Every finding on record at Guardian Angels Health & Rehab Center

Based on interview and document review, the facility failed to establish, and implement, a facility-specific water management program, based on a comprehensive assessment of the building's water-system hazards, to prevent waterborne pathogens including Legionella. This deficient practice had the potential to affect the 52 residents who resided in the facility.Findings include:According to the ASHRAE (American Society of Heating, Refrigeration and Air-conditioning Engineers) Standard 188 - Legionellosis: Risk Management for Building Water Systems, dated 10/2015, there are seven key elements of a Legionella water management program: -Establish a water management program (WMP) team-Describe the building water systems using text and flow diagrams-Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them-Establish ways to intervene when control limits are not met-Make sure the program is running as designed (verification) and is effective (validation)-Document and communicate all the activitiesIn addition, specific preventative measures are required for the following water systems: Potable water, Open and closed-circuit cooling towers and evaporative condensers, Whirlpool spas, Ornamental fountains and other water features, and Aerosol-generating misters, atomizers, air washers, and humidifiers. A facility-specific water management assessment and plan were requested from the facility. In response, the facility provided a Water Management Program Legionella Prevention policy dated 11/19/2025. The policy identified its purpose was to provide directions to staff to prevent, identify and manage hazardous conditions that inhibit the growth of and spread of Legionella. A Procedure section was broken into two main categories: Water Management Program (WMP) and a section for what to do if there was a suspected case of Legionnaires' disease in the care center. The WMP section indicated the Environmental Services Department was responsible for the WMP; the WMP would identify where the domestic water supply source entered the care center and the size of the water main, where water was distributed to vulnerable 'dead leg' or other bacterial growth sources, where cold water was heated and to what temperature including water heaters that serve resident rooms, laundry, dietary and public bathrooms, and where mixing valves used to temper water were found; the WMP would identify specific potential hazard areas where Legionella could grow and spread within the care center with external and internal factors identified; and the WMP was to address individually the control measures and corrective actions used to mitigate Legionella once the potentially hazardous areas were identified where a control measure should be documented for each specific hazard using CCEP.ES.O13-F1 Legionella Prevention Monitoring Record and gave examples of hazards such as water features, ice machines, humidifiers for central air units, unused fixtures, and plumbed water bottle/drinking fountains. These hazard examples indicated these were to be cleaned per manufacturer guidelines and/or on a routine basis. The second section identified that if there was a suspected case of Legionnaires' disease associated with the care center, the facility was to review their water management program and revise it if necessary. The policy lacked facility building specifics related to a WMP in which the policy overall only identified the facility was required to have a WMP with the identified information and that the policy, after review, was in and of itself was not an WMP. The facility-provided 2026 Legionella Prevention Monitoring Record document identified a 12-month period for 2026. Each month had four spots identified as W (week) 1, W2, W3, W4 for documented checks of the following: Eye wash run & check; No fish-water feature PH; No fish-water feature chlorinization; Water feature with fish filter cleaning; Ice maker scaling/cleaning; Empty rooms water fixture run & check. The form lacked additional information to indicate additional details such as specific locations if more than one location in the facility, the frequency of routine checks which were based on manufacturer guidelines when applicable, or any other possible hazards within the facility such as water fountains or dead legs. Information was requested on additional information related to this form; however, none was provided. During an interview on 7/29/2026 at 10:17 a.m., EVS-D stated he did not know what the facility's WMP was and could not provide a water management assessment for the building. Additionally, he had never seen a facility map identifying dead legs in the plumbing. EVS-D stated there was a spigot in the boiler room that was a dead leg of which he had not previously been aware and, as a result, had not been flushing. During an interview on 7/29/2026 at 12:35 p.m., the regional director (RD) stated there was a system wide water management policy, but each facility should have their own water management plan. If EVS-D had any questions about water management, RD would direct him to the CDC website.During an interview on 7/30/2026 at 10:45 a.m., the administrator stated the facility's water management policy included a mitigation plan for Legionella. The administrator stated there was a weekly checklist for flushing water lines and caring for water features and ice makers. The administrator stated the policy directed staff to routinely run water in unused fixtures and that someone had determined weekly flushing would be adequate. The administrator stated he was not aware of any dead legs in the facility but thought there may be a map where the dead legs were indicated. The administrator acknowledged that a water management plan was needed to protect residents from waterborne pathogens.On 8/3/26, after the onsite survey exit, the facility provided an undated water-system map identifying water flow, water mains, mixing valves, dead legs, and water faucets. The map did not establish when it was created or demonstrate that it had been incorporated into the facility's WMP or communicated to staff responsible for implementing water-management activities. On numerous occasions, the facility's WMP was asked for; however, information was not provided that demonstrated that its WMP had been fully assessed, implemented, monitored, and operationalized for the facility, based on nationally accepted standards to mitigate Legionella or other opportunistic waterborne pathogens within the facility's plumbing.

Based on interview and document review, the facility failed to ensure supply and administration of ordered medications for 3 of 3 resident (R1, R2, and R3) reviewed for pharmacy services.Findings include: R1 R1's Face Sheet dated 3/9/25, identified R1 had diagnoses of lower back pain, arthritis, and pain in left hip. R1's care plan revised on 3/16/25, identified R1 had chronic pain and instructed staff to administer medications per provider orders. R1's medication administration record (MAR) dated 8/2025, identified R1 had orders for oxycodone (a prescription medicine used to treat moderate to severe pain) 10mg twice daily for pain. The MAR lacked documentation R1 received ordered medications on 8/9/25 at 8:00 p.m., through 8/11/25 at 8:00 a.m. R1's progress note dated 8/8/25 at 8:43 p.m., identified R1's medical provider (MD)-A was called on 8/8/25 at 5:00 p.m., regarding R1's oxycodone 10mg pain medication needing a new order. MD-A indicated he would take care of it. On 8/9/25 at 6:12 a.m., a progress note identified R1's oxycodone never arrived from the pharmacy. On 8/10/25 at 10:45 p.m., a progress note identified MD-A was faxed regarding R1's oxycodone. Pharmacy was called and stated MD-A never sent new orders to pharmacy. On 8/11/25 at 7:19 a.m., a progress note identified oxycodone 10mg dose was not on cart and MD-A was notified. R2 R2's care plan dated 3/26/25, identified R2 had potential for pain and instructed staff to administer medications per orders. R2's Face Sheet dated 5/23/25, identified R2 had diagnoses of polyneuropathy (nervous system disorder that can cause symptoms of numbness, burning, and pain in multiple areas of the body), polymyalgia rheumatica (inflammatory disorder causing muscle pain around shoulders and hips), and lower back pain. R2's MAR dated 8/2025, identified R2 had orders for hydromorphone (a prescription medicine used to treat moderate to severe pain) 1mg (milligram) three times a day for pain. The MAR lacked documentation R2 received the ordered medications on 8/10/25 at 8:00 a.m. through 8/13/25 at 8:00 a.m. R2's progress note dated 8/10/25 at 9:02 a.m., identified R2's hydromorphone was not administered, was ordered, and staff waited for delivery. On 8/11/25 at 7:14 p.m., a progress note identified R2's hydromorphone was not given, and facility continued to wait for pharmacy to deliver the medication. On 8/12/25 at 12:29 p.m., a progress note identified R2 was out of scheduled hydromorphone. Pharmacy had stated the order appeared to be discontinued, but facility had no record of the medication being discontinued, facility needed to provide pharmacy with a new order or confirm the medication was discontinued. On 8/12/25 at 12:48 p.m., a progress note identified MD-A was called and preferred to be sent a fax in regards to R2's out of stock pain medication. On 8/13/25 at 9:07 a.m., a progress note identified pharmacy was called and stated they were awaiting MD-A's response to a refill request for R2's hydromorphone. R3 R3's Face Sheet dated 6/24/25, identified R3 had diagnoses of surgical amputation of right toes and gout (form of arthritis that causes severe pain). R3's care plan dated 7/1/25, identified R3 had potential for pain due to right toe amputation and instructed staff to administer pain medications per orders. R3's MAR dated 8/2025, identified R3 had orders for hydromorphone 2mg every four hours as needed for pain. R3 did not received ordered medications on 8/12/25. R3's progress note dated 8/12/25 at 11:44 a.m., identified R3 had no hydromorphone at the facility, MD-B was called and left a message to advise on R3's pain medication. On 8/12/25 at 1:48 p.m., a progress note identified a nurse from MD-B's office called the facility and stated a new order was sent to pharmacy on 8/11/25. Facility called pharmacy but pharmacy phone was not working. On 8/13/25 at 9:02 a.m., a progress note identified the pharmacy received new orders for R3's hydromorphone and would be delivering the medication as soon as possible. During an interview on 8/19/25 at 11:31 a.m., R1 stated she had not received her pain medication in the past due to not having any in the facility. During an interview on 8/20/25 at 7:48 a.m., licensed practical nurse (LPN)-A stated R1 had ran out of pain medications twice. At times, the providers did not reply to our requests for new pain medication prescriptions and residents would run out of their pain medications. During an interview on 8/20/25 at 9:53 a.m., R3 stated he did run out of his pain medications and the facility told him they would keep a better eye on his medication to ensure he did not run out again. During an interview on 8/20/25 at 12:10 p.m., registered nurse (RN)-A stated she did not believe the facility received medications for residents in a timely manner. RN-A called MD-A about R1 running out of her pain medication and MD-A stated not to call him just fax. RN-A explained to MD-A that not getting pain medications in a timely manner was an issue. During an interview on 8/20/25 at 12:34 p.m., the director of nursing stated the facility had a system issue when it came to pharmacy services and physician's responses. As a result, the medications not received timely at the facility for residents. During an interview on 8/20/25 at 1:22 p.m., MD-A stated the pharmacy would not accept verbal orders for pain medications, so residents were running out of their pain medications at the facility. During an interview on 8/20/25 at 1:32 p.m., the consultant pharmacist stated the pharmacy could only take verbal orders for narcotics if it was an emergency. Pharmacy did not receive timely faxed orders and as a result, residents were running out of pain medications. During an interview on 8/20/25 at 2:35 p.m., the administrator stated it was expected that residents had their order medications and were given the medications per orders. The facility planned to work on a solution with the pharmacy and MD-A to ensure residents did not run out of their medications in the future. The facility policy Ordering and Receiving Medications undated, indicated reorder medications three to five days in advance of need to assure an adequate supply was on hand. When reordering medications that require special processing (such as Schedule II controlled substances), order at least seven days in advance of need.

Based on interview and document review, the facility failed to ensure there was an active antibiotic stewardship program and that antibiotic time-outs were performed for 3 of 5 residents (R28, R48, R218) reviewed for antibiotic use. Findings include: R28: R28's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of Alzheimer's dementia and depression. R28's medical record reflected she was tested for COVID after developing respiratory symptoms on 5/23/25, and that result was negative. The facility then obtained orders for a respiratory panel for R28, which resulted negative for influenza, RSV, and COVID. R28's provider order dated 6/3/25, identified an order for azithromycin (a broad-spectrum antibiotic) 250 milligrams (mg) for five days for an upper respiratory infection. R28's medical record didn't contain an antibiotic time-out. R48: R48's quarterly MDS dated [DATE] identified moderately impaired cognition and diagnoses of urinary tract infection (UTI), chronic thromboembolic pulmonary hypertension, pulmonary fibrosis, heart failure, and low back pain. R48's medication administration record (MAR) for June 2025, identified an order for Macrobid (an antibiotic) 100 milligrams (mg) give one capsule by mouth two times per day related to other lower back pain until culture results, initiated 6/9 to 6/12/25. On 6/12/25, an order for Macrobid 100 mg give one capsule by mouth every morning and at bedtime for UTI for 3 days. R48's progress note dated 6/9/25 at 12:48 a.m., identified the urinary culture had no growth. On 6/10/25 at 9:48 p.m., a note identified R48 reported no signs or symptoms of UTI, and voiding clear yellow urine, temperature 97.2 degrees Fahrenheit (F). Tylenol given for lower back pain. R48's medical record didn't contain an antibiotic time-out. R218: R218's admission MDS dated [DATE] identified intact cognition and diagnoses of UTI, heart disease and diabetes mellitus. R218's MAR for June 2025, identified an order dated 6/2/25 for Levaquin 750 mg by mouth in the morning every other day for UTI until 6/8/25. R218's medical record didn't contain an antibiotic time-out for the antibiotic ordered 6/2/25. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-F stated the facility used Health Connex (infection control software) to provide infection surveillance, including antibiotic tracking. RN-F stated the system was dependent on user-input to trigger an antibiotic time out, 48-72 hours after initiation, report. During an interview on 6/11/25 at 3:32 p.m., the director of nursing (DON) stated the facility used the McGreer's criteria for infections. The RN consultant (RNC)-C thought the McGreer's criteria was posted at the nurse's stations. Posted McGreer's criteria was only found on one nurse's station. RNC-C asked RN-E about McGreer's criteria and if it was posted, and RN-E stated she didn't know the facility had decided which criteria to follow and she hadn't seen anything around. During an interview on 6/12/25 at 8:23 a.m., RN-D stated for R218, the antibiotic was started in the hospital and the three days were passed prior to admission. R218 was re-admitted on [DATE]. RN-D was familiar with antibiotic time-outs, the infection prevention (IP) nurse would have been the one following that. RN-D stated time-outs were important to see the culture results to make sure the antibiotic was right, or it could create antibiotic resistance. During an interview on 6/12/25 at 2:36 p.m., licensed practical nurse (LPN)-C stated she was not familiar with McGreer's criteria, but she was familiar with the criteria for a urinary tract infection (UTI). During an interview on 6/12/25 at 3:03 p.m., the RNC confirmed she couldn't find the antibiotic time-outs for R28, R48, or R218. The RNC stated the expectation was that antibiotic time-outs were done 48-72 hours after initiation of the antibiotic. It was important to make sure the resident was getting the right antibiotic for the least amount of time. A policy, Antibiotic Stewardship Program dated 1/21/25, identified its purpose was to provide guidance to care center staff on the appropriate use of antibiotics. The guidance aims to preserve the effectiveness of antibiotic medications, reducing adverse side effects, limiting antibiotic resistance, and minimizing healthcare associated infection and includes: Care center will use McGeer's, Loeb's, or The National Healthcare and Safety Network (NHSN) criteria for assessing resident for infections, utilizing the Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities Appendix K: Infection Surveillance Definition Worksheet or electronic antibiotic tracking software. Direct care nurse and prescriber will conduct an antibiotic review process after an antibiotic is started, also known as antibiotic time-out for all antibiotics prescribed in the care center. When culture results are received, the nurse will contact the prescriber to review the results to ensure follow up on appropriate antibiotic therapy.

Based on observation, interview, and document review, the facility failed to ensure cleaning and sanitization of surfaces for 1 of 1 resident (R59) reviewed for infection control. In addition, the facility failed to ensure proper handling of laundry to avoid contamination in the laundry area, and failed to have an active water management program. These deficient practices had the potential to impact all residents residing at the facility. R59: R59's re-entry Minimum Data Set (MDS) dated [DATE], indicated R59 was cognitively intact with the diagnoses of chronic kidney disease, resistance to vancomycin, and congestive heart failure. During a continuous observation on 6/10/25, at 9:01 a.m., licensed practical nurse (LPN-A) parked their cart outside of R59's room, donned PPE and entered R59's room. Signs on the door indicated R59 was in isolation with droplet precautions. LPN-A exited R59's room with a nasal swab, put swab in tube, discarded swab and put specimen tube in tray holder on the middle of the medication cart work area. LPN-A removed PPE and sanitized hands and parked the medication cart in front of the nurse station with the specimen on the cart. LPN-A assisted a resident to the dining table. Returned to the medication cart, sanitized hands, moved the specimen sample to a pull-out extension on the medication cart and proceeded to pull 3 medication bottles from the medication cart setting them on the center of the medication cart where the specimen had been. During an interview on 6/10/25 at 9:05 a.m., LPN-A confirmed they had taken a nasal swab from R59 and had put the specimen tube and tray on their medication cart. LPN-A stated they had sanitized their hands before they moved the specimen to the side of their medication cart but was not clear if they had sanitized their hands before touching the pill bottles. LPN-A confirmed they had not sanitized the surface of their medication cart prior to setting another resident's pill bottles on the surface. LPN-A moved the pill bottles and sanitized the top of the cart mid interview and indicated they were sanitizing the surface for infection control. The specimen was still on LPN-A's medication cart at the end of the continuous observation at 9:23 a.m During an interview on 6/12/25 at 2:27 p.m., the infection prevention registered nurse (RN-F) stated the medication cart was not the best place to set collected specimens, it would be best practice to place COVID tests or other collected specimens in an area away from resident care areas. The medication cart surfaces should have been properly sanitized before other residents' mediations were set on the surface. This is important to prevent contamination and for infection prevention. The DON was present during the interview and expressed agreement with RN-F. Laundry During observation and interview on 6/12/25 at 7:20 a.m., laundry personnel (LP)-A was walking down the front hall with a rolling bin of dirty linen and personal laundry in bags, the bin was not covered. LP-A was wearing gloves, kept the same gloves on after collecting dirty linen from the tub room, then went into the Home Acres unit and collected dirty linen there, placed it in the bin and rolled over to the clean laundry door and opened the door with the same gloved hands. LP-A rolled the dirty linen through the clean side of the laundry area and loaded the washing machine by ripping open the bags and placing the clothes and linens together inside. LP-A stated they brought the dirty bins through the clean side, but when the nursing assistants (NA)s brought in dirty clothes and linen they went into the dirty side and just dropped off the bags into bins. LP-A stated they didn't have face shields or gowns for handling the dirty laundry, but they could go out to one of the units and get one or that a lot of times there were some clean ones in the dryer, and they could use those. LP-A also provided the mop heads and rags got washed separately, and they did them last and let them set overnight and then put in the dryer the next morning. During an interview on 6/12/25 at 7:50 a.m., registered nurse consultant (RNC) stated it would be the expectation for dirty laundry to be brought through the dirty side of the laundry area, and for staff to use personal protective equipment when needed. A policy, Linen Handling dated 9/1/23, defined its purpose was to provide guidelines for staff handling linens. The policy defined linen as non-disposable personal clothing, towels, washcloths, tablecloths, sheets and other bedding and any garments worn or used in the care center. The risk of environmental contamination may be reduced by having employees bag or contain contaminated linen at the point of use, and not sorting or pre-rinsing in resident care areas. The following process will be necessary when performing this procedure: -Personal protective equipment will be worn (e.g. gowns, gloves, mask, etc.) per the standard. -Do not allow linen, clean or soiled, to touch clothing or uniform. -Handle all soiled linen as though it is potentially infectious. -Remove gloves and wash and dry hands thoroughly after contact with soiled linen. -All soiled linen or clothing will be rinsed out in a hopper in the soiled utility room. -Gloves, gowns and face masks will be available for use when rinsing out soiled linen. -Employees sorting or washing linens must wear a gown/apron, gloves, and a mask (as needed if aerosolization occurs). -Wear heavy-duty gloves when handling and sorting soiled linen. Always wash hands after completing the task and removing gloves. -Keep soiled and clean linen, in their respective hampers and laundry carts, and separate at all times. Water Management During observations 6/11 and 6/12/25 it was noted facility had two water features, one a fishpond in the center of the 400's unit and one small fountain in the 100s unit. During an interview on 6/12/25 at 3:15 p.m., maintenance worker (MW)-B explained the Legionella Prevention Monitoring Record for January to June 2025 and identified the question marks for the row titled Ice Maker Scaling/Cleaning had question marks for April weeks one, three and four because he didn't know if the other MW had done it when he put this together. For the row titled no fish water feature, where no was entered in every week, every month since the second week of January, MW-B stated the non-fish water feature had been off for a while, but he had turned it on back in January and did put chlorine tabs in it once a month. During an interview on 6/12/25 at 4:30 p.m., maintenance worker (MW)-B stated they weren't doing any kind of water testing for their water features and didn't get water testing information from the City of Hibbing regarding their chlorination or pH levels. MW-B stated the map provided was the only water map they had. Review of facility-provided map of the building designating the water main shut-off, but no diagram of hot and cold-water flow from entrance throughout the building, and no identification of mixing or shut-off valves. A policy, Water Management Program (WMP) Legionella Prevention dated 2/27/24, identified its purpose was to provide direction to staff to prevent, identify and manage hazardous conditions that inhibit the growth of and spread of Legionella and identified the environmental services department was responsible for the program. The WMP would map the water system using text or flow diagrams indicating where cold water enters, was distributed including resident rooms, water features, ice machines, faucet fixtures and shower heads. Where cold water was heated and to what temperature including hot water heaters that served resident rooms, laundry, dietary and public restrooms. Where mixing valves were sued to temper water. Where hot water was distributed. pH balance was maintained through use of disinfectants are most effective within a narrow range of 6.5 to 8.5 pH. Scale and sediment deplete disinfectants and harbor a protective environment for Legionella and other germs.

