Every finding on record at Haven Homes of Maple Plain

Based on interview and document review, the facility failed to complete quarterly care conferences for 1 of 1 residents (R17) reviewed for care conferences. R17's annual minimum data set (MDS) dated [DATE], included R17 was cognitively intact and had diagnoses of cerebral palsy (a disorder that affects movement, muscle tone and posture) and anxiety disorder. R17's last completed care conference summary assessment was dated 11/25/24 and included R17 and family were in attendance. During interview on 7/21/25 at 6:17 p.m., R17 stated she did not remember having a care conference in March or June and that she could not remember the last time she had one. During interview on 7/22/25 at 3:33 p.m., social work designee (SSD)-A stated care conferences were held quarterly, annually and with any significant change. The care conferences were documented on an assessment form and in a progress note. SSD-A confirmed R17 had not had a for the last two quarters. During interview on 7/23/25 at 7:14 a.m., MDS coordinator stated she completed MDS assessments annually, quarterly and with significant changes. MDS coordinator stated she would meet with SSD-A to discuss when assessments are due so the social work department could schedule a care conference. During interview on 7/23/25 at 12:38 p.m., director of nursing (DON) stated care conferences should happen every 90 days, with significant changes or as needed. Notifications are typically mailed to families and residents would have a reminder posted in their rooms. DON confirmed that last documented care conference for R17 was on 11/25/24 and therefore was not completed every 90 days as required. DON stated it was important to complete care conferences as required to give residents a space to voice any concerns they had to update on any changes. Facility provided policy for care plans dated 3/10/25, included a resident's care plan would be updated and approved at a care conference with the family and resident representative in attendance.

Based on observation, interview and document review, the facility failed to complete proper hand hygiene for 1 of 5 residents (R66) reviewed for wound care of a pressure ulcer.R66's current wound care order dated 5/22/24, included to remove old dressing and packing, cleanse wound bed by irrigating with saline wound wash, cut alginate AG (an absorbate dressing with silver) into 1/4 inch ribbon and loosely pack wound including any undermining (the edge of the wound separates from the surrounding tissue creating a pocket), and cover with a bordered dressing. The dressing was ordered to be changed daily on the evening shift. During wound care observation on 7/22/25 at 3:45 p.m., registered nurse (RN)-B washed hands with soap and water prior to starting wound care and gathered supplies. RN-B removed the old soiled dressing, removed gloves, failed to complete hand hygiene, placed new gloves on hands and completed wound measurements and wound cleansing. RN-B again changed gloves without completing hand hygiene, placed alginate AG in wound bed and covered with a bordered dressing as ordered. RN-B removed gloves, dated wound dressing, then washed hands with soap and water. During interview on 7/22/25 at 4:00 p.m., RN-B stated she washes her hands before and after wound care. She would change her gloves after touching a dirty area. She would only wash her hands if they got dirty during wound care. During interview on 7/23/25 at 7:34 a.m., nurse manager RN-A stated hand hygiene should have been completed any time gloves were changed during wound care. RN-A stated gloves should have been changed any time they are soiled during wound care or any time a nurse goes from a dirty to clean task. This was important to prevent infection and to keep the area clean. During interview on 7/23/25 at 12:35 p.m., director of nursing (DON) stated hand hygiene should have been completed any time gloves are changed. Soap and water or alcohol-based hand sanitizer would have been appropriate to use for hand hygiene. DON stated this was important to prevent infection. Facility provided wound care policy dated 3/10/25, included to complete hand hygiene prior to starting wound care. Hand hygiene should have been performed when gloves were changed after removing the old dressing and again after cleansing the wound as ordered.

Based on interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R1) who had fallen asleep at a table in the common dining room. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition with minimal difficulty hearing with hearing devices. R1's Face Sheet indicated R1 had diagnoses of vascular dementia and bilateral hearing loss. R1's care plan dated 7/21/23 indicated R1 had minimal difficulty hearing, utilized a right cochlear implant and left hearing aid with an intervention to speak slow and with a loud voice for resident to hear. On 8/4/23 at 11:40 p.m., R2 stated while sitting at the same table, he witnessed a staff person put a wrapped straw near R1's ear. R2 further stated that R1 got madder than hell because everyone at the table was laughing when he woke up after the straw touched his ear. On 8/4/23 at 12:07 p.m., R1 was interviewed and stated, There's a little problem right now. R1 stated a nursing assistant (NA) stuck a straw into his ear while he was sleeping at the dining room table. R1 stated he was upset and embarrassed when his table mates were laughing at him. R1 stated staff shouldn't treat people like that. During the interview, R1 was observed to have tears in his eyes, was rubbing his hands together, and had a shaky voice when speaking. On 8/4/23 at 1:30 p.m., the director of nursing (DON) stated she had watched the surveillance video from the time in question. The DON stated nursing assistant (NA)-A looked at R1, used a wrapped straw to touch R1, then everyone at the table laughed after R1 awakened. On 8/4/23 at 1:30 p.m., NA-B stated sometimes R1 slept at the dining room table, but usually awakened when NA-B talked to R1. On 8/4/23 at 2:50 p.m., the DON stated staff was expected to approach a resident from the front and address the resident verbally. If talking to the resident does not wake them up, the staff member should place a gentle hand on the resident's shoulder. The DON stated staff should alert residents verbally as much as possible. If a resident was not treated with dignity, the resident could be embarrassed. The Resident Dignity, Choices and Preferences facility policy dated 10/14/22 directed all employees would treat residents with dignity and respect at all times.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R6, R17, R24, and R35) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC's PneumoRecs VaxAdvisor identified: -based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 is administered, their pneumococcal vaccinations are complete. The CDC's Pneumococcal vaccine timing for adults identified: -together, with the patient, vaccine providers may choose to administer PCV20 to adults [AGE] years and older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSC23 at or after the age of [AGE] years old. R6's face sheet, identified she was [AGE] years old and admitted on [DATE]. R6 had no allergies to vaccines or contraindications to vaccine listed. R6's immunization report, identified R6 had previously received the PCV23 on 5/2/2012 and the PCV13 on 10/7/2015. R6's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered, received, or discussed with their primary physician. R17's face sheet, identified he was [AGE] years old and admitted on [DATE]. R17 had no allergies to vaccines or contraindications to vaccine listed. R17's immunization report, identified R17 had previously received the PCV23 on 11/27/2013 and the PCV13 on 3/19/2015. R17's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered, received, or discussed with their primary physician. R24's face sheet, identified she was [AGE] years old and admitted on [DATE]. R24 had no allergies to vaccines or contraindications to vaccine listed. R24's immunization report, identified R24 had previously received the PCV13 on 2/5/2015 and the PCV23 on 1/20/2017. R24's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered, received, or discussed with their primary physician. R35's face sheet, identified she was [AGE] years old and admitted on [DATE]. R35 had no allergies to vaccines or contraindications to vaccine listed. R35's immunization report, identified R35 had previously received the PCV23 on 9/6/2016 and the PCV13 on 2/9/2015. R35's medical record lacked evidence the recommended pneumococcal (PCV20) vaccination was offered, received, or discussed with their primary physician. When interviewed on 6/21/23 at 3:59 p.m., infection preventionist (IP) stated when a resident was admitted to the facility, they go through an admission event, where the immunization record was reviewed. Facility also reviewed the resident's Minnesota Immunization Information Connection (MICC) for immunization record. If resident was eligible for a vaccine, IP gave residents the Vaccine Information Sheet (VIS) and completed a consent/decline form. For pneumococcal vaccines, IP stated he used the CDC's Pneumococcal Vaccine Timing for Adults chart to see if resident was eligible and if so, vaccine would be administered vaccine within the first couple of weeks. Edition of the Pneumococcal Vaccine Timing chart that IP was using was dated 3/2016. IP showed another edition that he has used that was dated 2/16/2022. IP stated that he periodically reviews the resident's immunization record to ensure that they have all recommended vaccines. IP stated that they have been offering the PCV20 for resident who have not received any pneumococcal vaccines in the past but have not offered PCV20 to residents who have received previous pneumococcal vaccination in the past. IP stated R4, R17, R24 and R35 were not offered the PCV20. The Pneumococcal vaccine policy dated 8/16/2022, identified it is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC or state guidelines and recommendations. 1. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. 3. On admission all residents and/or their representatives will complete the designated consent form indicating consent or declination of the pneumococcal vaccine or indicating dates of previous vaccinations if they are fully immunized. 4. The signed standing orders will be following for administration of the vaccine. 5. Prior to administration of the pneumococcal vaccine the resident or the resident's representative has the opportunity to refuse immunization. 6. The type of pneumococcal vaccine (PCV12, PPSV23/PPSV; PCV15; PCV20) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC or state guidelines and recommendations.

Based on observation, interview, and document review, the facility failed to ensure an Enteral (feeding) tube was consistently check for placement prior to the administration of medications and Enteral nutrition for 1 of 1 resident (R36) whose medication administration and Enteral nutrition was offered through a stomach tube. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had dysphagia (difficulty swallowing) following decline in status as evidenced by need for tube feeding to meet nutritional needs. R36's current orders, dated 12/8/22, identified a G-tube (gastrostomy tube) (a type of tube going straight into the stomach) and received medications and Enteral nutrition given directly into stomach. During observation on 6/21/23, at 12:03 p.m., licensed practical nurse (LPN)-B performed medication administration and tube feeding in R36's room following medication review, gathering a new syringe, and a beaker of water. LPN-B raised the head of the bed, donned clean gloves, connected syringe onto G-tube and pushed 60 mL of water to flush out tube. LPN-B did not check the placement of the tube prior to the 60 mL flush of water. LPN-B continued to administer crushed medication and tube feeding through G-tube, flushing with 30 mL of water in between each syringe of Jevity (fibre-fortified, high-nitrogen liquid tube-feeding formula), and then flushing again with a 30 mL pour of water before disconnecting, and capping G-tube line. During interview on 6/21/23, at 12:23 p.m., LPN-B stated that checking tube placement was done with the first medication administration of the day. LPN-B stated she tugs at the tube to see if it moves and if it doesn't move then it is good. I then flush with 5 mL of water and if there is not drainage from the sides, then it is good. LPN-B stated that it was important to check tube placement to ensure that resident was actually getting his medications and feedings. During interview on 6/21/23, at 12:30 p.m., director of nursing (DON) said her expectations of skilled nursing staff administering medication and tube feeding through a G-tube was to check for tube placement every shift. The DON stated, I would expect placement be checked through a residual volume check. The DON continued, I would not tug at tube but would twist it slightly to make sure that it was not stuck to the skin, and flushing was not done to check for tube placement. The facility Tube feeding/Enteral feeding-gravity or bolus feeding policy dated 10/17/2022, identified purpose, responsibility, general guidelines, procedure, and initiate feedings. Under steps in the procedure on step 7, the policy identified confirm placement of tube.

