 into the bathroom and R16 had used the grab bar to stand up. The report indicated staff had then moved the wheelchair out of the room so they'd have room to help the resident however, R16 had suddenly slipped to the floor. The report identified the root cause of the fall may have been related to R16's left foot hurting from a fall 2 hours prior. Following the fall, R16 was assisted with the mechanical lift and 2 staff into bed. At the time she was transferred to bed, her pain rating was identified as a 2 (scale of 1-10 with 10 indicating the worst pain). Nursing notes indicated R16 had a urine specimen obtained per physician order [REDACTED]. Additional notes indicated at 7:48 a.m. on 6/16/18, R16 required an ice pack for swelling to the left ankle, which would be provided every 4 hours as needed (PRN), and the notes indicated R16 had complained of pain to her left ankle. A nurse's note from 8:09 a.m. 6/16/18, reiterated R16 had fallen twice within 2 hours. R16 was described in the note as Alert but confused and had stated, I laid there since 10 p.m. last night. The nurse's note further indicated the resident was confused because R16 had been observed in her bed at 3:30 a.m. during rounds, and there had been no calling out or screams from her during the night. The nurse documented it was unlikely R16 could have been on the floor all night: No tears, flat affect, and skin had no reddened areas of pressure .Left ankle was still painful after administration of PRN Tylenol 650 mg (milligrams). Called primary doctor since she is confused, urine is very foul and incontinent of urine times 2 in last two hours. Used mechanical lift both times to lift her off the floor. Resident stood up in bathroom, hung onto grab bars until writer could remove the wheelchair to assist her to pivot onto toilet. That sudden, she went down slowly on her buttocks. 6/16/18, 8:13 a.m. After second fall in 2 hours, phoned Dr. (doctor) to inform she had fallen twice, hurt left ankle, no swelling after 2 hours of initial fall. 6/16/18, 9:06 a.m. Ice pack for swelling to left ankle every 4 hours as needed. Apply to left ankle for swelling PRN (as needed) administration was effective not swollen but still hurts. 6/17/18, 12:02 a.m. Due to not able to bear full weight on left ankle after her fall, now using sit to stand times two assist to use bedside commode. Left ankle not swollen but is painful. Applied ice pack to affected area. Call placed to eLTC (electronic long term care Dr. available via video) for an order to medicate with PRN Tylenol. At 12:04 a.m. the note indicated [MEDICATION NAME] tablet 650 mg had been given by mouth. The note further indicated R16 had discomfort in her left ankle, rating it a 5 out of 10 on the pain scale. At 12:07 a.m., the documentation indicated R16 had an ice pack placed due to swelling of her left ankle. The note included, Has ice pack to left ankle, not swollen but is very tender to touch. an eLTC (telemedicine) note from 6/17/18, with electronic signature at 1:00 a.m., included orders for tylenol 325 mg 2 tablets every 4 hours PRN pain. The note included, Pt (patient) recently sprained her left ankle. She has an order fo rice, but no order for pain medication. See order above (referring to Tylenol order). The nurse's note from indicated R16 continued to have swelling and pain in her left ankle throughout 6/17/18. At 5:33 a.m., R16 described th pain as an 8 out of 10. At 7:00 a.m., R16 stated the Tylenol was no help at all. At 4:15 p.m. on 6/17/18, R16 stated, I don't think I can stand on my left leg. However, when transferred with a sit to stand lift, the resident had put most of her weight on the left leg with no facial grimacing or complaints, and had denied pain but stated the ankle was a little sore. On 6/17/18 at 9:57 p.m., the notes indicated R16 had complained that her right ankle hurt. A purple bruise was noted on her inner right ankle. The note indicated, Will continue to monitor. Nursing notes from 6/18/18 at 2:03 a.m., indicated R16 had received Tylenol ([MEDICATION NAME]) 650 mg and was gotten up to bathroom (BR), able to bear weight on both legs but says, very painful. Subsequently, notes indicated ice packs had been applied to both ankles at 2:12 a.m. At 2:16 a.m., a nurse's note included, Resident states 'I hurt my right ankle and can't stand on my leg.' When resident is placed in the sit to stand lift for a transfer resident is placing most of her weight on that leg with no facial grimace or any C/O (complaints) noted from the resident. Does have discoloration of teh inner right foot. She has full ROM (range of motion) with that foot & ankle. She did fine with standing and bearing weight on both feet. States, 'It's a little sore is all'. Additional notes included: 6/18/18, 6:58 a.m. [MEDICATION NAME] 650 mg given. Pain scale 9. Resident stated no relief to right leg and ankle pain. 6/18/18, 7:30 a.m. Resident complained of severe right leg pain, requesting [MEDICATION NAME]. 