Based on observation and interview, the facility failed to ensure food and beverages were monitored for safe food temperatures. This had the potential to effect all residents in the facility. Findings include: During observation on 6/11/25 at 10:37 a.m., residents observed sitting in the dining room waiting for brunch meal. Beverage cart positioned by serving area of kitchenette and contained these items in a plastic tub: apple juice carton, cranberry juice carton, orange juice carton, ice water pitcher, milk in half gallon plastic carton. Tub did not contain any ice cubes or cooling device. All residents on units [NAME] Woodland and [NAME] were served beverages from this cart. On 6/11/25 at 11:28 a.m., dietary aide (DA)-A prepared to take beverage cart back to kitchen. DA-A prompted to pour a glass of milk and to check the temperature. DA-A retrieved thermometer from kitchenette, and poured a glass of milk. Milk measured to be 44.5 degrees Fahrenheit (F). DA-A stated the milk was above the guidelines for serving cold beverages and should be thrown away. DA-A then disposed of remaining milk from the beverage cart. During observation on 6/12/25 starting at 10:32 a.m., beverage cart positioned by serving area of kitchenette and contained these items in a plastic tub: apple juice carton, cranberry juice carton, orange juice carton, ice water pitcher, milk in half gallon plastic carton. Tub did not contain any ice cubes or cooling device. On 6/12/25 at 11:20 a.m., dietary aide (DA)-A prepared to take beverage cart back to kitchen. DA-A prompted to pour a glass of milk and to check the temperature. DA-A retrieved thermometer from kitchenette, and poured a glass of milk. Milk measured to be 41.5 degrees Fahrenheit (F). DA-A stated the milk was above the guidelines for serving cold beverages and should be thrown away. DA-A then disposed of remaining milk from the beverage cart. During interview on 6/12/25 at 3:20 p.m., director of nursing (DON) stated expectation for food and beverages to be served at the proper temperatures. DON stated serving food and beverages at unsafe temperatures could lead to food-borne illness. Food Temperature policy undated, indicated all cold food items must be served at a temperature of 40°F or below. Policy also indicated temperatures should be taken periodically to ensure cold food stays below 40 degrees Fahrenheit during the portioning, transporting, and serving process until received by the resident. The United States Food and Drug Administration (FDA) Food Code dated 2022, identified milk as a 'temperature control for safety' food and foods requiring refrigeration should be maintained at or below 41 degrees F to prevent food-borne illness. Temperature logs for fridges, freezers, and meals requested but not provided.

Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares including activities of daily living (ADLs), toileting program/schedules, and check and changes, were completed timely for 4 of 5 residents (R1, R64, R16, R9), residents food requests were acted upon for 1 of 10 residents (R218), and residents were properly supervised during medication administration for 1 of 2 residents (R40). This had the potential to affect all residents residing in the facility. Findings include: Staff and Family Interviews/Observation: During an interview on 6/9/25 at 2:37 p.m., family members (FM)-A, B, C, stated on 5/28/25, when R40 returned from the hospital at 2:00 p.m., no one checked on R40. At 9:00 p.m., (seven hours later)FM-A went to the nurses station to get help. FM-A stated no one could figure out how to connect the alarm pad that would turn on the call light if R40 got up without help. FM-A said she didn't feel safe leaving so stayed all night. FM-A stated at 3:00 a.m., (six hours later) staff came in and then no more checks were done. FM-A met with leadership that morning to discuss her concerns. FM-A, B, C stated they would come to visit and R40 would still be in her pajamas from the day before (said once it was three days in the same pajamas). On 6/9/25 at 6:53 p.m., on [NAME] Woodland /[NAME] there were no staff at the desk or visible in the hallways, R17 was eating ice cream and had a cup of coffee, and was asking where her husband was. Nursing assistant (NA)-O said she had to rush to get everything done because she was alone on the unit. During an interview on 6/12/25 at 8:31 a.m., registered nurse (RN)-D stated staffing in that hall (Wells Woodland) didn't get as much attention. Stated it could be staffing related if nursing was not offering toileting every two to three hours. During an interview on 6/12/25 at 9:55 a.m., scheduler (S)-G said staffing calls would come to the nurse, the nursing unit, or the staffing office. They would then be circled on the schedules and messages would go out via bright arrow (two different groups licensed and NAs). If no response then text messages to individuals, if no response, then mandate staff (verified have run out of staff to mandate). If unable to fill the call in then work short, nursing and the scheduler would decide how to divide up the staff or if it was possible to pull staff from another unit. During an interview on 6/12/25 at 11:45 a.m., anonymous staff (AS)-G stated they did rounds as able. AS-G and their partner were caring for about 30 residents. AS-G stated when they would come out of rooms there were often lots of call lights on, sometimes as many as four. AS-G stated they struggle to get the work done when there were only two NAs. AS-G stated they had a week where they cried after work and felt like quitting because of short staffing. During an interview on 6/12/25 at 12:40 p.m., NA-D stated she recalled a shift on 5/29/25, said she was taking care of 30 residents by herself, said that had happened more than that time. We get behind, can't do check and changes timely, can't get baths done, and had been told by nurses to let it go. She had reported not being able to get work done to the nurse manager and the director of nursing (DON). During an observation on 6/12/25 at 11:15 a.m., FM-B handed several hand written notes regarding concerns with care and staffing (which had previously been brought to the facility's attention): -R40 weak, doesn't use call light, needs frequent monitoring -R40 not independent in ADLs, doesn't remember to get dressed without someone physically being there. Had not been dressed several days when family arrived to visit. -Not ready three times for appointments (had called or discussed the need to be ready at a specific time) when family arrived incontinent, in pajamas, hair not combed. -needs a toileting schedule and needs assistance with incontinence products -no assessment completed upon return from the hospital on 5/28/25, (after return around lunch time, RN saw her asked about skin, vital signs were completed, NA saw her said hello, no offer to toilet, meal tray delivered, nebulizer treatment). Around 8:30 p.m., FM-A went to nurses station, R40 was begging to go to bed (no call light in the room), at the station two staff, one identified self as NA said, we should've at least checked on her. I'm sorry. This is the first time I've sat down, it's been so busy. FM-A had taken R40 to the bathroom several times and had gotten her ready for bed. None of the staff knew how to connect the pad that would turn on the call light if R40 got up without calling for help. FM-A decided to stay because no one had checked on R40 for an entire shift. I decided I didn't dare leave so I sat in Mom's recliner all night. No one checked on R40 until 12:38 a.m., (three and one half hours). FM-A had taken R40 to the bathroom twice during that time period. At 4:30 a.m., a staff came in said, glad to have you back, but did not offer to toilet or check incontinence product. FM-A requested a meeting, at 10:00 a.m., a meeting was held with management staff. Assurances were made for cares. Prior to the meeting none of the day staff had come in to check on R40. By 1:00 p.m., no one had assisted R40 with morning cares (toileting, oral care, dressing, hair brushing). Went to the nurse manager to ask why no cares. About 10 minutes later a NA arrived, apologized, said they were short staffed with only two NAs for 30 residents. -6/5/25, no brief, chair soaked, bed wet -6/6/25, not dressed when arrived at 10:00 a.m. -6/7/25, in pajamas all day -6/8/25, same pajamas, no shower, was told if there was time they might do it, there for over three hours, no checks, no toileting, no shower Activities of Daily Living: see also F677 R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses which included dementia, anxiety, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), insomnia, and macular degeneration (an eye disease that causes vision loss). In addition, R1's MDS identified she required substantial to maximum assistance with ADLs, was frequently incontinent of bowel and bladder, and was at risk for pressure ulcers. According to R1's MDS she had no rejections of care. R1's care plan dated 3/9/25, identified R1 had an ADL self-care performance deficit related to dementia. Interventions included I like my nails trimmed and cleaned during my bath, preferred bathing twice a week in the afternoon. R1's care plan dated 4/22/25, identified R1 was at risk for bladder incontinence and required staff assistance. Interventions included to offer toileting four times a day - upon rising, after brunch, before supper and before bed. R1's bath report for May and June 2025, did not identify if nail care was offered, refused or completed. On 6/9/25 at 6:12 p.m., R1's fingernails were noted to be long, polished and had a dark brown caked substance under them. On 6/11/25 during a continuous observation that began at 8:16 a.m., R1 was observed seated in the dining room eating hot cereal, she had a nutritional drink, was dressed for the day, and had a newspaper on the table. -8:32 a.m. R1 remains at the table said breakfast was okay but not her favorite, would have rather had peanut butter toast. -8:51 a.m. R1 remains at the table in the dining room, no staff interactions -9:11 a.m. R1 remains at the table in the dining room, no staff interactions -9:30 a.m. table cleared R1 ate 100 % of breakfast -9:56 a.m. R1 remains at the table in the dining room, no staff interactions, no position change, no off-loading -10:37 a.m. R1 has remained seated at the table in the dining room, no repositioning, no position change, no offer of bathroom, no staff interactions -11:16 a.m. R1 has remained in the dining room at the same table no position change, no offer of bathroom, no staff interactions (now 3 hours seated in the same chair in the same spot) -11:22 a.m. R1 has been served her brunch meal -11:40 a.m., asked licensed practical nurse (LPN)-C about R1 sitting in the same spot since breakfast. LPN-C stated it was too long for anyone to sit in one position and she would find someone to do a position change. -12:01 p.m., LPN-C asked two different nursing assistants for help to reposition R1 and both stated they were busy and unable to assist -12:19 p.m. activity staff were going to bring R1 directly to exercise class with out a bathroom break -12:21 p.m. R1 was brought to her room by NA-E and NA-F. Both donned isolation gowns, gloves, placed transfer belt on R1 and transferred her to the toilet. NA-E stated R1 was not always continent and said R1's brief was wet but not soaked. -12:36 p.m. R1 was was transferred back to the wheel chair, brought to her bed, transferred to her bed for skin check. Skin was slightly red with no open areas. R1 was transferred back to her wheel chair. -12:43 p.m., NA-E looked at R1's nails and said oh ya, her nails look dirty, NA-E stated she was going to try to soak her hands and clean her nails later. On 6/12/25 at 12:30 p.m., R1 was brought from the dining room directly to the exercise program in [NAME] Park. No stop was made in R1's room for toileting. On 6/11/25 at 12:26 p.m., NA-E stated R1 was not on a toileting schedule. NA-E and NA-F said they were taking care of 30 residents. During the chair to toilet transfer and chair to bed transfer NA-F said can we do this later, said they had no time to wait around. On 6/11/25 at 2:13 p.m., LPN-C stated it had been too long for R1 to sit without a position change. Said she had never seen R1 move or change her position once she was in her wheel chair. LPN-C said they did not have enough staff today. Verified the NAs were taking care of 30 residents, she was passing medications for 25 residents, they were expecting two new residents and one resident was coming back to the facility. LPN-C stated she worked days and would not pick up night shifts because she didn't want to be the only licensed staff in the building. On 6/12/25 at 7:55 a.m., RN-E verified resident nails should have been looked at daily when they were being dressed. RN-E sated there was not enough staff on the unit, staff are running and triaging their work. RN-E verified sitting for over three hours in one place is too long and she would expect a resident to be offered every two hour toileting. RN-E stated R1 was on a toileting schedule and not being left sitting in one spot for over three hours might be related to staffing (lack of). During an interview on 6/12/25 at 12:40 p.m., NA-D stated R1 was supposed to be toileted after brunch, but doesn't always happen because sometimes working alone. On 6/12/25 at 3:00 p.m. the DON verified R1 sat too long without being offered a position change or toileting. The DON stated nail care should have been done on bath days. The policy Nails care of (finger and toe) dated 9/2006, identified the purpose of nail care was to provide cleanliness, prevent the spread of infection, for comfort, and to prevent skin problems. The policy did not address the frequency of nail care. The policy Urinary Incontinence Program dated 4/6/15, identified the purpose as follows: Each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence. Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible. R64: R64's significant change MDS dated [DATE], identified R64 had diagnoses which included dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus) following cerebral infarction, vascular Parkinsonism (a form of parkinson's caused by damage to blood vessels in the brain, often due to stroke or other vascular issues), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), anxiety, and adult failure to thrive. In addition, R64's MDS identified she was dependent on staff for ADLs, was always incontinent of bowel, was at risk for pressure ulcers, and had no rejections of care. A complaint was received on 3/24/25, with concerns R64 was left soiled and wet on 3/19/25, 3/20/25, from end of day shift through evening and night shift until day shift on the following day. During an interview on 6/9/25 at 6:17 p.m., NA- O stated she was working in [NAME] Woodland /[NAME] and was taking care of 28 residents. NA-O was working with two other NAs who would be leaving at 6:30 p.m., so after dinner they got almost everyone on the unit to bed because the other two would be leaving soon. Still had four residents to settle for the night. During an interview on 6/10/25 at 1:44 p.m., NA-J stated they had put their initials on R64's brief at the end of their shift for three days. They stated their initials were on the brief when they returned for their next day shift and said the brief had not been changed by evenings or nights. R64 had been a resident on the [NAME] Woodland / [NAME] unit. NA-J stated they reported this to two different nurses, the nurse manager, and the DON. NA-J stated the past weekend there were only two NAs working, could not complete check and changes and could not get a shower done for R40. NA-J stated feels like every day it's short staffed, can't get residents up by 10:30 a.m., can't get daily weights done, no time for one to ones with residents, do what you can. Said there should be three NAs for [NAME] Woodland / [NAME], but there isn't always. During an interview on 6/12/25 at 8:20 a.m., RN-D stated she had no knowledge of any NA coming to her with concerns that R64's brief was not being changed. During an interview on 6/12/25 at 9:01 a.m., NA-I stated he recalled helping a co-worker with a brief change for R64 and saw twice that the brief had NA-J's initials on it from the day before. NA-I stated he recalled NA-J had reported the concern to management. NA-I stated could not recall any education on check and changes after the reported incident. NA-I stated when they were the only NA couldn't get checks and changes done timely. NA-I stated evening shift was the shift where there typically wasn't enough help, often leaving the unit(s) short from 6:30 p.m.-10:30 p.m., when trying to get residents ready for bed. Said the facility can only mandate NAs for four hours when there is a call in so then work short for the rest of the shift. During an interview on 6/12/25 at 12:40 p.m., NA-D stated she recalled changing R64 with another NA and saw the NA's initials from the day before on the resident's brief. NA-D said R64's brief would often be soaked in the morning. On 6/12/25 at 2:09 p.m., the DON brought in a nursing note for R64 dated 3/21/25, 11:13 a.m., Peri area/buttocks checked today for concerns. ADON and NAR present. No redness, irritation or open areas noted to groin/vaginal or buttock areas. Coccyx has a dry/flaky area on it. Calmoseptine applied to coccyx. Catheter patent and draining amber colored urine. The ADON was not available for interview, no longer worked at the facility. The DON stated nothing was wrong and they did not complete an investigation. She recalled she was not working on that day. The DON stated it would be her expectation that R64 would have been checked and changed every two hours and repositioned to prevent skin breakdown. R9: R9's admission MDS dated [DATE], indicated cognitive patterns weren't assessed. R9's MDS included diagnoses of pneumonitis due to inhalation of food and vomit, acute cystitis, orthopedic aftercare, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, heart failure, and dementia. R9 had limited range of motion in both upper extremities, one lower extremity, needed assistance with ADLs, and had an indwelling catheter. R9's Order Summary Report dated 6/12/25, didn't contain a line item for indwelling catheter care. R9's care plan dated 5/22/25, didn't address ADL status, catheter care, medications, or treatments. During an interview on 6/9/25 at 6:44 p.m., R9 stated she didn't get washed up in the morning and would like the opportunity to wash her face and stuff. During an interview on 6/11/25 at 10:46 a.m., R9 was up in her wheelchair with the over-the-bed table in front of her. R9 stated the aids helped her up to her chair and got her some breakfast, but she didn't get washed up. During an interview on 6/11/25 at 1:19 p.m., AS-G stated they would normally get their work done on the [NAME] Park unit, but not on the [NAME] unit. AS-G reported some of the things they couldn't get done were restorative care, charting, and things like that but that they could get showers and ADLs done most of the time. AS-G stated they were constantly on their feet, keeping up with call lights, running around and doing the best they could. For R9, AS-G stated they got her up right before brunch and they were not able to do her cares. During an interview on 6/11/25 at 1:37 p.m., AS-H stated they were able to get their work done but not to the ability they would like; they have so many call lights and the staffing was usually only two staff on this unit. AS-H stated there were about 10 two-person transfers in this unit so when they went into a room to help a resident, the floor was left empty. AS-H stated they could get everyone up and dressed but would like to be able to give a nice bed bath and spend more than 10 minutes with them and get to really get to know them. For R9 today, she got up later than usual, and AS-B wasn't able to do any washing up for her today, just able to get her dressed, empty her catheter and transfer her to a chair. AS-B confirmed this meant catheter care wasn't done. During an interview on 6/12/25 at 8:43 a.m., RN-D stated care plans were done 14 days after admit and R9's assessment reference date (ARD) was 5/22. RN-D didn't comment about R9's incomplete care plan, but did say care plans were important, so aids and nurses knew how to care for the resident. RN-D stated they should be doing catheter cares at least twice a day, anytime incontinent, and this included peri care and cleaning the tubing where it exited the body. This was important to prevent infection. During an interview on 6/12/25 at 9:34 a.m., the DON stated it was their protocol to have a comprehensive care plan in place 14 days after the ARD, or 21 days after admission. The DON stated catheter care was part of AM and PM cares, and the risk of not doing it could be a urinary tract infection (UTI). A policy, Catheter Care dated 9/11/23, identified the purpose was to maintain catheter patency, prevent infection and ensure dignity and provided instructions for care, but didn't address frequency. The daily care procedure was described: Gather all equipment: basin with warm water and soap, towel and washcloth, disposable gloves and other personal protective equipment as necessary, collection device, and antiseptic ointment as ordered, if applicable. Wash your hands thoroughly before and after performing the procedure; immediately after your hands encounter blood, body fluids, or tissues, and/or after handling soiled laundry or linen. Gloves must be worn while giving catheter care. Gowns will only be necessary if soiling of your clothing with urine, feces, or blood is likely. Masks/eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. Keep soiled linen from touching your clothing. Knock before entering the room, introduce yourself, and inform the resident of the procedure. Place the equipment and supplies on the bedside stand or over the bedside table and arrange the supplies so that they can be easily reached. Position resident in semi-Fowlers position, if tolerated. Put on gloves. For female, separate labia. For male, push back foreskin. Wash perineum with soap and water, taking care to wash from front to back; using one area of washcloth per washing stroke; rinse and pat dry using same procedure. Cleanse area of catheter insertion site using soap and water being careful not to pull on catheter or advance further into urethra. Hold catheter at insertion site to anchor, wash downward from meatus four inches, changing washcloth with each stroke; rinse and pat dry using same procedure. Towel dry perineal area and on the male return the foreskin to normal position. Secure catheter by utilizing a leg band. Position resident for comfort and remove and clean used equipment. Make sure catheter tubing and drainage bag are kept off the floor. Place it in a basin if it cannot hung from the bed. Cover drainage bag with a cloth/vinyl bag to protect the dignity of the resident. Remove and discard gloves. Wash hands. R16 R16's quarterly MDS dated [DATE], identified intact cognition and diagnoses of hemiplegia and hemiparesis affecting left side, cerebral infarct (stroke), dysphagia (difficulty swallowing), traumatic subarachnoid hemorrhage (brain bleed), and post-traumatic seizures. R16 needed maximum assistance with personal hygiene and dressing upper and lower body, and was dependent for transfers. R16's provider orders dated 3/27/25, identified vital signs, weight, and skin checks were to be done weekly on bath/shower day every Monday. R16's care plan dated 3/24/25, identified a self-care deficit with interventions to provide an assist of one for oral and personal hygiene, and to shave face upon request. R16's progress notes didn't contain an entry for resident refusal of bath/shower, and didn't contain a skin check for Monday 6/9/25. During an observation and interview on 6/9/25 at 2:28 p.m., R16 was noted to have chin hair approximately ¼ to 1/3 inch long. R16 stated they were going to shave her when she had her bath, but they were short staffed and she didn't get her bath and that was when they usually shaved her. During an observation on 6/10/25 at 8:53 a.m., R16 was noted to have chin hairs as she did yesterday. During an observation on 6/11/25 at 8:32 a.m., R16 was in bed eating toast and was noted to have chin hairs still present. During an interview on 6/12/25 at 1:04 p.m., LPN-E stated she had noticed the facial hair on R16 and had asked NA-I to shave her on maybe Tuesday, but it must not have gotten done. During an interview on 6/12/25 at 1:26 p.m., the DON stated R16 often refused different things, and they had been adequately staffed on her bath day. The DON would expect a note with refusals and if a resident refuses often, she would expect it to be in their care plan. Resident Rights: see also F550 R218's admission MDS dated [DATE], identified R218 had diagnoses which included heart disease, hypertension, and hyperlipidemia, no concerns with swallowing or oral/dental concerns. In addition, R218's MDS identified she was moderately cognitively intact. R218's care plan dated 3/21/25, identified R218 had a potential for alteration in nutrition due to leaving 25 % or more food uneaten at meals. Interventions included to monitor food and fluid intake, to offer fluids and snacks. On 6/9/25 at 3:39 p.m., R25 said there was sometimes not enough food during a meal. On 6/9/25 at 4:19 p.m., R218 said didn't always like the choices for food. On 6/11/25 at 11:00 a.m., in the [NAME] Woodlyn and [NAME] dining room R38 asked a staff member for more and pointed to a black bowl. R38 was told I don't think we have any more of that. The staff person did not go to the kitchen window and inquire if there was more watermelon. On 6/11/25 at 11:02 a.m., R38 verified she was told by staff there wasn't any more watermelon and said it was good. On 6/11/25 at 11:13 a.m., NA-C stated she didn't' really know if they were out of watermelon and stated residents get one serving each at a meal. On 6/11/25 at 11:40 a.m., LPN-C stated residents could have seconds as long as it was okay with their diet. On 6/11/25 at 12:08 p.m., dietary aide (DA)-A stated they did not run out of watermelon at brunch, added residents can have seconds and there was plenty of watermelon in the kitchen if staff would have asked. On 6/12/25 at 8:16 a.m., RN-D stated residents should get seconds unless they have a dietary restriction. RN-D stated possibly the failure to see if there was more watermelon could have been related to staffing as staff are always rushing to the next thing they have to do. The facility policy titled Dining - Atmosphere undated, identified residents should be treated with dignity and respect, included it was extremely important to offer as many choices as possible when it came to meal time, including what to eat. In addition, the policy identified the dietary manager would routinely perform meal rounds to determine if the meals were attractive and nutritious and met the needs of the residents. The dietary manager would observe meals for preferences, portion sizes, and would report any concerns to the director of nursing or administrator. Resident Medication Administration: see also F554 R40: R40's admission MDS dated [DATE], identified R40 had diagnoses which included chronic obstructive pulmonary disease (COPD [a group of lung disease that block airflow and make it difficult to breathe]), mild cognitive impairment, and supraventricular tachycardia (SVT [a faster than normal heart rate beginning above the heart's two lower chambers]). In addition, R40 required partial to moderate assistance with activities of daily living. R40 had no rejections of care. R40's Order Summary Report current as of 6/12/25, identified R40 had orders for ipratropium-albuterol (used to treat COPD by opening the airways and reducing inflammation) inhalation solution 0.5-2.5 (3) milligrams per 3 milliliters one vial inhale orally three times a day dated 6/10/25. Instructions included to assess respiratory status, oxygen saturation, pulse and lung sounds after the treatment. R40's care plan dated 4/7/25, identified R40 was not able to administer her own medications. Interventions included, need to supervise medication per order. On 6/10/25 at 10:16 a.m., during a continuous observation, LPN-D set up a nebulizer treatment for R40 and said, all right I'll see you in a little bit and then left the room. -at 10:24 a.m., R40 was holding the nebulizer set up with the mouth piece in her mouth, the treatment sounded done, no staff returned to check on her. -10:28 a.m., R40 continued to hold the nebulizer set up with the mouth piece in her mouth, the treatment sounded done, no staff returned to check on her. -10:30 a.m., R40 held the nebulizer set up in her hand no longer in her mouth, no staff returned to check on her. -10:33 a.m., R40 had put the nebulizer set up with the mouth piece back into her mouth, no staff had returned to check on her. -10:37 a.m., no staff had returned to the room R40 continued to hold the nebulizer treatment with the mouth piece in her mouth. -10:45 a.m., no staff had returned to the room R40 continued to hold the nebulizer treatment with the mouth piece in her mouth. -10:50 a.m., 34 minutes after the nebulizer treatment had been started the nurse was alerted that R40 was still holding the nebulizer set up with the mouth piece in her mouth. LPN-D returned to the room, stopped the nebulizer treatment, took the nebulizer set up into the bathroom and rinsed the nebulizer set up. LPN-D did not listen to R40's lungs, check her heart rate or an oxygen saturation. On 6/9/25 at 2:37 p.m., FM-A, B, C stated staff were not staying with R40 during her nebulizer treatments. They thought this was because there was not enough staff. On 6/10/25, at 2:10 p.m., LPN-D verified she left R40 until she was alerted that R40 was still holding the nebulizer treatment. LPN-D verified she did not return during the treatment to check on R40 and did not check, R40's heart rate, oxygen saturation, or listen to R40's lung sounds. LPN-D stated, just too busy, stated she set up the treatment and went on to pass more medications and did not return until alerted. LPN-D reviewed R40's record and verified she was not assessed for self-administration of medications. On 6/12/25 at 8:31 a.m., RN-D stated if a resident had been assessed to be okay to self-administer medications it would be okay to start a nebulizer treatment and come back in 15 minutes, check vital signs, listen to lung sounds, rinse the equipment. RN-D verified if a resident had not been assessed to self-administer medications, it would not have been okay to leave the resident alone during the nebulizer treatment. RN-D stated that portion of the hallway was split with another resident unit and the residents in the split hall don't get as much attention. On 6/12/25 at 11:15 a.m., FM-B handed over several pages of notes that included concerns about staffing (lack of). Note dated 6/3/25, second time in three days that I found neb hooked up, used, laying on the overbed table. I cleaned it. No one ever came in to check it in the three plus hours I was there. Facility Assessment: A review of the Facility assessment dated [DATE], identified the facility mission statement as Expressing Christ love by providing care that values every human life. The average daily census for the past 12 months was documented as 63. The unit staff analysis for [NAME] Woodland and [NAME] was number of active beds 31. Nursing assistant hours in 24 hour plan was 2.88 hours per resident. A grid provided by the facility in the initial facility assessment dated [DATE], identified staffing for the facility as follows: licensed staff providing direct care on days, evenings and nights was three (weekend staffing was the same) nursing assistant / trained medication aides on days, evenings was listed as six and nights was listed as three (weekend staffing was the same). The Daily Nursing Schedules identify the following staffing for [NAME] Woodland / [NAME]: Days 6:30 a.m. - 3:00 p.m. one licensed nurse = one 6:30 a.m. - 2:30 p.m. two nursing assistants and 6:00 a.m. - 2:00 p.m. one nursing assistant = three Evenings 2:30 p.m. - 11:00 p.m. one licensed nurse 2:30 p.m. - 10:30 p.m. three nursing assistants Nights 10:30 p.m. - 7:00 a.m. one licensed nurse 10:30 p.m. - 6:30 a.m. one nursing assistant A review of staff working on [NAME] Woodland and [NAME] for the following days revealed the following staffing: 5/28/25, Days one licensed staff, one NA for eight hours and one NA for six hours (short by 10 hours) Evenings one licensed staff, three NAs Nights no licensed staff, one NA (short 8 hours of licensed staff) 5/29/25, census 66 Days one licensed staff, two NAs for eight hours and one NA for 1.5 hours and one NA for four hours (short 2.5 hours) Evenings one licensed staff and one NA for eight hours and one for seven hours (short by one hour) Nights one licensed staff and one NA. 6/6/25, census 65 Days one licensed staff, two NAs (short eight hours) Evenings one licensed staff and two NAs (short eight hours) Nights one licensed staff and one NA 6/7/25, census 65 Days one licensed staff, two NAs for eight hours and one NA for four hours (short four hours) Evenings one licensed staff and two NAs for eight hours and one for four hours (short four hours) Nights one licensed staff and one NA 6/8/25, census 65 Days one licensed staff, two NAs (short eight hours) Evenings one [NAME][TRUNCATED]

