Every finding on record at Green Lea Senior Living

Based on interview and record review, the facility failed to implement necessary interventions and provided adequate supervision consistent with the person-centered care plan for 1of 1 resident (R14) reviewed. This deficient practice resulted in actual harm when R14 was left unattended in a shower chair, lost balance, fell to the floor, and sustained a forehead laceration requiring eight sutures and an acute subdural hemorrhage (brain bleed). The noncompliance that began on 6/17/26 was corrected prior to the start of survey when the facility implemented a corrective action plan on 6/22/26. This is issued at past noncompliance.Findings include: Review of R14's Quarterly Minimum Data Set (MDS) assessment, dated 6/10/26 revealed R14 was cognitively intact with no symptoms of delirium and no behavioral expressions. The MDS indicated R14 had limited range of motion in both lower extremities, utilized a wheelchair, was dependent on staff for transfers to/from bed and showers, and was dependent on staff for personal hygiene, bathing, and showering.Review of R14's diagnoses list revealed active diagnoses of Multiple Sclerosis (a disorder affecting muscle movement and control), osteoporosis (a condition causing increased risk of bone fractures), muscle weakness, and unsteady gait. R14's care plan indicated R14 had a self-care performance deficit related to limited mobility. R14 required assistance by 1 staff for bathing and showering, 2 assist to reposition in bed, and 1 assist for dressing. The care plan also indicated R14 required 1 assist for personal hygiene and was dependent on 2 staff for transfers to and from bed/chair. The care plan was updated 6/17/26 to include R14 was not to be left unattended in the shower.R14's fall risk assessment dated [DATE] indicated R14 was at a moderate risk for falls.Review of a facility Incident Progress Note dated 6/17/26 revealed R14 sustained an unwitnessed fall in the shower room, resulting in emergency medical services (EMS) transfer to the emergency room. The note indicated R14 reported she leaned forward and lost her balance. R14 was found on the floor with a laceration to the left forehead, bruising to the left outer shoulder, bruising to the left outer hip, and an abrasion to the left knee. Review of the facility's Root-Cause Analysis (RCA) Report dated 6/17/26 revealed R14 was at risk for falls due to impaired mobility and was left alone in the shower chair. Under environmental factors, the report noted water running over resident, soap being used for hygiene. Under functional status, the report noted impaired mobility due to disease process and progression. Review of R14's Hospital Discharge Summary and Neurosurgery Consultation Report dated 6/17/26 revealed R14 sustained head trauma, a left-sided facial laceration, and tenderness to the left outer elbow. Diagnostic imaging revealed an acute right-sided minimal subdural hemorrhage (brain bleed). R14 received eight (8) sutures to repair the forehead laceration and was returned to the facility with monitoring parameters.Review of the facility's post-hospitalization Physician Progress Notes dated 6/22/26 revealed R14 was taking a shower unsupervised on 6/17/26 because staff were providing privacy. The physician documented: the plan to prevent this from happening again is for the staff to always remain with [R14] in the bathroom and give her more closer supervision. Interview on 7/20/26 at 11:53 a.m. with NA-B verified that post-incident staff training was effective. NA-B stated she reviews the care plan/Kardex before performing care, received recent shower education, and understands that no resident is ever to be left unattended in the shower room. NA-B stated that any resident requests for solitary showering must be routed through therapy and the charge nurse for safety evaluation.Interview on 7/20/26 at 12:00 p.m. with Occupational Therapist (OT)-A revealed that R14 requires a mechanical lift for all transfers due to severe physical deficits. OT-A stated that a resident's safety to be left alone in a shower depends on both cognition and core abdominal trunk strength. OT-A confirmed that R14 had never been formally assessed by therapy for safety or independent trunk control while seated in the shower chair.Interview on 7/20/26 at 12:38 p.m. with Nursing Assistant (NA)-A revealed that on 6/17/26, she took R14 to the shower room, set her up in the shower chair, and left the room unattended to change the resident's bed linens. NA-A stated that within minutes, she heard a noise and found R14 on the floor bleeding from her head. NA-A stated it had been customary practice to leave R14 unattended in the shower room for years because R14 was alert and requested privacy, and that staff checked on her every couple of minutes. NA-A confirmed she knew R14's care plan required an assist of one for showering, but she did not know management was unaware of this custom. Interview on 7/20/26 at 1:13 p.m. with R14 revealed she has always had staff leave her unattended in the shower room during her 4-5 years at the facility. R14 stated that on 6/17/26, nanoseconds after the staff member exited the room, she closed her eyes to wash, lost her balance, and fell out of the chair. R14 stated that due to her Multiple Sclerosis, she loses her balance and becomes unstable whenever she closes her eyes. Interview on 7/20/26 at 1:25 p.m. with Registered Nurse (RN)-A revealed she was across the hall when she was alerted R14 was on the floor. R14 was lying on her left side with her arm under her head. R14 had a 1.5-centimeter laceration to her forehead and bruising to the left shoulder, hip, and knee. RN-A stated R14 has a movement disorder affecting her balance and mobility. RN-A stated R14 leaned too far forward, and her legs were not enough to provide a counterbalance causing her to fall. RN-A confirmed R14 is a 1 assist for bathing so facility policy would indicate staff be present during showering; however, it has always been R14's preference to be left unattended. Interview on 7/20/26 at 1:56 p.m. with the Director of Nursing (DON) confirmed she was notified on 6/17/26 that R14 was left alone in the shower and sustained a fall requiring hospital evaluation. The DON confirmed R14 sustained a small brain bleed and a laceration. The DON stated residents should never be left alone in the shower and confirmed R14's care plan indicated 1 assist for bathing. The DON stated she would expect at least 1 staff member to stay with residents in the shower for supervision and assist with showering as the resident needs.A policy titled Care plans, comprehensive person-centered dated 3/26 included development of a care plan however did not mention staff expectation for following a resident's care plan.Actions taken included, staff training following the fall included review of bathing and shower/tub policy and procedure as well as care plan, comprehensive person-centered policy and procedure. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on interview and document review, the facility failed to notify the Ombudsman of the discharge for 1 of 1 resident (R32) reviewed. This practice had the potential to affect all residents who transferred or discharged from September 2025 to July 2026 reviewed for Ombudsman notification.Findings IncludeR32 record reviewed discharged [DATE]. R32's record lacked ombudsman notification.During an interview on 07/20/26 3:30 p.m., social service designee (SSD) revealed unaware of the facility ombudsman notification process as SSD was new in the role.On 07/21/2026 6:14p.m., SSD and administrator provided a binder containing logs titled Monthly Notice to MN Ombudsman for Long Term care of Emergency Acute Care Transfer and Discharge . The logs were reviewed and indicated, last notification to the Ombudsman was sent on by facsimile was on July 9th, 2025.The facility policy for transfer and discharge was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the resident's wishes would be followed in the event of a cardiac arrest for 1 of 16 residents (R22) reviewed for code status. Findings include: During interview on [DATE] at 4:26 p.m., R22 stated the facility did discuss code status with him a long time ago. R22 confirmed in the event his heart stopped, or he stopped breathing he would want full CPR. R22's Minimum Data Set (MDS) assessment, dated [DATE], indicated R22 was cognitively intact with no delirium and no behaviors. R22's form titled Advanced Directives dated [DATE] indicated no code.R22's readmission hospital Discharge summary dated [DATE] indicated full code.R22's most recent Provider Orders for Scope of Treatment (POST) dated [DATE] indicated full code. R22's [DATE] Electronic Medication Administration Record (EMAR) indicated on the banner at the top of the screen cardiopulmonary resuscitation (CPR)- full code. R22's [DATE] readmission hospital Discharge summary dated [DATE] indicated full codeR22's facility signed provider orders [DATE] indicated no code as of [DATE].R22's [DATE] EMAR banner indicated do not resuscitate (DNR)-No code. During an interview on [DATE] at 4:36 p.m., licensed practical nurse (LPN)-A stated if a resident was found without signs of life, she would check code status on the banner in the electronic medical record (EMR). If she questioned the code status, she would check the binder containing the POSTs. LPN-A confirmed the EMR banner indicated R22 was a no code and, if found with no signs of life, she would not initiate CPR. LPN-A checked the binder and found an advanced directive for R22 that indicated no code. LPN-A confirmed that date of the advanced directive was dated [DATE]. In a different sleeve of the binder, LPN-A found a POST for R22, dated [DATE], that indicated full code. LPN-A confirmed the discrepancy and stated it needed to be clarified. LPN-A stated based on R22's current banner she would not have needed to check the binder and would not have initiated CPR for R22. During an interview on [DATE] at 4:40 p.m., trained medication aide (TMA)-A stated she would check the banner in the Electronic Medical Record (EMR) for code status and would only check the binder if the code status needed to be confirmed. During an interview on [DATE] at 5:40 p.m., the director of nursing (DON) stated if a resident is found unresponsive or with no signs of life, she would go to the orders to check code status and have someone grab the POST. The DON stated based on R22's current orders, she would not initiate CPR for R22. The DON then checked the treating clinic portal and R22's primary clinic portal to verify code status. The DON confirmed both clinic portals indicate R22 should be a full code. The DON then changed R22's code status from no code to full code. The DON stated facility staff have limited access to clinic portals however she is always available if there are questions regarding code status. The DON stated the admitting nurse is responsible for verifying code status via admitting paperwork and discussion with the resident and/or responsible party. During a follow-up interview on [DATE] at 9:00 a.m., the DON stated R22 was hospitalized in May of 2026 . The DON confirmed R22 was a full code at the time of his hospitalization. On [DATE] R22 returned to the facility. The DON stated R22 returned with a hospital discharge summary, hospital AVS, and an advanced directive form. The director of nursing stated she changed R22's code status based on the advanced directive for that indicated no code. The DON reviewed the [DATE] discharge summary and AVS and confirmed both indicated R22 was full code. The DON reviewed the advanced directive form and confirmed it was dated [DATE]. The DON stated she could not recall if she reviewed the AVS or discharge summary. When asked how hospital orders are verified correctly in the EMR, the DON stated after the admitting nurse should review the entire AVS and enter the orders. The AVS is placed in a basket that directs a second nurse to verify them. The second nurse then signs the orders indicating they were verified. The DON also stated she did not confirm with R22 his code status wishes when she changed to full code on [DATE]. Care conference notes dated [DATE] section 1b titled Current Advanced Directives indicated full codeDuring interview on [DATE] at 9:19 a.m., the social services designee (SS)-A stated code status is verified during care conferences. The SS-A confirmed R22's care conference notes dating [DATE] indicated R22 was a full code. SS-A stated she verifies the resident's wishes during care conferences by asking them, if your heart were to stop would you like staff to perform CPR and puts the response in the care conference notes. SS-A stated she does nothing more with that information. If there was question regarding code status, SS-A stated she believed nursing staff change it and contact the medical doctor. During a follow-up interview on [DATE] at 9:43 a.m., the DON confirmed she was present at R22's care conference on [DATE], however does not recall what was discussed regarding code status. The DON verified R22's care conference notes dated [DATE] indicated full code however nothing is done with that information unless there is concern. When asked to confirm the admission/readmission process, the DON stated once the admitting nurse enters the orders, they are considered live. The verifying nurse just compares the AVS and the orders entered and signs the AVS. The DON confirmed R22's hospital AVS dated [DATE] did not have a verification signature. During an interview on [DATE] at 10:00 a.m., the facility medical director (MD) stated code status must be confirmed when a resident is admitted or readmitted from an acute care facility. If a POST was previously completed, it must be verified with the resident or responsible party. If a discrepancy is found on an advanced directive the facility must verify that with the resident or responsible party and also notify the provider. A policy titled Advanced Directives dated 11/2025 defined advanced directives as a written instruction, recognized by state law relating to the provisions of health care when the individual is incapacitated. Do not resuscitate (DNR) indicates, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy or representative has directed that no cardiopulmonary resuscitation (CPR) or life sustaining treatments or methods are to be used. POST is defined as a form designed to improve patient care by creating a portable medical order form that records the resident's treatment wishes so emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration The policy also indicated if the resident has an advanced directive, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any staff. The director of nursing or designee notifies the attending physician of advanced directives, or changes in advance directives, that the appropriate orders can be documented in the resident's medical record and plan of care. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advanced directive document in a prominent, accessible location in the medical record and discussing the residents' wishes in care planning meetings. The plan of care for each resident is consistent with their documented treatment preferences and or advanced directive. The interdisciplinary team will review annually with the residents their advance directives to ensure such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The nurse supervisor is required to inform emergency medical personnel of a resident's advanced directives regarding treatment options and provide such personnel with a copy of the advanced directive or POST when transferring from the facility via ambulance or other means.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (R6) reviewed for antipsychotic medication use. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2025, identified Section N: Medications to be completed with an intent to record the number of days, during the last 7 days that select medications were received by the resident to include antipsychotic medications. The manual further indicated, Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. Further, the manual provided several coding instructions, including directing staff to check if an antipsychotic medication was taken by the resident at any time during the 7 day look-back period (or since admission/entry or reentry if less than 17 days). It also directs staff to check if there is an indication noted for all antipsychotic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). The Antipsychotic medication Review section directs staff to indicate if the resident received antipsychotic medications since admission/entry or reentry or the prior assessment by answering yes or no. R6's quarterly MDS assessment dated [DATE] indicated R6 was cognitively intact. The MDS indicated R6 received antipsychotic medications during the previous 7 days. however the Antipsychotic medication review section indicated R7 had not received antipsychotic medications. R6's medication administration record (MAR) dated 6/2026 showed no record R6 received antipsychotic medications during the month. During an interview on 7/21/26 at 3:37 p.m., the facility MDS nurse stated she would typically look at the residents MAR to determine medications taken during the observed 7 days of the assessment. If the MAR shows a resident was administered certain medications, she will code it as such on the MDS. The MDS nurse reviewed R6's MAR and confirmed R6 did not receive antipsychotic medications during the observed time. The MDS nurse reviewed R6's quarterly MDS dated [DATE] and confirmed she did indicate R6 received antipsychotic medications and there were indications for the administration of the medication. The MDS nurse then reviewed the antipsychotic medication review section of the MDS and confirmed she indicated R6 did not receive antipsychotic medications. The MDs nurse stated R6's MDS was one of the first ones she did for the facility and she must have marked yes by mistake. During an interview on 7/21/26 at 6:00 p.m., the director of nursing indicated MDS accuracy is important for coordination of residents' care and proper reimbursements rates for the facility. A policy titled Certifying Accuracy of the Resident assessment dated 11/2025 indicated the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment.