Based on observation, interview and record review, the facility failed to assure there were orders and interventions in place for a continuous positive airway pressure (CPAP - a type of ventilator that is used to treat sleep apnea) usage for 1 of 2 residents (R1) reviewed for CPAP therapy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, and able to express needs. R1 received assistance to complete activities of daily living (ADLs), however, was an active participant with cares. The following diagnoses were identified within the MDS: hypertension (high blood pressure), diabetes mellitus, and displaced fracture of olecranon process with intraarticular extension of left ulna. During interview on 6/20/23 at 2:14 p.m., R1 confirmed she owned and used a CPAP machine on a routine basis. R1 stated she thought the settings needed to be adjusted as when [she] wore it [her] head got all plugged up. R1 stated staff assisted with applying CPAP mask at bedtime. R1 stated it helped to wear the CPAP mask. During interview on 6/21/23 at 2:07 p.m., trained medication aide (TMA)-A stated she was not sure if R1 used the CPAP at night because that was not her normal shift. TMA-A checked with other staff and confirmed that she had used it in the past week. During interview on 6/21/23 at 2:14 p.m., registered nurse (RN)-B stated R1 used the CPAP machine at night and had been using it regularly. He had been assisting R1 with applying it at night for the past week. RN-B confirmed there was no order for the CPAP. During interview on 6/21/23 at 2:26 p.m., licensed practical nurse/TCU nurse manager (LPN)-B stated when the facility received an order from the provider, the health unit coordinator (HUC) processes the order, and then the order was double checked by another nurse. If a piece of medical equipment was brought into the facility by family or resident, and staff does not see an order for it, the nurse practitioner was notified equipment had been brought in and the resident wished to use equipment. Once orders were received, the resident could begin using equipment. LPN-B confirmed R1 did not have an order for the CPAP machine. However, she was not aware R1 had been using a CPAP machine. During interview on 6/21/23 at 2:56 p.m., director of nursing (DON) stated families sometimes brought in equipment and didn't tell the facility. DON stated once the facility was aware of equipment, they reached out to the provider with an update and requested an order. DON confirmed R1 did not have an order for the CPAP machine and was just made aware of machine that was brought in. During interview on 6/21/23 at 4:57 p.m., RN-B confirmed that R1 did not have an order for the CPAP machine. RN-B stated that orders should be checked prior to equipment usage to ensure that there was an order from the provider for equipment. The CPAP/BiPAP policy dated 10/17/22, indicated the purpose was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; to improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; and to promote resident comfort and safety. Procedure directed staff to verify physician's order. BiPAP and CPAP settings are ordered by the provider and machine will come with the proper settings.

Based on observation, interview, and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R310), who were observed for self-administering medications. R310's admission MDS dated [DATE], identified R310 was cognitively intact, and required assistance/supervision with ADL's. R310 face sheet indicated admission on 6/15/23. R310's medical record lacked evidence of R310 being assessed for self-administration of medications. During observation on 6/20/23 at 1:00 p.m., a bottle of eye drops were on R310's nightstand next to bed and a bottle of glucose tablets were on the dresser. During observation and interview on 6/20/23 at 6:09 p.m., R310 confirmed eye drops and glucose tablets were on the bedside table and dresser respectively, and he used them when needed. R310 stated he put eye drops in his eyes whenever needed and he had needed glucose tablets this morning, so he took some. During interview on 6/21/23 at 10:05 a.m., R310 stated he had put the eye drops and glucose tablets in his drawer. R310 stated he has had medications since admitting to the facility and staff should know about them as they had been sitting out on the dresser ever since he arrived. During interview on 6/21/23 at 10:46 a.m., registered nurse (RN)-A stated if a resident wanted to self-administer medications, an assessment was completed by the nurse. Assessment consists of the resident returning demonstration and determining if resident was capable of self-administration. Once assessment was completed, order was sent to the provider for resident to self-administer medications. When signed orders were received from the provider, resident wass then able to self-administer medications. RN-A stated R310 had not had a self-administration assessment completed and staff should administer eye drops. RN-A stated staff saw the eye drops on R310's nightstand this morning, removed them, and brought them to nurse on medication cart. RN-A stated eye drops were now in the medication cart but was not aware of the glucose tablets that remained in R310 room. RN-A stated it was important to monitor glucose tablets usage, they may elevate blood sugars even more and R310's blood sugars were not controlled the way was. During interview on 6/21/23 at 12:30 p.m., director of nursing (DON) indicated for a resident to self-administer medication a self-administration of medications assessment needed to be completed. Assessment consisted of reviewing medications with resident, checking to see if resident understood what the medication was prescribed for and demonstration of proper usage of medication. When assessment was completed, the provider was contacted to receive an order. The order was processed in the computer under resident's orders. DON stated whenstaff found medications in a resident's room, a discussion would occur with resident with staff explaining the process and would remove medications from room until an assessment was completed and a signed order was received. Occasionally a resident has an issue with handing over medication, we would then get family and/or provider to assist facility with removing them from room until assessment could be completed. DON stated R310 was asked upon admission if he wanted to self-administer medications, and stated no at the time. DON confirmed R310 did not have a completed assessment or order for self-administration of medications. DON stated it was important to monitor the glucose tablets as they affected blood sugars. The Self-Administration of Medications policy dated 2/20/2023, directed that upon admission and PRN, the licensed nursing staff informs every resident of his/her right to self-administer medications and explain the self-administration of medication program. 3. If the resident wishes to self-administer medications, complete the application observation/assessment in the EHR. 4. If the nurse determines through this assessment that the resident is unable to self-administer his/her medications because of a danger to themselves or others the observation/assessment will reflect that. 5. If the nurse determines through this assessment that the resident is able to self-administer medications complete the following: a. Obtain an order from the provider that the resident may self-administer medications. Order should indicate which medications will be self-administered. b. If medications can be left at the bedside in a locked drawer or box, the order should specify that the medications can be kept at the bedside. c. Within the order for the medications that will be self-administered, it will state that the medication is being self-administered. d. Information regarding self-administration of medications will be added to the care plan. 6. Licensed staff or TMA/CMA is to check with the resident to assure they have taken their medications per orders. This will be documented in the EMAR. 13. Upon admission or new request to self-administer medications, licensed staff or TMA/CMA will administer medications until the resident has been assessed and a physician's order is in place for self-administration of medications.

Based on observation, interview, and document review, the facility failed to timely follow up on transportation arrangements to a medical appointment for 1 of 1 resident (R314) reviewed for choices. Findings include: R314's quarterly Minimum Data Set (MDS) dated [DATE], identified she intact cognition and required extensive assistance with activities of daily living (ADL's). During interview on 6/20/23 at 4:14 p.m., R314 stated she was supposed to have an appointment, with orthopedics, for follow up on her surgical incision yesterday (6/19/23). R314 stated appointment was canceled due to no transportation. R314 stated she was not aware until shortly before leaving for appointment. R314 contacted her son and daughter for transportation, but it was too late. R314 stated facility was aware of the appointment but R314 was not aware of transportation arrangements. Review of R314's medical record indicated resident was admitted to facility with an appointment scheduled for 6/19/23 at 4:10 p.m. for follow up on surgical incision. During interview on 6/21/23 at 2:30 p.m., licensed practical nurse/ transitional care unit manager (LPN)-B stated when a resident admited with a scheduled appointments, the health unit coordinator (HUC) set up transportation. She talked with family to see if they can transport resident or if a transport company was needed due to physical limitations with getting in a normal vehicle. LPN-B indicated she recalled hearing R314's appointment got canceled due to not having transportation. LPN-B stated the facility normally set up transportation. There was miscommunication regarding R314's transportation, so the appointment was canceled, and a new one rescheduled for later in the week. During interview on 6/21/23 at 2:33 p.m., HUC stated when residents admit with already made appointments, HUC asked the resident if they wanted transportation arranged or if family would transport. HUC indicated R314 needed transportation arranged as she was not able to get in a normal vehicle due to surgical incision. HUC indicated she was aware of R314's appointment and she didn't touch base with R314 before her vacation. HUC stated R314 had reached out to another staff member to ensure transportation was arranged and was told it was all taken care of. HUC stated after vacation she touched base with R314. HUC could not have transportation arranged in a timely manner due to short notice, so the appointment needed to be rescheduled. During an interview on 6/21/23 at 2:56 p.m., director of nursing (DON) stated when the facility was notified of an appointment, the HUC reached out to resident or family to see if family was going to transport of if transportation was needed. If transportation was needed, HUC made transportation arrangements. DON stated when the HUC was out of the office or on vacation, the other HUC was backup and responsible for arrangements. The Appointment, Accompanying Resident policy dated 1/18/2023, identified that Cassia facilities will assist residents in making appointments for outside providers as requested. They will also assist in arranging transportation as needed or desired by the resident and/or their representative.