Based on observation, interview and document review the facility failed to ensure activities of daily living (ADLs) were completed for 4 of 5 residents (R1, R64, R16, R9). Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses which included dementia, anxiety, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), insomnia, and macular degeneration (an eye disease that causes vision loss). In addition, R1's MDS identified she required substantial to maximum assistance with ADLs, was frequently incontinent of bowel and bladder, and was at risk for pressure ulcers. According to R1's MDS she had no rejections of care. R1's care plan dated 3/9/25, identified R1 had an ADL self-care performance deficit related to dementia. Interventions included I like my nails trimmed and cleaned during my bath, preferred bathing twice a week in the afternoon. R1's care plan dated 4/22/25, identified R1 was at risk for bladder incontinence and required staff assistance. Interventions included to offer toileting four times a day - upon rising, after brunch, before supper and before bed. R1's bath report for May and June 2025, did not identify if nail care was offered, refused or completed. On 6/9/25 at 6:12 p.m., R1's fingernails were noted to be long, polished and had a dark brown caked substance under them. On 6/11/25 during a continuous observation that began at 8:16 a.m., R1 was observed seated in the dining room eating hot cereal, she had a nutritional drink, was dressed for the day, and had a newspaper on the table. -8:32 a.m., R1 remains at the table said breakfast was okay but not her favorite, would have rather had peanut butter toast. -8:51 a.m., R1 remains at the table in the dining room, no staff interactions -9:11 a.m., R1 remains at the table in the dining room, no staff interactions -9:30 a.m., table cleared R1 ate 100 % of breakfast -9:56 a.m., R1 remains at the table in the dining room, no staff interactions, no position change, no off-loading -10:37 a.m., R1 has remained seated at the table in the dining room, no repositioning, no position change, no offer of bathroom, no staff interactions -11:16 a.m., R1 has remained in the dining room at the same table no position change, no offer of bathroom, no staff interactions (now 3 hours seated in the same chair in the same spot) -11:22 a.m., R1 has been served her brunch meal -11:40 a.m., asked licensed practical nurse (LPN)-C about R1 sitting in the same spot since breakfast. LPN-C stated it was too long for anyone to sit in one position and she would find someone to do a position change. -12:01 p.m., LPN-C asked two different nursing assistants for help to reposition R1 and both stated they were busy and unable to assist -12:19 p.m., activity staff were going to bring R1 directly to exercise class with out a bathroom break -12:21 p.m., R1 was brought to her room by nursing assistants (NA)-E and NA-F. Both donned isolation gowns, gloves, placed transfer belt on R1 and transferred her to the toilet. NA-E stated R1 was not always continent and said R1's brief was wet but not soaked. -12:36 p.m., R1 was was transferred back to the wheel chair, brought to her bed, transferred to her bed for skin check. Skin was slightly red with no open areas. R1 was transferred back to her wheel chair. -12:43 p.m., NA-E looked at R1's nails and said oh ya, her nails look dirty, NA-E stated she was going to try to soak her hands and clean her nails later. On 6/12/25 at 12:30 p.m., R1 was brought from the dining room directly to the exercise program in [NAME] Park. No stop was made in R1's room for toileting. On 6/11/25 at 12:26 p.m., NA-E stated R1 was not on a toileting schedule. NA-E and NA-F said they were taking care of 30 residents. During the chair to toilet transfer and chair to bed transfer NA-F said can we do this later, said they had no time to wait around. On 6/11/25 at 2:13 p.m., LPN-C stated it had been too long for R1 to sit without a position change. Said she had never seen R1 move or change her position once she was in her wheel chair. LPN-C said they did not have enough staff today. Verified the NAs were taking care of 30 residents, she was passing medications for 25 residents, they were expecting two new residents and one resident was coming back to the facility. LPN-C stated she worked days and would not pick up night shifts because she didn't want to be the only licensed staff in the building. On 6/12/25 at 7:55 a.m., registered nurse (RN)-E verified resident nails should have been looked at daily when they were being dressed. RN-E sated there was not enough staff on the unit, staff are running and triaging their work. RN-E verified sitting for over three hours in one place is too long and she would expect a resident to be offered every two hour toileting. RN-E stated R1 was on a toileting schedule and not being left sitting in one spot for over three hours might be related to staffing (lack of). During an interview on 6/12/25 at 12:40 p.m., NA-D stated R1 was supposed to be toileted after brunch, but doesn't always happen because sometimes working alone. On 6/12/25 at 3:00 p.m. the director of nursing (DON) verified R1 sat too long without being offered a position change or toileting. The DON stated nail care should have been done on bath days. The policy Nails care of (finger and toe) dated 9/2006, identified the purpose of nail care was to provide cleanliness, prevent the spread of infection, for comfort, and to prevent skin problems. The policy did not address the frequency of nail care. The policy Urinary Incontinence Program dated 4/6/15, identified the purpose as follows: Each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence. Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible. R64: R64's significant change MDS dated [DATE], identified R64 had diagnoses which included dysphagia (difficulty swallowing foods or liquids arising from the throat or esophagus) following cerebral infarction, vascular Parkinsonism (a form of parkinson's caused by damage to blood vessels in the brain, often due to stroke or other vascular issues), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), anxiety, and adult failure to thrive. In addition, R64's MDS identified she was dependent on staff for ADLs, was always incontinent of bowel, was at risk for pressure ulcers, and had no rejections of care. A complaint was received on 3/24/25, with concerns R64 was left soiled and wet on 3/19/25, 3/20/25, from end of day shift through evening and night shift until day shift on the following day. During an interview on 6/9/25 at 6:17 p.m., nursing assistant (NA)- O stated she was working in [NAME] Woodland /[NAME] and was taking care of 28 residents. NA-O was working with two other NAs who would be leaving at 6:30 p.m., so after dinner they got almost everyone on the unit to bed because the other two would be leaving soon. During an interview on 6/10/25 at 1:44 p.m., NA-J stated they had put their initials on R64's brief at the end of their shift for three days. They stated their initials were on the brief when they returned for their next day shift and said the brief had not been changed by evenings or nights. R64 had been a resident on the [NAME] Woodland / [NAME] unit. NA-J stated they reported this to two different nurses, the nurse manager, and the director of nursing (DON). NA-J stated the past weekend there were only two NAs working, could not complete check and changes and could not get a shower done for R40. NA-J stated feels like every day it's short staffed, can't get residents up by 10:30 a.m., can't get daily weights done, no time for one to ones with residents, and you do what you can. There should be three NAs for [NAME] Woodland / [NAME], but there isn't always. During an interview on 6/12/25 at 8:20 a.m., RN-D stated she had no knowledge of any NA coming to her with concerns that R64's brief was not being changed. During an interview on 6/12/25 at 9:01 a.m., NA-I stated he recalled helping a co-worker with a brief change for R64 and saw twice that the brief had NA-J's initials on it from the day before. NA-I stated he recalled NA-J had reported the concern to management. NA-I stated could not recall any education on check and changes after the reported incident. NA-I stated when they were the only NA couldn't get checks and changes done timely. NA-I stated evening shift was the shift were there typically wasn't enough help, often leaving the unit(s) short from 6:30 p.m.-10:30 p.m., when trying to get residents ready for bed. Said the facility can only mandate NAs for four hours when there is a call in so then work short for the rest of the shift. During an interview on 6/12/25 at 12:40 p.m., NA-D stated she recalled changing R64 with another NA and saw the NA's initials from the day before on the resident's brief. NA-D said R64's brief would often be soaked in the morning. On 6/12/25 at 2:09 p.m., the DON brought in a nursing note for R64 dated 3/21/25, 11:13 a.m., Peri area/buttocks checked today for concerns. ADON and NAR present. No redness, irritation or open areas noted to groin/vaginal or buttock areas. Coccyx has a dry/flaky area on it. Calmoseptine applied to coccyx. Catheter patent and draining amber colored urine. The ADON was not available for interview, no longer worked at the facility. The DON stated nothing was wrong and they did not complete an investigation. She recalled she was not working on that day. The DON stated it would be her expectation that R64 would have been checked and changed every two hours and repositioned to prevent skin breakdown. During an interview on 6/12/25 at 2:50 p.m., the DON said the NAs should know who is on a toileting program by looking at the kardex. In addition, the toileting program should also be on the care sheets. R9 R9's admission Minimum Data Set (MDS) dated [DATE], indicated cognitive patterns weren't assessed. R9's MDS included diagnoses of pneumonitis due to inhalation of food and vomit, acute cystitis, orthopedic aftercare, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, heart failure, and dementia. R9 had limited range of motion in both upper extremities, one lower extremity, needed assistance with ADLs, and had an indwelling catheter. R9's Order Summary Report dated 6/12/25, didn't contain a line item for indwelling catheter care. R9's care plan dated 5/22/25, didn't address ADL status, catheter care, medications, or treatments. During an interview on 6/9/25 at 6:44 p.m., R9 stated she didn't get washed up in the morning and would like the opportunity to wash her face and stuff. During an interview on 6/11/25 at 10:46 a.m., R9 was up in her wheelchair with the over-the-bed table in front of her. R9 stated the aids helped her up to her chair and got her some breakfast, but she didn't get washed up. During an interview on 6/11/25 at 1:19 p.m., an anonymous staff (AS)-G stated they would normally get their work done on the [NAME] Park unit, but not on the [NAME] unit. AS-G reported some of the things they couldn't get done were restorative care, charting, and things like that but that they could get showers and ADLs done most of the time. AS-G stated they were constantly on their feet, keeping up with call lights, running around and doing the best they could. For R9, AS-G stated they got her up right before brunch and they were not able to do her cares. During an interview on 6/11/25 at 1:37 p.m., AS-H stated they were able to get their work done but not to the ability they would like; they have so many call lights and the staffing was usually only two staff on this unit. AS-H stated there were about 10 two-person transfers in this unit so when they went into a room to help a resident, the floor was left empty. AS-H stated they could get everyone up and dressed but would like to be able to give a nice bed bath and spend more than 10 minutes with them and get to really get to know them. For R9 today, she got up later than usual, and AS-B wasn't able to do any washing up for her today, just able to get her dressed, empty her catheter and transfer her to a chair. AS-B confirmed this meant catheter care wasn't done. During an interview on 6/12/25 at 8:43 a.m., RN-D stated care plans were done 14 days after admit and R9's assessment reference date (ARD) was 5/22. RN-D didn't comment about R9's incomplete care plan, but did say care plans were important, so aids and nurses knew how to care for the resident. RN-D stated they should be doing catheter cares at least twice a day, anytime incontinent, and this included peri care and cleaning the tubing where it exited the body. This was important to prevent infection. During an interview on 6/12/25 at 9:34 a.m., the director of nursing (DON) stated it was their protocol to have a comprehensive care plan in place 14 days after the ARD, or 21 days after admission. The DON stated catheter care was part of AM and PM cares, and the risk of not doing it could be a urinary tract infection (UTI). A policy, Catheter Care dated 9/11/23, identified the purpose was to maintain catheter patency, prevent infection and ensure dignity and provided instructions for care, but didn't address frequency. The daily care procedure was described: Gather all equipment: basin with warm water and soap, towel and washcloth, disposable gloves and other personal protective equipment as necessary, collection device, and antiseptic ointment as ordered, if applicable. Wash your hands thoroughly before and after performing the procedure; immediately after your hands encounter blood, body fluids, or tissues, and/or after handling soiled laundry or linen. Gloves must be worn while giving catheter care. Gowns will only be necessary if soiling of your clothing with urine, feces, or blood is likely. Masks/eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. Keep soiled linen from touching your clothing. Knock before entering the room, introduce yourself, and inform the resident of the procedure. Place the equipment and supplies on the bedside stand or over the bedside table and arrange the supplies so that they can be easily reached. Position resident in semi-Fowlers position, if tolerated. Put on gloves. For female, separate labia. For male, push back foreskin. Wash perineum with soap and water, taking care to wash from front to back; using one area of washcloth per washing stroke; rinse and pat dry using same procedure. Cleanse area of catheter insertion site using soap and water being careful not to pull on catheter or advance further into urethra. Hold catheter at insertion site to anchor, wash downward from meatus four inches, changing washcloth with each stroke; rinse and pat dry using same procedure. Towel dry perineal area and on the male return the foreskin to normal position. Secure catheter by utilizing a leg band. Position resident for comfort and remove and clean used equipment. Make sure catheter tubing and drainage bag are kept off the floor. Place it in a basin if it cannot hung from the bed. Cover drainage bag with a cloth/vinyl bag to protect the dignity of the resident. Remove and discard gloves. Wash hands. R16 R16's quarterly MDS dated [DATE], identified intact cognition and diagnoses of hemiplegia and hemiparesis affecting left side, cerebral infarct (stroke), dysphagia (difficulty swallowing), traumatic subarachnoid hemorrhage (brain bleed), and post-traumatic seizures. R16 needed maximum assistance with personal hygiene and dressing upper and lower body, and was dependent for transfers. R16's provider orders dated 3/27/25, identified vital signs, weight, and skin checks were to be done weekly on bath/shower day every Monday. R16's care plan dated 3/24/25, identified a self-care deficit with interventions to provide an assist of one for oral and personal hygiene, and to shave face upon request. R16's progress notes didn't contain an entry for resident refusal of bath/shower, and didn't contain a skin check for Monday 6/9/25. During an observation and interview on 6/9/25 at 2:28 p.m., R16 was noted to have chin hair approximately ¼ to 1/3 inch long. R16 stated they were going to shave her when she had her bath, but they were short staffed and she didn't get her bath and that was when they usually shaved her. During an observation on 6/10/25 at 8:53 a.m., R16 was noted to have chin hairs as she did yesterday. During an observation on 6/11/25 at 8:32 a.m., R16 was in bed eating toast and was noted to have chin hairs still present. During an interview on 6/12/25 at 1:04 p.m., LPN-E stated she had noticed the facial hair on R16 and had asked NA-I to shave her on maybe Tuesday, but it must not have gotten done. During an interview on 6/12/25 at 1:26 p.m., the DON stated R16 often refused different things, and they had been adequately staffed on her bath day. The DON would expect a note with refusals and if a resident refuses often, she would expect it to be in their care plan.