Based on interview and document review, the facility failed to ensure there was a communication process between the long-term care (LTC) facility and the hospice provider to ensure the needs of the resident were met for 1 of 1 resident (R6) reviewed for hospice services. Findings include:R6's quarterly Minimum Data Set (MDS) assessment, dated 6/12/26, indicated R6 was cognitively intact and received hospice services. The High-Risk Drug Classes: Use and indication section of the MDS indicated R6 received antipsychotic medications (medications used to treat mood disorders).R6's diagnoses list included dementia with agitation, stroke, mode disturbances, depression, palliative care, and mental/behavioral disordersR6's care plan indicated R6 was on hospice and had history of anxiety, agitation, and verbal outbursts. R6's care plan does not indicate R6 received antipsychotics. R6's hospice residential communication form dated 3/11/26 indicated R6 was started on Seroquel per hospice provider recommendation. The communication form, signed by the hospice nurse, indicated the director of nursing and another staff member were updated on the new order. An order from hospice dated 3/11/26 indicated to start Seroquel 25 mg at bedtime and as needed for behaviors. R6's monthly Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report , located in the facility hospice binder, dated from 3/26 to 7/26 indicated R6 received Seroquel at bedtime and as needed.R6's medication administration record (MAR) from 3/26-7/26 did not indicate R6 received antipsychotic medications. During an interview on 7/21/26 at 2:20 p.m., the director of nursing (DON) stated R6 was receiving Seroquel (antipsychotic medication). The DON stated she remembered entering the medication into the record herself. The DON reviewed the current MAR and confirmed the MAR showed no record R6 received antipsychotic medications. The DON reviewed the hospice plan of care update reports in R6's hospice binder and confirmed Seroquel is listed as a current medication. During an interview on 7/21/26 at 3:01 p.m., R6's hospice nurse confirmed an order was written 3/11/26 for Seroquel 25 mg at bedtime and as needed and thought the facility providers must have discontinued it. RN-A stated she spoke with the hospice medical provider who confirmed R6 should still be receiving Seroquel.During interview on 7/21/26 at 3:22 p.m., the facility's physician's assistant (PA) stated on 6/16/26 there is documentation from clinic staff indicating R6's medication list was reconciled with the hospice medication list. The PA stated she was unable to find documentation the Seroquel was discontinued by their staff and the medication is still active in their system. During an interview on 7/21/26 at 4:30 p.m. the DON stated they do not always review the hospice IDG care plan update notes. The DON confirmed Seroquel is listed on R6's IDG care plan notes in the binder located in the facility. During an interview on 7/21/26 at 4:37 p.m., hospice nurse stated hospice nurses will try to talk to available facility staff for updates during the visits, however the IDG care plan update notes are not specifically discussed with facility staff.A policy titled Hospice Program dated 8/25 indicated In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriate based on the individual resident's needs. The list of responsibilities included administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during Quarter 2 2026 (January1-March 31), to the Centers for Medicare Services (CMS), according to specification established by CMS. Findings include:Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D for quarter 2 2026 (January 1-March 31) identified the facility had one star staffing, 4 or more days within the quarter with no Registered Nurse (RN) hours (35 of 90 days), 4 or more days within the quarter with <24 hours/day licensed nurse coverage (66 of 90 days) , and excessively low weekend staffing. During a joint interview on 7/21/26 at 9:00 a.m., with the facility administrator and administrative assistant, the administrator stated the facility receives a payroll report from a 3rd party payroll agency and the administrative assistant submits the information to CMS. The administrative assistant stated she receives the report from the 3rd party payroll company, logs into the PBJ system, and uploads the report. The facility did not review the information on the report. The administrator and administrative assistant felt the PBJ might have triggered due to how the report was printed from the payroll company which caused issues with transmitting the information to CMS. On 7/21/26 at 9:20 a.m., email communication was sent to the facility's contact person at the payroll management company to discuss PBJ submission data. Multiple attempts to discuss the payroll submission data were made however could not be arranged. During interview on 7/21/26 at 11:09 a.m., the director of nursing pulled payroll and scheduling information for a sample of triggered dates during Quarter 2 2026. The facility verified sufficient staffing on those dates therefore, the data submitted in the payroll-based journal (PBJ) report to the Center for Medicare and Medicaid Services (CMS) was inaccurate. During an interview on 7/21/26 at 11:59 a.m., the administrator stated he was unable to determine if the PBJ triggered due to inaccuracy of information or issues with transmitting information. A policy titled Payroll Based Journal revised 7/21/26 indicated It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility will ensure all staffing data entered in the Payroll0Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and or/tied back to a contract. The facility will utilize the current submission guidelines as described in the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual. The administrator, HR director and Director of Nursing are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports. The Business Office Manager is responsible for verifying the accuracy of census data and collaborating with MDS [Minimum Data Set] coordinator for any needed corrections. Reports available through CASPER may be utilized to assist with verifying data. MCHS CFO is responsible for submitting data and obtaining validation reports. the administrator is responsible for reviewing validation reports and ensuring that any needed corrections are made before the quarterly deadline.

Based on observation, interview and documentation, the facility failed to comprehensively assess and monitor a wound for 1 of 3 residents (R3) reviewed for wound care.Findings include:R3's diagnoses list dated 4/7/26 included orthopedic aftercare following surgical amputation, acquired absence of right leg below the knee, and other complications of amputation stump.R3's significant change Minimum Data Set (MDS) dated [DATE] identified R3 did not have cognitive impairment. R3's received surgical wound care.R3's care plan dated 3/24/26 indicated a risk for impaired skin integrity related to surgical intervention right below the knee amputation (BKA), decreased mobility and need for assistance with personal cares. Interventions included but were not limited to dressing change every other day initiated on 3/31/26 and evaluate skin integrity. The care plan also included R3 has peripheral vascular disease (PVD) related to diabetes mellitus type 2 and hypertensive heart disease with chronic kidney disease. Interventions included but were not limited to BKA related to PVD: right leg: inspect incisions daily, drain in place, cover with gauze and abdominal pad followed by stump protector initiated on 3/17/26.R3's outside wound care provider note dated 3/23/26 indicated R3's wound drain was removed on 3/23/26. R3's wound care order dated 3/23/26 instructed: dressing change every other day to right stump wound. Irrigate with normal saline (water) and dry. Pack wound with Mesalt ribbon (narrow strip of gauze dressing) in wound 5.5 centimeters going almost straight down. Cover with Mepilex border dressing (a foam wound dressing).R3's progress note dated 4/5/26 at 4:20 p.m. indicated wound care was provided as ordered. Moderate amount of sanguineous and purulent drainage. Tunneling approximately 7-7.5cm. Peri wound saturated with brown, yellow, and green drainage. No odor. Surrounding tissue pink. Leg dry and flaky, lotion applied. Resident denied pain or discomfort.In review of R3's wound documentation records between 3/1/26 and 4/5/26 revealed although there were wound mentions with descriptions the assessments/monitoring there was no indication a comprehensive assessment was completed that included measurements in order to determine improvement or deterioration. During an observation on 4/6/2026 at 4:18 p.m. R3 was sitting in a wheelchair with his right leg elevated in a padded brace with Velcro straps. During an interview, R3 stated he had a wound to his right stump that had been giving him trouble. He was going to an outside wound care provider who assessed the wound and took measurements. R3 could not recall the last time a facility nurse measured the wound.During an interview on 4/6/2026 at 4:32 p.m., licensed practical nurse (LPN)-a stated there was an order on the resident's TAR to measure wounds once a week. The measurements would be written down in the wound book. Every resident wound had a page in the book. A registered nurse needed to complete the weekly wound measurements and assessments.During an observation on 4/7/2026 at 9:43 a.m., R3's wound page was observed in the wound care binder. Weekly dates were entered along with dressing change order. The page did not include measurements nor characteristics of the wound. During an interview, registered nurse (RN)-A stated Friday was wound measurement day. Measurements were documented in the weekly wound care binder. Description of the wound characteristics wound be documented in a wound note. Monitoring of the wound was done with every dressing change. RN-A confirmed the weekly wound care binder did not contain measurements of R3's wound. RN-A stated she was uncertain whether she would measure R3's wound on Fridays because he was seen by an outside wound care provider every other week who measured the wound. RN-A stated she would look for a wound note in R3's chart or the wound care provider notes to determine if the wound was improving or deteriorating.During an interview on 4/8/2026 9:46 a.m., medical doctor (MD) stated nurses should be documenting what a wound looks like with every dressing change and measured at least weekly. MD expected to be notified if a wound was deteriorating. MD would ask the nurse about R3's wound because she could not rely on documentation in the chart for description of the wounds. MD did not know about the book with weekly wound measurements. Measurements and a description of the wound were especially important for R3 because his wound had deteriorated several times so the wound needed close monitoring.During an interview on 4/8/2026 at 10:48 a.m. nurse consultant (NC) stated the director of nursing (DON) would add an order to the resident's TAR for wound measurement on Fridays when an RN was working. NC stated R3's wound note on 4/5/26 was a good description of the wound but did not contain measurements. NC confirmed R3's did not contain weekly wound assessments in March 2026 or April 2026. A resident's wound should be measured weekly and a wound note written with the measurements and the nurse's assessment of the wound.The Wound Care policy dated 10/15/24 instructed the following information should be recorded in the resident's medical record:The type of wound care given.The date and time the wound care was given.The name and title of the individual performing the wound care.Any change in the resident's condition.All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, weekly and as needed by wound nurse.Any problems or complaints made by the resident related to the procedure.If the resident refused the treatment and the reason(s) why.The signature and title of the person recording the data.

Based on observation, interview and document review, the facility failed to establish a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications stored in an emergency medication kit and failed to establish a system to account for medications brought from home and stored in the medication room. Findings include:During an observation on 4/7/2026 at 9:43 a.m., registered nurse (RN)-A was observed unlocking the medication room then unlocking a cabinet to access the emergency medication kits (e-kit). A small e-kit was labeled with a list of controlled medications including the number of stocked pills/bottles and was secured with a breakaway lock with numbers. A larger e-kit labeled with non-controlled medications was also secured with a breakaway lock with numbers. A binder was observed with an every shift listing of lock numbers and staff initials. During an interview, RN-A stated to remove a controlled medication the nurse would first check the resident's provider orders. If the order matched a medication in the e-kit, the nurse would break the lock on the e-kit, fill out the pharmacy usage form, remove the required medication, then place a new lock on the e-kit and record the new lock number in the binder. The usage form would be faxed to pharmacy then placed in a basket on the counter to be scanned into the resident's medical record. If the number of pills in the e-kit did not match the number indicated on the cover of the controlled e-kit, RN-A would contact the pharmacy to find out when the other pills had been removed. RN-A further stated if a resident admitted with home medications, the nurse would ask a family member to bring the medications home. If there were no family members available, the medications would be placed in the medication room until the resident discharged or the medications were destroyed with resident or family approval. RN-A did not know if there was a procedure to account for a resident's home non-controlled medications that were stored in the medication room.During an interview on 4/6/2026 at 4:32 p.m., licensed practical nurse (LPN)-A stated when a resident brings medications from home, the nurse would ask family to bring the medications home. If that was not possible, the medications would written down on a piece of paper, the medications placed into a plastic bag, list of medications attached to the bag, then the bag placed in the medication room.During an observation on 4/7/2026 at 11:35 a.m., trained medication assistant (TMA)-A opened an unlocked cabinet in the medication room and removed a gallon size bag filled with medication bottles. During an interview, TMA-A stated when a resident brought medications from home, the nurse would go through the bag to look for controlled medications then would give the bag to TMA-A to place in a medication room cabinet. TMA-A did not know what the procedure was to account for all the non-controlled medications a resident brought from home.During an interview on 4/7/2026 at 12:31 p.m., pharmacist (Ph) stated the facility should be accounting for all medications removed from the e-kit and complete an inventory every shift. E-kits were replaced at the pharmacy's discretion and might need to be accessed several times before replacement. During an interview on 4/7/2026 at 11:54 p.m. director of nursing (DON) stated a nurse should count the pills in the controlled e-kit before removing any medications and compare the number of pills in the e-kit with the number of stocked pills on the top of the e-kit. If the numbers are different, the nurse would look at the pharmacy usage sheet that was placed in the e-kit from a previous medication removal. If there were no completed sheets in the e-kit, the nurse should call the pharmacy for information about any pills that had been removed since the last e-kit replacement. During an interview on 4/8/2026 at 9:59 a.m., the nurse consultant (NC) stated when a resident brings medications from home, a nurse would ask family to take the medications out of the facility. If there is no one to take the medications, a nurse should document all the medications including the number of pills in a nurse's note in the resident's electronic medical record.The Controlled Substance Storage policy dated 4/1/2019 instructed at each shift change or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented.The Medications Brought to the Facility by a Resident or Responsible Party policy dated 4/1/19 instructed a licensed nurse to receive the medication delivered to the facility and documented delivery of the medication on the appropriate form/chart.

Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and implement/revise the care plan to prevent and/or reduce the risk of fall with major injury for 2 of 3 residents (R1, R4) who had falls. This resulted in an immediate jeopardy (IJ) for R1 who sustained a resulted in a subarachnoid hemorrhage (type of brain bleed) and was hospitalized .The IJ began on 9/30/25 after R1's third fall with no completion of a causal analysis or implementation of fall interventions which resulted in and/or could have mitigated the risk of R1's fall on 10/3/25 fall with major injury that required 5-day hospitalization and two subsequent falls on 10/8/25 upon readmission to the facility. The administrator and director of nursing (DON) were notified of the IJ on 10/14/25 at 5:31 p.m. The immediate jeopardy was removed on 10/17/25 at 2:50 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include:R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). R1's hospital Discharge summary dated [DATE], identified R1 was admitted to the hospital 9/6/25 and discharged to the facility on 9/25/25 with diagnoses that included cerebral vascular accident (CVA), diabetes, and bipolar disorder. The discharge summary indicated R1 required assist of two for activities of daily living and assist of two with total mechanical lift for transfers. R1's admission Nursing assessment dated [DATE], identified R1 was alert and orientated to person, but not aware of time and place, used a wheelchair for mobility, had poor trunk control due to right sided deficit from stroke, and surface to surface transfer was not steady and needed staff assistance for transfers. R1's Morse Fall Scale (a tool used to assess a resident risk for falling) dated 9/25/25, identified R1 was moderate risk for falling. R1 had impaired gait and overestimates or forgets limits. There was no further information included. R1's Temporary Care Plan dated 9/25/25, did not identify R1's level of risk for falling as identified in the Morse Fall Scale. R1's care plan identified R1 was assist of two with a full body mechanical lift, R1 was incontinent of bowel and bladder, but did not identify a toileting routine/schedule. Further the care plan did not include any interventions to prevent/reduce falls including applicable interventions associated with R1's fall risk factors identified on the Morse Fall Scale (impaired gait and overestimates or forgets limits). R1's fall incident report dated 9/26/25 at 2:00 p.m., identified R1 had an unwitnessed fall from wheelchair in room. R1 stated she was trying to get to the bathroom. R1 was incontinent of urine, and the floor was wet. Review of facility incident reports and R1's record did not include a comprehensive fall investigation and analysis to determine all potential risk factors for which appropriate interventions would be implemented to prevent/mitigate the risk for falls. Although the progress note indicated one potential causal factor of R1's fall was attempting to use the bathroom, there was no indication R1's care plan was revised to include associated interventions. R1's physical therapy (PT) treatment note dated 9/26/25, identified R1 was impulsive and had decreased alertness and judgement. R1's care plan did not identify R1 was impulsive nor include interventions to decrease the risk of falls related to R1's impulsivity. R1's progress dated 9/28/25 at 2:19 a.m., included R1's bed was kept in low position and fall mat along bedside. R1 was found in bed making squirming movements from her bed to the mat, incontinent of urine, and did not use the call light. Subsequent progress note at 4:26 a.m., identified R1 was found scooting herself from the bed to the floor mat. R1 fall focus care plan initiated on 9/28/25, identified R1 was high risk for falls related to confusion, incontinence, poor communication/comprehension, and unaware of safety needs. R1's impulsivity that was documented by PT on 9/26/25 was not included in the listing of risk factors. Interventions included: anticipate and meet the needs of the resident, be sure call light is within reach and encourage the resident to use it for assistance, the resident needs prompt response to all requests for assistance, ensure the resident is wearing appropriate footwear and no-skid gripper shoes and/or gripper socks. R1's care plan did not include the interventions of low bed nor the fall mat which were identified in the 9/28/25 at 2:19 a.m. progress note. R1's progress note dated 9/28/25 at 7:17 p.m., indicated R1 fell from bed onto cushioned mat on the floor. Subsequent note at 7:19 p.m. included R1 forgets her physical limitations and attempts to move or stand and cannot support self. No further information was documented. There was no corresponding incident report, no indication of a comprehensive analysis to identify causal factors, and no indication R1's care plan was revised. R1's progress note dated 9/30/25 at 9:47 p.m., identified R1 had a fall at 8:50 p.m. R1 was found lying on the fall mat next to her bed. R1 had removed brief and only had on gripper sock on. R1 was very fidgety and unable to remain still. There was no corresponding incident report, no indication of a comprehensive analysis to identify causal factors, and no indication R1's care plan was revisedR1's minimum data set (MDS) dated [DATE] (assessment reference date), identified R1 was cognitively intact, had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self) that occurred 1 to 3 days, had impairment on one side for upper and lower extremities, was frequently incontinent of bowel and bladder, used a wheelchair, and was dependent for all transfers/toileting. The MDS identified R1 did not have any falls since admission even though R1's record had documented falls on 9/26/25, 9/28/25, and 9/30/25. R1's fall incident report dated 10/1/25 at 8:50 a.m., identified R1 was sitting in the lobby when she leaned too far forward and fell out of her wheelchair. There was no indication of a comprehensive analysis to identify causal factors was completed and no indication R1's care plan was revised. R1's PT treatment note dated 10/1/25 (no time stamp), identified R1 had a fall in the lobby prior to be treated. PT educated staff on therapy ball R1 used for left upper extremity and added pillow behind back to increase comfort and decrease need to be repositioned. There was no indication R1's care plan was revised to include these recommendations. R1's fall incident report dated 10/3/25 at 9:24 a.m., identified R1 was found on floor between door and bed. R1 had an injury above right eye that was swollen and bleeding, and two skin tears on right forearm. Predisposing factors of restless, gait imbalance, and weakness. R1 was sent to emergency department (ED) for evaluation. Report indicated R1 had self-propelled to an area where R1 was not observed by staff. There was no indication of a comprehensive analysis to identify causal factors and no indication R1's care plan was revised. R1's hospital emergency department (ED) note dated 10/3/25, identified R1 was seen in the ED following an unwitnessed fall in the skilled nursing facility after trying to get out of bed. R1 had a hematoma (a localized collection of blood outside the blood vessels) and a small laceration on the right lateral (side) eyebrow and a skin tear on right forearm and computed topography (CT) of the head showed findings concerning for traumatic subarachnoid hemorrhage and was admitted for observation. R1's therapy recommendation dated 10/3/25 (no time stamp), identified R1 was to have supervision when in wheelchair due to R1 was high fall risk and do not leave in room alone when in wheelchair. There was no indication R1's care plan was revised to include these interventions. During an interview on 10/10/25 at 5:55 p.m., therapy director (TD) stated R1 had been impulsive and had poor safety awareness since admission. TD had communicated this to the nursing staff since admission and placed a sign in R1's room after her fall on 10/3/25 to ensure staff did not leave her alone in her room when she returned from the hospital. R1's hospital Discharge summary dated [DATE], identified R1 was hospitalized [DATE] through 10/8/25 following a fall. R1 was kept for observation and was discharged back to the nursing facility on 10/8/25 at 9:30 a.m. In review of R1's record there was no documentation of what time R1 returned to the facility. There was no indication of revisions to R1's care plan for falls upon re-admission. R1's progress note dated 10/8/25 at 12:03 p.m., identified R1 stays in lobby for staff to keep an eye on her while awake. R1's fall incident report dated 10/8/25 at 1:10 p.m., identified R1 was found lying on the floor in her room off the fall mat. R1 stated she rolled out of bed and just kept rolling and rolling. There was no indication of a comprehensive analysis to identify causal factors was completed and no indication R1's care plan was revised. R1's progress note dated 10/8/25 documented at 9:46 p.m., identified at 4:10 p.m., R1 was observed attempting to stand up from wheelchair in main living area. R1 fell to one knee and staff quickly assisted R1 by lifting her back into her wheelchair. No injury. There was no indication an incident report was completed, no comprehensive analysis, and no indication R1's care plan was revised. R1's fall incident report dated 10/8/25 at 7:15 p.m., identified R1 was found on the floor in the main living area. Staff reported hearing R1's head hit the floor. R1 sustained a large skin tear on tip of right forearm. Ambulance called and R1 was transported to ED at 7:50 p.m. There was no indication of a comprehensive analysis to identify causal factors and no indication R1's care plan was revised. R1's progress note dated 10/8/25 at 11:36 p.m., identified that facility received a call from hospital ED and that R1's test came back negative and R1 will be sent back to facility. R1's bed was placed near the nursing station and will plan to always keep R1 in view. R1's MDS dated [DATE] triggered the fall Care Area Assessment (CAA) which was signed as completed on 10/8/25, identified R1 had a potential (versus actual) problem for falls due to taking high risk drugs (antidepressant). The CAA did not include all of R1's risk factors identified in R1's record nor her seven falls, one which resulted in major injury. R1's progress note dated 10/9/25 at 2:56 a.m., identified R1 arrived back to the facility at 1:50 a.m. Providing 1:1 as able and bed in low position and fall mat. R1's fall focus care plan had been updated on 10/9/25 to the following intervention: R1 needs activities to minimize the potential for fall while providing diversion and distraction. R1 needs to be in common area for supervision and enjoys 1:1 activity and had fidget items to utilize. R1's records were reviewed between 10/9/25 to 10/13/25, it was not evident the 1:1 supervision was implemented with the exception of the mentions in progress note dated 10/9/25 and 10/11/25. The duration of the 1:1's on 10/9/25 and 10/11/25 was not identified. During an observation and interview on 10/10/25 at 10:54 a.m., R1 had a sutured laceration above her right eye and yellowish/green bruise below the eye. Nursing assistant (NA)-E and NA-K were assisting R1 onto a commode. Two signs were placed on the wall near R1's bed that directed Press the red button if you need help or need to get up. R1 stated the sign meant to remind her to use the call light or to just get up if she needed something. NA-E stated she had heard R1 had fallen a while ago that resulted in her right eye with bruises. NA-E stated she was unaware of what the fall prevention interventions were for R1 because she was in training and had not been shown how to look up the interventions. During an interview on 10/10/25 at 12:03 p.m., registered nurse (RN)-B stated when a resident falls, she would perform range of motion, vitals, and enter the information in the Risk Management tab in the electronic health record (EHR). RN-B was unaware of how to complete a fall causal analysis, nor did she know how to add/update a resident's care plan. RN-B explained floor nurses did not complete causal analysis nor update the care plans, management would perform those tasks. During an interview on 10/10/25 at 4:20 p.m., NA-G stated R1 would self-transfer since admission. R1's fall prevention interventions were a low bed with a fall mat on the floor. NA-G was not sure how other staff would know R1 needed those. NA-G stated R1 had been on 1:1 supervision for a short time but was not sure if they had stopped or if that was ongoing. Staff try and 'keep eyes' on R1 when she is in her wheelchair, but sometimes we get busy and may not watch her as close as we should. NA-G could not articulate any additional fall prevention interventions for R1 and stated she would have to reference a nursing assistant communication book that had each resident's care plan in it, however, was not able to find a care plan for R1 in the book. During an interview on 10/10/25 at 5:25 p.m., director of nursing (DON) stated R1 was a high fall risk upon admission due to not being aware of her own limitations. DON reviewed R1's fall documentation since admission. DON stated none of R1's falls included a comprehensive investigation and causal analysis. R1's care plan had not been revised after each fall and not all interventions documented in the record were represented on the care plan. During an interview on 10/14/25 at 2:53 p.m., trained medication aide (TMA)-C stated he was unaware of all the fall prevention interventions the facility was doing for R1. He was not able to locate the Kardex in R1's electronic health record and stated the only fall intervention he was aware of was to keep R1 in eyesight when she is up in her chair. TMA-C stated they try to do this as best they can. During an interview on 10/14/25 at 3:01 p.m., nursing assistant (NA)-J could not articulate what the fall prevention interventions were for R1. NA-J stated normally there was a book with the Kardex in it and this would tell staff what the fall interventions would be, however, NA-J could not find R1 in the book. NA-J stated she would then go to the kardex/care plan in the EHR (electronic health record) to determine fall prevention interventions, however, upon looking at R1's kardex/care plan she only identified that R1's call light should be within reach. The immediate jeopardy that began on 9/26/25, was removed on 10/17/25 at 2:50 p.m., when it was verified, the facility implemented the following: -R1 had an updated fall risk assessment completed. -R1's falls since admission had a root cause analysis and appropriate fall prevention interventions added to the clinical chart. - Interdisciplinary team met and reviewed R1's falls and root cause analysis to ensure appropriate fall interventions in place based on resident needs and resident's status based on the individual falls and root cause analysis. -R1's care plan updated to include current fall interventions and fall risk level. -All high risk fall residents who had a fall in the past 30 days had a root cause analysis completed and care plans were updated to remove/negate the risk of falls based on potential risks of falls. -Staff were re-educated on the facility's falls and fall risk, managing, fall risk assessment, assessing falls and their causes, falls-clinical protocol, baseline care plan, and comprehensive care plan policies. -All clinician staff was re-educated on the facility policies, ensuring licensed staff adding immediate intervention post fall, updating care plan, -Agency nursing staff orientation checklist update to include education on fall prevention policies and procedures. R4 R4's face sheet dated 10/16/25, identified diagnoses of Huntington's disease (a rare neurodegenerative disorder that causes progressive physical, cognitive, and psychiatric symptoms), muscle weakness, and history of falling. R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact, continent of bowel and bladder, needed moderate assistance for transfers, and had a fall in the last month prior to admission. R4's Morse Fall Scale dated 8/26/25, identified R4 was high risk for falling due to weak gait; overestimates or forgets limits. R1's Morse Fall Scale did not identify any further information. R4's fall focus care plan dated 9/5/25, identified R4 was high risk for falls. Goal was that R4 would not sustain serious injury. Interventions included: anticipate needs; be sure call light is within reach; ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. R4's fall incident report dated 9/4/25 at 8:36 p.m., identified R4 had an unwitnessed fall and was found on knees with them under the bed holding onto the railing. R4 stated she pushed herself back to her room after the tractor pull and just wanted to go to bed but could not reach the call light. R4 was incontinent of urine at the time of the fall. There was no indication of a comprehensive analysis to identify causal factors and no indication R1's care plan was revised. R4's fall incident report dated 10/2/25 at 6:40 p.m., identified R4 was self-transferring from wheelchair to the bathroom with walker and slipped out of wheelchair. Vital signs taken and assisted from ground. There was no indication of a comprehensive analysis to identify causal factors and no indication R1's care plan was revised. R4's fall incident report dated 10/14/25 at 7:15 p.m., identified R4 was found in room with bottom on the floor, back to bed, and legs straight out towards door. R4 stated she was going to the bathroom. There was no indication of a comprehensive analysis to identify causal factors and no indication R1's care plan was revised. R4's fall focus care plan was updated on 10/15/25 to include fall prevention intervention to toilet every two hours while awake and after all meals. However, R4's Treatment Administration Record (TAR) identified R4 was to be checked on every hour beginning on 10/15/25 at 1:00 p.m., due to R1 having recent falls. R4's fall incident report dated 10/15/25 at 8:05 p.m., identified R4 was found on her bottom scooting to the toilet. R4 was using hands on the ground to propel herself, knees bent with feet on the floor, and bottom on the ground. R4 stated, I was crawling to the bathroom and did not want to pee the bed. R4's incident report did not specify when R4 was toileted last. There was no immediate intervention identified and no indication of a comprehensive analysis to identify causal factors until 10/16/25 at 10:51a.m. During an interview on 10/17/25 at 3:05 p.m., DON stated R4's falls had not been comprehensively assessed or had any causal analysis completed for the falls prior to 10/15/25 to ensure the appropriate fall prevention interventions were in place. Review of the facility's Fall and Fall Risk, Managing Policy dated 10/15/25, identified the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period, as needed. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling, as appropriate. Position-change alarms may be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk: If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls, as needed. Documentation: - The licensed nurse shall promptly initiate and document the accident or incident. - Licensed nurses will update the care plan with the new fall intervention post fall.- Licensed nurse will update the resident's Kardex with fall intervention. - Licensed nurse will document the new fall intervention in the nursing communication binder for clinical staff to review. - Licensed nurse will complete a Morse Fall Scale with each new fall. -IDT will meet on every business day to review resident falls and interventions. Progress note will be made in the residents' record of this review.