Based on observation, interview, and document review the facility failed to follow implementation of a comprehensive person-centered care plan for 1 of 2 residents (R19) reviewed for accidents. Findings included: R(19) significant change Minimal Data Set (MDS) dated [DATE], indicated diagnosis of Alzheimer's, (a reduction in memory and brain function disease) Non-Alzheimer's dementia (a reduction in memory and brain function disease), and anxiety. R19 transferred and walked in room with limited assistance with assistance of 1. R19 used Antianxiety (anxiety reducing medication), Antidepressants (depression reducing medication), and opioid (Strong Pain medication) medications. Facility fall assessment dated [DATE], identified R19 had history of falls in past 6 months, one fall in previous 6 months, use of 2 or more high risk medications, and was impulsive. Fall risk assessment score result was high. Progress note dated 5/6/2023 at 3:01 a.m., revealed R19 had been found lying on the floor next to the toilet on the left side, fully dressed, with gripper socks on, and resident fell attempting to use bathroom. Care Plan identified R19 was at risk for falls related to advanced age and diagnosis of dementia osteoarthritis, weakness, and impulsiveness with a goal to offer resident assistance to minimize falls related to injuries. Facility interventions dated 5/23/23 instructed staff to store wheelchair under counter in entry way to room and not by bed. On 6/21/23, at 2:39 p.m., wheelchair observed about 3 feet from bed of R19, who was sleeping in bed. On 6/21/23 at 2:56 p.m., certified nursing assistant (CNA) NA-A said dementia training was provided to her. She worked with the resident individual needs, and reviewed the care guide. NA-A stated R19 attempted to self-transfer, so the bed was lower, call light in reach, and her wheelchair near her bed. NA-A said the care sheet had the most recent information. NA-A provided the care guide she utilized which revealed wheel chair under front desk. During subsequent interview, at 4:13 p.m., NA-A confirmed she had not followed the care guide. On 6/21/23, at 3:28 p.m., Licensed Practical Nurse (LPN)-C confirmed she was the unit nurse and was aware R19 had a history of falls. LPN-C stated management reviewed falls, provided interventions, and updated the care plan. All intervention were shared with nursing in report and through the care guide. LPN-C stated it was her expectation staff followed the care guides and interventions. On 6/21/23, at 4:33 p.m., Director of Nursing (DON), stated R19 had intervention to keep the wheel chair under the desk due to a behavior of using it during self-transfers. The wheel chair had a roll back feature which could increase the risk of fall if utilized during a self-transfer. Further, the care plan and care guide were the best source of information for the most recent interventions. It was the facility's responsibility to train staff correctly. Facility Policy, titled, Fall Assessment and Managing Fall Risk with revision date of 10/17/2022 section 9 indicated, Based on review of the fall, interventions in the care plan are updated as indicated. Section 12 indicated, All employees are educated on the fall prevention standards as part of new employee orientation, and updates to this training are complete as needed. Section 13 indicated; Staff nurses are responsible to make safety rounds throughout their shift to ensure compliance with required safety devices as indicated on the residents' plan of care.

Based on interview and document review, the facility failed to revise the care plan to include [CONDITION(S)] medications used for as needed (PRN) behavioral interventions for 1 of 5 residents (R50) who were reviewed for the use of unnecessary medications. Findings include: R50's Face Sheet, printed 7/21/22, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R50's admission minimum data set (MDS) dated [DATE], identified R50 was cognitively impaired and required extensive assistance with activities of daily living. R50's medical record, a HealthPartners order sheet (untitled) dated 6/24/22, indicated R50 was prescribed [MEDICATION(S)] (anti-anxiety medication) 2 milligrams / 1 milliliter (mg/ml) concentrated solution take 0.125 ml (0.25 mg) by mouth every 4 hours as needed. In review of R50's nursing progress notes, R50 returned from a hospitalization on [DATE]. In further review of R50's progress notes documented resident had an unwitnessed fall on 6/25/22. Prior to this fall, R50's progress notes documented R50's restlessness and staff observation of resident kept taking off his clothes and briefs. R50's Progress notes between 6/25/22 and 7/06/22 had behavior documentation which indicated resident displayed anxious / restless behavior consisting of calling out, continued stripping of clothes and briefs, attempted self-transfers with falls and hallucinations of being at home with the house on fire. A review of R50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 6/24/22 - one dose 7/01/22 - zero doses 6/25/22 - 4 doses 7/02/22 - one dose 6/26/22 - 4 doses 7/03/22 - 4 doses 6/27/22 - 4 doses 7/04/22 - 1 dose 6/28/22 - 4 doses 7/05/22 - 1 dose 6/29/22 - 3 doses 7/06/22 - 1 dose 6/30/22 - 4 doses All doses given to R50 were documented with the behavior displayed and the effectiveness of the dose given. However, in review of R50's care plan (start date of 6/09/22) indicated the following: Resident received antipsychotic medication [MEDICATION(S)] related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Target behaviors are: restlessness, pacing, refusal of cares, physical aggression. Original order date: [MEDICATION(S)] 6/7/22, [MEDICATION(S)] 7/14/22 ([MEDICATION(S)] was started upon return from the hospital on 7/14/22 when enrolled in hospice). Although R50's care plan indicated the use of [CONDITION(S)] medications for identified behaviors, the care plan lacked documentation of the use of [MEDICATION(S)]. During an interview on 7/21/22, at 9:11 a.m. MDS coordinator (RN)-A stated R50 was started on [MEDICATION(S)] after his second hospitalization where resident began to display more anxiety and restless behavior when he was placed on palliative care. RN-A stated it appeared the facility forgot to include [MEDICATION(S)] in R50's care plan. An interview on 7/21/22, at 9:51 a.m. licensed social worker (LSW) stated that currently, it was the responsibility of the social worker to develop and maintain resident behavior concerns on the care plan, which included making sure all behavioral medications given are documented. LSW stated at the time R50's [MEDICATION(S)] order was received the care plan should have been updated. In review of the facility policy, entitled: Care Plan and Baseline Care Plan (last revised 6/27/22) indicated the following: The resident care plan is constantly changing. It is to be updated routinely in the electronic record to reflect the resident's current condition. The resident care plan is reviewed for accuracy, updated with quarterly MDS review, and all other scheduled MDS assessment.

Based on observation, interview and document review, the facility failed to ensure stainless steel pans used for the steam table and food storage were dried prior to storage. This had the potential to affect all 46 residents who were served from the dietary department. Findings include: During a follow-up tour of the kitchen on 7/26/21, at 4:22 p.m. executive chef (EC) lifted three different stainless-steel pans that were stacked on top of each other and confirmed that the pans were wet. In addition, EC continued to separate two larger stainless-steel pans and another medium sized pan and confirmed those were wet as well. On 7/26/21, at approximately 4:22 p.m. EC states technically we [dietary staff] dry them on the rack and place them on the empty tray. I know I am shooting myself in the foot, but food safety is important. EC indicated the importance of letting the stainless-steel pans air dry was any contact surfaces there can be remnants on there and sanitizer needs to do its job, so it needs to dry. On 7/29/21, at 12:37 p.m. registered dietician (RD) indicated the stainless-steel pans should be washed and sent through the dishwashing machine. Then there is a cart, they [dietary staff] will have things dry before they [dishes] are put away. Further, RD indicated the importance of letting dishes air dry is to cut down on bacteria that is growing in the water. Facility policy titled Sanitation revised 1/6/21, indicated food preparation equipment and utensils that are washed will be allowed to air dry. Once dry, equipment and utensils should be stored enclosed or covered.

Based on observation, interview and document review, the facility failed to ensure nail care services were provided for 1 of 1 residents (R41) who was dependent upon staff assistance for activities of daily living (ADLs). Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], indicated R41's hearing was adequate and her speech was clear. R41 was able to make herself understood and could understand others. R41 was cognitively intact and required physical assistance from staff for personal hygiene. R41's face sheet printed 7/29/21, indicated R41 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's care plan last reviewed and revised 7/7/21, did not indicate if R41 required assistance from staff for nail care. R41's progress notes for July 2021, did not indicate if nail care had been attempted but refused. R41's documented weekly visual body inspections dated 6/15/21 to 7/26/21, did not indicate R41's nails were inspected. On 7/26/21 at 2:22 p.m., R41's toenails, on both feet, were noted to be approximately 0.5 inch long. R41 stated no one had offered to cut her toenails in a long time. She was not able to recall the last time nail care had been offered by the staff. R41 indicated she would appreciate it if someone would cut them for her, as she was not able to it herself. On 7/28/21 at 2:10 p.m., licensed practical nurse (LPN)-A indicated nail care included fingernails and toenails. Nail care is supposed to be completed after the resident has a shower, a bath or a bed bath. Residents who are not diabetic received their nail care from the nursing assistants. LPN-A confirmed R41 was not diabetic. LPN-A confirmed the length of R41's toenails on both feet, they are extremely long, and indicated they did not look difficult to cut. LPN-A stated R41 requested someone cut her toenails during the observation. On 7/28/21 at 2:24 p.m., registered nurse (RN)-A stated if a resident's toenails are long, they should be cut. R41 will occasionally refuse cares but was not sure if R41 had refused toenail care. RN-A was not aware if refusal of nail care would be documented in R41's medical record. RN-A observed R41's toenails and confirmed they were long and needed to be cut because long toenails could get caught on R41's bedding and tear the nail off, causing injury and pain. RN-A confirmed R41 is not diabetic, so did not require a licensed staff to cut her nails. On 7/29/21 at 12:55 p.m., director of nursing (DON) stated nail care, including toenails, is expected to be done weekly on the resident's bath and as needed. If a resident is not diabetic, the nurse who completed the weekly visual body inspection should have verified nail care was completed. DON indicated there is no section on the weekly visual body inspection form that asks specifically about the condition of fingernails or toenails. Facility nail care policy dated 12/9/19, indicated nails will be maintained in a clean and neat manner to support resident dignity and to avoid problems associated with rough, cracked, overly long or broken nails. Floor nurse will inspect the nails of all residents on bath day as part of the weekly visual body inspection.