Based on observation interview and record review the facility failed to ensure medications and biologics stored in the medication room were safely secured to prevent resident access and diversion. In addition, the facility failed to ensure safe refrigeration temperatures were maintained for medications requiring refrigeration. These unsafe practices had the potential to impact residents who received medication from the 200s/300s medication fridge and or could gain access to the mediation room. Findings include: A review of the medication room located at the intersection of the 200 and 300s hallways was completed on 6/11/25 at 3:39 p.m., with RN-B and RN-C. Some storage cupboards had locks but were not locked, and some cupboards did not have locks. Stock meds were stored in a lockable cupboard that was not locked. Three bins of medications were stored in a lower cupboard without a lock. The cupboard was labeled medications for destruction. The medication fridge was locked. RN-B unlocked the fridge and confirmed the fridge internal temperature was 48 degrees Fahrenheit. RN-B stated 48 degrees was out of safe storage parameters and indicated they would have to notify maintenance. The fridge contained immunizations, GLP-1 injectables, insulin and controlled medications. The temperature log on the front of the fridge had incomplete documentation. The last recorded temperature was 46 degrees Fahrenheit on 6/10/25. During a follow-up interview on 6/11/25 at 4:10 p.m., RN-B stated they had put in a work order and notified the director of nursing (DON) the fridge was out of temperature range. During an interview on 6/11/25 at 4:16 p.m., the DON stated 48 degrees was out of the safe medication storage range for insulins and immunizations and indicated the medications would likely have to be destroyed. They intended to contact the consulting pharmacist for advisement on final disposition of the medications in the fridge. During a follow-up on 6/12/25 at 7:23 a.m., the DON unlocked the medication fridge and confirmed the internal fridge temperature reading was 48 degrees Fahrenheit. The DON instructed unit staff not to use any medications from the medication fridge and stated they were waiting for a return call from the consulting pharmacist. On 6/12/25 at 8:47 a.m., the DON reported the consulting pharmacist had recommended the following medications from the unit fridge temping at 48 degrees Fahrenheit be destroyed and replaced by the facility: ---five lantus Solostar pens ---four Mountjaro prefilled Pens 7.5mg/0.5ml ---four Mounjaro prefilled Pens 2.5mg/0.5ml ---one dose Prevnar injection ---one dose Shingrix injection ---one dose Abrysvo powder injection. During an interview on 6/12/25 at 2:04 p.m., registered nurse consultant (RNC-C) confirmed on 6/11/25, they had witnessed the 200s/300s medication room being exited by staff and left open and unattended. RNC-C stated medication rooms should be locked when unattended by a licensed staff for the safety of residents and to prevent diversion. The DON was present and expressed agreement with RNC-C and indicated it was the expectation medication rooms remained locked per policy. The DON reported because the refrigerator was temping at 48 degrees Fahrenheit medications from that fridge had been destroyed. No residents at the facility had received medications from that fridge once the temperature was found to be 48 degrees. The refrigeration logs utilized by the facility had two spots each day to record fridge temperatures. The facility provided monthly Refrigeration Temp Logs for 3/2025 through 6/10/25, for the 200s/300s medication fridge. The logs showed 36 missed temperature entries in March, 31 missed entries in April, 37 missed entries in May, and the June log showed 3 missed entries as of 6/10/25. The facility policy Medication Storage Policy dated 7/27/16, included the following: ---Line item 7: compartments: including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals shall be locked when not in use. ---Line item 9: medication refrigerator temperatures are to be kept between 36 to 46 degrees Fahrenheit.

R28: R28's quarterly MDS assessment dated [DATE], indicated R28 was severely cognitively impaired with the diagnoses of Alzheimer's Disease, depression, psychotic disorder, and hallucinations. Section N. Medications indicated R28 received antipsychotic medications. R28's Care plan last revised 3/26/25, indicated R28 received antipsychotic medications and instructed AIMS assessments to be completed per policy. R28's Order Summary Active orders as of 6/18/25, contained the following orders: ---Seroquel 50 mg tablet at bedtime for Alzheimer and delusion disorder ---Seroquel 25 MG tablet give 1.5 tablet by mouth in the morning related to Alzheimer and delusional disorder. ---Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) R28's electronic and paper medical record lacked evidence to show Aims [assessment for EPS (antipsychotic drug side effects)] and orthostatic blood pressure [drop in blood pressure when going to an upright position from laying or sitting] monitoring had occurred as ordered. During an interview on 6/12/25 at 11:41 a.m., registered nurse (RN-A) stated the facility completed AIMS assessments in conjunction with quarterly assessments. AIMS assessments should be completed because it assessed for signs of tardive dyskinesia. Orthostatic blood pressures were done on residents receiving antipsychotic medication for safety. RN-A reviewed R28's record and confirmed R28 had missing AIMS assessments and orthostatic blood pressures were not being done on R28. During an interview on 6/12/25 at 2:04 p.m., the director of nursing (DON) stated they would expect orthostatic and AIMS assessments to be completed per policy on residents who were receiving psychotropic medications. In a follow-up e-mail on 6/12/25 at 3:07 p.m., the DON reported no AIMS assessments had been completed on R28 since 10/1/24. The policy Psychotropic Medications dated 5/21/25, instructed AIMS or DISCUS assessments were to be completed at least every six months on residents prescribed antipsychotics. The policy included the provider was to identify if a resident required monthly orthostatic blood pressure monitoring. Based on interview and document review, the facility failed to ensure as-needed (PRN) psychotropic (medications which affect the mind, emotions, and behavior) medications had an end date for 2 of 5 residents (R32, R21), and failed to ensure residents receiving psychotropic medications were assessed for extrapyramidal movements (involuntary, uncontrolled muscle movements) and orthostatic blood pressure for 2 of 5 residents (R11, R28) reviewed for unnecessary medications. Findings include: R32: R32's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of Parkinson's disease with dyskinesia, and dementia. R32 was enrolled in hospice services. R32's care plan dated 3/24/25, identified a mood problem related to anxiety and included interventions to administer medications as ordered. Monitor and document side effects and effectiveness. R32's electronic medical record (EMR) contained an order dated 5/16/25, for lorazepam (a benzodiazepine used for anxiety) 0.5 milligrams (mg) PRN every four hours for anxiety and restlessness. The order didn't contain a stop date. During an interview on 6/12/25 at 8:55 a.m., RN-D confirmed R32's lorazepam order didn't have a stop date, she added she had faxed about it last week. During an interview on 6/12/25 at 9:53 a.m., the director of nursing (DON) confirmed there wasn't a stop date for the lorazepam, but the hospice provider/rounding provider was on vacation. R21: R21's quarterly MDS dated [DATE], identified R21 as moderately cognitively impaired, with diagnoses that included severe protein-calorie malnutrition, anxiety, adjustment disorder, depression, radiculopathy of the lumbar region, hypertension, and a stage IV pressure ulcer in the sacral region. R21's order summary dated 6/11/25, indicated an order for clonazepam (psychotropic medication used to treat anxiety) 0.5 milligram (mg) tablet to be given by mouth every 4 hours as needed (PRN) for anxiety. The order started on 6/10/25, and did not have an end date. During interview on 6/12/25 at 7:45 a.m., registered nurse manager (RN)-E stated R21's order for PRN clonazepam was discontinued on 6/9/25. RN-E checked R21's medical record and verified the order for PRN clonazepam was active in resident's chart. RN-E stated the order needed to have an end date due to being a PRN antipsychotic medication. During interview on 6/12/25 at 3:20 p.m., director of nursing (DON) stated expectation for PRN psychotropic medications to have an end date. Psychotropic Medications policy issued on 5/21/25, indicated PRN psychotropic medications ordered will be limited to 14 days. The prescribing practitioner will evaluate and document the medications necessity, benefits, and improvement (expressions, indications of distress). If the physician deems it appropriate to extend beyond the 14-day limit, supporting rationale must be documented. R11: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 as cognitively intact with diagnoses that included congestive heart failure, type 2 diabetes, chronic kidney disease, chronic pain, severe depression with psychotic symptoms, atrial fibrillation, anxiety, anemia, post-traumatic stress disorder, hypothyroidism, and hypertension. MDS indicated R11 received an anxiolytic (treats anxiety) medication. R11's care plan last revised on 6/9/25, identified resident taking antipsychotic medication with an intervention of completing an abnormal involuntary movement scale (AIMS) or dyskenesia identification system: condensed user scale (DISCUS) as indicated. Review of R11's medical chart revealed no AIMS or DISCUS had been completed. R11's order summary report dated 6/12/25, indicated an order for buspirone 1 milligram (mg) tablet and instructed staff to give 2.5mg by mouth as needed (PRN) for anxiety. The order for buspirone started on 4/22/25 and did not have an end date. R11's order summary also indicated an order for risperidone 0.5mg tablet to be given once a day at bedtime for depression. The order for risperidone started on 5/15/25 and did not have an end date. R11's medication administration record (MAR) reviewed 4/1/25 through 6/11/25, identified no PRN buspirone was given, however the order remained active. During interview on 6/12/25 at 3:20 p.m., director of nursing (DON) stated expectation for PRN psychotropic medications to have an end date. DON also expected residents taking antipsychotic medication have an assessment such as the abnormal involuntary movement scale (AIMS) done to monitor for side effects like tardive dyskinesia (neurological condition with involuntary and repetitive muscle movements). Psychotropic Medications policy issued on 5/21/25, indicated PRN psychotropic medications ordered will be limited to 14 days. The prescribing practitioner will evaluate and document the medications necessity, benefits, and improvement (expressions, indications of distress). If the physician deems it appropriate to extend beyond the 14-day limit, supporting rationale must be documented. Policy also indicated Complete a DISCUS or AIMS assessment on any resident prescribed an antipsychotic at least every 6 months. Any changes will be reported to the physician.