Based on interview and document review the facility failed to ensure 4 of 7 facility employed nursing assistants' (nursing assistant (NA)-B, NA-H, NA-I, and NA-L) certificates were current with the states nursing assistant registry. This had the potential to affect all thirty-two residents that resided in the facility.Findings include: Review of the State of Minnesota Nursing assistant registry on [DATE] identified the following:-NA-B's nurse aide certificate expired on [DATE].-NA-H's nurse aide certificate expired on [DATE].-NA-I's nurse aide certificate expired on [DATE].-NA-L's nurse aide certificate expired on [DATE].The facility's employee records were reviewed on [DATE] and identified NA-B, NA-H, NA-I, and NA-L were scheduled and completed shifts from [DATE] thought [DATE] with an expired nurse aide certificate.During an interview on [DATE] at 12:25 p.m., director of nursing (DON) stated she was not aware that NA-B, NA-H, NA-I, and NA-L had been working without a current nursing assistant certificate since [DATE]. DON further stated she was not responsible for ensuring that staff had a current license/certificate and was unsure who was responsible for ensuring staff maintained their certification and/or professional licenses. During an interview on [DATE] at 12:05 p.m., administrator stated she had not been aware that NA-B, NA-H, NA-I and NA-L nursing assistant certificates expired and that the facility did not have process in place to ensure verification of licensed/certified staff's credentials are verified that they are current. Administrator further stated the responsibility to ensure the licenses/certificates are currently would be ultimately her responsibility and it was not completed.Review of the facility's License Verification Policy undated, identified all personnel that require a license, or certification shall be verified through the appropriate issuing agency. Policy Explanation and Compliance Guidelines included the following: 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure.2. An individual will not be employed and or/will be terminated from employment (whichever case may apply) if:a. The individual has lost licensure/certification for any reason, orb. The individual has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.3. Any licensed/certified employee is responsible for maintaining continuing education hours as required for current licensure/certification status. 4. Any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration.

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI)committee identified, investigated, analyzed, and responded to identified resident care issues by developing and implementing action plans for process improvement identified resident care issues related to high number of falls. This had the potential to affect all 32 residents residing in the facility. Findings include:SEE F689: Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and implement/revise the care plan to prevent and/or reduce the risk of fall with major injury for 2 of 3 residents (R1, R4) who had falls. This resulted in an immediate jeopardy (IJ) for R1 who sustained a resulted in a subarachnoid hemorrhage (type of brain bleed) and was hospitalized .Review of the QAPI facility minutes for past 6 months identified the following:-5/8/25 QAPI meeting minutes identified two falls for month of April and falls isolated (one with no injury and 1 with minor injury). No trends identified.-6/12/25 QAPI meeting minutes identified one fall for the month of May and fall was isolated and no injury. No trends identified.-7/10/25 QAPI meeting minutes identified two falls for the month of June falls were isolated and one with no injury and one with minor injury. No trends identified.-8/14/25 QAPI meeting minutes identified one fall for the month of July-isolated fall with no injury. No trends identified.-9/11/25 QAPI meeting minutes identified the facility had no falls for the month of August.Review of the facility fall incident reports between 9/9/25 through 9/30/25 identified there were a total 9 falls. -10/9/25 QAPI meeting minutes identified the facility had 9 falls for the month of September. Identified falls on the following dates: 9/3/25; 9/4/25; 9/4/25; 9/15/25; 9/24/25, 9/25/25; 9/26/25, 9/27/25; 9/30/25. Noted one resident (R1) had multiple falls since admission. The data documented was inaccurate; the minutes did not identify R1's two falls that occurred on 9/28/25 nor identified that two resident falls occurred on 9/30/25 versus one. Although there was an increase in the number of falls in the month for September, the minutes did not reflect the increased number of falls continued into October one of which resulted in major injury with hospitalization. Although the minutes identified medical director spoke of starting a fall interdisciplinary team group due to increase in the number of falls this past month and will email to set things up and have a team established there was no indication the falls were comprehensively analyzed to determine trends and/or possible quality deficits in the fall management program nor was there an action plan developed. During an interview on 10/17/25 at 4:00 p.m., administrator stated the facility did not create an action plan to identify the concern for a sudden jump in falls from August to September. However, the medical director brought up the increase in the number of falls during the 10/9/25 meeting but the quality committee did not analyze or investigate the falls and only talked about making a committee to do this. During an interview on 10/17/25 at 3:45 p.m., director of nursing (DON) stated the facility had seen an increase in the falls from no falls to 8 falls in one month (from August where no falls-to 8 reported falls in the month of September).During the 10/9/25 QAPI meeting the medical director had identified a concern/problem due to sharp increase with falls and recommended the facility add an interdisciplinary team (IDT) fall committee and stated she would be sending some information to the facility with steps to begin this, however, did not formally create action plan to analyze or investigate the increase in falls to identify a quality concern related to falls.Review of the facility's QAPI Change Process Policy undated, identified the facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained.Policy Explanation and Compliance Guidelines:1. The facility has in operation a Quality Assessment and Assurance (QAA) Committee that is responsible for coordinating and evaluating activities under the facility's QAPI program.2. The QAA Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action, and performance tracking.3. Data analysis -a. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. This data is reported to the QAA committee.b. The QAA committee analyzes the data in order to identify or better understand a problem.c. Once a potential problem is identified, the committee utilizes a systematic approach (e.g., Five Whys, flowcharting, fishbone diagram, Failure Mode and Effect Analysis, etc.) (specify one or more methods) to help identify the root cause of the problem.d. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes.4. Corrective action -a. Once the root cause of a problem is identified, the QAA committee oversees the development of an appropriate corrective action. An appropriate corrective action is one that addresses the underlying cause of the issue comprehensively, at the systems level.b. Corrective action plans include: i. A definition of the problem - which includes determining contributing causes of the problem. ii. Measurable goals. iii. Step-by-step interventions to correct the problem and achieve established goals; and iv. A description of how the QAA committee will monitor to ensure changes yield the expected results.c. Example corrective actions may include, but are not limited to: i. Introducing new equipment or products, with staff input, that specifically address the identified problem. ii. Updating policies and procedures. iii. Posting reminders or posters depicting desired behaviors. iv. Providing education and verifying competency following the education. v. Eliminating barriers to following facility policies and procedures. vi. Observing staff members and providing feedback on their performance of new practices. vii. Convening a Performance Improvement Project (PIP) to improve a systematic problem or improve quality in absence of a problem.d. The QAA committee uses the Plan, Do, Study, Act (PDSA) cycle of improvement for testing any changes within a PIP. i. Plan: developing a plan related to the change that will be tested ii. Do: carrying out the plan iii. Study: observing and analyzing data collected, learning from any consequences iv. Act: making a decision regarding the change, such as to adopt, modify, or abandon the change and start overe. Multiple PDSA cycles may be implemented until the desired performance goals have been met.5. The facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified in the facility assessment.6. The facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis.7. Performance Tracking -a. Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained.b. A combination of process and outcome measures are used to measure success following the implementation of change. i. Process measures look at the specific steps in a process that lead, either positively or negatively, to a particular outcome. ii. Outcome measures track results. iii. Performance on the measures is discussed in QAA Committee meetings. Data is analyzed, and the process continues as appropriate.c. At least annually, the facility conducts a self-assessment to determine the facility's performance improvement culture. Corrective action is taken as appropriate.

Based on observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R1) observed for handwashing/hand hygiene during toileting/incontinence care. Findings include: R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction(stroke). R1's minimum data set (MDS) dated [DATE], identified R1 was dependent for all transfers and toileting, and was cognitively intact. During an observation and interview on 10/16/25 at 4:11 p.m., R1 informed nursing assistant (NA)-F and registered nurse (RN)-C that she needed to go to the bathroom. NA-F pushed R1 to her room. Upon entering R1's room, NA-F applied gloves without performing hand hygiene. NA-F used a stand-aide to transfer R1 to the commode; she voided and had a bowel movement. NA-F instructed R1 to stand. Once standing, NA-F used her gloved right hand and wet wipes to clean R1's bottom from any stool. Once cleaned, NA-F started to pull up R1's pants without removing her gloves and perform hand hygiene. When surveyor prompted NA-F to perform hand hygiene, NA-F stated, I do that once I am done with all of my cares. NA-F continued to pull R1's pants up with the same gloved hands used for R1's peri care. NA-F stated, My hands are not dirty, because the wipe was between R1's bowel movement and my glove. NA-F grabbed R1's wheelchair by the left arm rest with her right hand and moved it behind R1 so she could sit down. R1 then sat down in the wheelchair. NA-F removed her gloves from both hands, she did not perform hand hygiene prior to folding R1's blanket. After NA-F placed the blanket on the bed, NA-F then washed her hands. During a follow up interview on 10/16/25 at 4:38 p.m., NA-F stated the risk of not removing gloves after performing peri care after a bowel movement could cause anything that was touched with the soiled gloves could be contaminated. During an interview on 10/17/25 at 4:35 p.m., registered nurse (RN)-C stated NA-F should have performed hand hygiene prior to entering R1's room, before and after removing gloves, and removed her contaminated gloves after performing peri care and performed hand hygiene. During an interview on 10/17/25 at 3:27 p.m., director of nursing (DON) stated her expectation of staff would be to perform hand hygiene before and after any cares, before and after removal of gloves. Gloves should be removed after performing peri care and hand hygiene performed and new gloves applied. Review of Hand Hygiene Policy undated, identified that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is indicated and will be performed when, during resident care, moving from a contaminated body site to a clean body site.

Based on observation, interview, and document review the facility failed to ensure received appropriate treatment and services to prevent decline in incontinence and urinary symptoms and further failed to develop and implement an individualized toileting program for 1 of 1 resident (R4) who had a diagnoses of Huntington's disease, was continent upon admission, but had fluctuating symptoms of incontinence, urgency, and frequency. Findings include: Urge Incontinence is associated with detrusor muscle over activity resulting in a sudden, strong urge (also known as urgency) to expel moderate to large amounts of urine before the bladder is full). It is characterized by abrupt urgency, frequency, and nocturia (part of the overactive bladder diagnosis). The resident can feel the need to void but is unable to inhibit voiding long enough to reach and sit on the commode. It is the most common cause of urinary incontinence in elderly persons. Stress Incontinence is associated with impaired urethral closure which allows small amounts of urine leakage when intra-abdominal pressure on the bladder is increased by sneezing, coughing, laughing, lifting, standing from a sitting position, climbing stairs, etc. Mixed Incontinence is the combination of urge incontinence and stress incontinence. Many elderly persons (especially women) will experience symptoms of both urge and stress. Overflow Incontinence is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended from urine retention. Symptoms of overflow incontinence may include: weak stream, hesitancy, or intermittency; dysuria; nocturia; frequency; incomplete voiding; frequent or constant dribbling. Functional Incontinence refers to loss of urine that occurs in a resident whose urinary tract function is sufficiently intact that he/she should be able to maintain continence, but who cannot remain continent because of external factors other than inherently abnormal urinary tract function. Examples may include inability to get to the bathroom on time, Physical weakness or poor mobility/, Environmental impediments including excessive distance from the toilet facilities, poor lighting, low chairs that are difficult to get out of, physical restraints and toilets that are difficult to access.R4's face sheet dated 10/16/25, identified diagnoses of Huntington's disease (a rare neurodegenerative disorder that causes progressive physical, cognitive, and psychiatric symptoms), muscle weakness, and history of falling.R4's continence evaluation assessment dated [DATE], identified R4 had history of incontinence of bladder which was a gradual onset. Symptoms over past 6 months were improving where R4 had one accident per week. The assessment did not identify or include additional information pertaining when and under what if any circumstances led to the incontinence, does not identify the type of incontinence, and does indicate interventions and/or treatments that had improved the incontinence. The assessment also included R4 had some leakage coded as soil/wet underwear only. R4 did not symptoms of urge incontinence and did not have symptoms of stress incontinence. R4 was aware of the urge to void and on average she was able to hold on after feeling the urge to void for more than 5 minutes. In the section Overflow Incontinence, the coded answers identified R4 felt her bladder was emptying completely, she was aware when urine was being passed, no issues with starting or passing urine, and no dribbling after passing urine. R4 was occasionally aware she was wet which was not further assessed to determine the type of incontinence that would contribute to wetness without R4's awareness. The assessment also identified R4 had mixed incontinence even though the assessment identified she did not have symptoms of stress and urge incontinence. R4's risk factors for bladder incontinence included diagnosis of cognitive impairment (not listed on diagnosis list), Huntington's disease, prescribed antipsychotic, and required one staff assistance with walker. Not applicable was marked for voiding record initiated however did not identify what R4's routine voiding patterns were. The summary section was blank. R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 did not have cognitive impairment. R4 required moderate assistance for toilet transfers, continent of bowel and bladder, and had intact cognition.Review of R4's Point of Care (POC) task documentation of bladder continence from dates 8/26/25 through 9/3/25- identified R4 was continent of bladder. R4's progress notes reviewed from between 8/26/25 through 9/4/25 identified R4 was continent of bowel and bladder; progress notes did not indicate any concerns or changes in voiding patterns or urinary function. R4's physician visit dated 9/4/25 identified reason for visit was new admission. R4 was admitted to the facility after a fall at home and required hospitalization where she was found to have cystitis (urinary tract infection-UTI).and was treated with antibiotics. The visit did not address and/or mention status of incontinence. R4's progress note dated 9/6/25 at 5:20 a.m. included R4 is having an increase in urinary urgency, she was unable to void but reports the urge to. Denies dysuria. No back or flank pain. Urine is normal and without any concerns. Nursing staff report new onset urinary incontinence within the last day for unknown reason. Continent tonight. Progress note at 1:13 p.m. indicated R1 requested toileting often not always able to void and was occasionally incontinent of urine. R4's progress note dated 9/7/25 indicated R4 was occasionally incontinent of urine but verbalizes toileting needs. R4's progress note dated 9/8/25 indicated R4 used the call light 5 times to request toileting assistance. Continues to have urinary urgency. Voiding amount minimal each time. Urine appearance is normal. R4's Care Area Assessment (CAA) signed 9/8/25, identified a potential problem triggered for urinary incontinence. Modifiable risk factors included pain, urinary tract infection, and restricted mobility. Medications included anticholinergics and antipsychotics. The objective for care planning was to minimize risk of incontinence. due to needing assistance with toilet use and/or perineal cares during the assessment period. No other information was included. R4's POC documentation indicated R4 had a change in continence on 9/4/25. Documentation identified incontinent episodes on 9/4/25, 9/5/25, 9/6/25, 9/8/25, 9/10/25, 9/12/25, 9/13/25, and 9/14/25. R4's POC documentation between 9/15/25 through 9/22/25, identified R4 did not have incontinence. R4's progress notes reviewed 9/9/25 between 9/22/25, identified R4 was continent of bladder ten days (9/9/25, 9/10/25, 9/11/25, 9/13/25, 9/14/25, 9/15/25, 9/16/25, 9/17/25, 9/18/259/19/25, and 9/22/25) and had frequency on 9/12/25, 9/14/25 and 9/18/25 (frequency and burning with urination). R4's physician visit dated 9/22/25 indicated R4 was seen for urinary frequency and some episodes of urinary incontinence, treated for a UTI when she was hospitalized and has urinary frequency here. Staff feel like the frequency is getting worse. R4 denies any burning or pain. She is not sure if she has really noticed the urinary frequency and there is nothing wrong. The physician ordered a urine analysis. R4's progress note dated 9/24/25 included did not show infection. R4's POC documentation between 9/23/25 through 10/4/25 R4 did not have any incontinent episodes except on 9/24/25, 9/29/25, 10/1/25, 10/2/25, and 10/4/25 with other days between R1 was continent of urine. R4's POC documentation between 10/5/25 through 10/11/25, identified R4 did not have any incontinent episodes. Between 10/12/25 through 10/17/25, identified R4 had episodes of incontinence on 10/12/25, 10/13/25, 10/14/25 and 10/15/25. R4's progress notes 9/23/25 through 10/17/25, identified R4 was continent of urine on 9/25/25, 9/26/25, 9/27/25, 9/28/25, 9/29/25, and 9/30/25. R4 had episodes of needed to urinate frequently (every 30 minutes to 1 hour) on 9/24/25 and 10/15/25. Review of R1's care plan indicated it was not initiated until 10/1/25 even though the CAA's were signed on 9/8/25. Further the care plan did not include a focus area that addressed R1's urinary continence that included goals and interventions that would prevent decline in bladder incontinence and/or maintain in addition to manage R4's urinary symptoms. R4's activities of daily living (ADL) focus care plan, initiated on 10/1/25, identified R4 had a self-performance deficit related to confusion, impaired balance, and Huntington's Disease. Corresponding interventions included: dependent on staff for transferring with gait belt and walker, transfer to toilet with assist of one and able to wipe herself after she is done. R4's care plan did not identify an individualized toileting plan. R4's fall focus care plan identified a new intervention on 10/15/25 to toilet every two hours while awake and after each meal however R4's record did not include a corresponding comprehensive bladder assessment and/or voiding diary that identified how that toileting schedule was determined.In review of R4's revealed although incident reports identified R4 had four falls (9/4/25, 10/2/25, 10/14/25, and 10/15/25) in which documentation indicated toileting as a causal factor there was no indication of a comprehensive bladder assessment was completed to determine type and/or possible changes in bladder function. Additionally, there was no indication of assessment to determine an appropriate toileting program/schedule. During an observation and interview on 10/17/25 at 8:30 a.m., R4 stated staff did not offer to take her to the bathroom regularly and further stated they think I only need to go once per day, but I need to go more than that. Sometimes I pee the chair, recliner, and bed. This makes me feel terrible and like a baby. R4 then began to cry and stated, Sometimes I cannot find the call light and just have to try and take myself to the bathroom, but I fall when I try and I just want to be able to able to keep my bladder control like I did when I first came.During an interview on 10/16/15 at 9:22 a.m., licensed practical nurse (LPN)-A stated that the standard for toileting people is that all residents are toileted every two hours. LPN-A was unsure how staff were keeping track of how often residents were toileted. R4 did not have a toileting plan in place prior to 10/15/25.During an interview on 10/10/25 at 4:20 p.m., nursing assistant (NA)-G stated staff tried to toilet every resident every two hours. NA-G was not aware if R4 had a different toileting schedule. NA-G stated R4 had been having more incontinent episodes lately. R4 would normally ask for assistance to use the bathroom however would attempt to take herself at times. During an interview on 10/17/25 at 3:35 p.m., director of nursing (DON) stated R4 was continent on admission and did have a toileting schedule added to her care plan on admission. DON reviewed R4's record, she explained the documentation identified R4's incontinence had worsened to frequently incontinent of urine. DON thought the increase in incontinence was because staff were not aware of how often R4 should be toileted. Review of the facility's Incontinence Policy undated, identified the facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