Based on observation, interview and document review the facility failed to ensure residents received the prescribed diet as ordered for 1 of 1 (R30) resident reviewed during dining. Findings include: R30's admission minimal data set (MDS) dated [DATE] indicated R30's diagnoses included stroke, [CONDITION(S)], and [CONDITION(S)]. Further review of MDS, indicated R30 required limited assistance with eating and was identified to have difficulty swallowing. R30's physician order report signed on 6/23/21, indicates a diet order of pureed texture and thick liquids. R30's care plan indicates R30 required a pureed texture, regular diet with mildly thick/nectar thick liquids related to dysphagia R30's progress note dated 7/22/21, indicated per swallow recommendation new order from certified nurse practitioner (CNP) 1. Upgrade to nectar thick liquids (dc honey thick). OK to allow cup drinking as tolerated. On 7/26/21, 6:12 p.m. at R30 was observed sitting in her wheelchair at the table in the dining room. R30 was independently drinking a glass of orange juice that was a thin liquid. R30 drank 100% of the thin liquid orange juice. R30 did not appear to have difficulty swallowing and did not cough while consuming the thin liquid orange juice. R30's meal ticket was placed on the right side of meal and indicated pureed solids and nectar thick. On 7/26/21, at 6:19 p.m. when asked how dietary aids know if a resident required a therapeutic diet, dietary aid (DA)-A stated we [dietary aids] ask what they [residents] prefer to drink and refer to the resident's meal ticket and there is a sign in the kitchen as well. We [dietary] have pre-thickened drinks we [dietary] keep in the fridge and just use that. When asked about R30's meal ticket on the table, DA-A stated R30 requires nectar thick liquids and confirmed the two beverages were thin liquid orange juice and thin liquid water. On 7/26/21, at 6:32 p.m. registered nurse (RN)-B confirmed R30 was supposed to receive nectar thick liquids and confirmed the beverages given were not nectar thick. Further, when asked the process of delivering resident's meal trays, RN-B stated we use a team process. We have dietary aids helping for the most part, but they [dietary] would usually look at what the resident has for a liquid and each resident is supposed to be asked what they [residents] want. In addition, RN-B indicated upon admission R30 had orders to receive nectar thick liquids due to having a significant stroke that left her with dysphasia and [CONDITION(S)]. On 7/26/21, at 7:39 p.m. licensed practical nurse (LPN)-B stated R30 required a pureed diet and nectar thick liquids due to having difficulty swallowing. On 7/29/21, at 11:47 a.m. during interview with director of nursing (DON) and administrator, DON stated R30 was receiving physical, occupational and speech therapy services and required a modified diet of thickened liquids because of her stroke and dysphagia. On 7/29/21, at 12:24 p.m. registered dietician (RD) indicated R30 required a pureed diet and nectar thick due to having dysphagia from a stroke. Further, RD indicated she expected dietary staff to utilize the list of diets for all residents that is posted in the kitchen and updated daily, and each resident had a meal ticket with their diet order before giving it[tray] to them [resident]. The resident's diet, texture, and liquid are on there, so they [dietary] should be looking at both sheets. Facility policy titled Diet Policy and Procedure review date of 1/5/21, indicated a meal identification and food preference card (i.e. tray ticket) is used to properly identify each individual's diet order, needs and desires for food.

Based on interview and document review, the facility failed to ensure a refusal of care was honored which resulted in an undignified bathing experience for 1 of 3 residents (R1) reviewed for choices. Findings include: A received State agency (SA) report, dated 10/19/20, identified an allegation of sexual abuse toward R1. The report outlined R1 had reported unwanted sexual contact during a bath provided by alleged perpetrator (AP) NA-A, and their initial investigation concluded the alleged incident occurred on 10/7/20. R1's significant change Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment and was able to communicate her needs if prompted or given time. Further, R1's MDS indicated it was 'very important' to R1 to chose her method of bathing (i.e. tub bath, shower, bed bath). R1's care plan, dated 1/13/20, identified R1 needed assistance with activities of daily living (ADLs). The care plan identified R1 required assistance with her personal hygiene, however, lacked specific dictation on bathing preference(s). Further, the care plan outlined, Allow resident to make decisions, set realistic goals, and to participate in self care to the extent of Resident's ability. During interview on 10/23/20, at 8:54 a.m. R1 recalled being bathed by NA-A on 10/7/20, and expressed she was given a bed bath against her wishes. R1 explained she did not want any bathing to be completed that evening, however, NA-A went ahead and did it anyway which she voiced made her feel icky and shake worse (due to a disease process). When interviewed on 10/23/20, at 12:37 p.m. NA-A recalled bathing R1 on 10/7/20, and verified R1 had told him she did not want her bath on that evening, however, the licensed practical nurse (LPN)-A working directed him to complete it anyway. NA-A proceeded and voiced he could tell R1 was extremely uncomfortable during the entire bath adding R1 seemed to display uncomfortable vibes. Further, NA-A stated he understood resident's had the right to decline care(s), including bathing, and reiterated the bathing experience for R1 on 10/7/20 seemed terrible and forced. During interview on 10/23/20, at 1:11 p.m. LPN-A recalled the incident from 10/7/20, and verified she was aware R1 had originally voiced she did not want her scheduled bath that night, however, stated she thought R1 had agreed to a bed bath after NA-A originally informed her R1 had declined bathing. LPN-A denied she forced NA-A to complete the bath for R1, despite her initial refusals, and acknowledged she never did follow-up with R1 or NA-A after the bath was completed. Further, LPN-A voiced residents had the right to refuse cares, however, added staff needed to make sure something is done or reschedule bath(s) if residents refuse them. On 10/23/20, at 1:49 p.m. the administrator, licensed social worker (LSW) and director of nursing (DON) were interviewed. They verified the incident involving R1 and NA-A stemmed from a bath given on 10/7/20, and the DON voiced R1 had expressed to her the bath given by NA-A had made her very uncomfortable. The administrator stated there had been a breakdown and they needed to figure out what caused it. Further, the DON voiced residents should not be forced to complete care(s) they do not want in accordance with their resident rights. A provided Resident Rights policy dated 6/3/18, identified the facility. recognizes the resident's right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making . Further, the policy directed each resident must be treated with respect and dignity while the facility further supported, protected, and promoted the rights of the resident without interference or coercion.

Based on interview and document review, the facility failed to ensure annual abuse prevention training was completed, in accordance with their established policies and procedures, for 1 of 1 nursing assistants (NA-A) reviewed who was identified as an alleged perpetrator (AP) in an abuse allegation. Findings include: A submitted State agency (SA) incident report, dated 10/19/20, identified an allegation of sexual abuse involving R1. The report listed the alleged perpetrator (AP) as nursing assistant (NA)-A. When interviewed on 10/23/20, at 12:37 p.m. NA-A explained he started working at the nursing home in July 2019, and his duties included direct resident care since then through 10/19/20, when he was removed from the facility pending investigation into the allegation from R1. NA-A stated if he witnessed abuse, (He) would report it right away. NA-A's education course history was reviewed. The form identified NA-A's completed education from 6/1/19 through 10/23/20. The form indicated NA-A completed Abuse & Neglect Self-Paced education 7/23/19. Further, the form indicated Preventing, Recognizing, and Reporting Abuse was completed on 7/24/19. No further evidence was provided demonstrating NA-A had been provided formal abuse training within the past 12 months. On 10/23/20, at 1:49 p.m. the administrator, licensed social worker (LSW) and director of nursing (DON) were interviewed. The administrator and DON stated NA-A had been working every other weekend; however, over the last month NA-A had worked several extra shifts. The DON reviewed NA-A's education history and verified it lacked any abuse training within the past 12 months; last being completed in July 2019. The administrator verified they tracked the training on a 'rolling calendar' system, and expressed they typically would remove an employee from the schedule until the training was completed, however, they had not had the luxury of being able to do so with staffing concerns from the pandemic. A provided Vulnerable Adult-MN policy, dated 11/21/18, identified a section labeled, Training, which directed all staff that provided care and services to residents would be provided training through orientation and with annual and ongoing training programs on issues related to abuse prohibition practices. The policy indicated training included, but was not limited to: definitions and identification of abuse; abuse reporting; protection of residents during abuse investigations; strategies for abuse prevention; resident rights; Elder Justice act; and Dementia management. Further, the policy indicated staff training would be documented and maintained with educational records in the facility.

Based on interview and document review, the facility failed to report an allegation of sexual assault to local law enforcement in a timely manner for 1 of 1 residents (R1) reviewed who had made allegations of sexual assault. Findings include: R1's quarterly minimum data set ((MDS) dated [DATE], identified R1 was cognitively intact and required extensive assistance with cares. State Agency (SA) report dated 6/10/20, included an allegation of sexual abuse (sexual contact or penetration between resident and service provider or facility staff, unwanted sexual contact). R1 reported to facility that an employee had been sexually inappropriate by squeezing breast and genitals. On 6/16/20, at 12:20 p.m. review of facility investigation file for R1 contained undated sheet of white paper which was typed with timeline. 6/10/20 - report from R1, employee suspended. 6/12/20 - interview with employee, police report filed. 6/15/20, resident and staff interviews. In addition, the review of the facilities investigation report indicated the alleged perpetrator (AP) denied the allegation made by R1. When interviewed on 6/16/20, at 2:18 p.m. social worker (SW)-A stated facility process for investigations was to interview the resident and staff then talk with the administrator and director of nursing (DON). R1 had reported the inappropriate sexual contact to her on 6/10/20, then she had been out of the office returning on 6/12/20 when she had been back to work and reported R1's allegation to the police at that time. When interviewed on 6/16/2020, at 1:55 p.m. R1 stated she reported to the SW on 6/10/20 that an employee had been sexually inappropriate on several occasions. R1 stated a police officer came on 6/12/20. When interviewed on 6/16/20, at 2:33 p.m. The administrator stated facility employees had been education on abuse and reporting in May 2019. Administrator further stated at the time R1 made the report, the facility was not sure if this was sexual abuse or not but upon further investigation found with was sexual abuse on 6/12/20, then notified the police right away. A facility policy Vulnerable Adult - MN revised 10/31/19, stated If sexual abuse is suspected, call the police immediately. DO NOT bathe/wash the resident or wash the resident's clothing or linen. Do not take items from the area in which the incident occurred.