Based on observation, interview and document review, the facility failed to track bowel movements and provide related interventions for 2 of 4 residents (R9, R32), failed to monitor a resident's oxygen saturation levels per provider order for 1 of 4 residents (R9), and failed to complete ordered skin checks for a resident with a skin condition for 1 of 4 residents (R22) reviewed for quality of care. Findings include: R9: R9's admission Minimum Data Set (MDS) dated [DATE], indicated cognitive patterns weren't assessed. R9's MDS included diagnoses of pneumonitis due to inhalation of food and vomit, acute cystitis, orthopedic aftercare, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, heart failure, and dementia. R9 had limited range of motion in both upper extremities, one lower extremity, needed assistance with ADLs, and had an indwelling catheter. R9's care plan dated 5/22/25, didn't address oxygen or bowels. R9's provider orders identified the following: -4/13/25, an order for docusate sodium 100 mg by mouth two times per day. -5/6/25 sennosides-docusate sodium 8.6/50 mg by mouth two times per day 1-2 tabs two times per day while on oral narcotics to prevent or treat constipation. -5/8/25 Hydrocodone 5/325 mg every four hours as needed for pain. -5/22/25, to take daily oxygen saturation, wean oxygen as tolerated to keep saturation levels greater than 90% one-time per day. R9's progress notes for May 2025 didn't reveal any notes regarding R9 not having had a bowel movement for more than 48 hours nor was there an assessment of R9's bowel status. R9's progress notes did identify an entry on 5/21/25, noting resident had a dry cough, but oxygen saturation was 94% on 2 liters per minute (LPM). R9's Weights and Vitals Summary for May and June 2025 had the following entries: -5/16/25 90% on room air -5/19/25 91% on room air -5/20/25 90% on room air -5/24/25 93% on oxygen (LPM not given) -6/1/25 95% on oxygen (LPM not given) -6/6/25 96% on oxygen (LPM not given) -6/7/25 94% on room air Review of R9's medication administration record (MAR) and treatment administration records (TAR) for May and June 2025, revealed no line items for oxygen administration indicating if oxygen was used, and if so at what liter flow. R9's electronic medical record (EMR) identified the following dates in May 2025 where no bowel movements were recorded: 5/22, 5/23, 5/24, 5/25, and 5/28, 5/29, 5/30. During an interview on 6/9/25 at 6:48 p.m., R9 stated she had trouble with constipation all the time, if she could get prune juice with her stool softener, she would be fine, but they didn't do that. R32: R32's significant change MDS dated [DATE], identified severely impaired cognition and diagnoses including Parkinson's disease with dyskinesia (a movement disorder), and dementia. R32 was non-ambulatory, dependent for mobility, toileting and toilet hygiene. R32's care plan dated 3/25/25, identified an activities of daily living (ADL) self-care deficit and needed an assist of two to check/change incontinent product and offer the bathroom every two hours. Check every two to three hours at night. Frequently incontinent of bladder, continent of bowel. Constipation was not addressed. R32's provider orders: -3/18/25 prune juice one time a day for constipation -4/16/25 monitor BMs, if no BM in 48 hours give PRN MiraLAX one time a day for constipation. -4/16/25 MiraLAX 17 grams give one scoop as needed for constipation if no BM in 48 hours - please give!! Review of R9's EMR revealed the following: -bowel movements for May and June 2025 were recorded on the following dates: 5/20, 5/25, 6/5 and 6/8. -MAR and TAR for May and June 2025 didn't have MiraLAX signed out. -MAR and TAR had the order monitor BMs, if no BM in 48 hours give PRN MiraLAX one time a day was signed off every day of June, and all but one day of May. During an interview on 6/9/25 at 2:16 p.m., family member (FM)-H stated R32 had lots of trouble with constipation and explained he was on many medications that made this worse, she had talked with staff about this before and he had an order for MiraLAX now. During an interview on 6/12/25 at 8:43 a.m., registered nurse (RN)-D stated R9's order for oxygen might be under the standing orders because she had gotten sick and needed it and then went to the hospital. RN-D confirmed the current order was for daily oxygen saturation levels and to wean to keep 90% or better and stated they usually started at one to two liters per minute (LPM), get a baseline from what the hospital had had them on and then work on weaning the oxygen. It would be important to know her levels to see if she was tolerating being weaned. BM protocol 3 days no BM they start with prune juice, then go to something a little heavier like MiraLAX, they can do MOM, supp, enema depending on how long they have gone without a BM. The NAs chart the BMs. On PCC there is a clinical dashboard where they can see if there is someone who has gone more than 48-72 hours. The expectation would be there is a one-time standing order for a prn or a nursing order. During an interview on 6/12/25 at 9:34 a.m., the director of nursing (DON) explained the standing orders for oxygen PRN one to four LPM would cover the PRN oxygen R9 was using because R9's provider had signed an order for house standing orders including the PRN oxygen. The DON confirmed the house standing orders for oxygen weren't on R9's orders, and a liter flow wouldn't be recorded on the MAR, but a copy of them was on every medication cart. The DON stated her expectation would be that bowel movements were recorded by the NAs and the nurses and would expect to see an intervention for the missed bowel movements. A document, House Standing Orders dated 10/10/23, identified under directions item number 2, the standing house orders are documented through the electronic health record. In addition: Bowel Regulation/Protocol - Constipation 1. If the resident hasn't had a BM in the last 24 hours may receive dietary interventions such as prune juice or fiber. 2. Milk of magnesia (or equivalent) 30 mL by mouth daily as needed for constipation. 3. Dulcolax suppository 1 supp rectally daily as needed for constipation. Fleets enema rectally daily as needed for constipation. If no results within 2 hours after the enema, notify the MD/NP. 4. MiraLAX 17 grams daily as needed for constipation. If PRN bowel meds are used more than twice in one week, assess for routine bowel regimen need. 5. Senna two tablets daily at bedtime as needed for three days. Cough/Respiratory Symptoms - Oxygen 1. One to four LPM via nasal cannula or mask as needed for respiratory distress, acute dyspnea, hypoxia (to bring saturations above 88%) or acute angina (no more than two LPM for residents with COPD. Notify MD. R22: R22's quarterly MDS dated [DATE], identified moderately impaired cognition and a diagnosis of livedoid vasculitis (a rare, chronic disorder causing painful, recurrent ulcers primarily on the lower extremities, which heal to an atrophic, porcelain-white scar). R22's care plan dated 3/25/25, identified she needed an assist of one for bathing/showering, and had potential for skin impairment of the buttocks/peri area related to incontinence. R22's care plan had interventions to keep fingernails short, inspect skin weekly, keep skin clean and dry, provide peri care with incontinent episodes and observe skin daily with cares. An order dated 4/1/25, identified skin charting every evening shift on Fridays, chart on the Nursing Advanced Skin Check in the assessments tab and complete. R22's EMR didn't contain any skin assessments. During an interview on 6/11/25 at 4:06 p.m., RN-D stated the cart nurse was responsible for the skin checks with the resident bath, all residents get them weekly on their bath day. The facility's expectation was that it was done every week. RN-D stated she did know R22 refuses baths. A policy, Skin Integrity dated 5/21/25, identified the purpose was to provide guidance to nursing staff on identifying, evaluating, monitoring, and preventing resident skin integrity issues. Braden, tissue tolerance, and skin assessments will be completed in the electronic health record (EHR). Further, under monitoring, the policy indicated a licensed nurse would complete a skin check weekly and document in the EHR. The licensed nurse will observe changes in skin integrity and treatments, will notify the nurse manager, wound nurse, or designee with any changes.

Based on observation, interview, and document review the facility failed to ensure a resident did not self-administer medications (SAM) as assessed and according to the care plan for 2 of 2 residents (R40, R219) reviewed for SAM. Findings include: R40: R40's admission Minimum Data Set (MDS) dated [DATE], identified R40 had diagnoses which included chronic obstructive pulmonary disease (COPD [a group of lung disease that block airflow and make it difficult to breathe]), mild cognitive impairment, and supraventricular tachycardia (a faster than normal heart rate beginning above the heart's two lower chambers). In addition, R40 required partial to moderate assistance with activities of daily living. R40 had no rejections of care. R40's Order Summary Report current as of 6/12/25, identified R40 had orders for ipratropium-albuterol (used to treat COPD by opening the airways and reducing inflammation) inhalation solution 0.5-2.5 (3) milligrams per 3 milliliters one vial inhale orally three times a day dated 6/10/25. Instructions included to assess respiratory status, oxygen saturation, pulse and lung sounds after the treatment. R40's care plan dated 4/7/25, identified R40 was not able to administer her own medications. Interventions included, need to supervise medication per order. On 6/10/25 at 10:16 a.m., during a continuous observation, licensed practical nurse (LPN)-D set up a nebulizer treatment for R40 and said, all right I'll see you in a little bit and then left the room. -at 10:24 a.m., R40 was holding the nebulizer set up with the mouth piece in her mouth, the treatment sounded done, no staff returned to check on her. -10:28 a.m., R40 continued to hold the nebulizer set up with the mouth piece in her mouth, the treatment sounded done, no staff returned to check on her. -10:30 a.m., R40 held the nebulizer set up in her hand no longer in her mouth, no staff returned to check on her. -10:33 a.m., R40 had put the nebulizer set up with the mouth piece back into her mouth, no staff had returned to check on her. -10:37 a.m., no staff had returned to the room R40 continued to hold the nebulizer treatment with the mouth piece in her mouth. -10:45 a.m., no staff had returned to the room R40 continued to hold the nebulizer treatment with the mouth piece in her mouth. -10:50 a.m., 34 minutes after the nebulizer treatment had been started the nurse was alerted that R40 was still holding the nebulizer set up with the mouth piece in her mouth. LPN-D returned to the room, stopped the nebulizer treatment, took the nebulizer set up into the bathroom and rinsed the nebulizer set up. LPN-D did not listen to R40's lungs, check her heart rate or an oxygen saturation. On 6/9/25 at 2:37 p.m., family members (FM)-A, FM-B, and FM-C stated staff were not staying with R40 during her nebulizer treatments. They thought this was because there was not enough staff. On 6/10/25, at 2:10 p.m., LPN-D verified she left R40 until she was alerted that R40 was still holding the nebulizer treatment. LPN-D verified she did not return during the treatment to check on R40 and did not check, R40's heart rate, oxygen saturation, or listen to R40's lung sounds. LPN-D stated she was too busy and set up the treatment and went on to pass more medications and did not return until alerted. LPN-D reviewed R40's record and verified she was not assessed for self-administration of medications. On 6/12/25 at 8:31 a.m., registered nurse (RN)-D stated if a resident had been assessed to be okay to self-administer medications it would be okay to start a nebulizer treatment and come back in 15 minutes, check vital signs, listen to lung sounds, rinse the equipment. RN-D verified if a resident had not been assessed to self-administer medications, it would not have been okay to leave the resident alone during the nebulizer treatment. RN-D stated that portion of the hallway was split with another resident unit and the residents in the split hall don't get as much attention. On 6/12/25 at 11:15 a.m., FM-B handed over several pages of notes that included concerns about staffing (lack of). Note dated 6/3/25, second time in three days that I found neb hooked up, used, laying on the overbed table. I cleaned it. No one ever came in to check it in the three plus hours I was there. R219: R219's admission Record dated 6/12/25, identified an admission date of 6/9/25 with diagnoses of fracture of the left lower leg, hyperthyroidism, dislocation of the left ankle joint, orthopedic aftercare following surgical amputation (right great toe). R219's 48-hour care plan, undated, identified resident was alert and oriented, needs assistance with dressing, grooming, bathing, and an assist of one to transfer. The care plan didn't indicate R219 could self-administer medications. R219's provider orders dated 6/9/25, didn't identify an order for self-administration of medications. R219's medication administration record (MAR) for 6/12/25, identified the following medications were give to R219 this AM: -Amlodipine 5 mg one time per day -Aspirin 325 mg one time per day -Atenolol 50 mg one time per day -Doxycycline 100 mg every 12 hours for 7 days -Gabapentin 300 mg three times per day -Levothyroxine 150 mcg one time pr day -Losartan 100 mg one time per day -Multiple vitamins, 1 tab daily -Spironolactone 25 mg one time per day R219's electronic medical record (EMR) didn't identify an assessment for self-administration of medication. During an observation and interview on 6/12/25 at 8:23 a.m., R219 was setting on the edge of his bed, the over-bed table was on the other side of the room with a white cup half full of medications. R219 stated the nurse left them there. On 6/12/25 2:50 p.m., during an interview the director of nursing (DON) stated a self-administration medication assessment needed to be completed prior to allowing a resident to self-administer medication. The Self-Administration of Medication by Resident policy dated 2/27/24, identified the purpose was To provide guidance to staff for assessing and accommodating resident's wish to self-administer their medications. The policy identified all residents would be asked on admission if they wanted to self-administer their medications. B. If the resident wishes to self-administer medications, they will be assessed for their ability to safely self-administer their medications. A Self-Administration of Medications (SAM) assessment will be completed and reviewed by the IDT (interdisciplinary team). This assessment will include: a. Cognitive status, b. Physical status, c. Which medications are appropriate to be self-administered, d. Where the medications will be stored safely, e. How the nursing staff will monitor the medication's use, and f. How it will be documented.

The facility failed to provide a requested second helping of food for 1 of 10 residents (R218) reviewed for dining. Findings include: R218's admission Minimum Data Set (MDS) dated [DATE], identified R218 had diagnoses which included heart disease, hypertension, and hyperlipidemia, no concerns with swallowing or oral/dental concerns. In addition, R218's MDS identified she was moderately cognitively intact. R218's care plan dated 3/21/25, identified R218 had a potential for alteration in nutrition due to leaving 25 % or more food uneaten at meals. Interventions included to monitor food and fluid intake, to offer fluids and snacks. On 6/9/25 at 3:39 p.m., R25 said there was sometimes not enough food during a meal. On 6/9/25 at 4:19 p.m., R218 said didn't always like the choices for food. On 6/11/25 at 11:00 a.m., in the [NAME] Woodlyn and [NAME] dining room R38 asked a nursing assistant (NA)-C for more and pointed to a black bowl. R38 was told I don't think we have any more of that. The NA-C did not go to the kitchen window and inquire if there was more watermelon. On 6/11/25 at 11:02 a.m., R38 verified she was told by staff there wasn't any more watermelon and said it was good. On 6/11/25 at 11:13 a.m., NA-C stated she didn't' really know if they were out of watermelon and stated residents get one serving each at a meal. On 6/11/25 at 11:40 a.m., licensed practical nurse (LPN)-C stated residents could have seconds as long as it was okay with their diet. On 6/11/25 at 12:08 p.m., dietary aide (DA)-A stated they did not run out of watermelon at brunch, added residents can have seconds and there was plenty of watermelon in the kitchen if staff would have asked. On 6/12/25 at 8:16 a.m., registered nurse (RN)-D stated residents should get seconds unless they have a dietary restriction. RN-D stated possibly the failure to see if there was more watermelon could have been related to staffing as staff are always rushing to the next thing they have to do. The facility policy titled Dining - Atmosphere undated, identified residents should be treated with dignity and respect, included it was extremely important to offer as many choices as possible when it came to meal time, including what to eat. In addition, the policy identified the dietary manager would routinely perform meal rounds to determine if the meals were attractive and nutritious and met the needs of the residents. The dietary manager would observe meals for preferences, portion sizes, and would report any concerns to the director of nursing or administrator.

Based on interview and document review the facility failed to ensure timely reveiw and revision of the care plan occured for 2of 2 residents (R41, R11) reviewed for care planning. Findings include: R41: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was moderately cognitively impaired with the diagnoses of stroke, dysphagia, generalized muscle weakness, and epilepsy. MDS Section GG indicated R41 was dependent for activities of daily living and transfers. R41's Care plan last revised 6/3/25, identified R41 as a risk for falls on 3/19/25. The care plan lacked evidence to show R41's fall prevention interventions had been revised before or after R41's fall on 6/7/25. A nursing note entry made on 6/7/25, identified R41 had been placed in their recliner and then was later found on the floor. Post assessment revealed R41 had not sustained a significant injury. A nursing note entry made on 6/10/25, indicated an interdisciplinary disciplinary review had been completed for R41's fall on 6/7/25, and the root cause was identified. R41 had gotten ahold of the remote and placed recliner in the upright position and slid out. Intervention identified was to unplug the chair. During an interview on 6/12/25 at 11:58 a.m., registered nurse (RN-A) reviewed R41's chart and confirmed R41 had fallen out of their recliner on 6/7/25. R41 had gotten ahold of the chair remote buttons which led to a fall to the floor. RN-A confirmed R41's care plan had not been updated with new fall prevention interventions after post fall analysis was completed. RN-A stated normally the care plan got updated with changes in care for residents, but R41's care plan had not been updated. During an interview on 6/12/25 at 2:00 p.m., the director of nursing (DON) stated falls get reviewed at the manager level and at an interdisciplinary team level. R41's care plan should have been updated with fall interventions after R41's fall was reviewed. The facility policy Person Centered Care Planning dated 12/18/23, identified resident's immediate health and safety concerns to prevent decline or injury such as fall risk should be addressed in the care plan. The policy also identified care plans were to be updated on an ongoing basis as needed based on changes that occurred between care conferences. R11: R11's quarterly MDS dated [DATE], identified R11 as cognitively intact with diagnoses that included congestive heart failure, type 2 diabetes, chronic kidney disease, chronic pain, severe depression with psychotic symptoms, atrial fibrillation, anxiety, anemia, post-traumatic stress disorder, hypothyroidism, and hypertension. R11's order summary report dated 6/12/25, indicated an order for risperidone (antipsychotic) 0.5 milligram (mg) tablet to be given once a day at bedtime for depression started on 5/15/25, an order for citalopram hydrobromide (antidepressant) 20mg to be given in the morning for depression started on 4/1/25, an order for warfain sodium (anticoagulant) 1mg tablet to be given in the evening every Tuesday, Thursday, Saturday, and Sunday for atrial fibrillation started on 5/20/25, and an order for 1.5 tablets of warfarin sodium 1mg to be given in the evening every Monday, Wednesday, and Friday for atrial fibrillation started on 5/21/25. R11's care plan last revised on 6/9/25, identified focus areas of I use antidepressant medication (Specify medications), I am on anticoagulant therapy (Specify medication), and I have a diabetic ulcer of the (specify location). During interview on 6/12/25 at 3:20 p.m., director of nursing (DON) stated expectation for care plans to be complete. DON stated importance of completing care plans as the plans contained information needed to effectively care for a resident. Person Centered Care Planning policy last revised 12/18/23, identified the care plan describing the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.' Policy indicated the resident's care plan is reviewed every 90 days or more frequently if necessary with a significant change. Care plans are updated on an ongoing basis as needed based on changes that occur between care conferences.

Based on observation, interview, and record review the facility failed to ensure competent, trained staff operated tube feeding pumps and managed tubing for 1 of 1 resident (R41) reviewed for tube feeding. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41 was moderately cognitively impaired with the diagnoses of stroke, dysphagia, generalized muscle weakness, and epilepsy. MDS Section GG indicated R41 was dependent for activities of daily living and transfers. MDS Section K. Percent Intake by Artificial Route indicated R41 received 51% or more of nutrition through parenteral or tube feeding. R41's care plan last revised 6/3/25, indicated R41 required tube feeding related to dysphasia and directed staff to use infection control precautions and related techniques following the manufacturer's recommendations when stopping, starting, flushing, and giving medications through the feeding tube. R41's Order Summary Report Active orders as of 6/12/25 included the following orders: -NPO diet -Enteral Feed Order six times a day continuous feeding: flush my tubing 6x/day with 150 ml [milliliters] of tap water. -Isosure 1.5 calorie oral liquid continuous feeding at 50 ML an hour. During an observation on 6/11/25 at 9:12 a.m., NA-A and NA-B donned personnel protective equipment PPE and entered R41's room to get R41 up for the day. -9:20 a.m., NA-A placed R21's tube feeding on hold and disconnected the tubing from R41 and hung it over the top of the pole without capping the end and then NA-A and NA-B proceeded with cares, and transfer to and from the bathroom and back to R41's chair. -9:28 a.m., NA-A took R41's tube feeding pump in hand and explained they were transferring it to R41's wheelchair pole. While maneuvering the pump the tubing and the uncapped connection end of the tube feeding tubing was noted to be on the floor. When pointed out to NA-A, NA-A picked the tubing off the floor and wiped it with a tissue, connected the tubing to R41 and then proceeded to restart R41's pump. During an interview on 6/11/25 at 9:39 a.m., NA-A stated when a resident had a tube feeding, they normally stopped and disconnected the tube feeding when they were taking the resident to the bathroom or transferring the resident in and out of bed. NA-A stated they had not had a class on tube feeding management or operating the tube feeding pump, nurses had shown them how to pause the pump. NA-A stated they did whatever they could to prevent infection and explained they weren't sure what to do when they saw the tubing on the floor, they had wiped the end of R41's tube feeding tube with a tissue to help prevent infection. R41 questioned if they should have wiped it with an alcohol wipe instead, said they hadn't been sure what to do and indicated they would be talking to the nurse. After interview, NA-A donned PPE and disconnected R41's tube feeding. On 6/11/25 at 9:52 a.m., NA-A reported they had stopped R41's tube feeding, talked to the nurse, and the nurse was going to replace R41's tubing. During an observation on 6/11/25 at 10:02 a.m., licensed practical nurse (LPN-B) replaced R41's tubing. During an interview on 6/11/25 at 11:26 a.m., LPN-B stated NAs were not trained to do anything but put the tube feeding pump on hold. The NA should be getting a licensed staff to stop, start or connect/disconnect a tube feeding. During an interview on 6/11/25 at 3:18 p.m., NA-N stated tube feeding pumps were strictly a nurse thing. NAs did not do anything with the pumps or connections to the resident. During an interview on 6/12/25 11:31 a.m., NA-M stated as an NA they did not disconnect/connect or touch the pump settings for tube feedings. Those were strictly nurse responsibilities. During an interview on an 6/12/25 at 11:52 a.m., registered nurse (RN-A) stated NAs should not be disconnecting or connecting a resident's tube feeding, nor should NAs stop or start the tube feeding pump. Only licensed staff should be doing those tasks. NAs are not trained to do anything with the pumps or tube feedings other than manage the position of the tube when providing cares so it does not get caught on anything. It is expected that a NA would get a licensed staff to carry out those activities. During an interview on 6/12/25 at 12:59 p.m., the director of nursing (DON) stated the facility did not train NAs to operate tube feeding pumps or to disconnect/connect tube feeding tubing. NAs are not to touch the tube feeding pump or connection to the resident. Only licenses staff may operate the pump and or connect/disconnect tube feeding tubing from the resident. The DON indicated they expected NAs to seek licenses staff for tube feeding pump management and tubing connection/disconnection. Tube feeding management and pump operating education was requested for NAs. The DON confirmed the facility did not provide/have record of this education. The facility policy Enteral Feeding Tube Usage dated 4/1/19, identified the purpose of the policy was to provide guidance to licensed staff and directed all licensed staff would be trained and observed for competency in enteral feeding tube care and services. The policy did not include NAs as approved for tube feeding tube management or pump operation.