Based on observation, interview, and document review the facility failed to assure baseline line care plan addressed safety interventions to prevent/mitigate the risk of decline or injury from falls for 1 of 1 resident (R1) at risk for falls had a fall with major injury. Findings include:R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). R1's admission Nursing assessment dated [DATE] (R1's admission date), identified R1was alert and orientated to person, but not aware of time and place, used a wheelchair for mobility, had poor trunk control due to right sided deficit from stroke, and surface to surface transfer was not steady and needed staff assistance for transfers. R1's Morse Fall Scale (a tool used to assess a resident risk for falling) dated 9/25/25, identified R1 was moderate risk for falling. R1 had not have a history of falling, had impaired gait and overestimates or forgets limits. R1's fall risk identified R1 did not have more than one diagnosis, however, R1's diagnosis list did identify more than one diagnoses. R1's did not use ambulatory aide due to none/bedrest/wheelchair/nurse assist. R1's paper Temporary Care Plan dated 9/25/25, did not include a fall focus area nor fall prevention interventions even though the Morse Fall Scale identified R1 was at risk for falls. Although the care plan identified R1 was incontinent of bowel and bladder the temporary care plan did not identify a toileting program or schedule. The Temporary care plan identified R1 transferred with a full-body mechanical left with two staff. R1's therapy note impulsive (added see below-AO) R1's physical therapy (PT) treatment note dated 9/26/25, identified R1 was impulsive and had decreased alertness and judgement.R1's progress dated 9/28/25 and 9/30/25 included R1's bed was kept in low position and fall mat along bedside. R1's baseline care plan did not identify either of those interventions.R1's electronic health record (EHR) care plan dated 9/28/25, identified R1 was at high risk for falls related to confusion, incontinence, poor communication/comprehension, unaware of safety needs. Goal to not sustain serious injury. Intervention were as followed: anticipate and meet the resident needs, be sure call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt responded to all request for assistance, be sure the resident is wearing appropriate footwear socks and no-skid shoes and/or gripper socks, follow facility fall protocol, PT to evaluate and treat as ordered (was on PT caseload already). Intervention to care plan added on 10/9/25 were as followed: review information on past falls and attempt to determine root cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team (IDT) as to causes; The resident needs activities that minimize the potential for falls while providing diversion and distraction. Resident needs to be in common area for supervision and enjoys 1:1 activities also has fidget items to utilize. R1's EHR care plan did not identify how R1 was to be transferred. R2's progress note dated 10/2/25, identified R1 was high fall risk and needed frequent checks. R1's care plan did not include frequent checks. R1's Physical Therapy Rehab Communication Form dated 10/3/25, identified R1 needed supervision when in wheelchair. R1 was a high fall risk and not to leave alone in room when in wheelchair. R1's baseline care plan did not indicate to not leave R1 alone in room when in wheelchair.R1's Physical Therapy Rehab Communication Form dated 10/8/25, identified R1 was to transfer with a sit to stand lift and must have two staff to assist and use gait belt. Staff to assist right hand up to bar and make sure right foot is in good position on foot plate. R1's baseline care plan did not indicate R1's transfers status had been changed from total mechanical lift to a sit to stand lift.During an interview on 10/10/25 at 11:30 a.m., nursing assistant (NA)-E stated staff will reference the care plan/Kardex located in the electronic health record (EHR) or look at the therapy recommendation paper. NA-E then logged on the EHR, however, was unable to locate R1's transfer status in her care plan/Kardex. nor locate the therapy recommendations for R1 on the therapy clipboard.During an interview and observation on 10/10/25 at 1:44 p.m., NA-G and NA-E entered R1's room to perform a transfer. NA-G brought in a full body mechanical lift, at which time NA-E informed NA-G that she did not think R1 was a full body mechanical lift, however, when she had checked R1's care plan/Kardex it did not identify how R1 was to be transferred. NA-G then left R1's room and stated she would go and check the care plan. NA-G then entered R1's room and provided the surveyor a piece of paper that had therapy recommendation on the top which was dated 10/8/25. The therapy recommendation stated R1 was to use a sit to stand lift for transfers with assist of two staff, assist right hand up to bar and make sure right foot in good position. NA-G stated she had to ask therapy to obtain this paper, because it was not on the therapy clipboard. NA-G stated last time she worked R1 was a full body mechanical lift and had not heard in report that her transfers status had changed. NA-G further stated R1's care plan had not been updated to reflect the change in transfer status. NA-G stated not having a resident's care plan updated timely could put the resident at risk for being transferred incorrectly and causing an injury. During an interview on 10/14/25 at 3:07 p.m., physical therapist (PT) stated recommendations for a resident the use a Rehab Communication Form and give four copies to the facility-one for director of nursing, one for the assistant director of nursing, one for nurses, one for nursing assistants. Therapy does have a licensed nurse sign for the communication form when it is dispersed to nursing. PT stated R1 was changed from a total mechanical lift on 10/8/25 when she returned from the hospital and would have expected R1's care plan to be updated as soon as the communication form was given to nursing. During an interview with Minimum Data Set Coordinator-RN (MDS-RN) stated baseline care plans should include a resident's fall risk and fall prevention interventions and should be updated as soon as possible to let staff know how to properly care for a resident. During an interview on 10/10/25 at 5:25 p.m., director of nursing (DON) stated R1's care plan had not updated to reflect the change in transfer status on 10/8/25, nor been updated to include fall risk, fall prevention interventions, low bed, fall mat. DON further stated, R1's care plan should have been updated as soon as possible, but I just have not gotten to doing it yet. Review of the facility's Baseline Care Plan Policy undated, identified the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.Policy Explanation and Compliance Guidelines:1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASARR recommendation, if applicable.2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care.c. Once established, goals and interventions shall be documented in the designated format.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.4. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/designee by the completion date of the comprehensive care plan.

Based on observation, interview, and document review the facility failed to ensure call lights were accessible and within reach for 2 of 3 residents (R2 and R5) reviewed for fallsFindings include:R2's face sheet dated 10/16/25, identified diagnoses of Parkinson's disease (a progressive brain disorder that affects movement, causing symptoms like tremors, stiffness, and slowed movements) and dementia (a decline in memory, thinking, reasoning and problem solving). R2's Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment, needed extensive assistance for all transfers. R2's fall focus care plan identified R2 was at risk for falls related to poor balance and unaware of safety risks. Intervention of call light to be within reach. During and observation and interview on 10/10/25 at 4:05 p.m., R2 was sitting in his room in his wheelchair with a tray table in front of him. R2 asked for surveyor to come into his room, there was a drinking cup on the floor to R2's left side. R2 asked surveyor to pick up his glass for him. R2's call light was sitting on the floor in front of the recliner about two feet behind R2. R2 stated he did not have my button. Nursing assistant (NA)-A entered R2's room at 4:10 p.m. NA-A identified R2's call light should have been placed within R2's reach because he tended to get agitated and may try to self-transfer if the call light is not accessible. R5's face sheet dated 10/16/25, identified diagnosis of Alzheimer's Disease (a progressive brain disorder characterized by gradual decline in memory, thinking, and language skills). R5's Minimum Data Set, dated [DATE], identified R5 had severe cognitive impairment and needed maximum assistance for transfers. R5's fall focus care plan identified R5 was at risk for falls related to limited physical mobility. Interventions included to have call light within reach. During an observation and interview on 10/14/25 at 3:58 p.m., R5 was sitting in a recliner in her room and had requested the surveyor to come into her room to pick of her cup and chocolate pieces that were located on the floor next to her feet. R5 explained she could not find her button. Her call light was on the floor next to her left foot, not within in reach. NA-F entered R5's room at 4:06 p.m. NA-F stated R5's call light was not within reach and should have been placed where R5 could reach it so she could ask for help. During an interview on 10/17/25 at 3:05 p.m., director of nursing (DON) stated all residents should always have call lights within reach and her expectation would be for all staff to ensure the call lights are place appropriately. Review of the facility's Call Light: Accessibility and Timely Response Policy undated, identified the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines included: Staff will ensure the call light is within reach of resident and secured, as needed.

Based on interview and document review the facility failed to timely report to the State Agency (SA) a fall with serious injury for 1 of 1 resident (R1) who had multiple prior falls without fall assessments and implementation of appropriate fall interventions to prevent/mitigate risk of re-current falls. R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). Review of R1's fall incidents identified R1 had falls on 9/26/25, 9/28/25, 9/30/25, and 10/1/25; no comprehensive analysis for causal factors were completed after each fall nor were appropriate interventions to prevent/mitigate the risk of falls and falls with major injury. R1's fall incident report dated 10/3/25 at 9:24 a.m., identified R1 was found on floor between door and bed. R1 had an injury above right eye that was swollen and bleeding, and two skin tears on right forearm. Predisposing factors of restless, gait imbalance, and weakness. R1 was sent to emergency department (ED) for evaluation. There was no indication a comprehensive fall investigation/analysis was completed. R1's progress note dated 10/3/25 at 9:38 p.m., identified R1 was sent out via ambulance earlier in the day due to a fall with head injury and at 2:57 p.m., the nurse called the hospital for an update and was informed that R1 was being kept for observation for a brain bleed. During an interview on 10/15/25 at 11:54 a.m., licensed practical nurse (LPN)-A stated on 10/3/25 she had called the hospital to check on R1 and was informed that R1 was being admitted to the hospital due to a brain bleed. LPN-A informed the assistant director of nursing (ADON) about R1's brain bleed. LPN-A assumed the ADON informed the administrator of R1's brain bleed following the fall; therefore, she did not report R1's injury to the administrator immediately. LPN-A explained she was under the impression that the incident needed to be reported to the administrator within two hours and was unaware of the reporting requirement to the SA. During an interview on 10/14/25 at 4:28 p.m., administrator stated R1's fall with serious injury had not been reported to the SA when the facility learned R1 sustained a brain bleed following a fall and should have been reported within two hours. Administrator was not aware the rationale the fall with serious injury was not reported to the SA in a timely manner or not at all. During an interview on 10/14/25 at 4:35 p.m., director of nursing (DON) stated when R1 had a fall on 10/3/25 and sustained a brain bleed the ADON was in charge due to DON being on vacation, however, R1's fall with serious injury should have been reported within two hours of the facility's knowledge of the injury and that R1's fall was not reported to the SA. Review of the facility's Abuse Investigation and Reporting Policy dated 4/17/25, identified all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. - An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and document review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 3 residents (R1) reviewed for residents who had falls. Findings include:R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). R1's fall incident report dated 9/26/25 at 2:00 p.m., identified R1 had an unwitnessed fall from wheelchair in room. R1 stated she was trying to get to the bathroom. R1's progress note dated 9/28/25 at 7:17 p.m., indicated R1 fell from bed onto cushioned mat on the floor. R1's progress note dated 9/30/25 at 9:47 p.m., identified R1 had a fall at 8:50 p.m. R1 was found lying on the fall mat next to her bed. R1 had removed brief and only had on gripper sock on. R1's 5-day MDS assessment with an assessment reference date of 9/30/25, identified section J1800 was coded as R1 had not had any falls since admission/entry even though R1's records identified three falls since admission. During an interview on 10/17/25 at 1:04 p.m., Minimum Data Set Coordinator/registered nurse (MDS-RN) stated R1's MDS with an ARD date of 9/30 was not accurate. Section J1800 should have been marked that R1 had falls since admission, however, was marked that R1 did not have any falls since admission. MDS-RN stated that he referenced the Risk Management fall incident reports and reviews the progress notes during the ARD window, however, must have missed seeing R1's falls on 9/29/25, 9/28/25 and 9/30/25. Review of the facility's Resident Assessments Policy dated 10/2023, identified the following: A comprehensive assessment of each resident is completed at intervals designed by OBRA regulations and PPS requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (IQEIS) as required. Policy interpretation and implementation included the following: Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observations/interviews.