Based on observation, interview and document review, the facility failed to ensure food service equipment used in the main production kitchen was kept in clean and sanitary condition to prevent potential food-borne illness. This had the potential to affect 37 of 44 residents, visitors and staff who consumed ice water prepared in the kitchen. Findings include: On 3/11/19, at 1:11 p.m. an initial kitchen tour was completed with the dietary director (DD). A Hoshizaki brand ice maker was just inside the doors of the kitchen next to the built in steam table. The outside of the ice maker was clean. The DM lifted the lid to expose the ice and a plastic guard that assisted in keeping the ice contained. DM unscrewed two knobs to expose the inner shoot where the ice falls down. Orange, mold like droplets were noted on the underside and perimeter of the shoot. DM closed and fastened the guard in place. DM stated the ice maker is cleaned annually per manufacturers recommendations by maintenance and DM personally cleans the ice machine quarterly by wiping it down with QUAT (disinfecting cleaner). On 3/12/19, at 1:38 p.m. the maintenance director (MD) and DD inspected the ice machine. DD exposed the inside shoot. The orange mold like droplets were gone, the ice machine had been cleaned. Review of the manufacturers manual indicated the ice maker be cleaned at least once a year, however, more frequent cleaning may be required dependent on existing water conditions. The Annual Ice Machine Log indicated the ice machine was fully cleaned per manufacture's specifications/policy on (MONTH) (YEAR). During an interview on 3/12/19, at 1:40 p.m. DD stated, I saw the orange scum when I showed you the machine, so I cleaned it yesterday. I've never seen anything like that before. DD also stated she wipes down the machine quarterly. When interviewed on 3/14/19, at 3:04 p.m. the administrator (ADM) stated the ice machine should be cleaned according to manufacturers recommendations and that it should be clean at all times. A facility policy for ice machine maintenance, dated 8/10/17, indicated cleaning and sanitization is to be performed annually by maintenance staff and parts that can be easily accessed should be cleaned quarterly and as needed by kitchen staff.

Based on observation, interview, and record review the facility failed to apply compression stockings or monitor for [MEDICAL CONDITION] per physician order [REDACTED]. Findings include: R9's admission Minimum Data Sets ((MDS) dated [DATE], indicated R9 required assistance with one person for putting on or taking off all items of clothing. The MDS indicated R9 had moderately impaired cognition. R9 had a physician order [REDACTED]. R9 had a [DIAGNOSES REDACTED]. R9's care plan dated 1/8/19, did not address her [DIAGNOSES REDACTED]. R9's last weekly comprehensive skin assessment dated [DATE], did not address her [MEDICAL CONDITION] and the extent of her [MEDICAL CONDITION] (swelling) of feet and ankles. During observation on 3/11/19, at 7:03 a.m. R9 was noted to have swelling ([MEDICAL CONDITION]) of bilateral feet and ankles. R9 had ankle sock and shoes on. During observation on 3/12/19, at 8:13 a.m. R9 was noted to be up in her wheel chair with feet resting on foot pedals. R9 was wearing ankle socks with shoes. R9 was noted to have swelling of bilateral feet and ankles. During observation on 3/12/19, at 12:30 p.m. R9 was noted to have on same ankle socks and shoes, and skin from bilateral ankles was hanging over socks and looked like a mushroom shape. During observation on 3/13/19, at 7:21 a.m. R9 was up in wheel chair dressed wearing shoes and pants that were long covering her ankles. During observation and interview on 3/13/19, at 10:58 a.m. registered nurse (RN)-A stated R9 had 3-4+ [MEDICAL CONDITION] (6-8 mm depression or very deep indentation to bilateral ankles and more [MEDICATION NAME] more than 20 seconds) RN-A stated she can see indentation marks from her ankle socks. RN-A stated she is unable to find any documentation of monitoring R9's [MEDICAL CONDITION], no offering of thigh high compression stocking for the [MEDICAL CONDITION] and R9's [MEDICAL CONDITION] was not addressed in her comprehensive care plan. During interview on 3/13/19, at 11:05 a.m. RN-B stated R9 does not like her compression stockings and there is documentation of R9 refusing the compression stocking in the last couple of weeks. RN-B was unable to locate any documentation of compression stocking being offered and no documentation of R9 refusing the compression stockings. RN-B stated R9 should have been offered the thigh high compression stocking with the 3-4+ [MEDICAL CONDITION] of bilateral ankles. During interview on 3/13/19, at 11:35 a.m. director of nursing (DON) stated R9 should have been offered the thigh high compression stockings or there should be documentation that R9 refused . DON stated there is no documentation of either in R9's charting. DON stated she is unable to find anything in R9's comprehensive care plan related to her [MEDICAL CONDITION] or compression stockings either. A facility policy titled Ace Bandage- Support/Compression stocking use dated 12/11/18, was provided for review. The policy indicates support/compression stockings or ace bandages will be applied per physician's orders [REDACTED].>

Based on observation, interview, and document review the facility failed to ensure a urinary catheter drainage bag was kept below the level of the bladder and was kept elevated off the floor at all times to prevent cross contamination and infection for 1 of 1 residents (R27) reviewed for catheter care. Findings include: R27's face sheet indicated R27 had [DIAGNOSES REDACTED]. R7's annual Minimum Data Set ((MDS) dated [DATE], indicated R27's cognition was moderately impaired. R27's care plan dated 2/7/19, indicated R27 had potential for infection related to use of an indwelling catheter and directed staff to provide Foley catheter cares per facility policy. During an observation on 3/12/19, at 1:33 p.m. R27 was observed in bed when nursing assistant (NA)-A and licensed practical nurse (LPN)-A exited R27's room. R27's urinary catheter drainage bad was observed laying on R27's bed next to R27's left thigh. The catheter tubing extending from the bed to the catheter bag looped downward off the side of the bed, looping back up to the catheter bag. During an observation on 13/12/19, at 2:38 p.m. LPN-B entered R27's room and brought R27 some water to drink. R27's urinary catheter bag remained on the bed next to R27's left thigh. During an interview 3/12/19, at 3:04 p.m. registered nurse (RN)-C entered into R27's room and stated the urinary catheter drainage bag should be hanging below the level of the bladder, on the side of the bed, not lying next to R27 on the bed. RN-C stated the urinary catheter drainage bag should be hanging to prevent urine from flowing back into the bladder and causing an infection. During an interview on 3/12/19, at 3:12 p.m. the director of nursing services (DON) stated if the resident is lying in bed then the urinary catheter drainage bag should be hanging below the level of the bladder and not touching the floor. During an observation on 3/13/19, at 10:43 a.m. R27 was in bed with the urinary catheter bag in a cloth bag touching the floor. During an interview on 3/13/19, at 11:54 a.m. NA-A stated the urinary catheter drainage bag should not be touching the floor. NA-A stated we are trained to have the urinary catheter bag hanging from the side of the bed when residents are in bed. During an interview on 3/14/19, at 8:55 a.m. the DON stated urinary catheter drainage bags should be hooked to the side of the bed when a resident is lying in bed and not touching the floor. The facility policy Urinary Indwelling Catheter Insertion and Management dated 2/21/19, indicated the urinary drainage bag must be positioned lower that the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder, unless the system is equipped with an anti-reflux valve. The policy further indicated be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and document review the facility failed to ensure medications available for use in a medication cart were appropriately labeled for 1 of 7 residents (R25). In addition, the facility failed to ensure medications were appropriately dated with an opened date in 1 of 1 medication refrigerators. Findings include: During a medication administration pass on 3/12/19, at 8:31 a.m. licensed practical nurse (LPN)-C was standing by a mobile medication cart in the hallway and prepared medications for R25. LPN-C removed a bubble pack card (one card of multi-dose pills contains a 30-day supply of medication) with magnesium tablets 400mg (milligram) to take one tablet four times a day and had R25's name on it. However when LPN-C and the surveyor looked at the order on the computer, R25's magnesium 400mg tablet was ordered for three times a day. LPN-C stated R25's magnesium order had changed and should have a change of direction order sticker when the order changed. R25's physician order [REDACTED]. During an interview on 3/14/19, at 8:52 a.m. the director of nursing (DON) stated a change of direction label should be on the medication bottle, bubble pack, or box that had the order changed. During the medication storage room tour on 3/14/19, at 9:42 a.m. the DON and surveyor observed R39's [MEDICATION NAME] 2mg/ml (milliliter) bottle with an orange date opened sticker without a date that the bottle was opened. R39's [MEDICATION NAME] was observed to be opened. During an interview on 3/14/19, at 10:09 a.m. with the DON stated the medication bottle should have a date that the bottle was opened by the staff. The DON stated R39's [MEDICATION NAME] was opened. A facility policy Medication Labels dated 6/15, indicated if the physician's directions for use change or the label is inaccurate, the nurse may place a direction change-refer to chart label on the container indicating there is a change in directions for use, taking care not to cover important label information.

Based on interview and record review, the facility failed to ensure a medication order was not discontinued without a physician order [REDACTED]. The resident was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. Review of the hospital record dated November 18, 2016 indicated the resident was discharged from the hospital with a prescription of [MEDICATION NAME], 20 milligrams (mg) capsule twice daily, to treat his/her and GERD. The [MEDICATION NAME] order did not have a stop date. Physician's discharge order, from the hospital, dated and signed on November 18, 2016 indicated an order for [REDACTED]. The quantity ordered was 60 capsule with two refills. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The progress note dated December 14, 2016 at 6:01 p.m. indicated R1 was sent to the emergency room for right-sided weakness. At the hospital, R1 had elevated temperature of 100.6 degrees Fahrenheit, bloating and abdominal pain. The hospital record dated December 16, 2016 at 10:20 a.m. indicated R1 was admitted with diminished level of consciousness with increased [MEDICAL CONDITION]. R1's chest x-ray and computed tomography (CT) scan indicated R1 had perforated [MEDICAL CONDITION] attributed to the facility's inappropriate stoppage of the R1's [MEDICATION NAME] order without a physician order. The hospital record dated December 21, 2016 at 11:25 a.m. indicated R1 was discharged to the facility with [DIAGNOSES REDACTED]. R1 was discharged with high dose of medication (proton-pump inhibitor) to manage R1's [MEDICAL CONDITION] continuously. The director of nursing (DON) was interviewed on January 3, 2017 at 1:00 p.m. and stated the facility transitioned from paper Medication Administration Record [REDACTED]. R1 was readmitted to the hospital and diagnosed with [REDACTED]. R1 was hospitalized for [REDACTED]. The facility's registered nurse (RN)-C was interviewed on April 3, 2017 at 1:20 p.m. and stated s/he transcribed the prescription for [MEDICATION NAME] from hospital discharge record to R1's physician order [REDACTED]. R1's primary physician was interviewed on April 25, 2017 at 11:33 a.m. and stated the facility's stoppage of R1's [MEDICATION NAME] without physician order [REDACTED]. The facility's policy and procedure titled Electronic Clinical Documentation: Orders dated June 2009 indicated a night nurse will audit all new physician orders [REDACTED].