6/18/18, 8:29 a.m. Pain scale 10. Resident stated no relief from pain. 6/18/18, 11:57 a.m. [MEDICATION NAME] 650 mg given. Resident complained of severe right leg and ankle pain. 6/18/18, 1:36 p.m. [MEDICATION NAME] 650 mg PRN administration was ineffective. Pain scale 10 resident stated not having any relief. 6/18/18, 11:06 p.m. [MEDICATION NAME] 650 mg followup. Ineffective pain scale 5 still hurting badly. 6/19/18, 12:03 a.m. Very painful when assessing right foot which now, is bruised entirely around the ankle and top of foot is swollen more than last two days. Rather than bear weight on it, will use bed pan tonight. Will get X-ray tomorrow. 6/19/18, 5:09 a.m. Has been using the bed pan to void tonight since she is having so much pain in both feet. Now total lift of mechanical lift with 2 assist to raise up off the bed to change soiled chux. Resident will not turn, insists she's in too much pain to move. Medicated with PRN Tylenol ([MEDICATION NAME]) 650 mg for severe discomfort. 6/19/18, 5:10 a.m. Pain is so extreme that the resident needs to be raised in bed using mechanical lift. Noted a bruise on under side of left breast. 6/19/18, 6:39 a.m. Had a whirlpool bath. Two assist out of bed with sit to stand lift. Right foot is swollen +2 and bruised Did have a lot of pain when transferred from bed to wheelchair. 6/19/18, 6:39 a.m. [MEDICATION NAME] 650 mg was ineffective. Pain scale 8. Resident continues to rate pain severe. On 6/19/18 at 9:17 a.m., the facility sent a facsimile (fax) to the physician questioning whether R16 should have an X-ray of her right foot related to swelling, bruising and pain following her falls on 6/16/18. A 2:41 p.m., the physician's faxed response indicated approval to get an X-ray of R16's right foot/ankle. The family was called and updated, and informed an X-ray had been scheduled for 6/20/18 at 11:00 a.m. 6/20/19, 7:01 a.m. [MEDICATION NAME] 650 mg given. Resident complained of severe right ankle pain. 6/20/19, 8:43 a.m. [MEDICATION NAME] 650 mg. Administration was ineffective. Pain scale 8. Resident stated having no relief. 6/20/18, 12:25 p.m. Resident left at 10:45 to get right ankle x-ray. Resident left in wheelchair. 6/20/18, 3:30 p.m. [MEDICATION NAME] 650 mg given. Resident complained of moderate pain in right ankle. Requesting [MEDICATION NAME]. 6/20/18, 4:01 p.m. Resdient arrived back at facility around 3:30 p.m. Right ankle was splinted. Pain was rated at 5. 6/21/18, 6:17 a.m. [MEDICATION NAME] 650 mg was not effective. Pain scale 8. 6/21/18, 8:15 a.m. To hospital for surgery right ankle. 6/21/18, 7:05 p.m. Returned from hospital where she had right ankle repair about 6:30 p.m. She is in a wheelchair. Right foot is splinted and wrapped with ace. Rates pain at 8 of 10. Will medicate when meds arrive. An order from eLTC dated 6/17/18, at 1:00 a.m. identified nurse called requesting order for Tylenol for pain. Patient recently sprained her left ankle, had an order for [REDACTED]. The record further indicated a fax had been sent to the MD on 6/16/18, at 5:40 a.m. identifying R16 had been found on the floor after walking to the bathroom with a 4 wheeled walker. The fax indicated R16's ROM (range of motion) to left ankle was painful when putting pressure on foot, but there was no swelling. The fax included, Does not want to stand on left ankle. No bruising. A return fax from the physician was received 6/18/18, at 12:20 p.m. with physician comment, I was called about this, I assume all is now well. Yes? No reply was sent to the physician regarding pain and swelling of right ankle. Review of a pain assessment dated [DATE], indicated R16 had pain associated with a [DIAGNOSES REDACTED]. The assessment also identified the current medication regimen of PRN Tylenol 650 mg and ice PRN was not working. X-Ray result findings of the right ankle dated 6/20/18 indicated: Findings: . a Weber type B distal fibular fracture. Probable medial malleolar fracture. Allowing for osteopenia no acute displaced facture is seen in teh mid to forefoot. of the right ankle. During interview with the director of nursing (DON) on 8/9/18, at 10:24 a.m. she stated staff should have been in touch with the doctor in a more timely way rather than faxing. The DON verified no follow up was done to ensure the pain medication was effective, or to notify the doctor of the resident's pain status and change in ADL ability