Based on interview and document review the facility failed to ensure safe transfers for 1 of 1 resident (R1) while using a mechanical lift and did not follow the correct procedure for applying the straps of the sling to the lift. As a result, the sling became unhooked from the mechanical lift, R1 fell to the floor, and sustained a hematoma (collection of blood outside a blood vessel) to the back of her head, and fractures to the left 3rd, 4th, and 6th ribs which resulted in an immediate jeopardy (IJ).The IJ began on 9/15/25 when facility staff failed to follow manufacturer directions for connecting a sling to a mechanical lift and R1 fell from the lift. The Administrator, nurse consultant, and director of nursing (DON) were notified of the past non-compliance (PNC) IJ on 9/26/25 at 11:35 a.m. The facility immediately implemented and began corrective action on 9/15/25, and the deficient practice was corrected on 9/17/25, prior to the start of the survey and was therefore issued as a PNC IJ.Findings include:R1's face sheet dated 9/26/25, identified diagnoses of spondylosis of the lumbosacral and cervical region (stiffening of the spine), pain in right shoulder, and muscle weakness.R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had no behaviors. R1 required maximum assistance to transfer between surfaces.R1's care plan revised on 9/16/25, identified R1 required two staff assistance to transfer with the mechanical lift. Staff refer to the mechanical lift sling size list posted at the nurses station and NA charting room for sling size.The facility Nursing Home Incident Report (NHIR) dated 9/19/25, identified on 9/15/25 staff used two slings and did not follow facility protocol. Staff were transferring R1 into a shower chair for a shower. Sling noted to be too small and instead of removing sling under resident the staff placed another sling under resident and hooked up both slings on the mechanical lift.R1's progress note dated 9/15/25 at 4:06 p.m., identified licensed practical nurse (LPN)-A received a call over the radio system to come to R1's room STAT (immediately). LPN-A entered the room and observed the bath chair with brakes locked, in the middle of the room. The mechanical lift was in the highest position, with two straps of the sling connected to the lift, and two straps dangling. Brakes on the mechanical lift were locked. R1 was observed below the lift with the left side of her head on the floor directly by the left front wheel of the bath chair, left side of body on the floor, left foot on the platform of the mechanical lift, with right leg crossed over the top of her left leg, left shoulder under body with left arm across chest to right shoulder, right arm was holding a nursing assistants (NA) hand. R1 stated she hit her head and LPN-A felt a quarter-sized lump on the back of her head. LPN-A took R1's vital signs. To prevent further injuries, LPN-A called for an ambulance to assist with lifting R1 and sent R1 to the emergency room for evaluation.R1's progress note dated 9/15/25 at 10:44 p.m., identified R1 returned to facility with a diagnosis of head injury. R1 complained of back pain and agreed to sleep in bed for pain management and ease of ability to make observations for further injuries. R1 was given hydromorphone (opioid given for moderate to severe pain) at 10:30 p.m. with a dose of Tylenol for pain rated 7/10.R1's emergency room After Visit Summary (AVS) dated 9/15/25, identified R1 was seen for a head injury. A Computed Tomography (CT) was done on R1's head and an x-ray of the left femur was completed.R1's progress note dated 9/16/25 at 3:06 a.m., identified R1 continued to have mild pain to left rib area and sensitivity to hematoma on the left back of head.R1's progress note dated 9/17/25 at 10:15 a.m., identified R1 was seen by her physician for follow-up from the fall on 9/15/25.R1's physician visit note dated 9/17/25, identified R1 unable to participate in rotator cuff muscle testing due to pain and limited range of motion. R1 was not able to lift her left elbow or shoulder off the bed due to pain. R1 reported significant pain all along her left side. R1 stated everything felt stiff. R1 was lying in bed for exam, which was unlike her as she typically detests her bed and prefers to sleep in her recliner.R1's progress note dated 9/21/25 at 3:30 a.m., identified R1 had 8/10 left rib pain. R1 was only able to move/shift very gently and limited in her bed. R1 refused to roll or be transferred from bed due to the pain as it intensified with upper body movement. R1 also had left upper arm pain with any left arm movement and kept the left arm resting across her chest. R1 stated the pain became worse on 9/20/25 in the afternoon. emergency room evaluation was offered and R1 refused at this time. Reviewed emergency department after visit summary from 9/15/25, and identified no chest x-ray had been completed. R1 questioned if she had broken ribs. Area under left breast very tender to touch. Unable to determine obvious asymmetry, bulge, or deformity. Skin is pink where R1's hand was resting, otherwise no bleeding or bruising visible. Mild to moderate discomfort with deep breaths, ok with regular breathing. Not in respiratory distress and oxygen saturations were between 91-96% on room air, with respirations 17-20 breaths per minute.R1's progress note dated 9/21/25 at 9:40 a.m., identified R1 was transferred to the emergency department for 10/10 left sided pain. R1 also expressed pain with breathing, grimacing/groaning/splinting with hand, crying out in pain. No bruising noted.R1's progress note dated 9/21/25 at 2:08 p.m., identified emergency department nurse called and stated R1 had multiple fractures of the ribs on the left side and would be returning to facility.R1's emergency room AVS dated 9/21/25, identified R1 presented with left sided rib pain. R1 had exquisite tenderness (severe pain) in the left lateral chest area with no bruising, crepitation (crackling or rattling sound), or subcutaneous air (air trapped under the skin). CT scans identified subtle nondisplaced (bone cracks but maintains its alignment) fracture along the lateral (side) aspect of the left 3rd rib. Probable nondisplaced fracture along the anterolateral (front and side) aspect of the left 4th rib, minimally displaced (ends of the break are not aligned) fracture along the posterolateral (back and side) aspect of the left 5th rib. Nondisplaced fracture along the posterolateral aspect of the left 6th rib. Severe central compression fracture at T12 (spinal injury where the 12th vertebra collapses).During an interview on 9/25/25 at 3:10 p.m., R1 recalled on 9/15/25, she was in the wheelchair, and the NA's put her in the sling and R1 stated to not put her in that sling, she did not like it and it hurt. It had the crisscross on it. The NA's barely got a little way out and all hell broke loose, the sling came apart and R1 was on the floor. R1 fell on her left side and bumped her head. R1 stated she laid on the floor for quite a while before she would let anyone move her. The first time she went to the emergency room they x-rayed her head and from her foot to her knee. The second time she went to the emergency room they discovered she had four broken ribs. R1 stated the NA's put two slings under her but had no idea how the fall occurred.During an interview on 9/25/25 at 4:25 p.m., NA-A stated on 9/15/25, NA-B asked for help to transfer R1. R1 was in the wheelchair and was going to transfer to the shower chair. R1 had a full body sling behind her. NA-B and R1 decided they did not want to use the sling that was already in place under R1 because they did not want it to get wet. NA-A and NA-B left the full body sling behind R1 and placed a crisscross sling behind R1, as well. NA-A stated she should have spoken up at that time and not placed the second sling behind R1 without removing the one that was behind her. NA-A stated she and NA-B hooked up the crisscross sling and lifted R1 into the air with no issues. NA-A pulled the wheelchair out from underneath R1 and put the shower chair under her. NA-A pulled back on R1's sling to position her in the shower chair and that is when she fell. NA-A stated the incident happened so fast and that her and NA-B should have slowed down and did the proper steps, triple checked that everything was okay. NA-A stated it was a mistake on both her and NA-B's part for not triple checking the sling prior to lifting R1. NA-A stated she could have clipped the sling onto the mechanical lift incorrectly.During an interview on 9/25/25 at 4:34 p.m., NA-B stated on 9/15/25, her and NA-A were going to transfer R1 from the wheelchair into the shower chair. They put the crisscross sling on R1 so that it could be taken out during the shower. NA-B stated she hooked the crisscrossed leg straps onto the mechanical lift and NA-A hooked the shoulder straps. NA-B began lifting R1 and they switched chairs. NA-A was pulling R1 back into the shower chair and NA-B reached for the incontinent brief to pull out and R1 fell. NA-B recalled both of R1's leg straps and one shoulder strap were still attached to the mechanical lift. The full body sling was still in the wheelchair, R1 was only attached to the crisscross sling. R1 hit the lower part of her head on the shower chair and landed on her left side on the floor.During an interview on 9/25/5 at 4:01 p.m., LPN-A stated on 9/15/25 around 4:00 p.m., LPN-A was called to come immediately to R1's room. LPN-A saw R1 on the floor and the mechanical lift in the highest position with one side of the sling connected to one side of the mechanical lift and the other side dangling. LPN-A did not want to use the mechanical lift to get R1 off the floor as she was worried afraid of cervical or spinal injuries and called emergency medical services to assist and transport R1 to the emergency room. R1 complained of left side rib and shoulder pain and had a hematoma approximately the size of a twenty-five to fifty cent piece on the back of her head. LPN-A examined the sling that was connected to the mechanical lift and did not notice any issues with it. The DON was called, and staff were not allowed to use the mechanical lift until they were re-trained on it.During an interview on 9/26/25 at 9:54 a.m., DON and Administrator were present. DON stated NA-A and NA-B explained R1 had the wrong size sling under her and was complaining about it digging into her thighs and that is why they used a different sling. The error happened when the NAs hooked both slings up to the mechanical lift to transfer R1 and did not follow protocol, contrary to NA interviews. Maintenance examined the mechanical lift prior to putting it back in use and there were no holes, tears, or rips in any of the slings. DON began training all nursing staff on mechanical lifts and correct sling sizes and would not let any staff use the mechanical lift until they had been retrained.The facility Using a Mechanical Lifting Machine policy dated 9/16/25, identified at least two NA's are needed to move a resident with a mechanical lift. Measure the resident for the proper sling size and purpose, according to manufacturer's instructions. Place the sling under the resident. Visually check to make sure it is not too large or small. Make sure the sling is securely attached to the clips and that it is properly balanced.The PNC IJ that began on 9/15/25, was removed on 9/17/25, when it was verified, the facility implemented the following:1) NAR's immediately removed from the floor and given education on mechanical lifts, safe transfers, and sling safety with return demonstration on 9/15/25.2) All nursing staff education on mechanical lifts, safe transfers, and sling safety with return demonstration began on 9/15/25 and continued until all staff were trained and completed on 9/17/25.3) Disciplinary action for NAR's involved in the incident on 9/16/25.4) Mandatory staff meeting regarding mechanical lifts and sling safety completed on 9/18/25.5) Audits will be completed bi-weekly for three months and reviewed with the Quality Assurance and Performance Improvement team.

Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) onsite for 8 consecutive hours/7 days a week. This had the potential to affect all residents who resided at the facility. Findings include: The payroll based journal (PBJ) staffing report for quarter 2 of 2025 (January 1-March 31) indicated no RN hours reported for the following days : 1/02 (TH), 1/03 (FR), 1/04 (SA), 1/05 (SU), 1/09 (TH), 1/18 (SA), 1/19 (SU), 2/02 (SU), 2/16 (SU), 3/1 (SA), 3/02 (SU), 3/15 (SA), 3/16 (SU), 3/29 (SA), 3/30 (SU). Review of facility payroll and staffing schedules indicated 4 hours of RN coverage on 1/4/2025 and no RN coverage for 1/05, 1/18, 1/19, 2/02, 2/16, 3/01, 3/02, 3/15, 3/16, 3/29, and 3/30. During interview on 6/3/25 at approximately 3 p.m., the regional nurse consultant confirmed there was no RN coverage for the indicated dates and confirmed it is an expectation to have an RN in the building 8 consecutive hours a day/ 7 days a week. During an interview on 6/5/25 at 12:17 p.m., the assistant director of nursing (ADON) stated the staffing coordinator is responsible for nursing schedules. The ADON stated there has been no issue with services not being provided due to not having an RN on duty for 8 consecutive hours. During an interview on 6/5/25 at 3:15 p.m., the staffing coordinator indicated there are two staff RNs who work at the facility. One RN works full time on the overnight shift, the other recently started and works evenings. The staffing coordinator confirmed struggling to have RN coverage every other weekend. A policy titled Staffing, sufficient and competent Nursing dated April 2025 line 3 indicated A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the residents and based on the facility assessment.

Based on interview, observation, and record review, the facility failed to maintain respect and dignity for personal possessions for 1 of 2 residents (R28) reviewed who had his room searched and items removed without consent. Findings include: R28's quarterly Minimum Data Set (MDS) assessment dated [DATE] included no cognitive impairment. Furthermore, his mood assessment indicated he rarely socially isolated. R28 is independent with eating, oral hygiene, toileting, dressing, and repositioning. R28 required minimal cueing for showering/bathing. During interview on 6/03/25 at 11:20 a.m., R28 stated the previous administrator at the facility entered his room without his permission and searched his room, the administrator told him they were searching his room because they thought he was making moonshine with orange peels and water or mouthwash. They also confiscated his vape pens and won't give them back. R28 added the administrator came into his room without consent and removed multiple cups and dishes. R28 said he felt he can't trust anyone here because they come in whenever they want, and he feels socially isolated since they searched his room. During interview on 6/05/25 at 11:41 a.m., certified nursing assistant (CNA)-A stated R28 has not been treated respectfully. CNA-A stated the previous administration had entered and searched his room without his permission. CNA-A stated the administrator believed he was using his orange peels to make moonshine. CNA-A stated the administrator believed he also had illegal substances in his room. CNA-A confirmed law enforcement was not at the facility at any point. CNA-A stated the previous administrator had confiscated his vape pens. During interview on 6/5/25 at 4:06 p.m., director of nursing (DON) and administrator stated it was possible the previous administrator had entered and searched R28's room without his consent. The DON and administrator confirmed they were not at the facility at the time of the search. The administrator confirmed a note in the chart on 3/12/25 at 10:40 a.m., indicated the resident's room had been search without his consent. The administrator confirmed a note in the chart on 3/11/25 at 3:18 p.m., indicated facility staff had entered the resident's room without permission to remove facility property. The DON confirmed entering R28's room without permission could have a negative impact on his social well-being. Per facility policy titled Dignity and dated February 2021, facility staff must knock and request permission before entering a residents' room. Residents' private space and property are respected at all times; staff do not handle or move a resident's personal belongings without the resident's permission.