Based on observation, interview, and record review, range of motion (ROM) services were not provided for 2 of 4 residents (R55 and R7) reviewed for ROM. R55 and R7 sustained actual harm with a reduction in functional ROM. Findings include: R55's quarterly Minimum Data Set ((MDS) dated [DATE], identified R55 did not walk, had no functional limitations in ROM (contractures), and was totally dependent on staff for transferring, toileting, dressing, and all activities of daily living. During interview on 9/8/14, at 5:55 p.m. registered nurse (RN)-A stated R55 had contractures (fixed high resistance to passive stretch of a muscle) in both knees only, did not utilize any splint devices, and was not receiving any formal ROM program. R55's care plan, last updated 6/9/14, did not identify the presence of any contractures nor did it instruct staff on the type of ROM exercises to be completed by staff. R55's restorative nursing sheets (which the facility identified as where resident restorative programs are documented and tracked), titled Routine Medications, was located in the restorative nursing book dated 1/1/14, through 6/30/14, and instructed staff R55 was to receive daily restorative nursing treatments which included the following: -Shoulder passive range of motion (PROM) 10-15 REPS-bilateral flexion/extension -Wrist PROM 10-15 reps bilateral flexion/extension -Ankle PROM 10-15 reps bilateral dorsiflexion/flexion -Digits PROM 10-15 reps bilateral flexion/extension -Elbow PROM 10-15 reps bilateral flexion/extension -Knee PROM 10-15 reps bilateral flexion/extension The 7/2014 restorative nursing sheet identified 3 restorative treatments were provided out of the 31 opportunities. The facility was unable to provide any restorative nursing sheets for R55 for the months of 8/2014, or 9/2014. The facility had no documentation any ROM was done for R55 for 2 months. The facility was unable to verify when R55's ROM program was started, and if it had been reassessed at any time to determine if it was appropriate for R55. Review of R55's Electronic Point Of Care Record from 7/1/14, to 9/12/14, did not identify R55 received any ROM services, nor was there any assessment to ensure the ROM program was appropriate for R55. During observation on 9/10/14, at 7:18 a.m. R55 was observed being assisted with dressing. R55's legs would not fully extend and rest on the bed, and the residents knees stayed bent. Nursing assistant (NA)-B was unable to raise R55's arms above her head to put on her shirt, and instead needed to slide the shirt up R55's arms and then stretch it over her head. R55 was not able to lift up her arms or straighten her arms from the elbow. NA-B verified R55 was becoming more stiff. During interview on 9/10/14, at 11:50 a.m. NA-B stated R55's ROM exercises were not being completed because they didn't have enough staff to spend time completing the exercises. NA-B stated R55 only received about 10% of the ROM exercises which the resident had been assessed as needing. During interview on 9/10/14, at 12:45 p.m., RN-C stated when restorative services or ROM was provided to the residents, the NAs should document in Point of Care when it was completed. RN-C was unable to provide any further documentation that R55 was receiving any ROM services, and verified there was no documentation in Point of Care R55 was receiving any ROM services. During interview on 9/11/14, at 9:38 a.m. licensed practical nurse (LPN)-B stated the NAs were responsible for completing the ROM treatments for the residents as well as charting when it was completed in the residents electronic point of care record. LPN-B was not aware R55's ROM was not being completed. R55's Physical Therapy Discharge Summary dated 9/6/11, indicated R55 demonstrated passive stretching of the right knee to 22 degrees and 25 degrees of the left knee. R55 was noted to be pain free and would be discharged to continue bilateral lower extremity ROM program with staff. R55's Occupational Therapy Discharge Summary dated 7/17/12, indicated R55 exhibited proper hip/knee/ankle alignment while in the wheelchair. The summary did not note the presence of any upper extremity contractures. During interview on 9/10/14, at 2:03 p.m. certified occupational therapy assistant (COTA)-D examined R55's upper extremities and indicated R55 was somewhat resistant when attempting to evaluate total ROM, so she was unable to completely assess the degree of the shoulder, wrist, and finger contractures. However, COTA-D indicated R55 appeared to have bilateral upper extremity contractures, which she was not aware of prior. COTA-D stated R55 would definitely benefit from a splint device for the right thumb which was identified to be the most contracted joint during the exam. Physical therapy assistant (PTA)-E was also interviewed at this time and completed an exam of R55's lower extremities. PTA-E stated when compared to the most recent physical therapy discharge summary dated 9/6/11, R55's knee contractures had worsened. PTA-E stated the right knee contractures had worsened to 55 degrees compared to 22 degrees before, and the left knee was now at 35 degrees compared to 25 degrees prior. COTA-D and PTA-E both verified R55 should be receiving ROM as had been assessed, and should have been referred back to OT/PT when staff noted R55's knees were becoming more contracted, and noted a decline in the resident's ability to move the upper extremities when being assisted with dressing. During interview on 9/11/14, at 9:09 a.m. family (FM)-A stated recently staff had asked him to purchase larger pants and different types of shirts so it would be easier to dress R55. FM-A stated R55 was becoming so stiff she was not able to lift her arms and straighten her knees so it was a struggle to get her dressed every day. FM-A stated staff asked for shirts that opened in the back, as well as larger pants, to make it slide on better. During interview on 9/11/14, at 10:13 a.m. NA-H stated range of motion services were not being completed and R55 was becoming stiff as a result. NA-H stated R55 wasn't able to stretch out her arms and legs like before which made getting the resident dressed more difficult, so staff asked the resident's family member to bring in different clothing. During another interview on 9/11/14, at 11:10 a.m. RN-A confirmed there was no formal ROM assessment in place for R55 to ensure the current restorative program was being implemented as assessed, nor to ensure the program is adequate to prevent further decrease in ROM. RN-A stated the NA's had brought up concerns about not having enough staff to complete resident ROM programs, however, she stated the facility had not reviewed the current resorative nursing programs to ensure they could be completed. The facility failed to ensure R55's restorative program was reassessed to ensure the ROM program was being implemented and was adequate to prevent further decline in ROM. Although the facility was aware R55 was having further difficulty with dressing related to decrease in ROM, the facility failed to provide further interventions and reassessment which resulted in actual harm to R55. R7's annual MDS dated [DATE], indicated R7 had severe cognitive impairment and had ROM impairment (contracture) to one side of the upper extremity. R7's clinic note dated 3/21/14, indicated the resident had a chronic right hand contracture which was released with surgery, had no pain, and was regaining muscular function back in the right hand. During observation on 9/9/14, at 2:50 p.m. R7 was lying in bed on her back and her left hand was in a fist. During observation on 9/10/14, at 6:53 a.m. R7 was sitting in her wheelchair in the activities room and her left hand was closed in a fist. During observation on 9/11/14, at 9:40 a.m. R7 was sitting in the activity room with her left hand closed in a fist. During observation on 9/12/14, at 8:40 a.m. R7 was sitting in the dining room with her left hand up to her face with her fingers bent inward. During observation of R7 from 9/9/14- 9/12/14, R7 was not observed to release the fist of her left hand, nor did she attempt to use her left hand. R7's PT Progress and Discharge Summary dated 3/4/14, indicated the resident was able to hang onto the walker without hand support, and was to receive ROM. R7's current Physician order [REDACTED]. ? Ankle PROM 0-15 reps bilateral dorsiflexion/flexion 1x ? Digits PROM 10-15 reps bilateral flexion/extension 1x ? Elbow PROM 10-15 reps bilateral flexion/extension 1x ? Hip PROM 10-15 reps bilateral flexion/extension, abduction/adduction 1x ? Knee PROM 10-15 reps bilateral flexion/extension 1x ? Shoulder PROM 10-15 reps bilateral flexion/extension 1x ? Walk 29-57 feet two times daily with wheelchair behind stand by assistance of two roller walker transfer belt x2 ? Wrist PROM 10-15 reps bilateral flexion/extension 1x R7's restorative nursing sheets (which the facility identified as where resident restorative programs are documented and tracked), titled Routine Medications, located in the restorative nursing book, indicated the resident had a right hand contracture. The restorative nursing sheets reviewed from April 2014, - September 2014, noted the following program to be completed for R7 on the day shift: ? Ankle PROM 0-15 reps bilateral dorsiflexion/flexion 1x ? Digits PROM 10-15 reps bilateral flexion/extension 1x ? Elbow PROM 10-15 reps bilateral flexion/extension 1x ? Hip PROM 10-15 reps bilateral flexion/extension, abduction/adduction 1x ? Knee PROM 10-15 reps bilateral flexion/extension 1x ? Shoulder PROM 10-15 reps bilateral flexion/extension 1x ? Walk 29-57 feet two times daily with wheelchair behind stand by assistance of two roller walker transfer belt x2 ? Wrist PROM 10-15 reps bilateral flexion/extension 1x R7's restorative nursing sheets for April 2014 - September 2014, noted the restorative nursing program to be completed for R7 on the day shift, however, there was no documentation R7 was receiving any ROM. R7's care plan dated 6/11/14, identified R7 had a right hand contracture. On 9/11/14, at 1:20 p.m. R7 was evaluated by PTA-E and COTA-D, who both verified R7 was resistive and had some contracture(s) in her left hand and bilateral knees. During the evaluation R7 grimaced and stated, "Ouch" on multiple occasions when PTA-E and COTA-D were attempting ROM. COTA-D and PTA-E both stated R7 would benefit from therapy and possibly a splint or cone for the new contracture in her left hand. During interview on 9/9/14, at 9:46 a.m. RN-A stated R7 had a contracture to her right hand and had surgery to release part of the contracture. RN-A stated the restorative program was not being completed for residents as assessed, and she was trying to revamp the program. RN-A stated R7 should be receiving the ROM services as had been assessed by PT. RN-A was not aware of R7's left hand or bilateral knee contractures. An interview on 9/10/14, at 1:00 p.m. was completed with NA-A who stated staff was not able to complete ROM for residents and stated, "I feel sorry for the residents because they need the range of motion." NA-A stated staff just does not have any extra time to provide any ROM or ambulation. During interview on 9/11/14, at 1:57 p.m. RN-D stated R7 had a contracture to the right hand, which was repaired via surgery, and was the contracture identified on the resident's MDS. RN-D stated several months ago R7 got to the point of being unable to hang onto the walker with her hands, so staff was ambulating the resident hand in hand. RN-D stated R7 was noted at that time to have a decline in ROM in her left hand related to being unable to hang onto the walker, however, R7's restorative program was not reassessed, and the resident was not referred back to PT to prevent further decline in ROM ability. The facility failed to ensure R7's restorative program was reassessed to ensure the ROM program was being implemented and was adequate to prevent further decline in ROM. Although the facility was aware R7 was no longer able to hang onto the walker to ambulate, the facility failed to provide further interventions and reassessment which resulted in actual harm to R7. The facility policy titled Restorative Nursing, undated, identified the philosophy was each individual admitted to the facility had the right to become involved in his/her own care and to have the services available to him/her to reach their highest possible, practicable physical and psychosocial level. Restorative nursing is a planned, systematic, organized program that builds on strengths and must meet the following criteria: 1. Measurable objectives and interventions must be documented in the care plan and in the clinical record 2. Evidence of periodic evaluation by licensed nurse must be present in the clinical record 3. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity 4. Restorative activities must be carried out or supervised by members of the nursing staff 5. Two Restorative programs must be provided a minimum of 6 days/week 6. Each Restorative program must be provided a minimum of 15 minutes in a 24 hour period The policy further identified nurses in management positions were responsible for maintaining the organization of the restorative program and monitoring the delivery of restorative care on a routine basis to assure the programs are being followed consistently and as planned. The summary of the policy documented the following, "Restorative nursing was mandated by OBRA (Omnibus Budget Reconciliation Act) in 1987, as a means to keep residents at their highest possible practicable physical, mental and psychosocial level. Maintaining function enhances dignity and self-esteem. It is the primary reason for implementing effective restorative nursing programs. A comprehensive organized program guides staff to accurately identify restorative needs, implement restorative programs that assure residents receive the restorative services as planned and document to maintain a permanent record of the entire process. It does not feel good to lose function. Loss of function decreases a person's self-worth and one's ability to experience and enjoy quality of life. An organized restorative program that delivers systematic care based on the resident's individual needs increases self-esteem and worth and enhances well being."