Based on interview and document review, the facility failed to ensure residents were educated on and offered pneumococcal and influenza vaccinations upon admission for 1 of 5 residents (R38) admitted before 3/31/25 and failed to offer and educate on pneumococcal vaccinations for 1 of 5 residents (R59) who were reviewed for vaccinations. Findings include: R38's admission Record identified an admission date of 3/11/25, and diagnoses of and kidney failure, heart disease and urinary tract infection. R38's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. R59's admission Record identified an admission date of 4/25/25, and diagnoses of status post-kidney transplant, chronic kidney disease, and immunodeficiency. R59's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-F stated the facility did a vaccination reconciliation within 48 hours, it was part of the admit paperwork along with checking the Minnesota Immunization Information Connection (MIIC) for history. RN-F reviewed R38 and R59's record and confirmed there was no vaccine data. RN-F stated it was important to make sure you reconciled and offered vaccines so that they were covered as they were at increased risk. A policy, Resident Immunizations dated 1/21/25, identified its purpose was to provide direction to St. [NAME] Health Services of [NAME] (SFHS) employees regarding offering vaccinations. The Adult Immunization Schedule prepared by the Centers for Disease Control (CDC) to ensure residents are offered and encouraged to accept the appropriate vaccinations. The policy further indicated an immunization history would be taken upon admission including checking the MIIC system. Any immunizations that were not current or unknown vaccination histories would be shared with the attending physician and appropriate physician orders obtained. The resident's immunization history will be documented and maintained in the resident's electronic medical record (EMR).

Based on interview and document review, the facility failed to ensure residents were educated on and offered COVID-19 vaccinations upon admission for 2 of 5 residents (R38, R59) reviewed for vaccinations. Findings include: R38's admission Record identified an admission date of 3/11/25, and diagnoses of and kidney failure, heart disease and urinary tract infection. R38's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. R59's admission Record identified an admission date of 4/25/25, and diagnoses of status post-kidney transplant, chronic kidney disease, and immunodeficiency. R59's Immunization Audit Report dated 6/12/25, didn't identify any vaccination history. During an interview on 6/11/25 at 3:06 p.m., registered nurse (RN)-F stated the facility did a vaccination reconciliation within 48 hours, it was part of the admit paperwork along with checking the Minnesota Immunization Information Connection (MIIC) for history. RN-F reviewed R38 and R59's record and confirmed there was no vaccine data. RN-F stated it was important to make sure you reconciled and offered vaccines so that they were covered as they were at increased risk. A policy, Resident Immunizations dated 1/21/25, identified its purpose was to provide direction to St. [NAME] Health Services of [NAME] (SFHS) employees regarding offering vaccinations. The Adult Immunization Schedule prepared by the Centers for Disease Control (CDC) to ensure residents are offered and encouraged to accept the appropriate vaccinations. The policy further indicated an immunization history would be taken upon admission including checking the MIIC system. Any immunizations that were not current or unknown vaccination histories would be shared with the attending physician and appropriate physician orders obtained. The resident's immunization history will be documented and maintained in the resident's electronic medical record (EMR).

Based on observation and interview, the facility failed to ensure resident call lights were within reach from the bathroom floor in a resident bathroom for 1 of 2 residents (R17) and failed to ensure bathroom call light was in good repair for 1 of 2 residents (R27) reviewed for call light accessibility. Findings include: On 6/9/25 at 3:22 p.m., the bathroom call light for R17 was checked to see if it was in working order. The bathroom call light did not have a cord. On 6/10/25 at 1:30 p.m., the bathroom call light for R27 was checked to see if it was in working order and the cord was found to be frayed in the middle of the red cord, able to see white thread. On 6/11/25 at 1:55 p.m., maintenance (M)-A verified the call light in R27's bathroom was frayed and stated in needed to be replaced because it could break. M-A verified R17 had no call light cord in the bathroom. M-A verified it was a safety concern if a resident fell in the bathroom they would not be able to reach the button on the wall and call for help. During an interview on 6/11/25 at 3:47 p.m., the administrator stated every resident bathroom should have a call light with a cord for safety. The Call light policy dated 10/23/17, identified staff should remember to position the call light within resident's reach and to orient /re-educate the resident to the call lights in the room and in the bathroom. The policy did not address call light cords.

Based on interview and document review, the facility failed to ensure pain management was provided according to the residents' goals and preferences for 1 of 3 residents (R1) reviewed for pain management. This deficient practice caused actual harm for R1, who experienced unmanaged severe pain, disturbed sleep and needed two doses of his narcotic medication to receive pain control. The facility implemented immediate corrective action, prior to the survey and was issued at past non-compliance. Findings include: R1's Face Sheet dated 10/15/24, identified R1 had diagnoses of chronic pain syndrome. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, had pain, and used as needed pain medications. R1's care plan dated 10/24/24 indicated R1 was at risk for pain, and directed staff to administer medications as ordered. Non-pharmacological interventions were identified to apply cold or heat to area of R1's pain or offer to repositioning. R1's Provider Orders dated 10/15/24 indicated orders for hydrocodone-acetaminophen (narcotic pain medication) 10-325 milligrams (mg) one tablet to be given as needed every six hours for pain. R1's electronic Medication Administration Record (eMAR) dated 10/25/24 through 11/11/24,since admission, R1 received pain medication at least once daily, and all but one day he had a dose between 3:00 p.m. and 9:30 p.m. He only received two doses of hydrocodone- acetaminophen 10-325 mg at 9:59 a.m. and 11:12 p.m. on 11/3/24. R1's call light log for 11/3/24 indicated R1 put his call light on at 6:11 p.m., 7:10 p.m., 7:36 p.m., 8:30 p.m., 8:43 p.m., 10:16 p.m., and 11:08 p.m. On 11/12/24 at 9:21 a.m., R1 stated on the evening of 11/3/24, it took the nurse five hours to bring him his pain medications. He had left sided flank pain (from a previous kidney donation surgery), and put his call light on to ask for pain medication. Nursing assistant (NA)-A answered his call light, and told him she was going to let the nurse know he was requesting pain medication. The pain continued to get worse and worse, it felt like someone was ripping my left side open, it was off the charts and was at a 13/10 pain level (a pain scale from 0 to 10 describes pain intensity; 0 meaning no pain, 1-3 meaning mild pain, 4-6 meaning moderate pain, and 7-10 meaning severe pain). He couldn't sleep because of the pain, so he kept putting on the call light, and everyone kept saying they had told the nurse. He kept pushing the call light until a nurse came in during the night and gave him pain medications. It took him until the morning of 11/4/24 to get his pain managed, he did not sleep well that night. On 11/12/24 at 10:23 a.m., RN-A stated on 11/3/24 at around 11:00 p.m., R1 had his call light on and she had answered it. R1 told her he had been waiting for his pain medications for over five hours. He told her he had asked for a pain pill around 6:00 p.m. and still hadn't received any medication. R1 told her his pain was off the charts and terrible. He rated his pain a 13/10 and he was upset. She gave him his pain medication around 11:05 p.m. The next morning around 6:00 a.m. she went to check on him again, he was still having pain of 10/10, so she gave him another dose of pain medication. On 11/12/24 at 10:54 a.m., NA-A stated on the evening of 11/3/24 she took care of R1. She went into his room three different times that evening due to answer his call light. The first time he asked for pain medications, and she went and told licensed practical nurse (LPN)-A. LPN-A stated, Ok. The second time NA-A went into R1's room, he stated he had been waiting an hour and a half for his pain medication. She told him the nurse had been told, and should be coming in with his pain meds soon. The third time she answered his call light, R1 told her he was still waiting for his pain medication, and it had been over two hours. She told him again LPN-A should be coming soon. She only told LPN-A the first time R1 requested pain medication, and did not go and tell LPN-A the other two times she had answered the call light. On 11/12/24 at 11:21 a.m., LPN-B stated on the evening of 11/3/24 he had answered R1's call light twice. The first time he answered R1's call light was between 7:00 p.m. and 8:00 p.m. R1 told him he needed a pain pill, and had already requested pain medication, but still hadn't received it. R1 was upset that he was still waiting. He went and told LPN-A R1 was requesting pain medication, and she stated she had to look to see if R1 could have anything yet. On 11/12/24 at 12:34 p.m., the director of nursing (DON) stated staff should follow provider orders and the care plans when a resident need or requested anything. On 11/12/24 at 12:53 p.m., R1's medical provider stated if R1 was having high pain levels and his pain was not under control, even though the pain was not life threatening, he would have concerns with the affect the pain could have on R1's quality of life. On 11/12/24 at 1:43 p.m., LPN-A stated she couldn't remember if anyone told her R1 needed pain medications on 11/3/24. Someone could have told her R1 needed pain medications, but she might not have heard them because she was busy. Although two separate individuals communicated to LPN-A that R1 request pain medication, he did not received it until five hours later. He identified his pain continued to get and worse, it felt like someone was ripping his left side open, and his pain was off the charts rating it a 13/10 pain level scale. Also, R1 had to take two doses of his narcotic pain medication which he had not done historically to get his pain under control on 11/3 to 11/4/24. The facility policy Pain Management dated 11/6/24 directed the facility will provide care and services that will recognize and manage resident's pain to support his or her highest practicable level of well-being. The deficient practice was corrected on 11/6/24, after the facility implemented a plan that included the following actions: Facility investigation was coordinated with interviews of staff and residents on unit. Pain management policy was reviewed on 11/6/24. Staff was educated on the pain management policy and expectations if a resident was in pain on 11/6/24. Audits monitoring pain management practices started on 11/6/24. LPN-A was provided education for pain management, resident rights, and customer service. The corrective actions were verified through observation, interviews and document review.

Based on interview and document review, the facility failed to safely use a toileting sling per manufacture's recommendations to transfer 1 of 3 residents (R1) reviewed for accidents. This resulted in immediate jeopardy (IJ) when R1 fell from a mechanical lift, sustaining subarachnoid and subdural bleeds (brain bleeds) that required a hospital admission. The IJ began on 7/25/24 at 4:10 p.m., when R1 fell from a mechanical lift. The administrator and director of nursing (DON) were informed of the IJ on 7/31/24 at 4:27 p.m. The facility had implemented corrective action on 7/26/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: R1's Face Sheet, undated, indicated R1 had diagnoses of hemiplegia affecting right dominant side, abnormal involuntary movements, epilepsy, and malignant neoplasm of frontal lobe. R1's care plan reviewed 7/24/24, indicated R1 needed total assist of two staff with a mechanical lift for transfers using a medium toileting sling. On 7/25/24 at 7:30 p.m. a progress note indicated R1 was sent to the emergency room (ER) and a call was made there to follow up on her. resident. R1 had a subarachnoid bleed and a subdural bleed, and was being transported to a larger hospital. On 7/26/24 at 1:28 a.m., a progress note indicated on 7/25/24 at 4:10 a.m., R1 was found on the floor, lying on her right side between the legs of the lift, and her head was on the left leg of the lift and her arms were in the air. R1 had an approx. 5 centimeter (cm) lump on the back of her head, and was complaining of increased lower back pain and dizziness. Due to her injury, R1 was sent to the emergency department (ED). On 7/30/24 at 2:07 p.m., nursing assistant (NA)-C and another NA entered room [ROOM NUMBER] to assist a female resident with a mechanical lift transfer from bed to her wheelchair. A size small toileting sling was placed under the resident, which was the correct size, and the legs straps were crossed in between the resident's legs. The belt was clipped around the resident's chest, her arms were outside of the sling, and the straps were attached to the mechanical lift. The resident was transferred into her wheelchair with no signs of distress. On 7/30/24 at 2:39 p.m., NA-C stated on 7/25/24 around dinner time, nursing assistant (NA)-D asked her to come help transfer R1 to the bathroom. NA-D told R1 to put her arms inside the toileting sling. She knew that was wrong, but did not want to argue with NA-D, so she did not say anything. The buckle to the sling was not buckled around R1's waist either. NA-D pressed the button to lift the machine, NA-C moved the wheelchair, and R1 fell out of the sling backwards hitting her head on the left leg of the mechanical lift and then on the floor. She then went and got the nurse, and R1 was sent to the hospital. Prior to this incident, she had never been trained on these types of mechanical lifts and sling placements, and she only watched others when she was being trained. NA-C stated she is now aware after training that the resident needs to be buckled into the sling and if the residents arms are inside of the sling to say something and make sure they are moved to the outside. On 7/30/24 at 3:17 p.m., NA-D stated when she was getting ready to toilet R1, the sling buckle that should have gone around R1's waist was not buckled, and R1's arms were inside the toileting sling. She pushed the button to lift the R1, and R1 fell out the back of the sling and hit her head on the ground. She had not had training on how to use the mechanical lifts or sling placement prior to the incident. NA-D stated she is now aware after training that R1 should have had her arms outside of the sling and that she should have been buckled into the sling. On 7/31/24 at 10:18 a.m., the mechanical lift company representative (CR)-A stated if a resident was not buckled into the toileting sling, or if their arms were not on the outside of the toileting sling, they would be at an increased risk of falling out of the sling. On 7/31/24 at 11:58 a.m., the facility medical director stated the toileting sling being put on R1 incorrectly was the cause of her injuries. On 7/31/24 at 12:26 p.m., the director of nursing (DON) stated staff were expected to ensure the resident was buckled into the toileting sling, and their arms were placed outside of the sling. She stated all staff have been re-educated on the use of the mechanical lifts and the slings. On 7/31/24 at 12:39 p.m., the administrator stated the staff were expected to use the toileting sling per the manufacturing instructions. SMT Health Systems Volaro Toileting Sling user guide dated 5/11/16 directed to use the sling on residents with some upper-body strength, and make sure the persons arms are on the outside of the sling. The past noncompliance immediate jeopardy began on 7/25/24. The immediate jeopardy was removed, and the deficient practice was corrected by 7/26/24, after the facility implemented a systemic plan that included the following actions: Reviewed their policies on use of mechanical lifts, including the proper placement and size of the slings. The facility has re-assessed all residents who utilize a mechanical lift to ensure they have the proper size sling. The facility has re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing. The facility completed audits three times weekly observing staff transferring residents with mechanical lifts results will then be brought to QAPI committee. Verification of corrective action was confirmed by observation, interview, and document review on 7/30/24 and 7/31/24.

Based on observation, interview and document review, the facility failed to ensure unauthorized staff, visitors, and residents did not have access to medication storage area. This practice had the potential to affect all residents on the 400 hallway. Findings include During observation on 7/16/24 at 7:18 a.m., the 400 hallway medication storage area doorway was completely open with no staff around the medication storage area or the nurses desk next to the medication storage area. During observation on 7/16/24 at 8:33 a.m. the 400 hallway medication storage area doorway was open and nursing staff were not around the medication storage area. The nurse manager was in her office, next to the medication storage area but had her back facing her door and the medication storage area. During an interview on 7/16/24 at 8:37 a.m., registered nurse (RN)-C confirmed the medication storage room was open and no staff were around except her, with her back facing the medication storage room. RN-C stated it was the responsibility of the nurse working the cart to make sure the medication storage room is secured when they are not around the room. During an interview on 7/16/24 at 11:16 a.m., licensed practical nurse (LPN)-B confirmed she had left the door open and walked away to administer medications when the doors were observed open. LPN-B stated it was the cart nurses responsibility to secure the door when not in the room, but did feel the nurse manager in there office was secure enough to allow the door to be left open. During an interview on 7/17/2024 at 1:18 p.m. the assistant director of nursing (ADON) stated an expectation all medication storage area doors would remain shut and secured when the cart nurse was not in the rooms so no other staff, residents, or visitors could access anything stored in the room. Facility policy Medication Storage, last reviewed 4/11/23, indicated the medicaion room was to be locked and door closed at all times when the licensed nures was not present.