due to the pain. The DON stated with complaints of pain something obviously changed since there was swelling and bruising. In addition, the DON confirmed R16 had been independent in her room with walking prior to the falls but after the falls required transfer assistance with a mechanical lift and 2 assist. As such, the DON said the doctor should have been notified after his fax had been recieved 6/18/18 to notify him of R16's increased pain, swelling and change in condition. The DON stated the nurse should have called the physician about getting an X-ray instead of faxing on 6/19, and should have tried to get the resident in for the X-ray sooner. She stated they saw bruising on the 17th, first on the left then on the right which should have been addressed and added, we have pain meds in the E-kit (emergency kit) we could have used to make her more comfortable since the Tylenol was obviously not working for pain control. During interview R16's doctor on 8/14/18, at 3:22 p.m. he stated he should have been notified of the increased pain and swelling of the ankle. He stated although he was notified by fax of the fall the morning it happened, he did not see the fax until Monday morning 6/18/18 at which time he'd responded back and asked if everything was ok. He stated, I did not hear anything back from them until they asked for an X-ray on the 19th. COORDINATION OF HOSPICE SERVICES: The facility failed to coordinate hospice services for R41. R41's medical director had signed a certification/recertification of hospice services on 6/7/18. The form indicated hospice services had originally been initiated 3/18/18, due to R41's [DIAGNOSES REDACTED]. R41's significant change MDS dated [DATE], indicated R41 had severely impaired cognition, and total dependence with all activities of daily living (ADLs). The MDS also indicated R41 was receiving hospice services. R41's care plan revised 4/3/18, indicated R41 had a terminal prognosis related to end stage dementia and was receiving hospice care. Interventions included: assess resident and family coping skills, contact hospice staff for support as needed, work with nursing staff to provide maximum comfort for the resident. A clip board with numerous papers attached was observed at the nurses station. Under numerous papers was a paper that said ATTENTION FACILITY STAFF! (R41) is under the care of (name of hospice). The team was identified as nurse, social worker and chaplain. No aide or volunteer was identified. A second page was located on the clip board under that page: (name of hospice) nurse-weekly visits on Monday, Aide- provides AM (morning) ADL cares Monday thru Friday. Chaplain/SS (social service) Thurs/Fri (Thursday/Friday). No patient name was identified on the second page. The hospice agency plan of care provided by the facility also failied to include a hospice visit schedule on it. During observation on 8/8/18, at 7:05 a.m. a hospice aide was present giving R41 a bath. At 7:43 a.m. R41 was sitting at the breakfast table being fed by a facility staff member. The staff stated the hospice aide left after giving R41 her bath. During interview on 8/8/18, at 8:13 a.m. nursing assistant (NA)-D stated, we don't know what they (hospice staff) are going to do when they come. For instance, today they couldn't feed her because they had to go do something else. Sometimes they give her a bath and feed her, sometimes they just feed her. We never know. We don't know days or times they will come either. Sometimes they tell us, sometimes they don't. I think they are supposed to come 3 days a week or something, but they maybe only come two. We never know what time, sometimes it's 6 a.m. when they are supposed to be her at 8. Other times, they've come at like 4 in the afternoon too. During interview on 8/8/18, at 8:30 a.m. NA-F stated, you never know around here when they will come. Sometimes they come and then they have to leave because they have to go somewhere else so they don't do everything they are supposed to. If they can't make it they don't tell us they just come another day. During interview on 8/8/18, at 9:00 a.m. RN-C stated, There is a calendar at the desk. The aide comes every morning Monday through Friday between 6 and 8 a.m. They have a chaplain and a social worker that come in the later part of the week. The nurse comes on Tuesday, she was here yesterday. She (R41) has a volunteer that comes a lot. If they can't make it they don't tell us they just come another day. My hospice people are stable so I'm not concerned about it. If they do let the nurse know they aren't coming then the aides should be told that too. During interview on 8/8/18 at 9:28 a.m., licensed