Based on observation, interview and document review, the facility failed to ensure a system for receiving, transcribing and communicating code status orders for cardiopulmonary resuscitation (CPR) for 1 of 12 residents (R228) reviewed for advanced directives and wishes for life sustaining treatment. This failure resulted in an immediate jeopardy (IJ) when it was identified R228 had conflicting advanced directives and could result in a resident's wishes not being honored as stated in their code status orders. This failure had the potential to effect any resident having their code status reviewed upon admission, quarterly or as needed. The immediate jeopardy began on [DATE] when conflicting code status orders were identified in R228's medical record and a lack of clarity in the process for attaining, transcribing, signing and communicating physician code status orders was confirmed. The facility administrator and DON were notified of the immediate jeopardy at 9:50 a.m. on [DATE]. The IJ was removed on [DATE], but noncompliance remained at the lower scope and severity level of D, isolated with the potential to cause more than minimal harm. Findings include: R228's admission Minimum Data Set assessment dated [DATE] indicated R228 had no behaviors, intake cognition and could make self known and could understand others. According to R228's Admission Record in the electronic health record (EHR), R228 was admitted to the facility [DATE] following a total knee replacement. According to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a hard copy record in R228's medical chart titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This form was signed by the facility social worker (SW) and R228 on [DATE]. On the same date a nurse practitioner signed the form making it an order. On [DATE] it was observed that R228's EHR held an electronically scanned form of the POLST signed [DATE], but the conflicting Full Code order remained on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] According to an interview on [DATE], at 11:14 a.m. a licensed practical nurse (LPN-A) stated nurses were trained to always go to the POLST for code status orders. According to an interview on [DATE], at 11:21 a.m. a registered nurse, RN-A stated there were multiple places to look in a resident ' s chart to find what their code status was, but in the case of conflicting orders she would perform CPR. According to an interview on [DATE], at 1:20 p.m. R228 stated she did not recall signing the POLST form, but thought she would like to have CPR done if her heart were to stop. On [DATE], R228's medical doctor (MD-A) was observed to be present in the building and visited R228. According to an interview on [DATE], at 4:15 p.m. Medical Records staff (MR-A) stated MD-A had signed orders for R228, that day but was no longer in the building. MR-A confirmed no previous printed/signed orders had been present in R228 's chart, and the orders signed on [DATE] were R228 's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They would then print the orders and put them on a clipboard for the physician to sign when he/she would next be in the building. MR-A stated she did not know if they were sent over to the physician any sooner for review. The physician Order Summary Report for R228 was observed on MR-A's desk and was dated as having been printed [DATE], 8:17 a.m. and was signed by MD-A on [DATE]. The orders contained the Full Code order originally entered on [DATE]. MR-A confirmed that this information was observed as being correct. During further review of R228's medical record on [DATE], R228's EHR Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an interview on [DATE], at 4:28 p.m. the SW stated she had not talked to R228 prior to entering the updated order on [DATE], saying, I had talked to her the day we signed the POLST order. SW said she had not reviewed R228's medical record for any updated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 4:30 p.m. DON stated she was sure the facility had a policy that addressed CPR and expected it would be followed. DON said the variance in orders would be an easy fix for me. According to an phone interview on [DATE], 8:47 a.m. MD-A confirmed he had been in the facility and had seen R228 and signed her printed order summary. MD-A stated he had not noticed the summary included a full code order and said, that was an error on my part; additionally, MD-A confirmed he had not spoken to R228 about changing her code status. MD-A stated orders pertaining to codes status should be sent to the nurse practitioner upon admission for a signature. A review of the facility CPR policy on [DATE] indicated the POLST was the correct place to find a code status; however, the policy failed to include a procedure for who was to obtain the orders, enter the orders into the system or communicate that information to the staff. The immediate jeopardy that began on [DATE] was removed on [DATE] when it could be verified the facility had implemented an appropriate removal plan including correcting R228's code status to reflect her current wishes; reviewing all other resident charts to ensure they had correct and current POLST's/code status in place; updating the facility POLST/CPR/Advanced Directives Guidelines to clarify that a nurse is responsible to get a signed order for code status upon admission. Additionally, if a resident arrives with a signed POLST order, it must be reviewed and the provider notified of the contents of the POLST, and further assess/address the contents of the POLST with the resident during their 14 day admission assessment period to ensure it continues to reflect the wishes of the resident. The facility initiated training with nursing staff and SW with a plan in place for educating in nursing staff not in the building that day. The facility will review all POLST documents upon admission, quarterly, significant change, and annually. Additionally, MD-A was advised of the updated process. Facility had a plan to continue to audit the process after each new admission.

Based on observation, interview and document review, the facility failed to complete a comprehensive skin assessment, including assessment of tissue pressure over bony prominences, in order to develop interventions to promote healing of existing pressure ulcers and prevention of new ulcer development, for 1 of 2 residents (R21) with one current facility acquired stage 2 pressure ulcer and a history of recurring pressure ulcers on buttocks. In addition, the facility failed to implement physician ordered treatments for a stage 4 pressure ulcer for 1 of 2 residents (R17). This deficient practice resulted in actual harm for R21 when a reoccurring stage 2 pressure ulcer developed. Findings include: R21's Admission Record Face Sheet indicated R21 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], included a brief interview for mental status (BIMS) with a score of 13 indicating R21 had intact cognition. The MDS further indicated R21 required limited assist of one with bed mobility, transfers and toilet use, and required extensive assistance of one for dressing. The MDS also indicated R21 was occasionally incontinent of bladder, was at risk for pressure ulcers, and utilized pressure-relieving devices in the bed and chair. R21's current care plan last revised 8/1/18, included: R21 has actual impairment to skin integrity r/t (related to) chronic and repeated [MEDICAL CONDITION], venous ulcer to LLE (left lower extremity), stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister)to right and left gluteal folds, and abrasions to toes on bilateral feet. The interventions included: Encourage reposition/position changes during rounds and every 2-3 hours PRN (as needed); Observe skin during cares. Report any changes to nurse, Observe/document location, size and treatment of [REDACTED]. to medical practitioner; OT (occupational therapy) recommends resting schedule: Encourage side lying in bed and or while seated in recliner for 1 hour 2 x/day for pressure relief on bottom. New coccyx cut out cushion in place as of 6/25/18. Pressure relieving support surfaces in bed and chair: Standard reduction necessary to reduce pressure and to improve comfort level in relation to positioning/repositioning in bed and chair. R21's nursing assistant care plan (a working care plan that includes services/cares needed by the resident) updated 9/6/18, indicated R21 was independent with transfers, toileting and repositioning. R21's Comprehensive Skin and Positioning Evaluation form dated 8/1/18, included interventions required: reposition/position changes during rounds and every 2-3 hours. Skin risk factors included: R21 is confined to bed or chair all or most of the day. Friction and Shear: Potential problem: Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Braden (a test to determine risk for pressure ulcer development) score of 17 identified at risk of developing pressure ulcers. Approaches/interventions currently in place include were identified as: pressure-reducing device for chair, pressure reducing device for bed. However, the assessment lacked any assessment of pressure over bony prominences to determine how long pressure over bony prominences could occur before tissue impairment or damage might occur. R21 was continuously observed on 9/5/18, from 2:31 p.m. until 6:24 p.m. -At 2:31 p.m. R21 was observed in his room sitting in his wheelchair, with his legs in a dependent position. -At 2:47 p.m. R21 in his room and the door remains shut. -At 2:52 p.m. R21 in his room and the door remains shut. -At 3:20 p.m. licensed practical nurse (LPN)-C entered R21's room. R21 remained seated in his wheelchair. LPN-A observed R21 complete his own blood sugar and administer his own medications. LPN-C did not encourage R21 to reposition or offer him a position change. -At 3:56 p.m. a housekeeper knocked on R21's door to check the floor in his room. R21 remained in his wheelchair. -At 4:03 p.m. nursing assistants had not entered R21's room, and staff had not encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. -At 4:27 p.m. nursing assistants had still not entered R21's room and staff had not encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. -At 4:40 p.m. nursing assistant (NA)-B walked by R21's room but did not enter. -At 4:47 p.m. nursing assistants had not entered R21's room and staff had not encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. -At 4:54 p.m. licensed practical nurse (LPN)-A, who was working as a nursing assistant on the shift, walked by R21's door but did not check on R21. -At 5:08 p.m. nursing assistants had still not entered R21's room and staff had not encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. -At 5:12 p.m. an unidentified activity staff member delivered R21 his supper. R21 was not encouraged to reposition. -At 5:26 p.m. nursing assistants had not yet entered R21's room, and no staff had encouraged R21 to reposition yet since the start of the continuous observation at 2:31 p.m. -At 5:47 p.m. an unidentified dietary aide knocked on R21's door and picked up his supper tray. -At 5:56 p.m. nursing assistants had still not entered R21's room, and no staff had encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. -At 6:10 p.m. nursing assistants had not entered R21's room, and no staff had encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. R21 remained seated in his wheelchair, with his legs in a dependent position. -At 6:15 p.m. nursing assistants had not entered R21's room and staff had not encouraged R21 to reposition since the start of the continuous observation at 2:31 p.m. R21 remained seated in his wheelchair, with his legs in a dependent position. This was 3 hours and 45 minutes after the start of the continuous observation. This surveyor found the director of nursing and requested an observation of R21's bottom be completed. On 9/5/18 at 6:24 p.m., the director of nursing (DON) completed an observation of R21's bottom with a registered nurse surveyor present, and the following observation was noted: R21's right lower medial buttock had an open area. The base was covered with yellowish slough. The DON stated the open area was a stage 2 pressure ulcer. The DON described the wound as having an 1/8 inch bright red-scabbed area with drainage. The DON stated she would have to measure the wound, fill out an incident report, and get a dressing on the wound. R21 stated the wound area felt sore. The DON stated the area was between an eraser head and dime size. The DON stated R21 had a bath yesterday and would have had a body audit. At the time of the observation, the director of nursing (DON) stated R21 was independent with turning and repositioning. The surveyor questioned the DON about R21's care plan approaches indicating he was to be encouraged to reposition during rounds and every 2-3 hours. The DON stated, they probably stopped asking because they are sick of getting yelled at. However, the DON confirmed she expected staff to offer to reposition R21 per the care plan. The DON also stated, that is something that may need to get changed in regards to the care plan approaches. R21's Weekly Wound Documentation completed 8/30/18, indicated all areas (left and right gluteal fold) were closed. The documentation included: Areas chronically open, cut appear to be from sitting on the toilet and sliding off and on .more like skin trauma. He is alert and orientated and uses his call light appropriately for assist, but prefers to do most things on his own, as far as toileting. He does continue to wish to use the Zguard ointment and the Watkins salve. He also sits on his egg sitter cushion for pressure reduction. Refuses to sit in recliner as suggested during the day. R21's Weekly Wound Documentation completed 9/5/18, following the observation of the new pressure ulcer found on 9/5/18 at 6:24 p.m. by the DON and surveyor at 6:24 p.m., the document indicated R21 had a small open area to the center of his right buttock cheek without any drainage. The note further indicated; Surrounding skin is pink measuring approx. (approximately) 8 cm (centimeters) x 8 cm. but that area does blanch well. [MEDICATION NAME] tissue present. Mild discomfort noted. He has been sitting on his egg sitter cushion per his preference. An incident report note for R21, dated 9/5/18, following the observation of the new pressure ulcer on 9/5/18, at 6:24 p.m. by the DON. The report included: Upon skin inspection of bottom area, noted an open area measuring 0.7 cm x 0.6 cm. Whitish, shiny tissue to center, but not slough. Pink area surrounding open area measuring approx. 8 cm x 8 cm. Entire pink area does blanch well. Mild discomfort noted with wound care. PAC (physician assistant certified) notified via fax. Border foam dressing. Apply skin prep surrounding wound. Apply dsg. (dressing) Change every 3 days and prn (as needed). Continue to educate R21 on importance of sitting in his recliner or laying down to reposition. R21 states that he does reposition to the toilet frequently. Continued to explain to him need for leg elevation and pressure change to buttocks with change in position. He did allow us to assist him into the recliner, but was very irritated. During a follow up interview with the DON on 9/5/18, at 7:35 p.m. the DON stated R21 was tricky because he was so uncooperative. The DON stated she would expect the staff to go in R21's room to encourage him to reposition even though he would get angry with them. The DON described R21 as very short tempered. The DON further stated staff were to check on residents every two to three hours during rounds, and stated the wound clinic had recommended R21 have repositioning provided every two to three hours. On 9/5/18, at 7:49 p.m. licensed practical nurse (LPN)-C stated R21 was supposed to be repositioned every two hours, and was suppose to have his feet elevated. LPN-A also said staff were to remind/encourage R21 to reposition every two hours but stated, (R21) kinda does his own thing. LPN-A stated she expected the aides to encourage him to reposition and let the nurse know if he refused. LPN-A stated none of the staff had reported to her today that R21 had refused to reposition. LPN-A also stated, He takes himself to the bathroom, maybe he calls that repositioning? On 9/5/18, at 7:53 p.m. LPN-A stated, We (staff) ask (R21) if he will put his feet up once or twice a shift. He doesn't like to sit in the recliner because he cannot get to his items. On 9/6/18, at 7:16 a.m. nursing assistant (NA)-A stated, Just this morning I was told in report (R21) needed to sit in his recliner 2 to 3 times a day as he has a new pressure ulcer. NA-A also stated, Before today, staff were to reposition him once a day in the afternoon to elevate his feet. (LPN-A) stated she was just given direction this morning in report that staff were to encourage him, every 2 to 3 hours, to reposition because of the new ulcer that was found. On 9/6/18, at 10:33 a.m. NA-C stated, No I do not have enough time to get my assignments done each day. We have heavy cares, dementia, behaviors, sometimes we do not have time to get toileting done timely, and turning and repositioning, those are the main things we do not get done. NA-C stated she works full time and it definitely happened a few times a week that they couldn't get their work done. On 9/6/18, at 11:19 a.m. the DON stated the stage II open area that was observed on 9/5/18 (at 6:24 p.m.) was new. On 9/6/18, at 12:07 p.m. registered nurse (RN)-A stated, We just do the typical every two to three hours repositioning for everybody unless there is some specification or a wound that would require them to be repositioned more. At 12:24 p.m. RN-A verified R21's care plan included 2 -3 hours encourage rounding/repositioning. RN-A stated she expected the staff to follow the care plan. On 9/6/18, at 12:09 p.m. the DON stated the comprehensive skin and positioning evaluation used at the facility was the Braden assessment. The DON said that assessment was used to determine positioning for residents. On 9/6/18, at 12:45 p.m. RN-A stated she did not think there was a system in place to determine how often residents should be repositioned. RN-A stated she was not able to tell what R21's repositioning schedule should be based on the comprehensive skin and positioning evaluation. RN-A stated the assessment tells a score of whether R21 would be at high risk for developing any skin integrity issues. RN-A stated if a resident was at higher risk they should be turned and repositioned more often. On 9/6/18, at 1:10 p.m. R21 stated staff had educated him about the risks and benefits of repositioning to prevent skin break down in the past. On 9/6/18, at 1:21 p.m. RN-A stated, We complete customer service rounds hourly and they should be offering (R21) repositioning during those rounds. On 9/6/18, at 3:37 p.m. NA-D stated, We are supposed to encourage him to move or reposition every two hours, this is not new. NA-D further stated, A lot of times (R21) will take himself to the bathroom or move himself, but we are supposed to go in and check and make sure. On 9/6/18, at 3:40 p.m. nursing assistant NA-B stated, I don't usually work on (R21's) wing. However, NA-B stated the nursing assistant care plan indicated R21 was independent with repositioning and toileting. NA-B stated, I usually go through every room at least every thirty minutes at a minimum. The facility policy Pressure Injury Prevention dated 10/2015, included: Standards of Practice: -Comprehensive evaluation of the resident's clinical condition and pressure ulcer risk factors at admission and as required throughout the resident's stay. -Evaluation of the individual risk factors and determination, based on clinical judgement, selection of risk reduction strategies to stabilize, reduce, remove the underlying risk factors identified on assessment(s). -Customer Service Rounds -An evaluation of the individuals need for turning and repositioning based on individual risk factors and ability to effect meaningful independent position changes both in and in the chair for development of positioning programs if required. -The individualized care plan will reflect approached to stabilize reduce or remove the individual's risk factors for Pressure Ulcer Development and/or promote healing of existing Pressure Ulcers. R17's Admission Record included a readmission date of [DATE], and included [DIAGNOSES REDACTED]. R17's quarterly Minimum Data Set (MDS) an assessment dated [DATE], indicated R17 was cognitively intact, required extensive assistance from two plus staff for bed mobility and transfers, and required extensive assist from one staff for dressing and personal hygiene. The MDS also indicate R17 has an indwelling urinary catheter and ostomy (bowel collection). The MDS further indicated R17 was a risk for pressure ulcers, had a stage 4 pressure ulcer, which was present at the time of the previous assessment, and during the assessment period measured 4 centimeters (cm) by 1.3 cm by 2.5 cm in depth. The MDS indicated interventions that included pressure ulcer care. R17's pressure ulcer care plan dated 11/10/17, included R17 had a stage 4 ulcer located on her right lower buttock/inner thigh that originated from sitting on the indwelling catheter tubing. The care plan directed: -Dressing changes daily to open area, clean with wound cleanser, pack open areas with [MEDICATION NAME] AG ( an antimicrobial dressing) monitoring amount, color, and any odor of drainage. -Treatment as ordered. Notify medical practitioner if skin alteration worsens or no improvement in 14 days. R17's (MONTH) (YEAR), Medication Administration Record [REDACTED]. The order included: [MEDICATION NAME] AG with gauze one time a day. Spray wound cleanser IN and AROUND wound and cleanse. Cut AG into spiral. Place into wound filling entire cavity using Q-tip. Use two small sheets of AG, fold 3 x 3 (gauze)in fours, Place on top and cover with ABD (army battle dressing) (a highly absorbent dressing that provides padding and protection for large wounds). Weekly Wound Documentation dated 8/18/18, indicated a stage 4 pressure ulcer to left (should be right) gluteal fold that measured 3 cm by 1 cm x 1 x 2.5 cm. No signs/symptoms of infection. The treatment to the ulcer included the aforementioned and indicated the response of the treatment was no decline since previous assessment. Weekly Wound Documentation dated 8/24/18, indicated a stage 4 pressure ulcer to the left (should be right) gluteal fold that measured 3 cm by 1 cm by 2.5 cm. No signs/symptoms of infection. The treatment to the ulcer included the aforementioned and indicated the response of the treatment was no decline since previous assessment. Weekly Wound Documentation dated 8/30/18, indicated stage 4 pressure ulcer to the left (should be right) gluteal fold with an onset date of 3/30/17. The note further indicated; the ulcer measured 3.0 centimeters (cm) by 1.5 cm x 2.7 cm. No signs/symptoms of infection. The treatment to the ulcer included, wound cleanser, [MEDICATION NAME] AG, ABD, pressure relieving cushion, and air mattress. The note indicated treatment is changing size, but does not appear to be declining since previous assessment. During an observation on 9/5/18, at 7:19 p.m. nursing assistant (NA)-B and licensed practical nurse (LPN)-A transferred R17 into bed via a full body mechanical lift. NA-B positioned R17 onto her left side and with gloves on removed the right side of the incontinent garment expositing R17's dressing to her right inner lower buttock. The ABD dressing was ¼ saturated with reddish/brownish drainage. When R17's legs were moved, the ABD cover dressing dropped down onto the incontinent garment with the packing that was 75% saturated with reddish/yellowish drainage. The folded 3 x 3's that were supposed to be in place per physician order [REDACTED]. NA-B indicated an unawareness using wipes instead of the physician ordered wound coverings was not appropriate. The director of nursing (DON) was then notified by the surveyor immediately following the wound treatment, that the packing had fallen out of the wound, and the DON stated she would do audits in the morning to make sure that wipes were not being used to cover the packing and wound. The DON then directed an unidentified LPN to replace R17's dressing. During an observation on 9/6/18, at 7:55 a.m. R17 laid in bed, the right side of R17's incontinent garment had moderate amount of light brownish/yellowish/reddish drainage in the area of the wound. The wound had 4 x 4 sponge pads covering it without an ABD pad covering. LPN-B entered the room washed her hands and donned gloves. LPN-B removed the 4 x 4 cover sponges and reported there was not any dressing packed inside of the wound. LPN-B stated she was not aware if the wound packing should be replaced because the order was only for once a day, and there was not an order to change as needed. LPN-B then completed the dressing change per physician order. At 8:34 a.m. DON stated R17's wound should have been repacked per physician orders, and if there was a question the physician should have been contacted for further direction and/or clarification.