Based on interview and document review, the facility failed to comprehensively assess, monitor and respond to signs of stroke like symptoms for 1 of 3 residents (R1) reviewed for change of condition. The facility's failures caused an excessive delay of medical diagnoses, management, and treatment of R1's condition which resulted in actual harm to R1. Findings include R1's Face Sheet identified R1 had diagnosis of Parkinson's disease R1's quarterly Minimum Data Set (MDS) dated [DATE] identified R1 had moderate cognitive impairment. Required assist of one for bed mobility, dressing, toilet use, and assist of two for transferring. R1's care plan dated 1/30/22, identified R1 required assist to safely transfer from one surface to another and staff were to monitor for changes in abilities. R1's medication administration record (MAR) dated 9/8/23 identified R1's medications were administered at 5:31 a.m. and 9:03 a.m. and a tylenol dose at 10:00:37 a.m. Email communication on 9/8/23 at 9:45 a.m., from family member (FM)-A to assistant director of nursing (ADON), activities director (AD)-A and registered nurse (RN)-A stated I'm wondering who got him up this morning. And how he was doing. I got here past 9:30 a.m No hearing aids in. No dentures in. He claims he slept well. But other than that conversing is a little difficult. He seems quite out of it. R1's progress note dated 9/8/23 at 11:23 a.m., included R1 weak, not eating, drooling, eyes glassed over, and left side of mouth drooping. No responding to questions. Resident appears to have possible stroke. Called MD and gave verbal orders to send to emergency room (ER). Family present signed bed hold. Ambulance called resident transported to Hibbing Fairview Range Medical Center. [FM-A] is going to ER. During an interview on 9/21/23 at 3:15p.m., licensed practical nurse (LPN)-A stated she worked the night shift on 9/7/23 into 9/8/23. LPN-A reported providing medication to R1 at around 5:00 a.m. R1 was able to swallow, sit on the edge of the bed, and followed commands. R1 was not talkative but that was not abnormal for him. During an interview on 9/21/23 at 3:07 p.m., nursing assistant (NA)-A stated she had cared for R1 for over a year. The morning of 9/8/23, she had noticed R1 had a big change, something was wrong and he was way off. NA-A recalled being in R1's room between 5:30-5:45 a.m. on 9/8/23 to provide morning cares. R1 was not speaking clearly, would not stand, and was not following instructions. NA-A was concerned about balance, so the mechanical lift was used to get R1 out of bed. During the transfer R1 could not figure out how to use his legs, he wasn't following directions to keep his feet flat on the lift's foot support, and was not holding onto the lift. NA-A stated she had to use excessive strength to transfer R1 safely. Once R1 was seated in his wheelchair, NA-A noticed R1 was drooling throughout cares and he was not participating like normal. She completed his cares around 6:15 a.m. There was not a nurse on R1's unit so NA-A did not report R1's changes and waited until the day shift NA's started at 6:30 a.m. NA-A stated she told NA-B and NA-C something was wrong, R1's legs were not working, was not sure what was going on, and they should use two assist to transfer. NA-A stated she did not notify LPN-A (night shift nurse), but thought LPN-A may have heard her giving report to NA-B and NA-C. NA-A stated she did not believe the NA's took her seriously and she should have immediately reported the changes to the nurse. During interview on 9/21/23 at 2:38 p.m., NA-B recalled receiving report from NA-A and was instructed to look out for him and monitor him because he wasn't doing too well NA-B also indicated in report from NA-A there was a near fall while getting R1 up and NA-A had expressed transfer concerns. NA-B explained after getting report she did not go in and check on R1 until around 9:40 a.m. when FM-A asked her about R1's condition and asked her why staff were not checking on him. NA-B was not sure if other NA's provided any cares or contact with R1. NA-B indicated if there was a change in a resident it should be reported to a nurse right away if possible. However, sometimes she would make a note to herself then report to other NA's at the end of her shift. NA-A indicated she was supposed to check on residents every two hours, however that morning she unable to check on R1 because she was busy getting other residents up for the day. During interview on 9/25/23 at 10:08 a.m., RN-B indicated staff are to report to a nurse right away on any change of condition including weakness on one side and difficulty speaking. NA's were to tell nurses immediately if there were any concerns or changes. NAs should always communicate with the nurse prior to the end of their shift and should not only report to other nursing assistants. RN-B stated NAs were supposed to fill out the Early warning tool that identified the changes and given to a nurse, nurse manager, or the DON to complete an assessment. RN-B reviewed submitted tools, she stated there was not a tool completed for R1. During an interview on 9/21/23 at 3:15p.m., LPN-A indicated that it was mandatory to get report from NAs at end of the shift. She recalled NA-A reporting R1 was not standing well, but nothing more specific. LPN-A stated after she heard report, she did not ask NA-A further questions, check on R1, or complete a comprehensive assessment. She did not think much of R1's change in ability to stand was concerning because his general health was declining. LPN-A stated her shift ended at 7:00 a.m. Review of R1's record from 9/8/23, identified after NA-A had identified and reported R1's condition at shift change, there were no recorded vital signs and no assessments or monitoring of R1's condition to determine his need for emergency medical treatment. Additionally not evident the physician was notified of the change in condition. During interview on 9/21/23 at 1:23 p.m., NA-C stated on 9/8/23, her shift started at 6:30 a.m. NA-C reported she was familiar with R1; he was an assist of one with a transfer belt, could brush his own teeth, shave himself, he was able to talk and make needs known, and he knew how to use the call light. It would be abnormal if he could not participate in or complete those tasks. NA-C recalled receiving report that day for R1, but did not provide cares or engage with R1. NA-C indicated FM-A asked her how R1 was doing, but told FM-A she was not the person who got R1 up for the day and did not know how he was. NA-C explained the first time she saw R1 was around 10:00 a.m. to get his brunch order and he was not able to understand, he was drooling, and was not normal. NA-C recalled R1's gaze being off and R1 was unable to look at her despite R1 being directly in front of her. NA-C stated there was not a nurse scheduled on R1's unit that morning, she could not get a hold of LPN-B on the phone so she walked around and found her just after 10:30 a.m. During interview on 9/21/23 at 4:39 p.m. LPN-B stated on 9/8/23, her shift started at 6:30 a.m. and was responsible for R1. LPN-B indicated she had not received any reports of concerns during shift report or from any day shift NAs about R1. LPN-B explained her first interaction was around 9:00 a.m., but did not recall anything specific about the interaction. LPN-B stated around 10:00 a.m. FM-A was with her voicing concerns about R1's condition; LPN-B attempted to administer pain medication however R1 was not swallowing and not himself. He was also not focusing and drooling. LPN-B indicated she did not complete an assessment, obtain vital signs, or notify the physician, but instead completed a couple of more tasks. She then went back to the dining room and offered FM-A to send R1 to the hospital (LPN-B could not remember the time). FM-A wanted R1 sent to the hospital so LPN-B notified the physician who gave an order to send R1 to the hospital. ADON was the one that called the paramedics. LPN-B stated she felt the most important thing to do was to get R1 to the hospital, so she did not complete a neurological assessment or vital signs at any time. During interview on 9/21/23 at 12:45 p.m., FM-A stated on 9/8/23 she arrived at facility at 9:30 a.m. to visit R1. Upon arrival she immediately noticed something was wrong with R1; he was drooling, favoring his left side, and difficulty with swallowing. FM-A reported an NA (name not known) had told her R1 was up earlier than normal and required the use of a mechanical lift. FM-A found LPN-B at 10:00 a.m. and told her she was concerned he was favoring his left side and drooling. LPN-B attempted to give him tylenol and was not able to swallow. LPN-B responded to the situation by telling FM-A let me know if he gets any worse. FM-A explained around 10:15 a.m. she was pushing R1 out of the dining room when LPN-B asked her Do you want me to call the paramedics? and FM-A responded Yes please!. FM-A expressed concerns with her own observations of staff's lack of identification, monitoring, taking vital signs and lack of urgency. FM-A was not informed of any condition changes prior to arriving at the facility. Review of R1's record from 9/8/23, identified after LPN-B was made aware of R1's changes, there were no recorded vital signs, no assessments or monitoring of R1's condition in order to determine need for emergency medical management. During interview on 9/22/23 at 8:39 a.m., ADON recalled witnessing LPN-B running down the hallway on 9/8/23 around brunch time. LPN-B reported to her, R1 was drooling, not eating, and not really responsive. She had not heard anything about R1's condition change prior. ADON went to R1 and FM-A, upon arrival she attempted to talk to R1, however wasn't responsive, eyes were glazed over and drooling. ADON informed FM-A plan to send R1 to hospital. ADON called 9-1-1 around 10:30 a.m.-10:45ish. ADON stated she did not do a neurological assessment or obtain vital signs. ADON explained NA's were supposed to notify a nurse, a nurse on the cart or DON if any concerns arise with change of condition. ADON indicated it was not appropriate for staff to be on shift for three hours and not have contact with residents they are responsible for. ADON reported an internal investigation was not completed. Review of R1's record from 9/8/23, identified after ADON had been notified of R1's change in condition R1's record continued to reflect no recorded vital signs and no assessments or monitoring of R1's condition to determine the need for emergency medical treatment. Hibbing fire department pre-hospital care report identified on 9/8/23, the facility's call was received at 11:03 a.m. with response action of emergent (immediate response). Paramedics arrived on scene and R1 was seated in wheelchair in common area. R1 was sitting slumped leaning to the left side, neglecting right side, alert to painful stimuli with incomprehensible speech, and not able to follow commands. Staff stated to paramedics R1's normal mental status was alert and oriented with clear speech. The report identified staff reported R1 appeared sleepier than normal upon waking up at 8:00 a.m., however showed altered mental status, slurred speech, and weakness that started at approximately 9:30 a.m. R1 was positive for BEFAST stroke assessment. (assessment for sudden loss of balance, eyes, face, uneven smile, arm weakness, speech). The report identified the ambulance left the facility at 11:21 a.m. Emergency Department Hospital records dated 9/8/23 identified the ambulance arrived at the hospital at 11:33 a.m. The provider attempted to call the care facility about 15 times to ensure R1 was not on blood thinning medication but was only transferred to voicemail despite using the emergency line. Notes indicated it was unknown the last time R1 was at base line due to not being able to get a hold of facility and the time of discovery or onset of symptoms is 8:00 a.m., however questionable. R1 presented with face/arm/leg weakness, speech difficulty, not following commands. All deficits were still present in ED upon provider exam. Stroke code was activated at 11:28 a.m., stroke provider first response 11:30 a.m., unknown last normal, questionable time of discovery, head CT was read by doctor at 11:43 a.m., and stroke code was not deescalated due to a bleed. Imaging findings of 2.6 cm left thalamic intraparenchymal hemorrhage (a brain bleed). During interview on 9/22/23 at 10:06 a.m., medical doctor (MD)-A indicated the facility notified her of the condition change on 9/8/23, however could not recall the time. She was not aware of the concerns that was noticed and reported by NA-A early that morning, nor facility nursing had not completed any type of assessment or monitored R1. MD-A stated she expected to be called immediately for any concern with change of condition especially if there were signs and symptoms of a stroke including change in mental status, speech, neuromuscular response, change in transfer status, and change with normal functional ability. MD-A would expect neurological assessments to be initiated right away, blood pressure to be completed and monitored. If assessments were not completed stroke signs and symptoms could progress without awareness. MD stated R1's current condition was poor and considering comfort measures versus placing a feeding tube. There had not been improvement in the last several days. MD-A indicated R1's type of stroke was hemorrhagic, therefore even with earlier identification likely would not have changed the outcome. However, it was important to act fast regardless because facility staff would not be able to identify the type of stroke without further imaging scans and testing. During interview on 9/25/23 at 11:06 a.m. ADON indicated staff should find a nurse and speak directly with them with any change of condition. The receiving nurse should do an assessment and complete vitals to monitor for any changes outside of the residents baseline. Depending on the assessment the resident should be sent in to the hospital or closely monitored. ADON indicated early warning tool was a tool nursing assistants to communicate resident status changes, however not aware if it was fully implemented. ADON was not aware if one was completed for R1. Early warning tool stop and watch . If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Seems different then usual Talks or communicates less then usual Overall needs more help than usual Participated in activities less than usual Ate less than usual (not because of dislike of food) N Drank less than usual Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring toileting more then usual A policy and procedure for quality care was requested and not received.

Based on observation, interview and document review, the facility failed to monitor fluid intake and daily weights for 1 of 3 resident (R10) reviewed for hydration. R10 sustained harm when admitted to the hospital for exacerbation of congestive heart failure and increased edema caused by facilities lack of monitoring residents physician ordered fluid restriction. In addition, the facility failed to have a process for monitoring bowel status for 2 of 5 residents (R6, R19) and provide medical monitoring per physician orders for 1 of 5 residents (R4) reviewed for quality of care. Findings include: Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R10 had no shortness of breath laying flat, sitting up at rest or with minimal exertion, acute on chronic systolic heart failure (a disease where the heart muscle weakens causing fluid to back up into the lungs suddenly and quickly from the left side of the heart), Cor Pulmonale -chronic ( process where fluid builds up on the right side of the heart and weakens heart muscle to make fluid back up into the rest of the body outside the lungs) and pulmonary hypertension ( increased high blood pressure that directly effects the arteries going to the lungs). R10's Care Assessment Area summary (CAA) of resident care that needed special attention indicated R10 had a dehydration/fluid maintenance concern. R10's care plan, indicated R10 had a fluid restriction of 1500 ml per 24 hrs started on 8/26/23. Monitor daily weights and update provider if 2 lb weight gain in 24 hrs or 5 lbs in one week started on 2/16/23. The care plan lacked documentation of the 750 ml fluid restriction or I&O's ordered 6/4/23. R10's Physician Order Summary, indicated: -on 8/26/22, a 1500 milliliter (ml) fluid restriction was ordered, -on 5/9/23, Spironolactone (used to treat high blood pressure and heart failure)25 milligrams (mg) daily was started for edema -on 5/22/23 Torsemide (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease)60 mg by mouth one time a day was started for acute on chronic systolic heart failure. R10's progress notes reviewed from 3/11/23 to 6/21/23, included: -3/11/23 03:05 a.m., slept well. Oxygen saturation 96% on 1 litter per minute (LPM) via nasal cannula (NC). -4/28/23 1:20 p.m., pt with feeling of filling up with fluid in his abdomen. 4+ pitting edema in both legs and lungs have crackles in the left side. Oxygen up to 1.5 LPM via NC. Provider notified by fax. No notes of response from provider. -4/29/23 1:48 p.m, Edema to lower extremities. -5/1/23 2:11 p.m., orders from provider received-Torsemide 40mg daily for 3 days and return to 20mg after. Clarification sent due to R10 already on 40mg Torsemide. -5/2/23 3:51 a.m., oxygen up to 2 LPM via NC and saturation is 93%, 4+ pitting edema to bilateral lower extremities (BLE), 2+ to left upper extremity will monitor. -5/3/23 8:55 p.m., Resident continues to have increased edema in arms, stomach and lower extremities. Short of breath at rest, Sa02 79% turned oxygen up to 2.5 Lpm via NC. Complaining of being more tired, some lightheadedness. Encouraged resident to use urinal and increase fluids while on increased diuretic. -5/9/23, orders from provider-reminder 1500 ml fluid restriction, Torsemide 60 mg daily. -5/10/23 to 5/21/23, notes indicated no improvements in condition -5/22/23 9:20am,- Resident stated that he did not feel the oral diuretics were working. Edema is present 4+ pitting in ABD, LE and UE. Resident requested to go to ER. 911 was called and hospital was given nurse to nurse. Emergency services arrived and report was given. Resident left via ambulance at approx. 9:20am. -6/4/23-returned from hospitalization due to exacerbation of congestive heart failure. -6/21/23 11:24 p.m., edema present in all extremities. R10's facility readmission orders from the hospital dated 6/4/23 indicated R10 was admitted with the following orders: -Fluid restriction on 750 ml every 24 hours. -Daily weights and to call provider for weight gain of more than 2 pounds per day or 5 pounds per week. -I&O (intake % output) -Spironolactone 25 mg by mouth daily -Torsemide 60 mg by mouth daily R10's ADL Flowsheet from 8/26/22 to time of survey were reviewed, indicated two entries for fluid monitoring: On 3/6/23 R10 took in 640 ml of fluid On 5/9/23 R10 took in 540 ml of fluid R10's weights indicated: 5/8/23 weight 177.4 lbs 5/22/23 weight 180.8 lbs 6/6/23 weight 174.4 lbs 6/7/23 weight 173.4 lbs 6/20/23 weight 165 lbs 6/24/23 weight 154.8 lbs 7/17/23 weight 154.8 lbs 7/22/23 weight 151.6 lbs 7/31/23 weight 151.0 lbs 8/1/23 weight 157.8 lbs The weight flowsheet did not include daily weights. On 7/31/23 at 3:25 p.m., R10 was observed to have a 1000 ml (milliliter) large gray pitcher full of water at his bedside. On 8/1/23 at 11:36 a.m., nurse assistant (NA)-A was observed filling the same gray pitcher with fresh ice water and two 247 ml of soda poured over ice and taken to R10's room. During an interview on 8/1/23 at 11:36 a.m., R10 stated he tried to keep track of his fluid intake but since he was not on a fluid restriction he could drink as much as he wanted. R10 stated the staff would fill up the gray mug usually 3 times a day. During an interview on 8/1/23 at 11:49 a.m., NA-A stated there were no residents on the 300 hallway that were on fluid restrictions. Staff would get R10 whatever he asked for to drink throughout the day since he was not on a fluid restriction. NA-A stated R10 did have several episodes of edema in his arms, legs and abdomen. R10 also complained a lot about shortness of breath or fell ing really tired. NA-A stated if a resident was on fluid restrictions the intake would be documented under intake in the care stream (where NA review care for residents). During an interview on 8/1/23 at 12:26 p.m., licensed practical nurse (LPN)-A stated no residents on 300 hallway were on fluid restrictions. If a resident was on fluid restriction nursing would document intake with medications and the NA's would document all of intake and all would show up under the intake tab in care stream. During an interview on 8/1/23 at 2:22 p.m., NA-B stated if a resident was on fluid restriction, it would be in the care plan. The fluid restriction would also be listed on the kitchen wall with the special diets. NA-B reviewed the kitchen list and acknowledged no residents on 300 hall were on a fluid restriction. During an interview on 8/1/23 at 2:31 p.m., registered nurse (RN)-A stated the cart nurse and the aides would keep track of the fluid restrictions and make sure they are documented. Staff will talk about fluid restrictions in IDT (interdisciplinary team) when residents were on a fluid restriction. The dietary manager would often discuss fluid restrictions. RN-A stated she was aware R10 was on a fluid restriction, but it was a 1500 ml fluid restriction. She reviewed R10's medical record and could not find documentation of the fluid restriction under intake. RN-A was unaware why there was no fluid intake documentation on record but acknowledged there should have been. RN-A acknowledged R10 was hospitalized on [DATE], because of increased edema and shortness of breath due to increased fluid intake. RN-A indicated the reason to monitor fluid intake when a resident was on fluid restrictions was to keep an accurate fluid count to prevent fluid overload. During an interview on 8/2/23 at 8:07 a.m., the registered dietician (RD) stated she would look at weights at least weekly to see if there were any changes. R10 had a lot of weight fluctuation because of all of the water pills and edema in his body. The RD was not aware R10 was on a fluid restriction and stated she never had looked at R10's fluid intake to see if that was why R10 would gain a lot of weight and then would need changes in his water pills to get the weight back down. When the RD reviewed R10's weight there was not much concern because of the medication and edema. During an interview on 8/2/23 at 11:21 a.m., the medical director stated that a resident with left sided heart failure and the cor pulonale, which effected the right side of the heart, would put them at great risk of fluid overload and pulmonary edema-increased fluid and edema in the lung lining, and would increase the risk of hospitalization and possible death. As the medical director, he would be concerned if there was a resident with those conditions and the facility was not following the orders and putting the resident at extra risk. During an interview on 8/2/23 at 12:40 p.m. The primary care provider (PCP) stated R10 had a bad valve in his heart and was treated medically due to R10 was not a candidate for surgery. R10 was very fragile in relationship to the fluid intake and that was why R10 was on a strict fluid intake. Staff were expected to monitor the fluid intake closely to attempt to prevent further hospitalization s and to notify PCP right away for any changes to adjust medications as needed to keep R10 at his baseline. R10's PCP stated he was concerned the monitoring was not followed for the fluid restriction and R10 was more than likely hospitalized on [DATE] partly because of it. During an interview on 8/1/23 at 3:05 p.m. , the director of nursing (DON) stated the staff should have been following the orders as they were written at the time and documenting the intake correctly each shift. The I&O should have been monitored closely to keep R10 at his baseline as long as they could have. Facility policy Weight Monitoring Program dated 1/18/21, indicated care centers would monitor weights of individuals receiving services (IRS) as ordered to prevent unintended weight loss and medically significant weight gain. Facility policy Intake and Output dated 12/5/11, indicated NA's recorded intake and output under monitoring for their shift and each nurse would be responsible for making sure the I&O is recorded. Residents on a fluid restriction would have only intake measured for each 8 hour shift. The policy for fluid restriction was requested but no received. 42587 R6 R6's Face Sheet, indicated R6 had diagnoses of diabetes mellitus, malignant neoplasm of right renal pelvis and bladder, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), muscle weakness, depression, opioid dependence, morbid obesity, constipation, anxiety, and depression. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R6 was severely cognitively impaired, required extensive assistance with activities of daily living and was always continent of bowel and bladder and had no rejections of care. R6's care plan modified on 6/15/23, indicated R6 was continent of both bowel and bladder with a goal of remaining so. Interventions included staff assistance with changing brief and peri-care after each incontinent episode. Staff were directed to remind and assist with toileting upon rising and every two to three hours during the day and at bedtime. Constipation was not addressed on R6's care plan. R6's current provider orders indicated R6 had orders for oxycodone-acetaminophen (a narcotic used to treat moderate to moderately severe pain, with a side effect of constipation). In addition, okay for standing house orders. Facility House Standing Orders dated 6/5/23, directed staff to do the following: -use dietary interventions if a resident had not had a bowel movement (BM) in the last 24 hours -milk of magnesia (or equivalent) 30 milliliters (ml) orally every day as needed for constipation -Dulcolax suppository (or equivalent) one rectally daily as needed for constipation -fleets enema (or equivalent) one rectally daily as needed for constipation. If no results within two hours after the enema, notify the provider -miralax -if as needed bowel meds are used more than twice in one week, asses for routine bowel regimen need -senna two tablets orally daily at bedtime as needed for three days R6's bowel movements from 5/02/23-8/2/23, R6 had seven documented bowel movements: During an interview on 7/31/23 at 5:21 p.m., R6 expressed concerns about constipation, stating he was not sure if he was having regular bowel movements. R19 R19's Face Sheet, indicated R19 had diagnoses which included pulmonary blastomycosis (a pulmonary disease caused by inhaling spores of the dimorphic fungus blastomyces dermatitidis), viral hepatitis C (a virus that attacks the liver and leads to inflammation), spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly), depression, and benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). R19's admission MDS assessment dated [DATE], indicated R19 was cognitively intact, had no rejections of care, and required extensive to total assistance with activities of daily living. In addition, R19's MDS indicated he was incontinent of bowel. R19's care plan activated 6/20/23, indicated R19 was always incontinent of bowel. Interventions included check and change every two hours, monitor bowel movements, and provide peri-care after each incontinent episode. R19's current provider orders indicated using the house standing orders. During record review of documented bowel movements from 6/20/23-8/2/23, R19 had 8 documented bowel movements: During an interview on 7/31/23 at 3:29 p.m., R19 expressed concerns he was having diarrhea, thought maybe it was from a recent antibiotic. During an interview on 8/2/23 at 2:26 p.m., registered nurse (RN)-A stated the nursing assistants charted BMs. RN-A stated there was a report to run to see if residents were having BMs every three days, she was unsure if anyone was running the report on a daily basis. During an interview on 8/2/23 at 2:52 p.m., the director of nursing (DON) stated she was unsure how staff were tracking resident BMs. The DON verified there could be serious consequences if residents were not having BMs. The DON stated they could end up in the emergency room with a need for harsh medications, or with a bowel obstruction. During an interview on 8/3/23 at 12:51 p.m., licensed practical nurse (LPN)-C stated the night nurse would run an audit and every morning they would check the sheet. LPN-C stated he did not see a sheet and nothing was noted on the 24 hour communication board, so guessing it's good. During an interview on 8/3/23 at 12:58 p.m. RN-A stated she was unsure if nights were running a BM report and was not able to provide any 24 hour reports to see if anything about BMs was ever documented and if there was a need to implement the house standing orders. During an interview on 8/3/23, at 3:20 p.m., the director of nursing verified the documentation for R6 and R19 was not tracking if residents were having BMs every three days. The facility policy Bowel Elimination Protocol dated 5/21/21, indicated staff would monitor bowel elimination patterns to ensure regular elimination and early detection of potential bowel complications related to inability to evacuate the bowel. Staff were directed to monitor and record BMs daily. Nursing staff would identify those residents at risk for increased risk for bowel complication and follow up per the procedure daily. The policy directed staff to the house standing orders for bowel protocol. 48109 R4 R4's admission Minimum Data Set (MDS) assessment, dated 5/24/23, indicated intact cognition and diagnoses of acute on chronic congestive heart failure (CHF), and chronic kidney disease (CKD) stage 3. R4's care plan indicated to offer fluid and snacks between meals . R4's provider orders, current 8/2/23, included a low-fat, low-cholesterol 2-gram sodium diet and torsemide (a medication that helps the body rid itself of extra fluid) 100 mg daily. R4's progress notes for 7/24/23 indicated R4 returned from a cardiology appointment with orders to change diet to heart healthy and 2000 mL fluid restriction. A form titled Clinic Appointment Order, dated 7/24/23, and filed in R4's paper medical record, indicated to start a low salt cardiac diet, salt 2.5 grams and liquids less than 2000 mL. During an observation and interview on 8/2/23 at 9:38 a.m., R4 was up at bedside table eating breakfast. R4 denied being on any kind of fluid restriction. Had a water pitcher that was about 2/3 full, 237 mL milk carton, and about 200 mL orange juice. At 10:39 a.m., the water, juice and milk cups were empty. During an interview on 8/2/23 at 12:24 p.m., nursing assistant (NA)-F stated she did not know of any residents with dietary restrictions on this unit. NA-F explained the place to check for restrictions was the care plan book. During an interview on 8/2/23 at 12:35 p.m., registered nurse (RN)-C stated there weren't any dietary restrictions on this unit beside diabetic diets. At 12:51 p.m., RN-C produced a provider order, written on paper from R4's paper medical chart indicating new orders for dietary and fluid restrictions from 7/24/23. RN-C explained the order had been missed and not fully processed. During an interview on 8/03/23 at 2:13 p.m., the director of nursing (DON) stated her expectation was that orders would be completed and acted on by nurses when they receive new orders.