Based on observation, interview, and document review, the facility failed to provide ambulation services to prevent loss of function for 2 of 4 residents (R47 and R7) who required physical assistance with ambulation, and were not reassessed upon a decline in ambulation. The decline in ability to ambulate resulted in actual harm for R47 and R7. Findings include: R47's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R47 had no cognitive impairment, needed extensive assistance of one staff for transfers and ambulation, and used a wheelchair or a walker to aid her ambulation. R47's balance was not steady during transfers and walking and she had no loss of upper and lower function range of motion (contractures). R47's Care Area Assessments (CAA) dated 10/9/13, identified R47 was alert and oriented, had clear speech, and she was understood and able to understand others. R47 had an unsteady gait, was able to bear weight, and required a wheelchair behind her when she was involved in the restorative walking program. During interview on 9/8/14, at 7:11 p.m. R47 stated she was concerned she was going to lose her ability to walk because staff had not been assisting her to ambulate. She stated she was supposed to be walked twice a day but there was not enough staff to do this. She indicated she was, "Very rarely being walked." Another interview was completed on 9/11/14, at 11:00 a.m. R47 stated she was, "upset, " about not being walked twice a day due to staff shortage. She stated, "They just don't have time to walk me." R47 stated she had been involved in therapy and the therapist recommended she be walked. Because staff had not been assisting her to walk, R47 stated her joints are getting stiff and was not able to move as easily as she had in the recent past. She stated the last time she could remember she was walked was about 7-10 days ago. R47's care plan dated 7/9/14, indicated R47 was to be ambulated per the "Restorative program." The restorative program was not specified in the plan of care. R47's nursing assistant care sheet, dated 9/9/14, directed nursing assistants to ambulate the resident 57 feet to 115 feet, twice per day with assistance of one staff, a transfer belt, rolling walker, and wheelchair behind. R47's physical therapy note dated 8/7/14, indicated the resident was able to ambulate up to 80 feet with a rolling walker and contact guard assistance. R47 was seen in the occupational therapy (OT) department from 7/14/14 to 8/14/14. R47 was considered to be alert and able to follow directions. R47's discharge from OT on 8/14/14, indicated she transferred with contact guard assistance (CGA- the therapist would hold a transfer belt for stabilization), tolerated standing for greater than three minutes while she maintained a safe balance while using a 4 wheeled walker, had an increase in her endurance while performing her activities of daily living, and reported no increase in fatigue while performing her exercises. R47's physician orders [REDACTED]. R47's restorative nursing sheets (which the facility identified as where resident restorative programs are documented and tracked), titled Routine Medications, located in the restorative nursing book, were reviewed from April 2014, to September 11, 2014 identified the following: -April 1 to June 30, 2014, R47 was ambulating twice a day, walking 57 to 115 feet consistently. -July, 2014, R47 was walked 15 times on the day shift, and twice on the evening shift. The last documentation of R47 being ambulated was 7/23/14, when she walked 115 feet. -August 2014, to September 11 2014, there was no documentation regarding R47 ambulating. During interview on 9/11/14, at 9:44 a.m. nursing assistant (NA)-J stated he was aware R47 was to be ambulated twice a day, however, he had never assisted R47 to ambulate. NA-J stated staff does not have time to complete R47 ambulation program because of short staff. During interview on 9/11/14, at 11:15 a.m. licensed practical nurse (LPN)-C stated R47 was to be ambulated twice a day, however, she stated there was no way to determine if R47 was being ambulated because there was no documentation. During interview on 9/11/14, at 2:39 p.m. physical therapy assistant (PTA)-E stated she had worked with R47 from 7/14/14, until her discharge from physical therapy on 8/12/14. PTA-E had recommended R47 be ambulated twice a day, 57-111 feet. PTA-E stated R47, "loved to be walked," and was able to consistently walk 80 feet when discharged from PT on 8/12/14. During interview on 9/11/14, at 3:24 p.m. registered nurse (RN)-A (who was identified as the person in charge of Rehab/Restorative Services), stated there was no record of staff efforts to walk R47. RN-A stated staff was to ambulate R47 twice a day, however, she was not sure if this was being done, and was unsure if R47 had declined in her ability to ambulate. RN-A stated there was no formal nursing assessment completed of R47's ambulation program to ensure it was appropriate and being implemented as ordered. RN-A stated NA's had complained to her that they were unable to assist residents with ambulation related to being short staffed, however, NA-A verified the ambulation programs were not reassessed and no changes had been made with the program to ensure it was being completed. During observation on 9/11/14, at 3:55 p.m. PTA-E assisted R47 to ambulate. R47 was able to walk 45-60 feet before becoming short of breath and needed to sit down. PTA-E stated R47's current ambulation ability was a decline from when the resident was discharged from physical therapy on 8/12/14. Although the facility was aware R47 was not being ambulated as assessed by PT, the facility did not reassess and put interventions into place to ensure the resident did not decline in the ability to ambulate. R47's decline in ambulation ability related to the lack of the facility completing the ambulation program as assessed resulted in actual harm for R47. R7's annual MDS dated [DATE], identified R7 had severe cognitive impairment, had impairment (contracture) to one side of the upper extremity, required extensive two person assistance with transfers and walking in the corridor, was only able to stabilize when standing with staff assistance, and walking in the resident room, unit, and off the unit had not occurred during the 7 day prior look back period of the MDS completion date of 8/27/14. R7's CAAs dated 8/27/14, did not address R7's walking, transfer ability, or current contractures. During observation on 9/9/14, at 2:50 p.m. R7 was lying in bed on her back and both knees were bent and raised off the bed. R7's Physical Therapist Progress & Discharge Summary dated 3/4/14, indicated R7 was to ambulate 20-30 feet, using a four wheeled walker with assist of two staff, two times a day. R7 was able to hang onto the walker without hand support and did not need the platform walker on even services. PT also indicated R7's knee range of motion (ROM) was 26 degrees of left knee extension, and 22 degree of right knee extension. R7's current signed physician orders [REDACTED]. R7's restorative nursing sheets (which the facility identified as where resident restorative programs are documented and tracked), titled Routine Medications, located in the restorative nursing book, from April 2014 - September 2014, instructed two staff to walk the resident 29-57 feet, two times daily. There was no documentation identifying if staff was ambulating R7 from 4/2014- 9/2014. R7's care plan dated 9/3/14, indicated staff pushed R7 to all destinations in the wheelchair and transferred with assist of two with a transfer belt and walker. R7's care plan did not address if the resident was able to ambulate, nor did it instruct staff on R7's assessed ambulation program. When interviewed on 9/9/14, at 9:46 a.m. RN-A stated the restorative/ ambulating program was in shambles right now, and she was trying to revamp the program to ensure residents were receiving their programs as assessed. RN-A was not aware R7 had not been ambulating or had a decline in transfer ability or ambulation, however, RN-A stated NA's had complained to her they were not able to complete residents ambulation programs becasue of short staffing. During interview on 9/11/14, at 1:42 p.m. NA-F stated R7 had a decline in ambulating as well as transfers, and staff was supposed to be walking her, however, R7 no longer walks, and staff did not have time to spend to try to assist her in walking prior. NA-F stated recently she had to order foot pedals for R7 because she could no longer raise her feet up when in the wheelchair when staff were pushing her to destinations. During interview on 9/11/14, at 1:57 p.m. RN-D stated she had observed R7 ambulating and transferring a few months ago, and R7, "got to the point," of being unable to bear weight on the walker, so staff was transferring the resident using a hand in hand method. RN-D stated she had done no formal assessment of R7's ambulation program when it was noted R7's ambulation program was not being implemented as assessed and R7 was noted to be declining in her ability to transfer and ambulate. On 9/11/14, at 1:20 p.m. R7 was evaluated by PTA-E and COTA-D, and stated R7 was resistive and had some contractures in her left hand and bilateral knees. PTA-E and COTA-D transferred R7 from the wheelchair to her bed. During the transfer, R7 did not take any steps, bear any weight on her feet, and was lifted into bed with heavy assist. During the evaluation, R7 stated, "ouch," on multiple occasions and grimaced when staff was attempting to straighten the resident's knees. PTA-E and COTA-D both verified R7 would benefit from therapy and should have been referred back to therapy when staff noted the resident was declining in transfers and no longer ambulating. COTA-D stated residents have expressed concerns with not being ambulated. Although the facility was aware R7's ambulation program was not being completed as assessed, and the resident was no longer ambulating and had a decline in transfers, the facility failed to reassess and refer the resident back to therapy. This resulted in actual harm for R7.