practical nurse (LPN)-B stated she did not know where the calendar for hospice was located in order to know when hospice was coming. RN-B came onto the unit during the interview and stated, The calendar is under the clip board. During observation on 8/9/18, at 7:47 a.m. a hospice aide (HA)-A was observed in the dining room feeding R41. At that time, HA-A stated, We are here 5 days per week for (R41). I come at 5:30 a.m. because I have another patient here also. We have 5 different aides and we all have different schedules. It depends on where the clients are, and who has them, as to what time they come. If I do morning cares then I don't feed, and if I don't do morning care then I feed her breakfast, play music, curl her hair. Normally her bath is done so then I feed her. Yesterday I had to go because we were short, someone called in so we had to split visits up so I had to go. I don't talk to the staff really unless something is out of the ordinary. I just come in and go directly to her room to help her. If I need to tell them (staff) something I will, such as if something is different or out of the ordinary. During interview with the DON on 8/9/18, at 12:47 p.m. she stated, The hospice should give us a schedule. We need to tell them we don't know when their people are coming. That is not good communication for continuity of care. [MEDICAL CONDITION] MONITORING R7's [DIAGNOSES REDACTED]. R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R7 as having a Brief Interview of Mental Status (BIMS) of 8 indicating a moderately impaired cognition. The MDS further indicated R7 required assistance with bed mobility, transfers, dressing, toilet use, hygiene, and bathing. R7's care plan reviewed 5/17/18, indicated R7 required assistance with activity of daily living (ADL's) related to impaired vision, muscle weakness, and impaired cognition. The care plan did not address the residents bilateral [MEDICAL CONDITION] in her feet/ankles. Review of R7's current physican orders dated 6/12/18, included [MEDICATION NAME] (a medication to reduce extra fluid in the body) 80 milligram (MG) daily for [MEDICAL CONDITION]. During observation on 8/8/18, at 12:50 p.m., R7 was observed to have bilateral [MEDICAL CONDITION] in her feet and ankles. The resident was sitting in a recliner chair in her room with her feet resting on the floor. The resident had velcro closing shoes and grippy socks on, however there was visible indentation to R7's ankles from the grippy socks. The right ankle also had a reddened appearance. During observation on 8/9/18, at 8:46 a.m. nursing assistant (NA)-C transferred R7 into a recliner chair. R7 was wearing socks and shoes, however visible bilateral [MEDICAL CONDITION] to ankles was noted, and her feet remained on the floor when NA-C left the room. During interview on 8/8/18, at 10:04 a.m. NA-C confirmed R7 had [MEDICAL CONDITION] ankles. NA-C further stated there were no specific interventions for the [MEDICAL CONDITION] but indicated R7 would elevate her feet if she wanted to. During interview on 8/8/18, at 1:09 p.m. registered nurse (RN)-B indicated R7 had long standing [MEDICAL CONDITION] to her lower extremities. RN-B confirmed there was no formal monitoring in place for the [MEDICAL CONDITION]. During observation and interview on 8/9/18, at 2:22 p.m., R7 was sitting in her recliner chair with her feet on the ground. RN-C assessed R7's lower extremities stating they were cool and dry. RN-C further verified right lower extremity had a redness present but no warmth or discomfort noted from R7. RN-C identified R7 had two plus [MEDICAL CONDITION] (swelling that is significant enough to cause an indentation of 3-4 millimeters deep in the skin when depressed with a finger) in right ankle and foot and one plus [MEDICAL CONDITION] (indentation of 2 millimeters) in left ankle and foot. RN-C stated R7 had refused to wear support stockings in the past, however indicated R7 should have other interventions in place to manage and monitor the [MEDICAL CONDITION], confirming there was nothing in place at this time. During interview on 8/10/18, at 2:48 p.m. the director of nursing (DON) confirmed R7's lower extremity [MEDICAL CONDITION] should be monitored with interventions in place to control it. A facility policy titled Care Plan revised 11/16, indicated each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial and educational needs. Through use of departmental assessments, the Resident Assessment Instrument and review of the physician's orders [REDACTED].