Based on interview and document review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (R1) reviewed who suffered verbal abuse from nursing assistant (NA)-B. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had already implemented corrective action prior to the investigation so the deficiency is issued as past noncompliance. The IJ began on 7/18/19, when NA-B was observed by other staff verbally abusing R1, but the allegation of abuse was not immediately reported to administration. NA-B continued to work with residents until [DATE], when the incident was finally reported and NA-B was suspended. The administrator and director of nursing (DON) were informed of the IJ on 9/25/19, at 1:17 p.m. The facility had fully implemented corrective action to prevent recurrence by 8/2/19. Findings Include: R1's Admission Record printed 9/25/19, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment. R1's current care plan, directed staff to assist with all activities of daily living (ADLs) including toileting and personal cares. On [DATE], a facility incident report indicated NA-A reported to the director of nursing (DON) that an incident had occurred on 7/18/19, involving verbal abuse towards R1. According to the report, during morning cares on 7/18/19, NA-A had observed NA-B yell and swear at R1 while providing toileting assistance. NA-A also reported R1 confided to her that while NA-B had been mean to her, she did not want NA-A to report NA-B. The facility's working schedule indicated NA-B continued to work with resident's on the unit where R1 resided 7/18/19, 7/19/19, 7/20/19, 7/21/19, and 7/22/19. Facility records indicated on [DATE], NA-B was immediately suspended once the allegation of abuse was reported. Review of the facility's investigation completed [DATE], indicated R1 had no recollection of the incident occurring, and was not fearful of NA-B at the time of the interview. During the survey, multiple attempts were made to complete phone interviews with NA-A and NA-B, without response. On 9/24/19, at 2:13 p.m. an interview was conducted with NA-C. NA-C stated she had witnessed NA-B being mean to residents. NA-C stated NA-B would use a horrible tone to her voice, and make statements to residents such as they did not need certain cares to be provided for them. NA-C stated she had witnessed NA-B being verbally abusive to residents by calling them names and swearing at them. NA-C stated she had reported this to management on at least three or four different occasions. On 9/24/19, at 2:32 p.m. an interview was conducted with R6. R6 stated there had been an incident a while back when NA-B refused to provide privacy for her while she was receiving a shower in the facility's shower suite. R6 stated NA-B had made her feel helpless, and she did not want NA-B to come near her. NA-B stated she had reported this however, NA-B had continued to work at the facility. R6 stated NA-B did not work on her unit after the incident however, she felt NA-B was harassing her by walking past her room intentionally, and giving her dirty looks. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. A facility concern report form dated 7/12/19, indicated NA-C had reported to the facility social worker (SW) that R6 felt unsafe during a shower being given to her on 7/12/19. The report further indicated NA-B had refused to leave the shower room, and had spoken rudely when asked by R6 to allow for her privacy. The report also indicated R6 had told the SW she did not want NA-B to provide cares for her again. On 9/24/19, at 2:43 p.m. an interview was conducted with R4. R4 stated, One morning (NA-B) refused to take me to the bathroom. (NA-B) also refused to change my linens that were soaked with urine. This made me feel ignored, and I felt (NA-B) would not take care of me. R4 also stated NA-B had refused to take her breakfast order in the dining room that same morning. R4 stated she did not like NA-B providing care for her, and was glad NA-B no longer worked at the facility. R4's quarterly MDS dated [DATE], indicated R4 had was cognitively intact. A facility concern report form dated 7/18/19, indicated NA-B had refused to provide cares for R4. The report indicated an allegation was made that NA-B had refused to toilet R4, refused to change R4's linens, and refused to take R4's breakfast order. The report further indicated corrective action was taken against NA-B [DATE], related to a different incident. On 9/25/19, at 8:25 a.m. an interview was conducted with R7. R7 he stated he had observed NA-B being loud and rude while providing care for residents. However, R7 stated NA-B had not provided cares for him. R7's quarterly MDS assessment dated [DATE], indicated R7 was cognitively intact On 9/25/19, at 11:27 a.m. an interview was conducted with NA-D. NA-D stated she had knowledge of NA-B being rude while providing cares. NA-D stated when this had happened, she had reported it to management immediately. NA-D stated NA-B had personally told her about an incident involving R5, who had since passed away. NA-D stated NA-B told her she had become frustrated while assisting R5 with eating a donut, and had pulled the donut out of her mouth and thrown it against the wall. NA-D stated NA-B had also been swearing in another resident room while telling her about the incident involving R5. NA-D stated there had been numerous reports to management about NA-B's behavior. A review of R5's closed record, included a quarterly MDS dated [DATE], which indicated R5 had severe cognitive impairment. Review of NA-B's employee file indicated on 2/19/19, a report had been filed regarding an allegation of abuse towards R5. NA-B had been given a 3 day suspension at that time. The report indicated NA-B had been re-educated to the facility's vulnerable adult guidelines, professionalism, and delegation of tasks. In addition, weekly meetings had been established and held with the DON until 3/21/19. On 9/25/19, at 12:11 p.m. an interview was conducted with employee (E)-A. E-A stated he had concerns with NA-B and the care she provided to the residents. E-A stated NA-B lost her patience for even the smallest of reasons. E-A stated he had personally witnessed NA-B ignore a resident's request for cares. E-A stated staff were afraid of retaliation if they reported NA-B. E-A further stated he had shared his concerns about the care NA-B was providing with the DON and SW (social worker) on at least three different occasions in the past 12 months. E-A stated he had been concerned for the welfare of the residents while NA-B was employed at the facility. On 9/25/19, at 4:21 p.m. an interview was conducted with the DON and administrator. The DON verified the incident which occurred on 7/18/19, was not reported until [DATE]. The DON stated once reported, NA-B was immediately suspended, removed from the schedule, and ultimately terminated. The DON stated the facility had retrained all staff on abuse prevention, and on the requirement to report allegations of abuse immediately, after becoming aware of the incident. The facility implemented corrective action to prevent recurrence by 8/2/19. The facility suspended and ultimately terminated NA-B from employment; education was provided 1:1 to all staff members regarding abuse and reporting policies, including timeliness of reporting. The corrective actions were verified by interview with staff and policy review. The facility's policy Maltreatment Reporting Guidelines dated 4/1/19, directed residents would be free from abuse, including verbal abuse. The policy further directed staff that any alleged maltreatment involving abuse or neglect must be reported immediately, and the administrator would notify the appropriate State Agency immediately in accordance with State guidelines.

Based on observation, interview and document review, the facility failed to monitor skin integrity and provide care as directed by the plan of care to prevent development of stage 2 pressure ulcers for 1 of 3 residents (R114) in the sample reviewed for pressure ulcers. This resulted in actual harm for R114. Findings include: R114 was not provided repositioning during continuous observations from 8:30 a.m. until 10:00 a.m. on 11/28/12. Observations of R114's coccyx on 11/28/12, at 11:30 a.m. indicated two newly acquired pressure ulcers above the coccyx, under an Allevyn dressing (intended for use for draining wounds). R114 had a history of [REDACTED]. On 11/28/12, at 8:30 a.m., R114 was observed sleeping on his back in bed with the head of the bed raised to approximately 30 degrees and knees raised as well. There was a foot cradle covered with blankets, slightly mis-alligned at the end of the bed. The light was on over the bed and the oxygen (O2) nasal cannula had slipped down from the nose and into R114's open mouth. R114's head was tilted and turned to the left side and his right hand was at the edge of bed with fingers over the edge of the bed. At 8:45 a.m. R114 was in the same unique position on his back with the O2 nasal cannula in his open mouth. At 8:55 a.m., R114 was observed to clear his throat, move his hand to his abdomen and straighten his head. R114 remained on his back with the head and knees elevated. At 9:08 a.m. R114 was lying in the same position with the nasal cannula under his chin. At 9:20 a.m. R114 remained in the same position with the O2 cannula under his chin when 2 staff walked by the room. At 9:30 a.m. R114 was in the same position when another nursing staff walked by the room. At 9:43 a.m. NA-C came from the other end of the hall, walked past R114's room and entered another resident room. R114 remained asleep on his back, head and knees elevated, the right hand off the side of the bed and had placed the O2 cannula back into his nose. At 9:51 a.m. and 10:00 a.m. staff were observed to walk past R114's room without entering. R114 remained on his back with the head and knees elevated and no staff had entered the room since 8:30 a.m. On 11/28/12, at 10:02 a.m. the nursing assistant (NA)-C came out of another resident room and entered R114's room. R114 yelled that he wanted to get up. NA-C lowered the knees and turned R114 to his side for the mechanical lift sling. An Allevyn dressing with a tan spot approximately one centimeter in size was observed over the area above the coccyx. NA-C was interviewed at 10:07 a.m. and stated R114 was supposed to be repositioned every hour. On 11/28/12, at 10:15 a.m. the Registered Nurse (RN)-C was interviewed and stated R114 required hourly repositioning and that the "[MEDICATION NAME]" dressing (intended to protect dry wounds) on the coccyx was for prevention. Requested to observe the coccyx skin condition; however, R114 was already seated in the wheelchair. On 11/28/12, at 11:35 a.m., R114 was transferred into bed with 2 staff and the mechanical lift. At 11:40 a.m., the director of nurses (DON) and RN-C came in to remove the Allevyn dressing and to assess the underlying skin. The Allevyn dressing was removed and two open ulcers were observed on the bony prominence above the coccyx. RN-C measured the lower ulcer at 0.2 x 0.2 cm. with some bleeding observed. The upper ulcer was oval/round in shape, had slough (whitish film) covering it, and measured 0.7 by 0.5 cm. The ulcers were approximately 1.5 cm apart and both ulcers had defined edges. RN-C confirmed the smaller ulcer had serous drainage. NA-C asked what time she had assisted R114 into bed because, "If you don't write it down right away, you forget." RN-C, interviewed on 11/28/12, at 12:09 p.m., stated staff were monitoring R114's coccyx area and that she knew the area was open above the coccyx. The monitoring and assessment information related to the ulcer was requested and RN-C provided a progress note dated 10/19/12, regarding two abrasions on the buttock cheeks that were no longer visible. RN-C confirmed the progress note referred to abraded areas on buttock cheeks, and not to the current pressure ulcers above the coccyx. RN-C's progress note on 11/28/12, at 1:04 p.m. indicated the buttocks abrasions were healed. R114 had two superficial abraded areas above the coccyx measuring 0.7 cm x 0.5 cm and 0.2 cm x 0.2 cm. RN-C cleaned the area and applied a [MEDICATION NAME] dressing related to scant amount of drainage and for protection. R114's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R114 was moderately cognitively impaired and required extensive assistance of 2 staff with bed mobility, transfers and toileting. The MDS further identified R114 to be at risk for the development of pressure ulcers. The Care Area Assessment (CAA) dated 10/25/12, indicated R114 was at risk for developing pressure ulcers related to existing pressure ulcers and requiring staff assistance to move sufficiently to relieve pressure. The CAA indicated further risks due to incontinence, immobility and being confined to a bed or chair most of the time. The CAA indicated R114 had diabetes and shortness of breath with exertion and while laying flat. The current plan of care for bed mobility dated 4/5/12, indicated R114 required extensive assistance of two staff for repositioning. The skin integrity care plan dated 10/25/12, identified right heel and great toe ulcers and indicated R114 was at moderate risk for skin breakdown related to [MEDICAL CONDITION], incontinence and a history of excoriation to the buttocks. Interventions included monitoring skin condition of the buttocks excoriation and right heel/great toe ulcers every shift. The care plan did not identify or address ulcers above the coccyx. The nursing assistant Care Guide indicated R114 required hourly repositioning with assistance of two staff. The assistant director of nurses (ADON) and RN-C were interviewed 11/28/12, at 2 p.m. RN-C stated she did not know that R114 had open areas under the Allevyn dressing. She indicated that an LPN-G applied the Allevyn dressing on R114's coccyx area on 11/26/12. RN-C stated there had been no documented description of the area, no assessment and no physician's orders [REDACTED]. On 11/29/12 at 9:30 a.m., RN-C, ADON and the wound nurse (RN-A) were interviewed. RN-C stated that LPN-G applied Allevyn to R114's upper coccyx for intact blanchable redness on 11/26/12. LPN-G did not report or document R114's coccyx red area. The facility policy and procedure on skin assessment and care, dated 9/12, identified that assessments would be completed "upon admission, on a routine basis, and as needed. The policy further indicated the comprehensive assessments would be utilized to develop appropriate individualized interventions. The policy indicated for reddened areas the staff should apply moisture cream or barrier ointment to area. Keep clean and dry. Do not massage. High friction area "(ie heels, elbows, and coccyx)" may apply transparent dressing. The policy did not direct the use of Allevyn for intact skin or dry ulcers.