Based on observation, interview and record review, the facility failed to provide services to restore, maintain and prevent loss of range of motion (ROM) for 1 of 1 resident (R11) reviewed for limited range of motion of the left hand. This resulted in harm for R11. Findings include: R11's Admission record indicated an initial admission date of [DATE], with a [DIAGNOSES REDACTED]. R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R11 to be cognitively intact, to need extensive assist with most activities of daily living (ADLs), to have impaired range of motion to one side of upper extremity, and no restorative nursing programs identified. During observation on 9/4/18, at 11:14 a.m. R11 was seated in her wheelchair in the activity area during an exercise activity trying to follow along. R11's legs appeared very swollen, the right hand was trembling, and the left hand appeared contracted with no device worn. On 9/4/18 at 1:41 p.m., R11 was unable to open her left hand when asked. R11 stated, I do have a splint for my left hand, but I guess I don't always wear it. During observation/interview on 9/5/18, at 1:01 p.m. R11 was observed sitting in her wheelchair up to the table in the dining room visiting with other residents. R11 continued to have swelling in her legs, and her left hand was observed in her lap with a closed fist appearance and no splint in place. When asked R11 stated, No one here has been stretching my left hand since I have been here. On 9/5/18 at 2:11 p.m. R11 was observed seated in her wheelchair in the activity room. When asked about wearing the splint to her left hand, R 11 stated she was unable to put the splint on herself. R11 stated, I need help putting it on. R11's current care plan (no date) identified an ADL self-care performance deficit related to [MEDICAL CONDITION] disorder and impaired mobility. The goal included: will maintain current level of function through the review date, with an interventions to: wear lamb's wool hand guard to left hand with blue finger separator during the day. Although record review identified therapy recommendations to wear the splint 22 - 24 hours per day, this was not identified on R11's care plan. In addition, there was no intervention for left hand finger stretches or hand hygiene identified. R11's occupational therapy (OT) plan of care dated 1/5/16, indicated the reason for referral was contracture and decline in functional ROM of left fingers and hand. The plan included: Underlying impairments include, maximum pain reported at left fingers with attempt to stretch into extension approximately 1/8 range extension tolerated. No current orthotic for left hand or contracture management program in place. The long term goal was identified to include patient/caregiver with complete proper left hand contracture management program with orthotics, hygiene, stretching in order to reduce contracture risk and increase skin integrity. R11's Functional Limitation assessment dated [DATE], indicated: 80 - 99% impaired, changing and maintaining body position function limitation, current status has been documented based on decrease in left finger active range of motion (AROM) with noted increase in contracture at left fingers and palm with increased in skin maceration that requires skilled OT intervention to implement contracture and skin integrity management program for skilled nursing facility (SNF) carryover and fit for orthotic that is most appropriate. R11's Functional Limitations assessment dated [DATE], indicated: 60 - 79% impaired, changing and maintaining body position function limitation, current status, at therapy episode outset and at reporting intervals. R11's Functional Limitations assessment dated [DATE], indicated: 20 - 39% impaired, changing and maintaining body position function limitation, discharge status has been documented based on patient demonstrating overall progress with increase in left finger ROM, tolerance for left finger stretching program with increased comfort and skin integrity, and positioning modified left hand and finger orthotic palm guard. Patient demonstrating increase in ability to open fingers in left hand to more safely grasp front wheeled walker handle with transfers. Discontinue OT as patient at maximum potential with good patient and caregiver carryover of left hand finger contracture management program and skin integrity. R11's OT recommendations dated 2/1/16, indicated the use of left splint/contracture management recommendations. 1. (R11) should wear her blue or green finger separators placed between index and middle, middle and ring, ring and pinky fingers. Please place this on first, then place on left hand in white palm guard with wear 22 - 24 hours per day. It should be removed only for am and pm cares at this time. 2. Please stretch Eleanor's fingers open as tolerated with proper hand hygiene, including thorough washing and drying and monitoring of skin integrity once in the am and once in the pm. 3. Reposition palm guard as needed to make sure is snug and is in palm. R11's quarterly Therapy Screen form, dated 8/25/17, indicated in the comments: staff reporting patient participates in restorative program, no change. R11's Order Summary report signed by medical provider on 9/5/18, did not identify OT therapy recommendations. R11's current treatment administration record (TAR) 9/2018, did not identify OT therapy recommendations. The facility's Nursing Assistant Care Plan for R11 updated 9/5/18, also did not identify any OT recommendations under restorative nursing. During interview on 9/5/18, at 1:56 p.m. registered nurse (RN)-A stated, We currently do not have anyone here who receives active range of motion (AROM). If we did have that the nurses would be responsible for it. We would utilize the therapy recommendations in the chart, the care plan and the nursing assignment care plan. During interview on 9/5/18, at 2:23 p.m. the physical therapist (PT) verified R11's current recommendations were to wear a lamb's wool splint with blue finger separators to be worn in the morning, and taken off at night, as the splint would be used to help prevent contractures. During interview on 9/5/18, at 2:26 p.m. licensed practical nurse (LPN)-A verified R11 does not receive any range of motion (ROM) services to her left hand, but should be using a left hand splint. LPN-A observed the splint in R11's room on the dresser, versus on R11's hand. LPN-A stated use of the splint was not on the nursing assistant care plan. At 2:30 p.m. LPN-A stated,The aides do not always tell me if she refuses her splint. During Interview on 9/5/18, at 2:31 p.m. RN-A verified R11 has not been wearing the splint to her left hand and the use of the splint is not on the nursing assistant care plan. RN-A stated, My expectation would be for aides/nurses to follow the care plan and put the splint on daily and notify me if there are refusals so we can follow up. During interview on 9/6/18, 11:59 a.m. the physical therapy assistant (PTA) verified R11 should be using a left hand splint, to be worn 22 - 24 hours per day, and should be receiving PROM to her left hand per OT recommendations. During interview on 9/6/18, at 12:07 p.m. nursing assistant (NA)-A stated, (R11's) hand splint is on her dresser with no finger separators. I didn't know we were supposed to be stretching her fingers as the nursing assignment sheet doesn't tell us to do it anywhere, her splint has never had finger separators that I know of and I have been here for 1 year. During interview on 9/6/18, at 12:13 p.m. NA-C verified R11's splint for her left hand is not on her assignment care plan, neither were any stretching exercises. NA-C stated she had been working at the facility for [AGE] years and she has never seen a splint with finger separators. NA-C said, I had no idea we had to stretch her fingers, I can't do something unless I know about it. During interview on 9/6/18, at 12:16 p.m. RN-A verified she did not know that R11 was supposed to be getting hand stretches and was not aware that she was supposed to have finger separators on her splint for her left hand. RN-A further verified she has been working at the facility for 3 years and has never seen a hand splint with the finger separators, just the lamb's wool one. During interview on 9/6/18, at 3:02 p.m. the occupational therapist registered (OTR), verified R11 should still be receiving gentle stretching of her left fingers twice a day, hand hygiene, and a hand splint with the finger separators. The OTR stated, This is for contracture prevention and skin hygiene, the risk of not having this done is she could potentially have skin breakdown and could develop further contractures with pain, discomfort and deformity. The OTR stated R11 did have a left hand contracture so on 2/2/16, We put these things in place to prevent further contracture, she had good patient tolerance at the time. If she would have refused it we would have put that in our notes and there were no refusals documented, she tolerated it pretty well. R11's risk of contracture is higher, if nothing is being done it makes it harder for other devices to fit. With further contractures it could ultimately cause more pain and less tolerance for the stretch because it is tighter. The OTR stated, When we give nursing our recommendations they should be followed through. During observation and interview on 9/6/18, at 3:23 p.m. R11 was sitting in her wheelchair in the dining room visiting with family, and was asked if she was able to open her left hand with the OTR present. R11 was barely able to open the last 3 fingers. The OTR verified R11 had a decrease in ROM and stated, She is at about 1/8 active range of motion, down from the 1/4 to 1/3 she was at before. During interview on 9/6/18, at 3:30 p.m. LPN-E, verified R11 has never had a PROM program. During interview on 9/6/18, at 3:34 p.m. director of nursing (DON) stated, I would expect therapy recommendations to get followed through, and to be added to the care plan. The DON verified R11 should be wearing the left hand splint with the finger separators 22 hours per day, and should be receiving passive range of motion twice daily. The DON stated, If she would be refusing any of the services recommended, I would expect documentation of the refusals. If she refused daily, we should provide education and speak with her doctor. A facility policy for Splints, Contracture Prevention and ROM was requested. No policy was received.