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure relieving interventions for 1 of 1 resident (R48) with two current facility acquired stage 2 pressure ulcers. This deficient practice resulted in actual harm for R48 when one stage 2 pressure ulcer worsened and a new stage 2 pressure ulcer developed. Findings include: R48's Admission Record Face Sheet, indicated R48 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R48's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R48 had severe cognitive impairment, was totally dependent on staff with locomotion on/off the unit, and required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The MDS further indicated R48 was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, and utilized a pressure relieving device in bed and chair. R48's current care plan, last revised 7/24/18, included: The resident has potential for pressure ulcer development R/T (related to) needs assist with mobility and frequent bladder incontinence. The interventions included: Pressure reduction mattress and cushion in w/c (wheelchair). Notify nurse immediately of any new areas of skin breakdown; redness, blisters, bruises, discoloration, etc. noted during bath or daily care. R48's Mobilization Support Data Collection Tool dated 6/28/18, indicated the resident had enough torso strength to maintain an upright, seated position, used a sit-to-stand lift with assist of two staff when transferring between surfaces, and required assist of two staff with a walker for ambulation. The data did not indicate what support R48 needed to position up in bed, turn in bed from side-to-side, to move from lying to sitting on the edge of bed, or to move from a seated position on the side of the bed to a lying or reclined position in bed. The data indicated: Does not sleep in a bed. R48's quarterly Braden Scale for Predicting Pressure Sore Risk dated 6/28/18 was scored as 13, indicating R48 was at moderate risk for skin breakdown. In addition, R48's recent Skin Observation form dated 8/5/18, indicated: no skin conditions observed. On 8/8/18, R48 was continuously observed from 7:15 a.m. until 9:38 a.m. lying in a recliner in the dining area. Staff were assisting other residents in and out of the dining room and providing breakfast during that time. R48 had one leg on the footrest of the recliner with the other leg hanging down with one shoe off and one shoe on. R48 would move his legs periodically and would make moaning/humming type sounds. At 9:38 a.m., nursing assistant (NA)-D approached R48 and asked if he was ready to get up; the resident responded he was. NA-D and NA-F pivot transferred R48 into his wheelchair (w/c) which had a pressure reducing waffle air cushion on the seat. The resident's recliner did not have a pressure reducing cushion on the seat. NA-D then propelled R48 into the tub room to assist him to the toilet. NA-D indicated the night aide (NA-J) had completed R48's morning cares earlier, and had assisted R48 to the toilet around 6:00 a.m. (approximately 3 1/2 hours earlier). NA-D and NA-F were observed to transfer R48 onto the toilet. When R48 was finished on the toilet, NA-D and NA-F stood the resident up to provide peri-care. R48's bottom was observed to have 2 small open red areas, one on the coccyx and one on the right upper buttock near the crease; the areas were circular and approximately 0.5 centimeters (cm) in diameter. When asked if the areas were new, NA-D stated they were new to her. The NAs then sat the resident back down onto the toilet and alerted the nurse to come into the tub room to observe the resident's bottom. Licensed practical nurse (LPN)-B entered the tub room and confirmed R48 had 2 open areas on his bottom. LPN-B stated the areas were new to her but that she would have to research the resident's medical record to make sure they had not been there prior to today. LPN-B then instructed the NA's to feed the resident breakfast first prior to providing treatment or measuring the open areas. When interviewed immediately following the observation, NA-D confirmed R48 always slept in the recliner in the dining area. NA-D stated when the resident first came to the facility they would attempt to have him sleep in the recliner in his room as the resident had slept in a recliner at home however, NA-D stated R48 would crawl out of the recliner in his room and come out to the recliner in the dining area to sleep. NA-D stated per R48's preference, they continued to have him sleep in the recliner in the dining area. When interviewed on 8/8/18, at 10:27 a.m. NA-D stated staff try to reposition R48 every 2 hours though sometimes it can be longer. NA-D further stated sometimes the resident was resistive to repositioning, and other days he was up and on the move. A facsimile (Fax) to R48's physician dated 8/8/18, and sent at 