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R56) who was admitted with a pressure ulcer was provided interventions as assessed, and was re-evaluated to prevent further pressure ulcers from developing. Findings include: R56's quarterly Minimum Data Set ((MDS) dated [DATE], identified R56 had no cognitive impairment, required extensive assistance of two staff for bed mobility, extensive assistance of one staff for repositioning in the chair, was at risk for developing pressure ulcers, and currently had one stage IV (unstageable) pressure ulcer that was present on admission and unhealed. R56's most recent Care Area Assessment (CAA) dated 6/23/14, revealed R56 was at risk for pressure ulcer development, was on a turning and repositioning program, receiving pressure ulcer care with dressing application, and had a pressure reducing device for the chair and bed. R56 was identified as being admitted with pressure ulcers both heels. R56's care plan dated 8/16/14, identified R56 had a 1.3 x 0.3 unstageable pressure ulcer on the coccyx, should be repositioned at no greater than 2 hour intervals, had a pressure redistribution mattress on the bed, and a pressure redistribution wheelchair cushion. R56's Skin Observation Reports dated 1/2/14, through 6/5/14, indicated the resident's skin was intact and had no pressure ulcers. R56's Braden Scale (a tool used to assess pressure ulcer risk) dated 6/8/14, indicated the resident had a mild risk of developing pressure ulcers. The Braden scale assessment indicated R56 had recently gotten a new wheelchair cushion related to the risk of developing pressure ulcers. R56's Tissue Tolerance Evaluation (assessment to determine skins ability to withstand pressure) dated 6/17/14, identified non-blanchable redness at the three hour mark in the lying position, and was unable to change position independently. The evaluation indicated R56 had no redness at the one, two or three hour mark in the sitting position and was unable to change position independently. There was no further assessment. R56's Tissue Tolerance Evaluation dated 6/23/14, identified no redness at the one or two hour mark in the lying position, and able to reposition independently. The evaluation indicated there was blanchable redness at the two hour mark while sitting and that R56 could reposition independently. There was no further assessment. R56's Tissue Tolerance Evaluation dated 8/25/14, identified blanchable redness at the two hour mark in the wheelchair and the resident was unable to reposition independently. There was no further assessment of the tissue tolerance evaluation. R56's Skin Injury/Wound Report(s) dated 6/17/14, indicated R56 developed a pressure ulcer in the right gluteal fold measuring 0.5 centimeter (cm) x 0.8 cm with a pink wound bed, and was a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough). The area was cleansed and a protective cream applied, and the physician was faxed for further orders. Measurements of the pressure ulcer were documented weekly on the Skin Injury/ Wound Report. Review of the weekly monitoring from 6/17/14, through 9/10/14, indicated the pressure ulcer had worsened increasing in size and developing into an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough, yellow, tan, gray, green or brown, and/or eschar, tan, brown or black tissue, in the wound bed). On 9/10/14, the pressure ulcer was 1.5 cm x 2 cm, with a 70% slough yellow wound base and was unstageable. Another pressure ulcer was identified on a Skin Injury/Wound Report(s) dated 7/27/14, on the right buttock measuring 0.5 cm x 0.4 cm was identified by staff as, "trauma from the adhesive dressing being used on the gluteal fold." However, the area was identified as a "pressure ulcer," on the Skin Injury/Wound Report because it was located on a pressure area. On 8/29/14, the facility identified the pressure ulcer was a stage 2. The documentation of the pressure ulcer on 9/10/14, identified the pressure ulcer had worsened to an unstageable pressure ulcer, and increased in size with a description of the pressure ulcer as 2.5 cm x 2 cm, with 50% white/ yellow slough wound bed, and was currently unstageable. R56's current physician orders [REDACTED]. [MEDICATION NAME] with a foam dressing was to be applied to the right buttock, sacrum, and gluteal fold every 3 days and as needed (PRN). The physician orders [REDACTED]. R56's Nurses notes dated 6/2/14. indicated the resident was admitted with two, stage 4 pressure ulcers on the right and left heel. R56 was being seen at the wound clinic for these wounds, and they had been debrided by the surgeon in the past. During continuous observation of R56 on 9/10/14, from 7:18 a.m. through 9:46 a.m., R56 was sitting in his wheelchair on a cushion, and was unable to shift his weight independently. Throughout the 2 hour and 28 minute observation, R56 was not approached by staff to reposition as assessed. During interview on 9/10/14, at 7:20 a.m., R56 stated he had pain in his buttocks and had been up sitting in his wheelchair since approximately 6:00 a.m. that morning without repositioning. During interview on 9/10/14, at 9:46 a.m. nursing assistant (NA)-A stated the facility was short staffed and NAs did their best to assist residents to reposition as assessed. NA-A stated she was aware of R56's pressure ulcers on his buttocks and, "They were pretty open," right now. NA-A verified R56 was to be repositioned every 2 hours. During interview on 9/10/14, at 9:54 a.m. licensed practical nurse (LPN)-B stated R56 should be repositioned after 2 hours and should lie down after breakfast. LPN-B requested assistance from staff to lay R56 down. During observation on 9/10/14, at 10:05 a.m. NA-B entered R56's room to reposition him, which was 2 hours and 47 minutes after the initial constant observation began, and 4 hours and 5 minutes since R56 stated he had been up in his chair. NA-B lifted R56 out of his chair using a standing lift and removed his brief. R56's buttocks were dark red in color and had a foam dressing on the right buttock. During interview on 9/10/14, at 11:23 a.m. registered nurse (RN)-A stated LPN-B had been the wound nurse, however, there was a recent re-assignment of wound duties and she was delegating them out to the staff. RN-A was unsure of the current condition of R56's ulcers. During interview on 9/10/14, at 11:35 a.m. LPN-B stated R56 had gotten a new wheelchair cushion when the buttock pressure ulcers developed around 6/21/14, and she though the resident currently had three pressure ulcers, however, LPN-B was not clear on the current condition of the pressure ulcers. LPN-B stated nursing decided to get R56 a new wheelchair cushion because the resident had complained he felt like he was sitting in a hole. LPN-B stated OT did not evaluate the resident to ensure the wheelchair cushion was appropriate. During observation of R56's current pressure ulcers on 9/10/14, at 1:58 p.m. the director of nursing (DON) and LPN-B verified R56 had two open areas on his buttocks, one on the upper gluteal cleft which was whitish at the wound base and was an unstageable pressure ulcer with 90% slough wound bed which currently measured 1.5 cm x 2 cm. The second pressure ulcer was on the right buttock and had 60-70% slough that was whitish in color at the wound base and measured 2.5 cm x 2 cm, and was also unstageable. LPN-B stated both pressure ulcers had increased in size and stage since the last time she had seen them, however, LPN-B was unable to verify the last time she had observed R56 pressure ulcers. During interview on 9/10/14, at 2:17 p.m. certified occupational therapy assistant (COTA)-D stated she had not been involved in assessing R56 for adequate wheelchair positioning or the wheelchair cushion. During interview on 9/11/14, at 1:07 p.m. director of nursing (DON) stated she was not aware of R56's worsening pressure ulcers. DON stated R56 repositioning schedule of every two hours should have been re-evaluated after the pressure ulcers developed and worsened to ensure the schedule was individualized and adequate to promote healing of the pressure ulcers. During interview on 9/11/14, at 1:10 p.m. RN-B stated she was not aware of R56's worsening pressure ulcers so she had not discussed interventions with OT, nor had she reassessed the current interventions in place to ensure they were being implemented and were adequate to prevent further pressure ulcers. On 9/11/14, at 1:39 p.m., a call was placed to R56's medical doctor (MD)-C who was unable to be reached to discuss R56's pressure ulcers. The facility policy, titled Repositioning, undated, indicated it was the policy of the facility to have in place a system to identify repositioning programs for each resident and repositioning every two hours or more frequently depending upon the resident's condition and tolerance of the tissue load may be implemented, and more frequent repositioning (i.e. off loading hourly) may be warranted for individuals at high risk for pressure ulcer development. The policy indicated the therapy department assessed postural alignment, weight distribution, sitting balance, stability, and pressure redistribution along with cushion/mattress recommendations in coordination with the nursing department. The facility policy titled Wound/Skin Care Policy, last revised 12/01/97, indicated an at-risk resident who sits too long on a static surface may be more prone to get ischial ulcerations.