11:34 a.m. indicated: (R48) has an open area on his coccyx. (MONTH) we have an order to read [MEDICATION NAME] to open area. Change q (every) 5 days or when it becomes dislodged or soiled. A fax response from the physician, dated 8/9/18 at 10:07 a.m., was reviewed with physician approval of this plan. On 8/8/18, at 1:10 p.m. R48 was observed laying in the recliner in the dining room with his knees bent and eyes closed. When interviewed at that time NA-D confirmed the resident had been transferred into the recliner at approximately 12:50 p.m. NA-D further confirmed LPN-B had not yet measured or done any type of treatment to the open areas on R48's bottom as she was awaiting direction from the registered nurse case manager (RN)-C. When interviewed on 8/8/18, at 1:57 p.m. LPN-B stated she had applied a [MEDICATION NAME] dressing to the open area on R48's coccyx. LPN-B stated the dressing was large enough to cover the smaller superficial reddish areas below the coccyx as well. When asked about the other open area on R48's right upper buttock, LPN-B stated not realizing the resident had more than one open area. LPN-B then stated she would be back to work tomorrow morning and could look at it then. LPN-B confirmed she had not measured the open area on R48's coccyx as staff was having a difficult time keeping the resident standing during the treatment. LPN-B stated the open area on the coccyx was approximately 0.5 cm round in diameter. LPN-B confirmed R48 had never utilized a pressure reducing cushion when in the recliner. On 8/9/18, at 8:56 a.m. NA-H and NA-D were observed getting R48 up out of his recliner to perform morning cares. The NA's utilized a standing lift (a mechancical lift) to transfer R48 into his w/c. R48's w/c had a pressure reducing waffle air cushion on the seat with very little air in the cushion; the recliner did not have a pressure reducing cushion on the seat. R48 was then propelled into the tub room to be toileted and assisted with cares. NA's utilized the standing lift to transfer the resident onto the toilet, NA-H removed R48's brief, which was soiled with bowel movement. NA-D asked NA-H if there was a duoderm dressing on the resident's bottom and NA-H informed her there was not. After assisting R48 with washing up and changing clothes for the day, NA-D and NA-H then raised the resident up to a standing position with the lift and provided peri-care. R48 hollered out Ow! while his bottom was being cleansed. R48's bottom was observed; there was no dressing covering the resident's coccyx. R48 had two open areas on the coccyx, an upper open area on the coccyx was new since the observation on 8/8/18. The lower open area on the coccyx was larger with white slough covering the wound bed. The area on the right upper buttock near the crease had decreased in size, was reddened and appeared to be closed, there was another small reddened area next to it. NA's put the call light on to alert the nurse. LPN-A entered the room and measured the open area's on R48's coccyx. The new upper area on the coccyx measured 1.0 cm and was circular, the lower open area measured 1.8 cm x (by) 1.0 cm. LPN-A also identified the small reddened areas on R48's right buttock though felt they were scratches. LPN-A applied skin prep to R48's coccyx then covered the open areas with a [MEDICATION NAME] dressing. NA-H then finished dressing R48 and transported him to the dining room for breakfast. When interviewed on 8/9/18, at 10:49 a.m. NA-E stated R48 was to be repositioned every 2 hours just like all the other residents on the unit. When interviewed on 8/9/18, at 10:55 a.m. LPN-A stated he was told when coming on duty today that RN-C wanted him to take a good look at R48's bottom as it had been reported there was an open area. LPN-A stated other than that there were no new interventions to inform RN-C of, or any further reports of what he'd observed, but that she'd (RN-C) take it from there. When interviewed on 8/9/18, at 10:59 a.m. RN-C stated LPN-B had reported R48 had an open area on the coccyx, was unable to measure the area due to the resident becoming uncooperative though was able to cover the area with a duoderm dressing. RN-C stated she had updated R48's care plan indicating the resident was to be repositioned once awake, before and after meals, for the 3:00 p.m. activity in the afternoon, and at HS (bedtime). RN-C confirmed that would be approximately every 2 hours, as R48 allowed. RN-C stated in the morning staff usually wait until R48 has his eyes open and is ready to get up before initiating cares. RN-C further stated staff do not push it and if R48 was resistive, they let him sleep. RN-C also stated they'd be implementing R48's pressure reducing cushion to be utilized when the resident was in the recliner as well as the w/c. RN-C stated prior to this a pressure reducing cushion had not been utilized in R48's recliner as they had not thought it necessary as the recliner cushion was soft. RN-C confirmed the pressure reducing cushion should have been utilized in R48's recliner last night and was not sure why it was not. RN-C further confirmed a new dressing should have been applied when R48's previous dressing had fallen off. RN-C stated staff should be monitoring for when the pressure reducing air cushions were deflating and/or needed more air. RN-C stated LPN-A was usually the one to do this as he also worked as a restorative therapy nurse. When interviewed on 8/9/18, at 1:48 p.m. LPN-A confirmed R48's pressure reducing waffle air cushion was on the low side and definitely needed more air in it. LPN-A stated it was nursing's responsibility to monitor the cushions and make sure they were inflated adequately. LPN-A also stated when the next shift came on at 2:30 p.m. he would have them take the cushion down to therapy to be inflated and would also have staff pick up an extra cushion to keep in the resident's recliner. Review of the Wound Data Collection dated 8/9/18 by LPN-A identified R48's open areas on the coccyx as moisture associated wounds. When interviewed on 8/10/18, at approximately 10:00 a.m. RN-C confirmed she had not yet visualized R48's open areas on the coccyx and could not say for sure if they were moisture associated or pressure wounds. RN-C further confirmed an RN had not assessed R48's open areas. During observation on 8/10/18, at 10:38 a.m. RN-C and the director of nursing (DON) confirmed R48 had two stage 2 pressure ulcers on his coccyx and a small 0.5 cm open area on the inner right buttock. When interviewed on 8/10/18, at 10:54 a.m. the DON provided documentation of the process staff were to follow when a new skin issue was discovered. The DON stated she would expect staff to notify the RN case manager right away and to fax the physician of the skin issue. The DON stated the RN case manager should evaluate the area as soon as she could to assess and to provide the appropriate treatment and interventions. When the DON reviewed R48's Mobilization Support Data Collection Tool dated 6/28/18, she stated the tool did not fully apply to R48 as he did not sleep in bed and was on his seat much of the time therefore should have been looked at a little differently in terms of positioning. The DON also confirmed a Positioning Assessment and Evaluation had not been completed for R48 to determine an individualized repositioning schedule, and added when R48 stopped utilizing his bed, the care plan should have been updated, and she would have expected a pressure reducing cushion to be utilized in the recliner. The DON stated with repositioning, she would need to see how well R48 slept and what that pattern looked like and go from there. She stated she would've started with every hour and a half to 2 hours for a repositioning schedule. As far as how often to reposition at night if the resident was sleeping would depend upon if he had a good cushion and had pressure mapping completed by physical therapy but confirmed that had not yet been completed for R42. DON confirmed staff should be monitoring for the appropriate amount of air in the cushion R48 was utilizing. DON confirmed an RN should have completed an assessment on the wound when first identified. DON stated when there are new interventions for residents' it will go on the care plan and it will come out with a k and that will transfer to the kardex so the NA's can see them on the kiosk - there was also a 24 communication written at the station for staff as well. DON stated the NA's should have known to utilize the cushion in his recliner once implemented into the care plan. The procedure titled, Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements revised 4/16 included: 6. Residents who are unable to reposition themselves independently, as indicated on the Mobilization Support Data Collection Tool UDA, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation UDA is a required tool that is used to determine an individualized repositioning schedule. 7. If a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The registered nurse should record the type of wound and the degree of tissue damage on the Wound RN Assessment UDA (i.e., for a pressure ulcer, record the stage). The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. Document the information on the Wound Data Collection UDA. Skin tears and bruises are not intended to be recorded on this form.